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Royal College: Emergency Medicine > Toxicology > Flashcards

Toxicology Flashcards

This deck covers Chapters 139-159 in Rosens, compromising all of toxicology.

1
Q

Outline treatment for BB/CCB poisoning

A
  • MOVID
  • ABCs
  • Charcoal/WBI
  • Fluids, Pressors
  • Calcium
  • Glucagon 5 mg IV
  • Insulin R 1-10 units/kg/hr
  • Intralipid
  • ECMO
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2
Q

Identify the following:

A

Water Hemlock

Signs/Symptoms

  • N/V
  • Seizures (GABA antagonism)

Treatment

  • Charcoal
  • Seizure control
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3
Q

Outline the metabolism of ethylene glycol

A

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

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4
Q

List 6 radio-opaque drugs

A

CHIPES

  1. CaCO3
  2. Heavy metals
  3. Iron
  4. Potassium
  5. Enteric-coated pills
  6. Solvents
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5
Q

List 5 benefits of fomepizole over alcohol

A
  1. Ease of administration
  2. Standardized
  3. Predictable
  4. Safer
  5. Longer duration of action
  6. No CNS effect
  7. ADH has higher affinity to fomepizole than alcohol
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6
Q

In asymptomatic or minimally symptomatic children, what guides lead chelation therapy?

A

Leads sucks (69)

  • BLL >69 - hospitalize
  • BLL 45-69 - OP oral succimer
  • BLL <45 - no chelation
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7
Q

List 5 non-selective and 4 selective beta-blockers

A

Non-Selective

  • PLaNTS
  • Propranolol
  • Labetalol
  • Nadolol
  • Timolol
  • Sotalol

Selective

  • BEAM
  • Bisoprolol
  • Esmolol
  • Atenolol
  • Metoprolol
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8
Q

Differentiate the type of injury caused by acids/alkalis

A

Acids

  • Coagulative necrosis
  • Concern re: systemic absorption

Alkalis

  • Liqufactive necrosis
  • Deeper penetration
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9
Q

What is the mechanism of action of CN and H2S?

A

Binds Complex IV in the electron transport chain

Uncouples oxidative phosphorylation

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10
Q

Outline management of ASA poisoning

A
  • 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
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11
Q

List 6 drugs that intralipid is indicated for.

A
  1. BB
  2. CCB
  3. Local anesthetic
  4. Buproprion
  5. TCAs
  6. Seroquel
  7. Diphendydramine
  8. Class I antiarrhythmics
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12
Q

List the antidote and dose for the following drugs/poisons:

  • Iron
  • Isoniazid
  • Lead
  • Local anesthetics
  • MDMA-related hyperpyrexia
  • Neuroleptics (NMS)
  • Methanol
  • Methemoglobin
  • Opioids
A
  • 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
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13
Q

Pulmonary irritants react with water to cause damage. Give 4 examples.

A
  1. Chlorine –> HCl
  2. Phosgene –> HCl
  3. Ammonia –> Ammonium hydroxide
  4. Sulfur dioxide –> H2SO4
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14
Q

When do you initiate lab testing (AST + APAP) in chronic APAP ingestion (3)?

A
  • Ingestion >10g/day x24h
  • Ingestion >6d/day x48h
  • Symptomatic (N/V, RUQ pain, Jaundice)
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15
Q

List 7 drugs which enhance lithium toxicity

A

Renal Toxins

  1. NSAIDs
  2. Diuretics
  3. ACEi
  4. ARB

Neuro/Psych Meds

  1. SSRI
  2. Antipsychotics
  3. Carbamazepine
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16
Q

List 5 drugs that induce CYP P450

A
  1. Sulfonylureas
  2. Phenobarbital
  3. Rifampin
  4. INH
  5. Phenytoin
  6. Carbamazepine
  7. HIV medications
  8. St. John’s wart
  9. Chronic EtOH
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17
Q

List 7 causes of a toxin-induced bradycardia

A
  1. CCB
  2. BB
  3. Opiate
  4. Clonidine
  5. Digoxin
  6. Barbiturates
  7. Organophosphates
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18
Q

List 5 reasons why the Done nomogram is not useful in all patients

A
  1. Derived in pediatric population
  2. Assumes 1st order kinetics
  3. pH must be >7.4
  4. Toxicity correlates poorly with serum levels
  5. Used after 6h from single, non-EC ASA dose
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19
Q

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
A

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)
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20
Q

List 8 indications for DigiFab

A

Adult

  1. Cardiac arrest
  2. Ventricular dysrhythmia
  3. Symptomatic, refractory bradycardia
  4. Progressive rhythm disturbance
  5. Potassium >5
  6. Increasing potassium
  7. Co-ingestion with CCB, BB, TCA
  8. Ingestion of plant containing drug AND dysrhythmia
  9. >10 mg ingestion with any of above
  10. Digoxin level >6 with any of above

Children

  1. Same as adults except K >6 and level >5
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21
Q

What kinetics does ASA undergo in therapeutic vs toxic ranges?

A

Therapeutic = 1st order

Toxic = zero order

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22
Q

List 10 indications for HD in ASA toxicity

A
  1. Coma
  2. Seizure
  3. Renal failure
  4. Hepatic failure
  5. Respiratory failure
  6. Severe acidosis
  7. Rising ASA level
  8. Acute level >7.2
  9. Chronic level >3.6
  10. Pregnant
  11. Intubated
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23
Q

List the antidote and dose for the following drugs/poisons:

  • Organophosphates/Carbamates
  • Rattlesnake bite
  • Serotonin syndrome
  • Sulfonylureas
  • TCAs
  • Valproate
A
  • 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
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24
Q

Outline the degree of IRON toxicity in terms of the amount ingested and serum iron level

A

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
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25
Q

Name 4 different chelators

A
  1. Deferoxamine
  2. BAL
  3. DMSA
  4. EDTA
  5. D-Penicillamine
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26
Q

List 3 reasons to start NAC in chronic ingestions

A
  1. AST >2x normal
  2. AST elevated + APAP >66 umol/L or symptomatic
  3. APAP greater than expected/toxic
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27
Q

List contraindications to activated charcoal

A
  • Can’t absorb toxin
  • Caustic ingestion
  • Aspiration
  • Ileus
  • Perforation
  • Airway not protected
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28
Q

What 5 hydrocarbons have increased toxicity?

A

CHAMP

  • Camphor
  • Halogenated Hydrocarbons
  • Aromatic hydrocarbons
  • Metals
  • Pesticides
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29
Q

List 6 ingested overdoses in which you would consider WBI

A

Basically, anything that is very toxic

  1. Heavy metals
  2. BB
  3. CCB
  4. TCA
  5. Iron
  6. Lithium
  7. Extended-release formulations
  8. Bezoar forming drugs
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30
Q

Differentiate acute and chronic lithium overdose by:

  • Cause
  • Presenting symptoms
  • Usefulness of WBI
  • Levels for HD
A

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
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31
Q

What is the dose of deferoxamine? Indications (3)? Adverse effects (4)?

A

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
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32
Q

Name 5 drugs that could be used to treat a hypertensive emergency secondary to cocaine

A
  1. Benzodiazepines
  2. Phentolamine
  3. Nitroglycerin
  4. Nitroprusside
  5. Hydralazine
  6. Diltiazem

AVOID BETA-BLOCKERS –> Unopposed alpha

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33
Q

List 6 causes of a ‘double gap’ (Anion + Osmolar)

A
  1. DKA
  2. AKA
  3. Ethylene glycol
  4. Methanol
  5. Propylene glycol
  6. Lactate
  7. MODS
  8. Chronic renal failure
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34
Q

List three types/forms of mercury

A
  1. Elemental
    * Not absorbed
    * Inhaled
  2. Inorganic salt
    * GI/GU toxin
  3. Organic
    * GI/Skin toxic
    * Neuro symptoms
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35
Q

How are inhaled toxins classified (4)?

A
  1. Asphyxiant (simple)
    * Takes up space, so no oxygen
    * CO2, N2, Helium
  2. Asphyxiant (chemical)
    * Inhibits oxygen utilization
    * CN, CO
  3. Irritant (high solubility)
    * Danger quickly (laryngospasm, bronchospasm, eyes)
    * Ammonia, HF, HCl
  4. Irritant (low solubility)
    * Danger later (pneumonitis, ARDS)
    * Phosgene
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36
Q

What drugs require urinary alkalinization?

A

STAMP CAME

  1. Sulfonamides
  2. TCAs
  3. ASA
  4. MTX
  5. Phenobarbital
  6. Cocaine
  7. Antihistamines
  8. Methanol
  9. EG
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37
Q

What is the mechanism of action of physostigmine? Adverse reactions? Contraindications?

A

MOA = AChEi

A/E = Cholinergic excess (Seizures)

CI = QRS >100 ms, TCAs

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38
Q

What are the 5 Hunter Criteria for serotonin syndrome?

A

Known exposure to serotonergic drug:

  1. Spontaneous clonus
  2. Inducible clonus AND Agitation or diaphoresis
  3. Ocular clonus AND Agitation or diaphoresis
  4. Tremor AND Hyperreflexia
  5. Tone AND Temperature AND Clonus
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39
Q

Name 8 drugs with primarily anticholinergic toxicity

A
  1. Atropine
  2. Scopolamine
  3. Homatropine
  4. Cyclopentolate
  5. Glycopyrrolate
  6. Atrovent
  7. Benztropine
  8. Diphenhydramine
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40
Q

A patient thought to be inhaling hydrocarbons arrives in VT. How do you alter ACLS?

A
  • Add esmolol or lidocaine
  • Avoid epinephrine
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41
Q

Outline your management of stimulant-induced hyperthermia

A
  1. Identification
  2. MOVID
  3. ABCs
  4. Benzos
  5. Ketamine if necessary
  6. Ice packs
  7. Cold IV fluids
  8. Intubate/Paralyze if necessary
  9. Antibiotics
  10. B/W including BCx, CK/urine myoglobin
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42
Q

What are the 3 treatment goals for EG/Methanol toxicity

A
  • 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
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43
Q

Name the 3 binding sites on a GABA receptor.

A
  1. GABA
  2. BZD
  3. EtOH/Barbituates/GHB
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44
Q

List 4 indications for HD in lithium poisoning

A
  1. Acute >4, Chronic >2.5
  2. CNS symptoms (seizure, decreased LOC)
  3. Renal insufficiency
  4. Can’t tolerate volume
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45
Q

What is the mechanism for sudden death with hydrocarbon abuse?

A

Sensitization of myocardium to catecholamines

46
Q

What is the clinical picture of GHB toxicity?

A

Sedative Hypnotic Toxidrome

  • Respiratory depression/Apnea
  • Miosis
  • Hypothermia
  • Bradycardia/Hypotension

Fluctuating between agitation and deep coma

Vomiting

Myoclonic movements

47
Q

What 2 types of NSAID overdoses are dangerous?

A
  1. Mefanamic acid
    * Seizures
  2. Phenylbutazone
    * Aplastic anemia + Agranulocytosis
48
Q

Outline the management of TCA overdose

A
  • 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
49
Q

Name & Describe the Stages of APAP Toxicity

A

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
50
Q

List 6 signs of serotonin syndrome

A

FARMED

  1. Fever
  2. Autonomic instability
  3. Rigidity
  4. Myoclonus
  5. Encephalopathy
  6. Diaphoresis
51
Q

What are 3 mechanisms of action of cocaine?

A
  1. Forces release of NE, Dopamine, Serotonin into synapse
  2. Blocks reuptake from the synapse
  3. Sodium channel blockade
52
Q

How do you calculate the dose for a naloxone INFUSION?

A

⅔ the initial effective total dose / hr

Initial effective dose = dose needed to achieve RR = 12

53
Q

What are the toxic effects of lithium?

A

LITHIVM

  • Leukocytosis
  • Insipidus diabetes
  • Tremor
  • Hypothyroidism/Hyperparathyroidism
  • Increased weight
  • Vomiting/Nausea/Diarrhea
  • Misc.
  • ECG (long QT)
  • SS
  • NMS
54
Q

List 8 risk factors for increased risk of digoxin toxicity

A
  1. Renal failure
  2. Heart disease
    * CHF, Myocarditis, Ischemic disease
  3. Electrolyte imbalance
    * HypoK, HyperK, HypoCa
  4. Hypothyroidism
  5. Sympathomimetic drugs
  6. Alkalosis
  7. Elderly women
  8. Cardiac drugs
    * CCBs, BB, TCAs
  9. Drug interactions
    * Captopril, CCBs, Erythromycin
55
Q

Outline 3 approaches to calculating and administering DigiFab

A

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
56
Q

List 2 adverse effects of Levamisole

A

Antihelminthic agent

  1. Agranulocytosis
  2. ANCA-positive vasculitis
57
Q

List 6 admission criteria for cocaine-related chest pain

A
  1. Persistent pain
  2. ECG changes
  3. Dysrhythmia
  4. Elevated Troponin
  5. Pre-existing CAD
  6. CAD risk factors
  7. ACS
  8. CHF
  9. Requiring IV anti-hypertensives
58
Q

List 8 causes of stimulant-induced chest pain

A
  1. ACS
  2. Endocarditis
  3. Pericarditis
  4. Aortic dissection
  5. PE
  6. Pulmonary infarction
  7. PTX
  8. FB
  9. Pneumomediastinum
59
Q

Describe the timing and clinical characteristics of each stage of ethylene glycol toxicity

A

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
60
Q

What is the universal antidote for decreased LOC NYD?

A

DONT

  1. Oxygen
  2. Thiamine
  3. Dextrose
  4. Narcan
61
Q

What is the mechanism of action of organophosphates?

A

Bind and inhibit AChE

Leads to cholinergic toxidrome

62
Q

What toxicities are specific to:

  • Toluene
  • Benzene
  • Chlorinated HC
  • Methylene Chloride
A

Toluene - HAGMA, RTA

Benzene - Cancer, Aplastic anemia

Chlorinated HC - Hepatic necrosis

Methylene Chloride - CO poisoning

63
Q

List 4 acid-base disturbances with ASA toxicity

A

Metabolic Acidosis (AG)

  • Uncouples oxidative phosphorylation

Respiratory Acidosis

  • Eventually tire

Metabolic Alkalosis

  • Volume contraction

Respiratory Alkalosis

  • Stimulates resp center in medulla
64
Q

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
A
  • 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
65
Q

List 5 differences in acute and chronic digoxin intoxication

A
  1. Chronic is more lethal
  2. Chronic has more ventricular dysrhythmias
  3. Chronic is usually older patients
  4. Chronic often need Fab
  5. Chronic often have worse underlying heart disease
66
Q

Name 4 classes of hydrocarbons

A
  1. Aliphatic HC
    * Methane, Butane
  2. Aromatic HC
    * Benzene
  3. Halogenated HC
    * Chloroform
  4. Wood distillates
    * Toluene
67
Q

What 4 characteristics determine the toxicity of a hydrocarbon?

A
  1. Viscosity
  2. Volatility
  3. Side chains (Halogenated/Metals)
  4. Surface tension
68
Q

List 5 properties that make a drug dialyzable

A
  1. Small Vd (<1L/kg)
  2. Low protein binding
  3. Small size
  4. Low endogenous clearance
  5. Severe toxicity without antidote
69
Q

What are the main symptoms of a nicotinic CHOLINERGIC toxidrome?

A

Days of the Week

  • Muscle cramps
  • Tachycardia
  • Weakness
  • tHypertension
  • Fasciculations
70
Q

What are the main symptoms of a muscarinic CHOLINERGIC toxidrome?

A

DUMBBELS

  • Diarrhea
  • Urination
  • Miosis
  • Bronchorrhea
  • Bradycardia
  • Emesis
  • Lacrimation
  • Salivation
71
Q

List 4 indications for HBOT in CO poisoning.

A

Best if started within 6 hours of exposure

  1. COHb >25%
  2. COHb >15% (pregnant/children)
  3. Altered LOC
  4. Neuro deficits (motor, visual)
  5. CV Instability (ischemia/arrhythmia)
  6. pH <7.2
72
Q

How can you differentiate isopropyl alcohol ingestion from EG/Methanol?

A
  1. Ketosis without acidosis
  2. Osmolar gap without anion gap
  3. Often get gastritis
  4. Breath
73
Q

Differentiate serotonin syndrome from neuroleptic malignant syndrome

A

Serotonin Syndrome

  • Exposure to serotoneric drug
  • More clonus
  • Mydriasis
  • Acute

NMS

  • Exposure to dopaminergic drug
  • More rigidity
  • Rhabdo
  • Subacute
74
Q

Name 4 mechanisms of action of NAC

A
  1. Glutathione precursor
  2. Glutathione substitute
  3. Enhance sulfation
  4. Free radial scavenger
  5. Alters hepatic microcirculation
  6. Reduces cerebral edema
75
Q

Outline your treatment of a suspected barbituate overdose

A
  • MOVID
  • MDAC - 25g q2h x3
  • Airway protection
  • IVF + Pressors
  • Dialysis
76
Q

What does a VBG sample look like in someone with CN poisoning?

A

Looks arterial

Due to lack of utilization of oxygen

77
Q

Outline the metabolism of methanol

A

Methanol

  • Alcohol dehydrogenase
  • NAD as cofactor

Formaldehyde

  • Aldehyde dehydrogenase
  • NAD as cofactor

Formic acid

  • Folate as cofactor

CO2 + H20

78
Q

List 6 drugs not absorbed by charcoal

A
  1. Alcohols
  2. Acids
  3. Bases
  4. Heavy metals
  5. Halogens
  6. Lithium
  7. Solvents
79
Q

List 4 ECG findings in TCA overdose

A
  1. Tachycardia
  2. QRS long
  3. QT long
  4. R’R in aVR
80
Q

What are the clinical features of PCP ingestion?

A
  • Extreme agitation/violence
  • Blank/Catatonic stare
  • Nystagmus
  • Ataxia
  • Rigidity
  • Hyperreflexia
  • Hyperthermia
  • Rhabdomyolysis
  • Bronchospasm
81
Q

List 3 different methods of predicting the need for liver transplant or death in APAP toxicity

A
  1. APACHE >20
  2. Lactate >3.5
  3. Modified King’s College
    * pH <7.3
    * Or all of:
    * Cr >300
    * INR >6.5
    * Encephalopathy > Grade 3
82
Q

What are the 3 components of the Lily kit? What is the mechanism of action of each?

A
  1. Amyl Nitrite IN
    * Causes methemoglobinemia
    * CN leaves ETC to form CNMetHb
  2. Sodium Nitrite IV
    * Causes methemoglobinemia
    * CN leaves ETC to form CNMetHb
  3. Sodium Thiosulfate IV
    * Rhodanese uses sulfur to catalyze:
    * CNMetHb –> Thiocyanate (SCN)- + Hb
83
Q

List 6 causes of increased osmolar gap

A
  1. Alcohol
  2. Methanol
  3. Ethylene glycol
  4. Isopropyl alcohol
  5. Sorbitol
  6. Mannitol
  7. Hypertriglyceridemia
  8. Multiple Myeloma
84
Q

Outline your treatment for amanita phalloids toxicity

A
  • 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
85
Q

List 8 dysrhythmias found with digoxin toxicity

A
  1. Atrial tachycardia
  2. Junctional tachycardia*
  3. Ventricular tachycardia
  4. Atrial fibrillation - slow*
  5. Ventricular fibrillation
  6. Bidirectional VT*
  7. PVCs
  8. Ventricular bigeminy/trigeminy
  9. Heart block
  10. Sinus bradycardia
86
Q

List 10 toxins/medications that can cause delirium

A
  1. Alcohol/WD
  2. Anticholinergics
  3. Anticonvulsants
  4. Antidepressants
  5. Antihypertensives
  6. Antiparkinsons
  7. Antipsychotics
  8. Cardiac medications
  9. Cocaine
  10. Lithium
  11. MAOIs
  12. Mushrooms
  13. LSD
  14. Opiates
  15. PCP
  16. ASA
  17. Steroids
  18. Sympathomimetics
87
Q

List 2 antipsychotics from each of:

  • 1st generation (low potency)
  • 1st generation (high potency)
  • 2nd generation
A

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
88
Q

When would you use multi-dose activated charcoal (6)?

A

Drink This Charcoal Quickly Please or An OG

  • Dapsone/Digoxin
  • Theophylline
  • Carbamazepine
  • Quinine
  • Phenobarbital
  • Amanita
  • Oleander
  • Gliclazide
89
Q

List 7 receptors that TCAs work on

A
  1. Serotonin
  2. NE
  3. Alpha
  4. Na
  5. K
  6. GABA
  7. Histamine
  8. Cholinergic
90
Q

What 2 drugs should be given in organophosphate poisoning?

A
  1. Atropine 1 mg, then doubled q5min until dry
  2. Pralidoxime 1g IV
91
Q

List the associated toxin with the following odours:

  • Bitter almonds
  • Carrots
  • Fishy
  • Fruity
  • Garlic
  • Glue
  • Pears
  • Rotten Eggs
  • Shoe Polish
  • Wintergreen
A
  • 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
92
Q

What 2 receptors does GHB bind?

A
  1. GHB
    * Excitatory
  2. GABA
    * Sedating

This explains the cycling somnolence and agitation

93
Q

List 8 drugs that are dialyzable

A

IVC STUMBLE NASA

  • Isopropyl alcohol
  • Valproate
  • Carbamazepine
  • Salicylate
  • Theophylline
  • Uremia
  • Methanol
  • Barbituates
  • Lithium
  • Ethylene glycol
  • Nadolol
  • Acebutolol
  • Sotalol
  • Atenolol
94
Q

List 10 drugs implicated in serotonin syndrome

A
  1. SSRI
  2. SNRI
  3. Buproprion
  4. TCAs
  5. MAOIs
  6. MDMA
  7. Cocaine
  8. LSD
  9. Amphetamines
  10. Linezolid
95
Q

List 7 factors that influence the extent of a caustic injury

A
  1. Type of agent
  2. Concentration
  3. Volume
  4. pH
  5. Duration of contact
  6. Viscosity
  7. Presence of food in stomach
96
Q

Describe the metabolism of isopropyl alcohol

A

Isopropyl alcohol

  • Alcohol dehydrogenase

Acetone

97
Q

List 4 indications for pralidoxime administration.

A

In the context of organophosphate poisoning:

  1. Respiratory depression
  2. Fasciculations
  3. Seizures
  4. Arrhythmias
  5. CV instability
  6. >4mg of atropine given

NOT HELPFUL IN CARBAMATES

98
Q

List 4 indications to start NAC

A
  1. 4 hour APAP level above treatment line
  2. APAP >60 umol/L and unknown ingestion time
  3. Elevated AST
  4. Presents after 8 hours
99
Q

What findings are prognostic of seizures and dysrhythmias in TCA overdose?

A

QRS >100 ms = Seizures

QRS >160 ms = Ventricular dysrhythmia

100
Q

What are the stages of iron toxicity?

A

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
101
Q

List 8 ‘one dose kills’ for children

A
  1. Sulfonylureas
  2. CCB
  3. BB
  4. Clonidine
  5. Methyl salicylate
  6. Methadone
  7. Antimalarials
  8. TCAs
  9. Camphor
  10. Lomotil
  11. Opiates
  12. Theophylline
102
Q

List 6 risk factors that increase the risk of hepatotoxicity with chronic APAP ingestion

A

Glutathione Depletion

  1. Chronic EtOH use
  2. Malnourishment
  3. Liver disease
  4. HIV/AIDS

P450 Induction

  1. Induced P450
  2. Smoking
  3. Febrile <5 yo
103
Q

What is meant by the term “aging” re: AChE?

A

Aging is when the bond between the AChE and an organophosphate becomes permanent

Starts at 48h, then become resistant to treatment

104
Q

What are the diagnostic criteria for NMS?

A
  1. A) Rigidity + Hyperthermia
  2. B) Two or more of:
    * Diaphoresis
    * Tremor
    * Tachycardia
    * HTN
    * Leukocytosis
    * Mutism
    * Altered LOC
    * Incontinence
    * Dysphagia
  3. A and B not caused by another substance, neurologic condition, or another mental disorder
105
Q

Name 3 management options for opioid withdrawal.

A
  1. Clonidine
  2. Buprenorphine
  3. Methadone
  4. Opioids
106
Q

What is the mechanism of action of PCP?

A
  • NMDA antagonist
  • Inhibits reuptake of NE, Dopamine, Serotonin
  • Opioid receptor agonist
  • Cholinergic receptor agonist
107
Q

Name 4 opioids that can precipitate serotonin syndrome

A
  1. Methadone
  2. Demerol
  3. Dextromethorphan
  4. Tramadol
  5. Oxycodone
  6. Buprenorphine
108
Q

List 5 differences between adults and children for digoxin poisoning

A
  1. Adults are toxic at lower levels
  2. Adults have more N/V and visual symptoms
  3. Adults have more tachy-, children more brady-
  4. Adults have more allergic reactions to DigiFab
  5. Adults have less variable Vd
109
Q

List cofactors that you should give in toxic alcohol ingestions

A
  • Ethylene Glycol
  • Thiamine 100 mg
  • Pyridoxine 50 mg
  • Magnesium sulfate 2 g
  • Methanol
  • Folinic acid 50 mg
110
Q

List 4 indications for starting fomepizole

A
  1. Serum methanol >6.2 mmol/L (20 mg/dL)
  2. Serum ethylene glycol >3.2 mmol/L (20 mg/dL)
  3. Known Ingestion + Elevated osmolar gap
  4. Strong suspicion of ingestion and 2+ of:
  5. pH <7.3
  6. Bicarb <20
  7. Osm gap >10
  8. End organ damage (ocular, renal, CNS)
  9. Urinary oxalate crystals (for EG)
111
Q

List 4 indications for dialysis in toxic alcohol ingestion

A
  1. Methanol >16 mmol/L
  2. Ethylene glycol >8 mmol/L
  3. Metabolic acidosis + end-organ damage (ocular, renal, CNS)
  4. Elevated osmolar gap if toxic alcohol levels not available
112
Q

How much elemental iron is present in 100 mg of:

  • Ferrous gluconate
  • Ferrous sulfate
  • Ferrous fumarate
  • Iron polysaccharide
A
  • Ferrous gluconate
  • 10% = 10 mg
  • Ferrous sulfate
  • 20% = 20 mg
  • Ferrous fumarate
  • 30% = 30 mg
  • Iron polysaccharide
  • 100% = 100 mg

Royal College: Emergency Medicine (25 decks)

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