Toxicology

Question 1

Broadly speaking what are the types of management for toxicity?

Answer 1

Decreased Absorption

• gastric lavage
• activated charcoal
• whole bowel irragation

Increased Elimination

• Urine Alkalinisation
• Haemodialysis

Reducing the rate of metabolite breakdown

Creating chemical complexes to bind with

Question 2

Outwith medical management, what other assessment should be done into someone presenting with an overdose?

Answer 2

Psychiatric assessment

Question 3

In paracetamol overdose - what important investigations should be done and how is it treated?

Answer 3

LFTS 
Coagulation studies 
U&Es
Paracetamol levels
ABG - Acidosis can occur 

• Activated Charcoal within 1 hour
• Acetylcysteine
• supportive care
• Antiemetics

Question 4

What are some of the clinical sign seen with Aspirin overdose?

Answer 4

Hyperventilation
Bounding pulse
Peripheral vasodilation

Severe:
Pyrexia
Cerebral oedema
Bleeding - hypoprothrombinemia

Question 5

How is Aspirin overdose treated?

Answer 5

Activated charcoal
- gastric lavage within 1 hour

Rehydration

Sodium Bicarbonate

Haemodialysis

Question 6

What are some signs and symptoms of TCA overdose?

Answer 6

Convulsions

Mydriasis

• dilated pupils
• dry mouth

Arrhythmias

Urinary retention

Upper reacting planters

Question 7

How is TCA overdose managed?

Answer 7

Supportive
Ventilatory
Anti-arrhythmic
Convulsion management

Question 8

Which drug is used to treat Benzodiazepines?

Answer 8

Flumazenil

Question 9

What is the definitive Carbon Monoxide poisoning test?

Answer 9

Carboxyhemoglobin Level

Question 10

What are the typical symptoms of digoxin toxicity?

Answer 10

Bradyarrhythmias
- AV block

Yellow/ greenish vision

Ventricular Bigeminy

Question 11

How is digoxin toxicity treated?

Answer 11

Digibind
Arrhythmia management
Monitor K+

Question 12

What are the initial symptoms of opioid overdose?

Answer 12

Confusion 
Myoclonus 
Vivid dreams Hallucination
Hypothermia 
Constipation

Question 13

What are the signs and symptoms of severe Opioid toxicity?

Answer 13

Bradypnoea
Pinpoint pupils - Miosis
Altered GCS

Question 14

How should sever opioid overdose be treated?

Answer 14

Naloxone
Oxygen therapy
**remember to ventilate the patient

*patient should be observed up to 6 hours after last naloxone

Question 15

How is Beta blocker overdose treated?

Answer 15

Atropine
Fluids
Glucagon

Question 16

How is ethylene glycol managed?

Answer 16

Fomepizole
- 1st line

Alcohol
- 2nd line

Question 17

How is Carbamoxide poisoning treated?

Answer 17

100% oxygen

Hyperbaric chamber

Question 18

How is warfarin overdose managed?

Answer 18

Vitamin K

Prothrombin complexes

Question 19

What drug is given to reverse Heparin?

Answer 19

Protamine

Question 20

At what levels should warfarin intervention be at?

Answer 20

INR 5-8 = Vitamin K

INR >8 , no bleeding = Vitamin K high dose orally

INR >8, Bleeding = IV Vitamin K

INR >8, large bleeding = IV Vitamin K, Prothrombin Complex concentrate or FFP if needed

Question 21

What criteria is used to assess the need for specialist help in paracetamol poisoning regarding liver functioning?

Answer 21

Kings college hospital criteria in acute liver failure 
	- pH <7.3 
Or 
	- PT >100s 
	- Creatinine 
Encephalopathy >3 

if these then liver transplant should be considered.

Question 22

How is Beta blocker overdose managed?

Answer 22

Atropine

if this fails then:
- Glucagon + 5% glucose

consider
- transcutaneous pacing

Question 23

What is the symptoms of anticholinesterase - nerve agents? and how are they treated?

Answer 23

SLUDGE

• salivation
• lacrimation
• urination
• Defecation
• G.I upset
• emesis

Atropine

Question 24

What is the King’s college criteria for paracetamol overdose?

Answer 24

<7.3 pH

INR> 100
Renal failure
Encephalopathy

Question 25

What do you want to know when someone comes in with overdose?

Answer 25

What have they taken? washed down with? When was it taken? How much?

Question 26

How is the diagnosis of serotonin syndrome made?

Answer 26

Using the: | - Hunter Serotonin Toxicity Criteria

Question 27

What is the main symptom in Anti-histamine overdose?

Answer 27

Hallucination Monitor them closely. - supportive treatment. Benzodiazepines

Question 28

What are the presenting symptoms of SSRI toxicity and how is it treated?

Answer 28

Serotonin syndrome Hyperthermia Hypertension Agitation Diarrhea Treatment: - IV magnesium (high risk of Detorde de pointes) - Cooling - Benzodiazepines

Question 29

What criteria is used to assess for serotonin syndrome?

Answer 29

Hunter serotonin syndrome criteria

Question 30

How is cyanide poisoning treated?

Answer 30

Sodium nitrite Hydroxocobalamin - B12

Question 31

What are the symptoms of organic phosphate poisoning? and how is it treated?

Answer 31

DUMBELS - Diarrhoea - Urination - Miosis - Bronchorrhea - excessive secretions - Emesis - Lacrimation - Salivation **you become wet Pralidoxime - binds to acetylcholinesterase

Question 32

How do you test the levels of TCA?

Answer 32

Urine sample

Question 33

What are the contraindications to a gastric lavage?

Answer 33

Ingestion of hydrocarbons Ingestion of corrosive substances If the airway cannot be protected

Question 34

How does TCA overdoses present and how are they managed?

Answer 34

``` Mydriasis Urinary retention Tachyarrhythmias - which can go into VT Seizures Metabolic acidosis ``` Management: - sodium bicarbonate (helps to manage the arrhythmias) - Cardiac input - Benzodiazepines

Question 35

What is the serious toxic dose of paracetamol requiring intervention?

Answer 35

150mg/kg

Question 36

How long after paracetamol ingestion do you wait to measure levels and why?

Answer 36

4 hours if satisfied a non staggered dose has been taken or timing of ingestion is known. measured 4 hours later because levels are inaccurate before

Question 37

Generalised management of Cocaine overdose?

Answer 37

Diazepines - for agitation and M.I and narrow complex tachy's GTN spray Sodium bicarbonate - for metabolic acidosis Dantrolene for muscle relaxant