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General Peds Boards > Toxicology > Flashcards

Toxicology Flashcards

1
Q

Name of toxic metabolite from acetaminophen

A

NAPQI (N-acetyl-p-benzoquinoneimine), overdose causes depletion of GSH and accumulation of NAPQI

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2
Q

Clinical effects/stages of acetaminophen overdose

A
  1. 0-24 hours - nausea, vomiting, malaise, pallor - normal AST/ALT and INR
  2. 12-72 hours - hepatotoxicity, RUQ pain - rising AST/ALT and normal or rising INR
  3. 72-96 hours - fulminant hepatic failure, encephalopathy, coma - AST/ALT > 10,000, elevated INR, elevated Cr, acidosis, lactemia
  4. > 96 hours - recovery with normalization of labs
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3
Q

Diagnosis of acetaminophen overdose

A
  • Obtain serum APAP level 4 hours after ingestion
  • Most important predictor of outcome is level taken at 4-10 hours post ingestion
  • “Overdose” is taking 140 mg/kg or more
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4
Q

Clinical effects of aspirin (salicylate) overdose

A
  • Vomiting, tinnitus, tachypnea, tachycardia, hypoxia, pulmonary edema, fever
  • “Wintergreen” odor on breath
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5
Q

Diagnosis/management of salicylate overdose

A
  • Labs: mixed respiratory alkalosis and metabolic acidosis
  • Treatment with activated charcoal
  • Aspirin level > 30 requires treatment with urinary alkalinzation (sodium bicarb), > 90 requires hemodialysis
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6
Q

Drugs that prolong QRS

A
  • Bupivacaine, bupropion, carbamazepine, cocaine, diphenhydramine, lamotrigine, quinidine, TCAs
  • Prolonged is > 100
  • Tx with sodium bicarbonate
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7
Q

Drugs that prolong QTc

A
  • Antipsychotics, fluoroquinolones, macrolides, methadone, ondansetron, SSRIs and SNRIs
  • Prolonged is > 500 (but age specific)
  • Tx with electrolyte correction (and mag)
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8
Q

Drugs that cause hypoglycemia

A

HOBBIES:

  • Hypoglycemics (sulfonylureas, meglitinides)
  • Other (unripened fruit, IV quinine)
  • B-Blockers
  • Insulin
  • Ethanol
  • Salicylates
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9
Q

Activated charcoal uses

A
  • Dose is 0.5-1 g/kg
  • If ingestion can cause respiratory depression, need to intubate before giving activated charcoal
  • Don’t give charcoal with antidotes (interferes with absorption of the antidote), only acception is NAC
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10
Q

Toxins that don’t require activated charcoal

A

CALM

  • Cyanide
  • Alcohol/alkaline ingestion
  • Lithium
  • heavy Metals
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11
Q

Treatment of acetaminophen overdose

A
  • Often asymptomatic initially so immediate ER discharge is never the right answer
  • If < 4 hours since ingestion, give activated charcoal
  • Treat with NAC if level is above nomogram (wait until 8 hours after ingestion to begin treatment)
  • NAC works by protecting liver and body from oxidative stress of NAPQI and regnerates GSH
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12
Q

Anion gap equation

A

Sodium - (Chloride + bicarb)

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13
Q

Ibuprofen ingestion signs/symptoms and treatment

A
  • Nausea and vomiting (on boards), asx in real life
  • Treatment is supportive
  • Should check for other drug ingestions though
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14
Q

Alcohol toxicity symptoms/levels

A
  • Mild: BL 100 - euphoria, lowered inhibitions
  • Moderate: BL 200 - slurred speech, ataxia, impaired judgement
  • Severe: BL 300 - confusion and stupor, seizures
  • Electrolyte disturbances: hypogylcemia
  • Alcohol is also present in mouthwash, cough/cold meds, cologne, perfume
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15
Q

What is methanol found in

A

Windshield washer fluid, cooking fuel, perfumes, antifreeze

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16
Q

Clinical presentation/labs of methanol toxicity

A

Abdominal pain, vomiting, inebriation, severe metabolic acidosis, increased anion gap, CNS depression
- Gets broken down into formic acid and formaldehyde and can cause huge issues with the liver and optic nerve

17
Q

Methanol toxicity treatment

A
  • Administration of ethanol - alcohol dehydrogenase antagonist (slowing conversion of methanol to formaldehyde)
  • Also can use 4-methypyrazole
  • Soduium bicarb - counters formic acid
18
Q

Ethylene glycol toxicity (3 phases)

A
  • Phase 1: drunken appearance with no alcohol odor, large anion gap metabolic acidosis, hypocalcemia d/t crystals in the urine, hypertension, N/V
  • Phase 2: coma and cardiorespiratory failure
  • Phase 3: 1-3 days, renal failure due to ATN
19
Q

Organophosphate toxicity

A
  • SLUDGE: salivaiton/sweating, lacrimation, urination, defecation/diarrhea, gastrointestinal, emeesis
  • Can be lethargic and have respiratory distress
  • Insecticide ingestion, unwashed fruits and veggies
  • Mechanism of action: inhibiting acetylcholinesterase (cholinergic effects)
20
Q

Muscarinic cholinergic effects and treatment

A
  • Salivation, lacrimation, diarrhea, wheezing, bradycardia

- Tx: atropine

21
Q

Nicotinic cholinergic effects

A
  • Neuromuscular, weakness, paralysis, muscle fasciculations

Tx: pralidoxime

22
Q

Tricyclic antidepressants toxic ingestion

A
  • Anticholinergic effects: Blind as a bat (mydriasis, dilated pupils), Red as a beet, Hot as a hare, Dry as a bone, Mad as a hatter, Bowel and bladder lose their tone, Heart runs alone
  • Need to monitor EKG for widening QRS complex (treat iwth sodium bicarb until QRS is < 100)
  • Tx: activated charcoal
23
Q

Beta blocker ingestion side effects

A
  • Bradycardia, hypotension, sweating

- Monitoring is all thats needed

24
Q

Hydrocarbon ingestion

A
  • Gasoline, kerosene, lighter fluid
  • Gastric irritation, nause, vomiting, choking/gagging, cough, wheezing
  • Labs with hypoxemia and CXR with diffuse bilateral infiltrates –> can lead to ARDS
  • Tx is symptomatic
25
Q

Carbon monoxide toxicity symptoms

A
  • Sudden flu like illness in an afebrile patient (headache, vomiting, weakness, fatigue)
  • Symptoms in other family members or recent death of a small family pet
26
Q

Carbon monoxide toxicity workup/treatment

A
  • Carboxyhemoglobin levels
  • Oxygen saturations are unreliable
  • Give high flow 100% oxygen
27
Q

Cyanide poisoning

A
  • Presents like carbon monoxide poisoning but failure to respond to oxygen therapy
  • Smell of almonds
  • Tx: hydroxocobalamin
28
Q

Treatment for ingestion of caustic substance

A
  • Endoscopy within 24 hours to determine extent of esophageal injury
  • No gastric lavage with caustic ingestion
29
Q

Alkaline ingestion

A
  • Alkali substances tend to injure the esophagus and can lead to esophageal perforation
  • Ingestion of dishwasher detergent or drain cleaner
  • Also watch for signs of burns on the face/hands/chest
30
Q

Lead screening and levels

A
  • > 27% of housing built before 1950
  • Level 5-14: report, venous sample in 3 months, do environmental history/screening
  • Level 15-44: report, venous sample in 4 weeks, consider xray if pica
  • Level 45-70: report, venous sample in 48 hours
  • Level > 70: report, venous sample immediately
31
Q

Lead toxicity treatments

A
  • Level as low as 10 can lead to cognitive deficit
  • Level 45-70 give outpatient chelation if symptomatic (oral succimer)
  • Level > 70 need hospitalization and IV chelation (edetate)
  • Need a venous sample to base treatment (not capillary)
32
Q

Lead sources

A
  • Lead based paint in older homes
  • Household dust, soil
  • Glazed ceramics, storage battery casings, bullets, cosmetics, leaded glass, jewelry, farm equipment
33
Q

Toxic iron ingestion amount and phases

A
  • 40 mg/kg of elemental iron is “toxic”
  • Phase 1: within 6 hours - vomiting, diarrhea, abd pain
  • Phase 2: slight improvement for 6-24 hours
  • Phase 3: metabolic acidosis, coagulopathy, cardiovascular collapse
  • Phase 4: GI obstruction due to scarring and strictures
34
Q

Management and treatment of iron toxicity

A
  • Lead level 4 hours post ingestion
  • Labs/imaging: abdominal film, electrolytes, liver function, CBC, coagulation
  • Tx: indications for chelation with deferoxamine are anion gap acidosis, serum iron > 500, significant iron on abdominal film
  • Deferoxamine turns the urine pink/red when serum iron level exceeds serum iron binding capacity - can stop when urine is no longer pink
35
Q

PCB exposure in utero

A

Low birthweight, dark pigmentation, early eruption of teeth, acneiform rash –> can be fatal

36
Q

Anthrax

A
  • Cutaneous form, incubation period is less than 2 weeks

- Lesions are pruritic papules –> central bullous lesion –> necrosis –> central black painless eschar

37
Q

Coin ingestion treatment

A
  • Proximal esophagus should be removed by endoscopy immediately
  • Middle to lower esophagus can be observed for 12-24 hours if asymptomatic, if in stomach it can just be observed for passage
  • Coins in the esophagus usually face forward on the PA film and from the side on the lateral film (opposite if in trachea)
38
Q

Three ingested objects that can’t be ignored

A
  • Button batteries, sharp/pointed objects, magnets –> all high risk for perforation so need immediate endoscopy
39
Q

Discoloration of blood, normal PaO2, clinical evidence of cyanosis

A

Methemoglobinemia

- Exposure to exogenous oxidizing drugs: amyl nitrite, butyl nitrite, isobutyl nitrite

General Peds Boards (24 decks)

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