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
2
Q
Identify the following:
A
Water Hemlock
Signs/Symptoms
- N/V
- Seizures (GABA antagonism)
Treatment
- Charcoal
- Seizure control
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
4
Q
List 6 radio-opaque drugs
A
CHIPES
- CaCO3
- Heavy metals
- Iron
- Potassium
- Enteric-coated pills
- Solvents
5
Q
List 5 benefits of fomepizole over alcohol
A
- Ease of administration
- Standardized
- Predictable
- Safer
- Longer duration of action
- No CNS effect
- ADH has higher affinity to fomepizole than alcohol
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
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
8
Q
Differentiate the type of injury caused by acids/alkalis
A
Acids
- Coagulative necrosis
- Concern re: systemic absorption
Alkalis
- Liqufactive necrosis
- Deeper penetration
9
Q
What is the mechanism of action of CN and H2S?
A
Binds Complex IV in the electron transport chain
Uncouples oxidative phosphorylation
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
11
Q
List 6 drugs that intralipid is indicated for.
A
- BB
- CCB
- Local anesthetic
- Buproprion
- TCAs
- Seroquel
- Diphendydramine
- Class I antiarrhythmics
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
13
Q
Pulmonary irritants react with water to cause damage. Give 4 examples.
A
- Chlorine –> HCl
- Phosgene –> HCl
- Ammonia –> Ammonium hydroxide
- Sulfur dioxide –> H2SO4
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)
15
Q
List 7 drugs which enhance lithium toxicity
A
Renal Toxins
- NSAIDs
- Diuretics
- ACEi
- ARB
Neuro/Psych Meds
- SSRI
- Antipsychotics
- Carbamazepine
16
Q
List 5 drugs that induce CYP P450
A
- Sulfonylureas
- Phenobarbital
- Rifampin
- INH
- Phenytoin
- Carbamazepine
- HIV medications
- St. John’s wart
- Chronic EtOH
17
Q
List 7 causes of a toxin-induced bradycardia
A
- CCB
- BB
- Opiate
- Clonidine
- Digoxin
- Barbiturates
- Organophosphates
18
Q
List 5 reasons why the Done nomogram is not useful in all patients
A
- 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
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)
20
Q
List 8 indications for DigiFab
A
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
21
Q
What kinetics does ASA undergo in therapeutic vs toxic ranges?
A
Therapeutic = 1st order
Toxic = zero order
22
Q
List 10 indications for HD in ASA toxicity
A
- Coma
- Seizure
- Renal failure
- Hepatic failure
- Respiratory failure
- Severe acidosis
- Rising ASA level
- Acute level >7.2
- Chronic level >3.6
- Pregnant
- Intubated
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
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
25
Name 4 different chelators
1. Deferoxamine
2. BAL
3. DMSA
4. EDTA
5. D-Penicillamine
26
List 3 reasons to start NAC in chronic ingestions
1. AST \>2x normal
2. AST elevated + APAP \>66 umol/L or symptomatic
3. APAP greater than expected/toxic
27
List contraindications to activated charcoal
* Can't absorb toxin
* Caustic ingestion
* Aspiration
* Ileus
* Perforation
* Airway not protected
28
What 5 hydrocarbons have increased toxicity?
**CHAMP**
* Camphor
* Halogenated Hydrocarbons
* Aromatic hydrocarbons
* Metals
* Pesticides
29
List 6 ingested overdoses in which you would consider WBI
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
30
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
31
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
32
Name 5 drugs that could be used to treat a hypertensive emergency secondary to cocaine
1. Benzodiazepines
2. Phentolamine
3. Nitroglycerin
4. Nitroprusside
5. Hydralazine
6. Diltiazem
AVOID BETA-BLOCKERS --\> Unopposed alpha
33
List 6 causes of a 'double gap' (Anion + Osmolar)
1. DKA
2. AKA
3. Ethylene glycol
4. Methanol
5. Propylene glycol
6. Lactate
7. MODS
8. Chronic renal failure
34
List three types/forms of mercury
1. Elemental
* Not absorbed
* Inhaled
2. Inorganic salt
* GI/GU toxin
3. Organic
* GI/Skin toxic
* Neuro symptoms
35
How are inhaled toxins classified (4)?
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
36
What drugs require urinary alkalinization?
**STAMP CAME**
1. Sulfonamides
2. TCAs
3. ASA
4. MTX
5. Phenobarbital
6. Cocaine
7. Antihistamines
8. Methanol
9. EG
37
What is the mechanism of action of physostigmine? Adverse reactions? Contraindications?
MOA = AChEi
A/E = Cholinergic excess (Seizures)
CI = QRS \>100 ms, TCAs
38
What are the 5 Hunter Criteria for serotonin syndrome?
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
39
Name 8 drugs with primarily anticholinergic toxicity
1. Atropine
2. Scopolamine
3. Homatropine
4. Cyclopentolate
5. Glycopyrrolate
6. Atrovent
7. Benztropine
8. Diphenhydramine
40
A patient thought to be inhaling hydrocarbons arrives in VT. How do you alter ACLS?
* Add esmolol or lidocaine
* Avoid epinephrine
41
Outline your management of stimulant-induced hyperthermia
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
42
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
43
Name the 3 binding sites on a GABA receptor.
1. GABA
2. BZD
3. EtOH/Barbituates/GHB
44
List 4 indications for HD in lithium poisoning
1. Acute \>4, Chronic \>2.5
2. CNS symptoms (seizure, decreased LOC)
3. Renal insufficiency
4. Can't tolerate volume
45
What is the mechanism for sudden death with hydrocarbon abuse?
Sensitization of myocardium to catecholamines
46
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
47
What 2 types of NSAID overdoses are dangerous?
1. Mefanamic acid
* Seizures
2. Phenylbutazone
* Aplastic anemia + Agranulocytosis
48
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
49
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
50
List 6 signs of serotonin syndrome
**FARMED**
1. Fever
2. Autonomic instability
3. Rigidity
4. Myoclonus
5. Encephalopathy
6. Diaphoresis
51
What are 3 mechanisms of action of cocaine?
1. Forces release of NE, Dopamine, Serotonin into synapse
2. Blocks reuptake from the synapse
3. Sodium channel blockade
52
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
53
What are the toxic effects of lithium?
**LITHIVM**
* **L**eukocytosis
* **I**nsipidus diabetes
* **T**remor
* **H**ypothyroidism/Hyperparathyroidism
* **I**ncreased weight
* **V**omiting/Nausea/Diarrhea
* **M**isc.
* ECG (long QT)
* SS
* NMS
54
List 8 risk factors for increased risk of digoxin toxicity
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
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
56
List 2 adverse effects of Levamisole
**Antihelminthic agent**
1. Agranulocytosis
2. ANCA-positive vasculitis
57
List 6 admission criteria for cocaine-related chest pain
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
List 8 causes of stimulant-induced chest pain
1. ACS
2. Endocarditis
3. Pericarditis
4. Aortic dissection
5. PE
6. Pulmonary infarction
7. PTX
8. FB
9. Pneumomediastinum
59
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
60
What is the universal antidote for decreased LOC NYD?
**DONT**
1. Oxygen
2. Thiamine
3. Dextrose
4. Narcan
61
What is the mechanism of action of organophosphates?
Bind and inhibit AChE
Leads to cholinergic toxidrome
62
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
63
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
64
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
65
List 5 differences in acute and chronic digoxin intoxication
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
Name 4 classes of hydrocarbons
1. **Aliphatic HC**
* Methane, Butane
2. **Aromatic HC**
* Benzene
3. **Halogenated HC**
* Chloroform
4. **Wood distillates**
* Toluene
67
What 4 characteristics determine the toxicity of a hydrocarbon?
1. Viscosity
2. Volatility
3. Side chains (Halogenated/Metals)
4. Surface tension
68
List 5 properties that make a drug dialyzable
1. Small Vd (\<1L/kg)
2. Low protein binding
3. Small size
4. Low endogenous clearance
5. Severe toxicity without antidote
69
What are the main symptoms of a nicotinic CHOLINERGIC toxidrome?
Days of the Week
* **M**uscle cramps
* **T**achycardia
* **W**eakness
* t**H**ypertension
* **F**asciculations
70
What are the main symptoms of a muscarinic CHOLINERGIC toxidrome?
**DUMBBELS**
* **D**iarrhea
* **U**rination
* **M**iosis
* **B**ronchorrhea
* **B**radycardia
* **E**mesis
* **L**acrimation
* **S**alivation
71
List 4 indications for HBOT in CO poisoning.
**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
How can you differentiate isopropyl alcohol ingestion from EG/Methanol?
1. Ketosis without acidosis
2. Osmolar gap without anion gap
3. Often get gastritis
4. Breath
73
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
74
Name 4 mechanisms of action of NAC
1. Glutathione precursor
2. Glutathione substitute
3. Enhance sulfation
4. Free radial scavenger
5. Alters hepatic microcirculation
6. Reduces cerebral edema
75
Outline your treatment of a suspected barbituate overdose
* MOVID
* MDAC - 25g q2h x3
* Airway protection
* IVF + Pressors
* Dialysis
76
What does a VBG sample look like in someone with CN poisoning?
Looks arterial
Due to lack of utilization of oxygen
77
Outline the metabolism of methanol
**Methanol**
* Alcohol dehydrogenase
* NAD as cofactor
**Formaldehyde**
* Aldehyde dehydrogenase
* NAD as cofactor
**Formic acid**
* Folate as cofactor
**CO2 + H20**
78
List 6 drugs not absorbed by charcoal
1. Alcohols
2. Acids
3. Bases
4. Heavy metals
5. Halogens
6. Lithium
7. Solvents
79
List 4 ECG findings in TCA overdose
1. Tachycardia
2. QRS long
3. QT long
4. R'R in aVR
80
What are the clinical features of PCP ingestion?
* Extreme agitation/violence
* Blank/Catatonic stare
* Nystagmus
* Ataxia
* Rigidity
* Hyperreflexia
* Hyperthermia
* Rhabdomyolysis
* Bronchospasm
81
List 3 different methods of predicting the need for liver transplant or death in APAP toxicity
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
What are the 3 components of the Lily kit? What is the mechanism of action of each?
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
List 6 causes of increased osmolar gap
1. Alcohol
2. Methanol
3. Ethylene glycol
4. Isopropyl alcohol
5. Sorbitol
6. Mannitol
7. Hypertriglyceridemia
8. Multiple Myeloma
84
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
85
List 8 dysrhythmias found with digoxin toxicity
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
List 10 toxins/medications that can cause delirium
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
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
88
When would you use multi-dose activated charcoal (6)?
**D**rink **T**his **C**harcoal **Q**uickly **P**lease or **A**n **OG**
* **D**apsone/Digoxin
* **T**heophylline
* **C**arbamazepine
* **Q**uinine
* **P**henobarbital
* **A**manita
* **O**leander
* **G**liclazide
89
List 7 receptors that TCAs work on
1. Serotonin
2. NE
3. Alpha
4. Na
5. K
6. GABA
7. Histamine
8. Cholinergic
90
What 2 drugs should be given in organophosphate poisoning?
1. Atropine 1 mg, then doubled q5min until dry
2. Pralidoxime 1g IV
91
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
92
What 2 receptors does GHB bind?
1. GHB
* Excitatory
2. GABA
* Sedating
This explains the cycling somnolence and agitation
93
List 8 drugs that are dialyzable
**IVC STUMBLE NASA**
* **I**sopropyl alcohol
* **V**alproate
* **C**arbamazepine
* **S**alicylate
* **T**heophylline
* **U**remia
* **M**ethanol
* **B**arbituates
* **L**ithium
* **E**thylene glycol
* **N**adolol
* **A**cebutolol
* **S**otalol
* **A**tenolol
94
List 10 drugs implicated in serotonin syndrome
1. SSRI
2. SNRI
3. Buproprion
4. TCAs
5. MAOIs
6. MDMA
7. Cocaine
8. LSD
9. Amphetamines
10. Linezolid
95
List 7 factors that influence the extent of a caustic injury
1. Type of agent
2. Concentration
3. Volume
4. pH
5. Duration of contact
6. Viscosity
7. Presence of food in stomach
96
Describe the metabolism of isopropyl alcohol
**Isopropyl alcohol**
* Alcohol dehydrogenase
**Acetone**
97
List 4 indications for pralidoxime administration.
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
List 4 indications to start NAC
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
What findings are prognostic of seizures and dysrhythmias in TCA overdose?
QRS \>100 ms = Seizures
QRS \>160 ms = Ventricular dysrhythmia
100
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
101
List 8 'one dose kills' for children
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
List 6 risk factors that increase the risk of hepatotoxicity with chronic APAP ingestion
**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
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
104
What are the diagnostic criteria for NMS?
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
Name 3 management options for opioid withdrawal.
1. Clonidine
2. Buprenorphine
3. Methadone
4. Opioids
106
What is the mechanism of action of PCP?
* NMDA antagonist
* Inhibits reuptake of NE, Dopamine, Serotonin
* Opioid receptor agonist
* Cholinergic receptor agonist
107
Name 4 opioids that can precipitate serotonin syndrome
1. Methadone
2. Demerol
3. Dextromethorphan
4. Tramadol
5. Oxycodone
6. Buprenorphine
108
List 5 differences between adults and children for digoxin poisoning
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
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
110
List 4 indications for starting fomepizole
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:
1. pH \<7.3
2. Bicarb \<20
3. Osm gap \>10
4. End organ damage (ocular, renal, CNS)
5. Urinary oxalate crystals (for EG)
111
List 4 indications for dialysis in toxic alcohol ingestion
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
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
