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Toxicology Flashcards

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1
Q

Acidic drugs like aspirin…

A

Increase respiration rate

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2
Q

Basic drugs like benzos or opiates…

A

Decrease respiration rate

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3
Q

What does a GCS <9 indicate?

A

Potential airway problem

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4
Q

What does absent gag response indicate?

A

No patent airway

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5
Q

Blue lips indicate…

A

Methaemoglobinaemia (haemoglobin in irreversible oxidised state from oxidant drugs)

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6
Q

Cherry red lips indicate…

A

Carbon monoxide (need a lot of exposure)

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7
Q

Which conditions are associated with Kussmal’s breathing?

A

DKA

Kidney failure

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8
Q

Effect of opiates on breathing?

A

Reduce the rate and efficacy

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9
Q

What can added breath sounds signify?

A

Opiates

Paraquat

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10
Q

Where can you get IV access in an IVDA?

A

Behind elbow

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11
Q

What do small pupils indicate?

A

Opiates
Organophosphates
Other cholinergics

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12
Q

What do large pupils indicate?

A 
Alcohol
Anti-cholinergics
Amphetamines
Beta blockers
TCAs
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13
Q

Charcoal (1g/kg) is only useful if given when?

A

Within 1 hour of ingestion
Except with aspirin or TCAs
Agent of choice for GI decontamination

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14
Q

Precaution with charcoal?

A

Must secure the airway as aspiration of charcoal can cause a nasty pneumonitis
Charcoal does not absorb metallics

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15
Q

Which substances are not well absorbed by charcoal?

A 
Pesticides
Hydrocarbons
Alcohols
Iron (metallics are not well absorbed)
Lithium 
Solvents
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16
Q

When would you use whole bowel irrigation (Klean-prep 1L/hour)?

A

Iron, heavy metals, “body stuffers/packers” and sustained released pills
Paracetamol, opiates, TCAs, aspirin and cocaine

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17
Q

What may suggest severe liver damage?

A

Peak ALT >1000 iu/L

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18
Q

What is the risk of severe liver damage with a paracetamol OD of <75mg/kg?

A

Unlikely

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19
Q

What is the risk of severe liver damage with a paracetamol OD of >150mg/kg?

A

Likely

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20
Q

What is the risk of severe liver damage with a paracetamol OD of >6g total?

A

Potentially fatal

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21
Q

Complication of anorexia and paracetamol?

A

Liver will not be able to process paracetamol efficiently

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22
Q

What is the antidote to a paracetamol overdose?

A

N-acetyl-cysteine (trade name Parvolex)

Infusion over 21 hours at least

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23
Q

Symptoms of paracetamol OD:

A

N+V

Coma, severe metabolic acidosis (high conc)

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24
Q

Signs of paracetamol OD complications:

A

Loin pain, haematuria and proteinuria after first 2 hours strongly suggests incipient renal failure
Right subcostal pain and tenderness, N+V and jaundice after 2-3 days suggests hepatic necrosis

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25
What is the half life of paracetamol?
4 hours
26
What should you monitor when treating with NAC?
INR U+Es LFTs
27
When should you measure paracetamol levels?
4 hours post OD (INR, U+Es, ALT)
28
What to do past 12 hours paracetamol OD?
See whether total amount was >75mg/kg
29
What is given to patient who has overdosed on opiates?
``` IV Naloxone (IM if can't get IV access) 0.4-2mg for an adult and 0.01mg/kg for child may need as much as 4mg for severe case Infusion at 1/2 waking dose given hourly may be needed ```
30
Features of naloxone:
Very short t1/2 (methadone has a huge t1/2) so may have to repeat doses If not in respiratory failure with good saturations then you don't have to give naloxone and can observe
31
Effects of TCAs:
Atropine-like anti-cholinergic effects at autonomic nerve endings and in the brain Quinidine-like effect on myocardium (increased AP duration as well as a prolonged QT interval)
32
Peripheral poisoning features of a TCA overdose:
``` Sinus tachycardia Hot dry skin Dry mouth Urinary retention Hypotension Hypothermia ```
33
CNS poisoning features of a TCA overdose:
``` Dilated pupils Ataxia, nystagmus, squint Decreased level of consciousness Coma, seizures, respiratory depression Increased tone, reflexes and plantars ```
34
ECG poisoning features of a TCA overdose:
Prolonged PR, QRS and QT | Ventricular dysrhythmias
35
What are the best indicators of toxicity in a TCA overdose?
ECG and GCS
36
Management of TCA overdose?
``` Repeat doses of activated charcoal Give diazepam for fits and agitation Correct hypoxia Give NaHCO3 if acidotic/ECG changes (not anti-arrhythmics) Correct hypotension with crystalloids ```
37
When should you not use flumazenil in the context of a TCA overdose?
If the patient has also taken benzodiazepines
38
What does a QRS >100ms indicate?
Cardiac toxicity
39
ECG changes in TCA overdose:
QRS >100ms Terminal R wave >3mm in aVR R/S ratio >0.7 in aVR
40
Early features of an aspirin overdose?
``` Hyperventilation Sweating Tremor Tinnitus N+V Hyperpyrexia ```
41
Metabolic features of an aspirin overdose?
Hypo/hyperglycaemia Hypokalaemia Respiratory alkalosis Metabolic acidosis
42
Serious features of an aspirin overdose?
Renal failure Pulmonary oedema Seizures Coma and death
43
Salicylate >700 | Salicylate >500
Potentially lethal | Moderate-severe
44
How do you treat an aspirin overdose?
Activated charcoal Rehydrate, monitor glucose, correct acidosis and K If >500 then alkalise the urine If >700 then consider haemodialysis
45
Effect of cocaine of myocardium?
Quinidine-like effect: QRS widening and QT prolongation
46
What is cocaine overdose?
A hyperadrenergic state
47
Symptoms of a cocaine overdose?
``` Agitation and anxiety Hallucinations Violence Twitches, tremors Grand mal seizures, status epilepticus ```
48
Signs of a cocaine overdose?
``` Dilated pupils and diaphoresis (sweating) Hyper-reflexia Hyperthermia Hypertension Tachypnoea Dysrhythmia Malignant hyperthermia ```
49
Extreme outcomes of cocaine overdose:
``` Cerebral infarction/haemorrhage Spinal cord infarction Myocardial ischaemia/infarction Retinal artery occlusion Pulmonary haemorrhage/barotrauma Rhabdomyolysis (muscle failure) ```
50
Treatment regimen for cocaine overdose:
1. Benzos for severe agitation and seizures 2. Alpha/beta blocker for hypertension and tachyarhythmia 3. Nitroprusside for malignant hypertension 4. GTN/benzos for MI
51
How can cocaine overdose cause myocardial toxicity?
Increased platelet aggregation and thrombogenesis Accelerated atherosclerosis Increased myocardial O2 demand and direct myocardial toxicity
52
What should you avoid giving for agitation in a cocaine overdose?
Anti-psychotics
53
What does the common law permit?
The patient lacking mental capacity means that the doctor can give medical treatment to preserve life and in the patient's best interests
54
Symptoms of an insulin/sulphonylurea overdose?
Agitation Sweating Confusion, drowsiness, coma or convulsions Tachycardia Hypotension Can have permanent neurological effect if prolonged
55
Treatment for sulphonylurea overdose?
Ocreotide 50mcg 8-12 hourly IV or SC for patients with prolonged hypo
56
Mechanism of ocreotide?
Prevents further release of insulin from the pancreas and reduces the dextrose requirement
57
Management of insulin/sulph overdose:
Check blood glucose, U+Es and BM Correct hypoglycaemia: 1-2ml/kg IV 50ml 50% dextrose OR sugary drink if conscious Then infusion of 10% or 20% dextrose titrated against blood glucose K replacement guided by frequent U+E checks normally 10-20mmol K per litre of dextrose
58
If patient refuses treatment with capacity then later becomes unconscious...
You cannot treat in absence of prior consent
59
Children over 16 are...
Treated as adults
60
What is the protocol if a child is <16?
They are assessed for Gillick competency Conset by a competent child cannot be overridden by a parent (reverse dose not apply) If any doubt then court order
61
Indicators for lead poisoning?
Moderately raised blood levels Children presenting with pica Children presenting with encephalopathy Abdominal pain and anaemia with no clear cause

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