Toxicology Flashcards
This deck covers Chapters 139-159 in Rosens, compromising all of toxicology.
Outline treatment for BB/CCB poisoning
- MOVID
- ABCs
- Charcoal/WBI
- Fluids, Pressors
- Calcium
- Glucagon 5 mg IV
- Insulin R 1-10 units/kg/hr
- Intralipid
- ECMO
Identify the following:

Water Hemlock
Signs/Symptoms
- N/V
- Seizures (GABA antagonism)
Treatment
- Charcoal
- Seizure control
Outline the metabolism of ethylene glycol
Ethylene glycol
- Alcohol dehydrogenase
- NAD as cofactor
Glycoaldehyde
- Aldehyde dehydrogenase
- NAD as cofactor
Glycolic acid
- NAD as cofactor
Glycoxylic acid
- Pyridoxine as cofactor (glycine)
- Thiamine and Mg as cofactor (a-hydroxy-…)
Oxalic acid + Glycine + a-hydroxy-b-ketoadipate
List 6 radio-opaque drugs
CHIPES
- CaCO3
- Heavy metals
- Iron
- Potassium
- Enteric-coated pills
- Solvents
List 5 benefits of fomepizole over alcohol
- Ease of administration
- Standardized
- Predictable
- Safer
- Longer duration of action
- No CNS effect
- ADH has higher affinity to fomepizole than alcohol
In asymptomatic or minimally symptomatic children, what guides lead chelation therapy?
Leads sucks (69)
- BLL >69 - hospitalize
- BLL 45-69 - OP oral succimer
- BLL <45 - no chelation
List 5 non-selective and 4 selective beta-blockers
Non-Selective
- PLaNTS
- Propranolol
- Labetalol
- Nadolol
- Timolol
- Sotalol
Selective
- BEAM
- Bisoprolol
- Esmolol
- Atenolol
- Metoprolol
Differentiate the type of injury caused by acids/alkalis
Acids
- Coagulative necrosis
- Concern re: systemic absorption
Alkalis
- Liqufactive necrosis
- Deeper penetration
What is the mechanism of action of CN and H2S?
Binds Complex IV in the electron transport chain
Uncouples oxidative phosphorylation
Outline management of ASA poisoning
- IV fluids
- U/O at 2-3 cc/kg
- Alkalinize the urine
- NaHCO3 infusion
- Target urine pH >7.5
- Replace potassium
- KCl in fluids
- Maintain glucose
- Target >5.5 mmol/L
- Consider dialysis
- Coma, Seizure
- Renal failure
- Hepatic failure
- Respiratory failure
- Severe acidosis
- Rising ASA level
- Acute level >7.2
- Chronic level >3.6
List 6 drugs that intralipid is indicated for.
- BB
- CCB
- Local anesthetic
- Buproprion
- TCAs
- Seroquel
- Diphendydramine
- Class I antiarrhythmics
List the antidote and dose for the following drugs/poisons:
- Iron
- Isoniazid
- Lead
- Local anesthetics
- MDMA-related hyperpyrexia
- Neuroleptics (NMS)
- Methanol
- Methemoglobin
- Opioids
- Iron - Deferoxamine 15 mg/kg/hr IV
- Isoniazid - Pyridoxine 5g IV
- Lead - DMSA 10 mg/kg PO
- Local anesthetics - Intralipid 1.5 mL/kg IV
- MDMA-related hyperpyrexia - Dantrolene 2.5 mg/kg IV
- Neuroleptics (NMS) - Dantrolene 2.5 mg/kg IV
- Methanol - Fomepizole 15 mg/kg, Folate 50 mg IV
- Methemoglobin - Methylene blue 1-2 mg/kg
- Opioids - Narcan 0.4 mg IV
Pulmonary irritants react with water to cause damage. Give 4 examples.
- Chlorine –> HCl
- Phosgene –> HCl
- Ammonia –> Ammonium hydroxide
- Sulfur dioxide –> H2SO4
When do you initiate lab testing (AST + APAP) in chronic APAP ingestion (3)?
- Ingestion >10g/day x24h
- Ingestion >6d/day x48h
- Symptomatic (N/V, RUQ pain, Jaundice)
List 7 drugs which enhance lithium toxicity
Renal Toxins
- NSAIDs
- Diuretics
- ACEi
- ARB
Neuro/Psych Meds
- SSRI
- Antipsychotics
- Carbamazepine
List 5 drugs that induce CYP P450
- Sulfonylureas
- Phenobarbital
- Rifampin
- INH
- Phenytoin
- Carbamazepine
- HIV medications
- St. John’s wart
- Chronic EtOH
List 7 causes of a toxin-induced bradycardia
- CCB
- BB
- Opiate
- Clonidine
- Digoxin
- Barbiturates
- Organophosphates
List 5 reasons why the Done nomogram is not useful in all patients
- Derived in pediatric population
- Assumes 1st order kinetics
- pH must be >7.4
- Toxicity correlates poorly with serum levels
- Used after 6h from single, non-EC ASA dose
How do you approach the following patients with iron ingestion?
- Asymptomatic, Ingestion <20 mg/kg, Level <60
- Asymptomatic, Ingestion >20 mg/kg, Pills on Xray
- Symptoms and level 60-90 umol/L
- Ingestion >60 mg/kg, level >90 umol/L
Asymptomatic, Ingestion <20 mg/kg, Level <60
- Observe x6h, then psych vs home
Asymptomatic, Ingestion >20 mg/kg, Pills on Xray
- Get level at 4h and 8h
- WBI
- If level >60 or systemic symptoms = chelate
- If level <60 and decreasing = don’t chelate
Symptoms and level 60-90 umol/L
- Chelate (DFO 15 mg/kg/hr)
Ingestion >60 mg/kg, level >90 umol/L
- Chelate (DFO 15 mg/kg/hr)
List 8 indications for DigiFab
Adult
- Cardiac arrest
- Ventricular dysrhythmia
- Symptomatic, refractory bradycardia
- Progressive rhythm disturbance
- Potassium >5
- Increasing potassium
- Co-ingestion with CCB, BB, TCA
- Ingestion of plant containing drug AND dysrhythmia
- >10 mg ingestion with any of above
- Digoxin level >6 with any of above
Children
- Same as adults except K >6 and level >5
What kinetics does ASA undergo in therapeutic vs toxic ranges?
Therapeutic = 1st order
Toxic = zero order
List 10 indications for HD in ASA toxicity
- Coma
- Seizure
- Renal failure
- Hepatic failure
- Respiratory failure
- Severe acidosis
- Rising ASA level
- Acute level >7.2
- Chronic level >3.6
- Pregnant
- Intubated
List the antidote and dose for the following drugs/poisons:
- Organophosphates/Carbamates
- Rattlesnake bite
- Serotonin syndrome
- Sulfonylureas
- TCAs
- Valproate
- Organophosphates - Atropine 1 mg then double
- Rattlesnake bite - CroFab 5 vials
- Serotonin syndrome - Cyproheptadine 4 mg PO
- Sulfonylureas - Octreotide 50 ug SC
- TCAs - Bicarb 1 mEq/kg, Intralipid 1.5 mL/kg
- Valproate - Carnitine 100 mg/kg IV
Outline the degree of IRON toxicity in terms of the amount ingested and serum iron level
No Toxicity
- Ingested <20 mg/kg
- Serum <30 umol/L
Mild
- Ingested 20-40 mg/kg
- Serum 30-60 umol/L
Moderate
- Ingested 40-60 mg/kg
- Serum 60-90 umol/L
Severe
- Ingested >60 mg/kg
- Serum >90 umol/L
Name 4 different chelators
- Deferoxamine
- BAL
- DMSA
- EDTA
- D-Penicillamine
List 3 reasons to start NAC in chronic ingestions
- AST >2x normal
- AST elevated + APAP >66 umol/L or symptomatic
- APAP greater than expected/toxic
List contraindications to activated charcoal
- Can’t absorb toxin
- Caustic ingestion
- Aspiration
- Ileus
- Perforation
- Airway not protected
What 5 hydrocarbons have increased toxicity?
CHAMP
- Camphor
- Halogenated Hydrocarbons
- Aromatic hydrocarbons
- Metals
- Pesticides
List 6 ingested overdoses in which you would consider WBI
Basically, anything that is very toxic
- Heavy metals
- BB
- CCB
- TCA
- Iron
- Lithium
- Extended-release formulations
- Bezoar forming drugs
Differentiate acute and chronic lithium overdose by:
- Cause
- Presenting symptoms
- Usefulness of WBI
- Levels for HD
Cause
- Acute - overdose
- Chronic - AKI, dehydration, drug interaction
Presenting symptoms
- Acute - GI, Cardiac
- Chronic - Neuro
Usefulness of WBI
- Acute - helpful
- Chronic - not helpful
Levels for HD
- Acute - >4 mEq/L
- Chronic - >2.5 mEq/L
What is the dose of deferoxamine? Indications (3)? Adverse effects (4)?
Dose
- 15 mg/kg/hr x24h
Indications
- Systemic toxicity
- Level >90 umol/L
- Ingestion >60 mg/kg
Adverse Effects
- Hypotension
- Anaphylactoid reactions
- Pink urine
- Ototoxic
- ARDS
- Yersinia sepsis
Name 5 drugs that could be used to treat a hypertensive emergency secondary to cocaine
- Benzodiazepines
- Phentolamine
- Nitroglycerin
- Nitroprusside
- Hydralazine
- Diltiazem
AVOID BETA-BLOCKERS –> Unopposed alpha
List 6 causes of a ‘double gap’ (Anion + Osmolar)
- DKA
- AKA
- Ethylene glycol
- Methanol
- Propylene glycol
- Lactate
- MODS
- Chronic renal failure
List three types/forms of mercury
- Elemental
* Not absorbed
* Inhaled - Inorganic salt
* GI/GU toxin - Organic
* GI/Skin toxic
* Neuro symptoms
How are inhaled toxins classified (4)?
- Asphyxiant (simple)
* Takes up space, so no oxygen
* CO2, N2, Helium - Asphyxiant (chemical)
* Inhibits oxygen utilization
* CN, CO - Irritant (high solubility)
* Danger quickly (laryngospasm, bronchospasm, eyes)
* Ammonia, HF, HCl - Irritant (low solubility)
* Danger later (pneumonitis, ARDS)
* Phosgene
What drugs require urinary alkalinization?
STAMP CAME
- Sulfonamides
- TCAs
- ASA
- MTX
- Phenobarbital
- Cocaine
- Antihistamines
- Methanol
- EG
What is the mechanism of action of physostigmine? Adverse reactions? Contraindications?
MOA = AChEi
A/E = Cholinergic excess (Seizures)
CI = QRS >100 ms, TCAs
What are the 5 Hunter Criteria for serotonin syndrome?
Known exposure to serotonergic drug:
- Spontaneous clonus
- Inducible clonus AND Agitation or diaphoresis
- Ocular clonus AND Agitation or diaphoresis
- Tremor AND Hyperreflexia
- Tone AND Temperature AND Clonus
Name 8 drugs with primarily anticholinergic toxicity
- Atropine
- Scopolamine
- Homatropine
- Cyclopentolate
- Glycopyrrolate
- Atrovent
- Benztropine
- Diphenhydramine
A patient thought to be inhaling hydrocarbons arrives in VT. How do you alter ACLS?
- Add esmolol or lidocaine
- Avoid epinephrine
Outline your management of stimulant-induced hyperthermia
- Identification
- MOVID
- ABCs
- Benzos
- Ketamine if necessary
- Ice packs
- Cold IV fluids
- Intubate/Paralyze if necessary
- Antibiotics
- B/W including BCx, CK/urine myoglobin
What are the 3 treatment goals for EG/Methanol toxicity
- Correct acidosis
- Bicarb to pH 7.45-7.5
* Aggressive in Methanol (save sight)
* Careful in EG (worsen hypoCa) - Enhance clearance
- HD
- Prevent metabolism
- Alcohol/Fomepizole
- Thiamine 100 mg/Pyridoxine 50 mg + Folate 50 mg
Name the 3 binding sites on a GABA receptor.
- GABA
- BZD
- EtOH/Barbituates/GHB
List 4 indications for HD in lithium poisoning
- Acute >4, Chronic >2.5
- CNS symptoms (seizure, decreased LOC)
- Renal insufficiency
- Can’t tolerate volume
What is the mechanism for sudden death with hydrocarbon abuse?
Sensitization of myocardium to catecholamines
What is the clinical picture of GHB toxicity?
Sedative Hypnotic Toxidrome
- Respiratory depression/Apnea
- Miosis
- Hypothermia
- Bradycardia/Hypotension
Fluctuating between agitation and deep coma
Vomiting
Myoclonic movements
What 2 types of NSAID overdoses are dangerous?
- Mefanamic acid
* Seizures - Phenylbutazone
* Aplastic anemia + Agranulocytosis
Outline the management of TCA overdose
- MOVID
- Charcoal 1 g/kg
- Airway management
- IVF + Pressors
- Bicarb/3% saline boluses until narrow QRS
- Na 155 or pH 7.55 limit
- Seizures with BZD
- Intralipid 1.5 mL/kg
- Lidocaine 1 mg/kg
- ECMO
Name & Describe the Stages of APAP Toxicity
Stage 1 (0-12 hours)
- N/V
- Elevated APAP level
Stage 2 (8-36 hours)
- N/V + RUQ pain
- Elevated LFTs
Stage 3 (2-4 days)
- Fulminant liver failure
- Coags, Glucose, Bili, Acidosis
Stage 4 (>4 days)
- Death/Recovery
List 6 signs of serotonin syndrome
FARMED
- Fever
- Autonomic instability
- Rigidity
- Myoclonus
- Encephalopathy
- Diaphoresis
What are 3 mechanisms of action of cocaine?
- Forces release of NE, Dopamine, Serotonin into synapse
- Blocks reuptake from the synapse
- Sodium channel blockade
How do you calculate the dose for a naloxone INFUSION?
⅔ the initial effective total dose / hr
Initial effective dose = dose needed to achieve RR = 12
What are the toxic effects of lithium?
LITHIVM
- Leukocytosis
- Insipidus diabetes
- Tremor
- Hypothyroidism/Hyperparathyroidism
- Increased weight
- Vomiting/Nausea/Diarrhea
- Misc.
- ECG (long QT)
- SS
- NMS
List 8 risk factors for increased risk of digoxin toxicity
- Renal failure
- Heart disease
* CHF, Myocarditis, Ischemic disease - Electrolyte imbalance
* HypoK, HyperK, HypoCa - Hypothyroidism
- Sympathomimetic drugs
- Alkalosis
- Elderly women
- Cardiac drugs
* CCBs, BB, TCAs - Drug interactions
* Captopril, CCBs, Erythromycin
Outline 3 approaches to calculating and administering DigiFab
Empirical
- Cardiac arrest = 20 vials
- Life-threatening dysrhythmia = 10 vials
Ingested Dose
- Digoxin is 80% bioavailable
- One vial binds 0.5 mg of digoxin
Steady-State Concentration
- Vials = (Serum concentration x Weight in kg) / 100
List 2 adverse effects of Levamisole
Antihelminthic agent
- Agranulocytosis
- ANCA-positive vasculitis
List 6 admission criteria for cocaine-related chest pain
- Persistent pain
- ECG changes
- Dysrhythmia
- Elevated Troponin
- Pre-existing CAD
- CAD risk factors
- ACS
- CHF
- Requiring IV anti-hypertensives
List 8 causes of stimulant-induced chest pain
- ACS
- Endocarditis
- Pericarditis
- Aortic dissection
- PE
- Pulmonary infarction
- PTX
- FB
- Pneumomediastinum
Describe the timing and clinical characteristics of each stage of ethylene glycol toxicity
Stage 1 (0-12h)
- Acute Neurologic stage
- Drunk +/- ocular findings
Stage 2 (12-24h)
- Cardiopulmonary stage
- Tachycardia, HTN, Tachypnea
- Myositis
- Hypocalcemia
Stage 3 (24-72h)
- Renal stage
- Flank/abdominal pain, hematuria w/ AKI
- Calcium oxalate crystalluria
Stage 4 (6-12d)
- Delayed Neurologic stage
- Cranial neuropathy
- Cognitive/Motor deficits
What is the universal antidote for decreased LOC NYD?
DONT
- Oxygen
- Thiamine
- Dextrose
- Narcan
What is the mechanism of action of organophosphates?
Bind and inhibit AChE
Leads to cholinergic toxidrome
What toxicities are specific to:
- Toluene
- Benzene
- Chlorinated HC
- Methylene Chloride
Toluene - HAGMA, RTA
Benzene - Cancer, Aplastic anemia
Chlorinated HC - Hepatic necrosis
Methylene Chloride - CO poisoning
List 4 acid-base disturbances with ASA toxicity
Metabolic Acidosis (AG)
- Uncouples oxidative phosphorylation
Respiratory Acidosis
- Eventually tire
Metabolic Alkalosis
- Volume contraction
Respiratory Alkalosis
- Stimulates resp center in medulla
List the antidote and dose for the following drugs/poisons:
- Tylenol
- Anticholinergics
- Arsenic/Lead/Mercury
- Benzos
- Black Widow
- Beta-Blockers
- CCBs
- Cyanide
- Digitalis
- Ethylene glycol
- Hydrofluoric acid
- APAP - NAC 150 mg/kg x1h, 50 mg/kg x4, 100 mg/kg x16h
- Anticholinergics - Physostigmine 1-2 mg IV
- Arsenic/Lead/Mercury - BAL 3-5 mg/kg IM
- Benzos - Flumazenil 0.2 mg
- Black Widow - one vial Latrodectus antivenin by slow IV infusion
- BB - Glucagon 5 mg IV, Insulin R, Intralipid 1.5 mL/kg
- CCBs - Calcium 1g, Glucagon 5 mg IV, Insulin R
- Cyanide - Hydroxycobalamin 5g IV
- Digitalis - 10-20 vials if VF, otherwise dose
- EG - Fomepizole 15 mg/kg, B1 100 mg IV, B6 100 mg IV
- Hydrofluoric acid - calcium gluconate top/IV/IA
List 5 differences in acute and chronic digoxin intoxication
- Chronic is more lethal
- Chronic has more ventricular dysrhythmias
- Chronic is usually older patients
- Chronic often need Fab
- Chronic often have worse underlying heart disease
Name 4 classes of hydrocarbons
-
Aliphatic HC
* Methane, Butane -
Aromatic HC
* Benzene -
Halogenated HC
* Chloroform -
Wood distillates
* Toluene
What 4 characteristics determine the toxicity of a hydrocarbon?
- Viscosity
- Volatility
- Side chains (Halogenated/Metals)
- Surface tension
List 5 properties that make a drug dialyzable
- Small Vd (<1L/kg)
- Low protein binding
- Small size
- Low endogenous clearance
- Severe toxicity without antidote
What are the main symptoms of a nicotinic CHOLINERGIC toxidrome?
Days of the Week
- Muscle cramps
- Tachycardia
- Weakness
- tHypertension
- Fasciculations
What are the main symptoms of a muscarinic CHOLINERGIC toxidrome?
DUMBBELS
- Diarrhea
- Urination
- Miosis
- Bronchorrhea
- Bradycardia
- Emesis
- Lacrimation
- Salivation
List 4 indications for HBOT in CO poisoning.
Best if started within 6 hours of exposure
- COHb >25%
- COHb >15% (pregnant/children)
- Altered LOC
- Neuro deficits (motor, visual)
- CV Instability (ischemia/arrhythmia)
- pH <7.2
How can you differentiate isopropyl alcohol ingestion from EG/Methanol?
- Ketosis without acidosis
- Osmolar gap without anion gap
- Often get gastritis
- Breath
Differentiate serotonin syndrome from neuroleptic malignant syndrome
Serotonin Syndrome
- Exposure to serotoneric drug
- More clonus
- Mydriasis
- Acute
NMS
- Exposure to dopaminergic drug
- More rigidity
- Rhabdo
- Subacute
Name 4 mechanisms of action of NAC
- Glutathione precursor
- Glutathione substitute
- Enhance sulfation
- Free radial scavenger
- Alters hepatic microcirculation
- Reduces cerebral edema
Outline your treatment of a suspected barbituate overdose
- MOVID
- MDAC - 25g q2h x3
- Airway protection
- IVF + Pressors
- Dialysis
What does a VBG sample look like in someone with CN poisoning?
Looks arterial
Due to lack of utilization of oxygen
Outline the metabolism of methanol
Methanol
- Alcohol dehydrogenase
- NAD as cofactor
Formaldehyde
- Aldehyde dehydrogenase
- NAD as cofactor
Formic acid
- Folate as cofactor
CO2 + H20
List 6 drugs not absorbed by charcoal
- Alcohols
- Acids
- Bases
- Heavy metals
- Halogens
- Lithium
- Solvents
List 4 ECG findings in TCA overdose
- Tachycardia
- QRS long
- QT long
- R’R in aVR
What are the clinical features of PCP ingestion?
- Extreme agitation/violence
- Blank/Catatonic stare
- Nystagmus
- Ataxia
- Rigidity
- Hyperreflexia
- Hyperthermia
- Rhabdomyolysis
- Bronchospasm
List 3 different methods of predicting the need for liver transplant or death in APAP toxicity
- APACHE >20
- Lactate >3.5
- Modified King’s College
* pH <7.3
* Or all of:
* Cr >300
* INR >6.5
* Encephalopathy > Grade 3
What are the 3 components of the Lily kit? What is the mechanism of action of each?
-
Amyl Nitrite IN
* Causes methemoglobinemia
* CN leaves ETC to form CNMetHb -
Sodium Nitrite IV
* Causes methemoglobinemia
* CN leaves ETC to form CNMetHb -
Sodium Thiosulfate IV
* Rhodanese uses sulfur to catalyze:
* CNMetHb –> Thiocyanate (SCN)- + Hb
List 6 causes of increased osmolar gap
- Alcohol
- Methanol
- Ethylene glycol
- Isopropyl alcohol
- Sorbitol
- Mannitol
- Hypertriglyceridemia
- Multiple Myeloma
Outline your treatment for amanita phalloids toxicity
- MOVID
- Anti-emetics
- MDAC - 0.5 g/kg PO q4h
- Penicillin G 1M units/kg, div q6h
- Slows toxin uptake into liver
- NAC - same as APAP
- Antioxidant
- Transfer to liver transplant center
List 8 dysrhythmias found with digoxin toxicity
- Atrial tachycardia
- Junctional tachycardia*
- Ventricular tachycardia
- Atrial fibrillation - slow*
- Ventricular fibrillation
- Bidirectional VT*
- PVCs
- Ventricular bigeminy/trigeminy
- Heart block
- Sinus bradycardia
List 10 toxins/medications that can cause delirium
- Alcohol/WD
- Anticholinergics
- Anticonvulsants
- Antidepressants
- Antihypertensives
- Antiparkinsons
- Antipsychotics
- Cardiac medications
- Cocaine
- Lithium
- MAOIs
- Mushrooms
- LSD
- Opiates
- PCP
- ASA
- Steroids
- Sympathomimetics
List 2 antipsychotics from each of:
- 1st generation (low potency)
- 1st generation (high potency)
- 2nd generation
1st generation (low potency) - controls + symptoms
- Chlorpromazine
- Prochlorperazine
- Hydroxyzine
1st generation (high potency) - controls + symptoms
- Loxapine
- Haloperidol
- Droperidol
2nd generation - controls +/- symptoms
- Quetiapine
- Risperidone
- Olanzapine
- Ziprasidone
When would you use multi-dose activated charcoal (6)?
Drink This Charcoal Quickly Please or An OG
- Dapsone/Digoxin
- Theophylline
- Carbamazepine
- Quinine
- Phenobarbital
- Amanita
- Oleander
- Gliclazide
List 7 receptors that TCAs work on
- Serotonin
- NE
- Alpha
- Na
- K
- GABA
- Histamine
- Cholinergic
What 2 drugs should be given in organophosphate poisoning?
- Atropine 1 mg, then doubled q5min until dry
- Pralidoxime 1g IV
List the associated toxin with the following odours:
- Bitter almonds
- Carrots
- Fishy
- Fruity
- Garlic
- Glue
- Pears
- Rotten Eggs
- Shoe Polish
- Wintergreen
- Bitter almonds - cyanide
- Carrots - water hemlock (cicutoxin)
- Fishy - zinc
- Fruity - ethanol, acetone, isopropyl alcohol
- Garlic - arsenic, organophosphate
- Glue - toluene
- Pears - chloral hydrate
- Rotten Eggs - disulfiram, hydrogen sulfide, NAC
- Shoe Polish - nitrobenzene
- Wintergreen - methyl salicylate
What 2 receptors does GHB bind?
- GHB
* Excitatory - GABA
* Sedating
This explains the cycling somnolence and agitation
List 8 drugs that are dialyzable
IVC STUMBLE NASA
- Isopropyl alcohol
- Valproate
- Carbamazepine
- Salicylate
- Theophylline
- Uremia
- Methanol
- Barbituates
- Lithium
- Ethylene glycol
- Nadolol
- Acebutolol
- Sotalol
- Atenolol
List 10 drugs implicated in serotonin syndrome
- SSRI
- SNRI
- Buproprion
- TCAs
- MAOIs
- MDMA
- Cocaine
- LSD
- Amphetamines
- Linezolid
List 7 factors that influence the extent of a caustic injury
- Type of agent
- Concentration
- Volume
- pH
- Duration of contact
- Viscosity
- Presence of food in stomach
Describe the metabolism of isopropyl alcohol
Isopropyl alcohol
- Alcohol dehydrogenase
Acetone
List 4 indications for pralidoxime administration.
In the context of organophosphate poisoning:
- Respiratory depression
- Fasciculations
- Seizures
- Arrhythmias
- CV instability
- >4mg of atropine given
NOT HELPFUL IN CARBAMATES
List 4 indications to start NAC
- 4 hour APAP level above treatment line
- APAP >60 umol/L and unknown ingestion time
- Elevated AST
- Presents after 8 hours
What findings are prognostic of seizures and dysrhythmias in TCA overdose?
QRS >100 ms = Seizures
QRS >160 ms = Ventricular dysrhythmia
What are the stages of iron toxicity?
Stage 1 (0-6h)
- GI
- N/V, abdo pain, hematemesis/melena
Stage 2 (6-24h)
- Latent
Stage 3 (>24h)
- Systemic
- Coma, Acidosis, Hypoglycemia, AKI, Coags
Stage 4 (2-5d)
- Fulminant liver failure
Stage 5
- Consequences
- GI strictures/obstruction
List 8 ‘one dose kills’ for children
- Sulfonylureas
- CCB
- BB
- Clonidine
- Methyl salicylate
- Methadone
- Antimalarials
- TCAs
- Camphor
- Lomotil
- Opiates
- Theophylline
List 6 risk factors that increase the risk of hepatotoxicity with chronic APAP ingestion
Glutathione Depletion
- Chronic EtOH use
- Malnourishment
- Liver disease
- HIV/AIDS
P450 Induction
- Induced P450
- Smoking
- Febrile <5 yo
What is meant by the term “aging” re: AChE?
Aging is when the bond between the AChE and an organophosphate becomes permanent
Starts at 48h, then become resistant to treatment
What are the diagnostic criteria for NMS?
- A) Rigidity + Hyperthermia
- B) Two or more of:
* Diaphoresis
* Tremor
* Tachycardia
* HTN
* Leukocytosis
* Mutism
* Altered LOC
* Incontinence
* Dysphagia - A and B not caused by another substance, neurologic condition, or another mental disorder
Name 3 management options for opioid withdrawal.
- Clonidine
- Buprenorphine
- Methadone
- Opioids
What is the mechanism of action of PCP?
- NMDA antagonist
- Inhibits reuptake of NE, Dopamine, Serotonin
- Opioid receptor agonist
- Cholinergic receptor agonist
Name 4 opioids that can precipitate serotonin syndrome
- Methadone
- Demerol
- Dextromethorphan
- Tramadol
- Oxycodone
- Buprenorphine
List 5 differences between adults and children for digoxin poisoning
- Adults are toxic at lower levels
- Adults have more N/V and visual symptoms
- Adults have more tachy-, children more brady-
- Adults have more allergic reactions to DigiFab
- Adults have less variable Vd
List cofactors that you should give in toxic alcohol ingestions
- Ethylene Glycol
- Thiamine 100 mg
- Pyridoxine 50 mg
- Magnesium sulfate 2 g
- Methanol
- Folinic acid 50 mg
List 4 indications for starting fomepizole
- Serum methanol >6.2 mmol/L (20 mg/dL)
- Serum ethylene glycol >3.2 mmol/L (20 mg/dL)
- Known Ingestion + Elevated osmolar gap
- Strong suspicion of ingestion and 2+ of:
- pH <7.3
- Bicarb <20
- Osm gap >10
- End organ damage (ocular, renal, CNS)
- Urinary oxalate crystals (for EG)
List 4 indications for dialysis in toxic alcohol ingestion
- Methanol >16 mmol/L
- Ethylene glycol >8 mmol/L
- Metabolic acidosis + end-organ damage (ocular, renal, CNS)
- Elevated osmolar gap if toxic alcohol levels not available
How much elemental iron is present in 100 mg of:
- Ferrous gluconate
- Ferrous sulfate
- Ferrous fumarate
- Iron polysaccharide
- Ferrous gluconate
- 10% = 10 mg
- Ferrous sulfate
- 20% = 20 mg
- Ferrous fumarate
- 30% = 30 mg
- Iron polysaccharide
- 100% = 100 mg