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Emergency > Toxicology/Poisoning/Overdose > Flashcards

Toxicology/Poisoning/Overdose Flashcards

1
Q

When is ipecac used?

A

It can be used at home, but not in the hospital. Ipecac needs 15 to 20 minutes to work and delays administration of antidotes. It is never used.

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2
Q

When are cathartic agents such as sorbitol used?

A

Cathartics are not used ever. Speeding up GI transit time does not eliminate the ingestion without absorption.

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3
Q

When is forced diuresis used?

A

Giving fluids and diuretics don’t work. More Pts are harmed with pulmonary edema than are helped.

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4
Q

When is whole bowel irrigation used?

A

It is almost never used, EXCEPT:

  • Lithium overdose
  • Massive iron ingestion
  • Drug-filled packets that are swallowed e.g. in smuggling
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5
Q

When is gastric emptying of any kind contraindicated?

A
  • Caustics (acid or alkali)
  • Altered mental status
  • Acetaminophen overdose
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6
Q

What are, by far, the two most common causes of death by overdose?

A

Aspirin and acetaminophen

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7
Q

What is the best initial management of altered mental status of unclear etiology?

A

An opiate antagonist (e.g. naloxone) and glucose (in case of opiate overdose and hypoglycemia, respectively) work instantaneously and have no adverse effects.

If those don’t work, intubate to protect the airway, possibly followed by gastric lavage.

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8
Q

When is charcoal used?

A

Charcoal is benign and should be given to any pt with a pill overdose. It may not be effective for every overdose, but it is not dangerous. Charcoal can also remove toxic substances even after they have been absorbed. It is superior to lavage and ipecac.

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9
Q

What is the management for acetaminophen overdose if:

  • A clearly toxic amount was ingested
  • It was more than 24 hours ago
  • The amount taken is unclear
A

What is the management for acetaminophen overdose if:

  • A clearly toxic amount was ingested: N-acetylcysteine
  • It was more than 24 hours ago: No therapy
  • The amount taken is unclear: Get a drug level
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10
Q

What are the signs and symptoms of aspirin overdose?

A
  • Tinnitus
  • Hyperventilation
  • Respiratory alkalosis progressing to metabolic acidosis (lactic acid)
  • Increased anion gap
  • Renal toxicity
  • Altered mental status
  • Increased PT
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11
Q

What is the major pulmonary complication of aspirin overdose?

A

ARDS

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12
Q

What is the treatment of aspirin overdose?

A

Alkalinize the urine (NaHCO3), which increases the rate of aspirin excretion.

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13
Q

When is gastric lavage useful after pill ingestion? When is it contraindicated?

A

Gastric lavage is rarely done, but it may be useful in the first hour of ingestion. It removes:

  • 50% of pills at 1 hour
  • 15% of pills at 2 hours

It is dangerous in:

  • Altered mental status: may cause aspiration
  • Caustic ingestion: causes burning of the esophagus and oropharynx
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14
Q

What are the common adverse effects of TCA toxicity? What are the severe adverse effects?

A

Common: Anticholinergic effects like dry mouth, constipation, and urinary retention.

Severe: Seizures, arrhythmias (esp. torsades)

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15
Q

What is the best initial test for TCA toxicity?

A

EKG shows a wide QRS, predicting arrhythmia due to prolonged QT interval.

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16
Q

What is the treatment of TCA toxicity?

A

Sodium bicarbonate will protect the heart against arrhythmia.

*This is a different mechanism from its action against aspirin toxicity in which it increases the urinary excretion.

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17
Q

What do caustics (e.g. drain cleaner) do if ingested?

A

Caustics cause mechanical damage (including perforation) to the oropharynx, esophagus and stomach.

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18
Q

How is caustic ingestion treated?

A

Flush out the caustics with high volume water. Endoscopy is done to assess the degree of damage.

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19
Q

When are people exposed to carbon monoxide?

A
  • Fires
  • Gas heaters or wood stoves
  • Automobile exhaust, particularly in an enclosed environment
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20
Q

What is the presentation of carbon monoxide poisoning? What is the ultimate cause of death?

A
  • Dyspnea
  • Lightheadedness
  • Confusion
  • Seizures
  • Death from MI
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21
Q

Describe ABG findings in CO poisoning?

A

Metabolic acidosis with a low bicarbonate and low pCO2. pO2 is normal.

22
Q

What is the most accurate test for CO poisoning?

A

Carboxyhemoglobin level

*Routine oximetry will be falsely normal

23
Q

What is the best initial therapy for CO poisoning?

A

Remove the pt from exposure and give 100% oxygen.

24
Q

When is CO poisoning considered severe? What is the treatment for severe CO poisoning?

A

“Severe” symptoms are defined as:

  • CNS symptoms
  • Cardiac symptoms
  • Metabolic acidosis

Hyperbaric oxygen is used whenever any of these symptoms are present.

25
Q

What is methemoglobin? What causes it?

A

Methemoglobin is oxidized hemoglobin locked in the ferric state. Oxidized hemoglobin is brown and will not carry oxygen. Methemoglobinemia occurs from a reaction of hemoglobin to certain drugs such as:

  • Benzocaine and other local anesthetics
  • Nitrites and nitroglycerin
  • Dapsone
26
Q

What is the presentation of methemoglobinemia?

A
  • Dyspnea and cyanosis
  • Headache, confusion, seizures
  • Metabolic acidosis
  • Brown blood
  • Same Sx as CO poisoning, except for the blood color
  • *Cyanosis + normal pO2 = methemoglobinemia
27
Q

What is the most accurate test for methemoglobinemia?

A

Methemoglobin level

*Routine oximetry will be falsely normal

28
Q

What is the treatment for methemoglobinemia?

A

The best initial therapy is 100% oxygen. The most effective therapy is methylene blue, which decreases the half-life of methemoglobin.

29
Q

What is the presentation of organophosphate (insecticide) and nerve gas poisoning?

A

Nerve gas poisoning is much faster and severe. The symptoms of either are:

  • Salivation
  • Lacrimation
  • Polyuria
  • Diarrhea
  • Bronchospasm, bronchorrhea, and respiratory arrest if severe

*Massively elevated ACh causes parasympathetic overload

30
Q

What is the treatment of organophosphate poisoning? What about nerve gas poisoning?

A

Pralidoxime is the specific antidote for organophosphates; it must be used very quickly. Atropine can be used as well; it acts faster than pralidoxime.

Atropine is used to treat nerve gas.

31
Q

What predisposes a pt to digoxin toxicity? Why?

A

Hypokalemia predisposes to digoxin toxicity because potassium and digoxin compete for binding at the same site on the Na/K ATPase. When less potassium is bound, more digoxin is bound.

32
Q

What is the presentation of digoxin toxicity?

A
  • GI disturbances are most common and include nausea, vomiting, and abdominal pain.
  • Hyperkalemia from the inhibition of the Na/K ATPase
  • Confusion
  • Visual disturbances such as yellow halos around objects
  • Arrhythmias
33
Q

What is the best initial test for digoxin toxicity? Most accurate test?

A

Best initial: EKG and potassium level; the EKG will show a downsloping of the ST segment in all leads.

Most accurate: Digoxin level

34
Q

What is the most common digoxin toxicity arrhythmia?

A

Any arrhythmia is possible, but the most common is atrial tachycardia with variable AV block.

35
Q

What is the treatment of digoxin toxicity?

A

Control potassium and give digoxin-specific antibodies (to remove digoxin from circulation).

36
Q

What is the presentation of lead poisoning?

A
  • Abdominal pain
  • Renal tubule toxicity (ATN)
  • Anemia (sideroblastic)
  • Peripheral neuropathy (e.g. wrist drop)
  • CNS abnormalities such as memory loss and confusion
37
Q

What is the best initial test for lead poisoning? Most accurate test?

A

Best initial: Increased level of free erythrocyte protoporphyrin

Most accurate: Lead level

38
Q

What is the treatment of lead poisoning?

A

Chelating agents remove lead from the body:

  • Succimer is the only oral form
  • EDTA and dimercaprol (BAL) are parenteral agents
39
Q

How does route of entry determine presentation of mercury poisoning?

A

Orally -> neurological Sx: pt may be nervous, jittery, twitchy, and sometimes hallucinating

Inhalation -> lung toxicity: interstitial fibrosis

40
Q

What is the treatment of mercury poisoning?

A

Chelating agents: succimer (oral) and dimercaprol (parenteral)

There is no therapy to reverse pulmonary toxicity. Chelating agents can prevent progression, however.

41
Q

What is the source of methanol poisoning? What about ethylene glycol?

A

Methanol: wood alcohol, cleaning solutions, paint thinner

Ethylene glycol: antifreeze

42
Q

What are the similarities between methanol and ethylene glycol poisoning?

A

Both produce intoxication and metabolic acidosis with increased anion gap. Both give an osmolar gap and are treated with fomepizole and dialysis.

43
Q

What is the toxic metabolite for methanol and ethylene glycol?

A

Methanol: Formic acid / formaldehyde

Ethylene glycol: Oxalic acid

44
Q

What is the presentation of methanol poisoning? What is the initial diagnostic abnormality?

A

Presents as ocular toxicity with possible blindness.

Initial Dx abnormality is retinal inflammation.

45
Q

What is the presentation of ethylene glycol poisoning? What is the initial diagnostic abnormality?

A

Presents as renal toxicity.

Initial Dx abnormalities include: hypocalcemia and envelope-shaped oxalate crystals in urine.

46
Q

How does death by snakebite occur?

A

Hemolytic toxin: hemolysis and DIC and damage to the endothelial lining of tissues.

Neurotoxin: can result in respiratory paralysis, ptosis, dysphagia, and diplopia.

47
Q

What therapies are beneficial for snake bites? What are some common ineffective or dangerous treatments?

A

Effective or beneficial: Antivenin, pressure, and immobilization (decreases movement of venom)

Ineffective or dangerous: Incision and suction (esp. by mouth), tourniquets blocking arterial flow, and ice

48
Q

What is the presentation of black widow spider bites?

A
  • Abdominal pain

- Muscle pain

49
Q

What lab test abnormalities are there in black widow spider bites? What is the treatment?

A

Dx: Hypocalcemia

Rx: Calcium, antivenin

50
Q

What lab test abnormalities are there in brown recluse spider bites? What is the treatment?

A

Dx: None

Rx: Debridement, steroids, dapsone

51
Q

What are the similarities among dog, cat and human bites in terms of bugs and management? What are the differences?

A

Bugs:

  • Pasteurella multocida for dogs and cats
  • Eikenella corrodens for humans

Management (for all):

  • Amoxicillin/clavulanate
  • Tetanus vaccination booster if more than 5 years since last injection

*Human bites are more dangerous than dog or cat bites

52
Q

When do you give the rabies vaccine following an animal or human bite?

A

Give the rabies vaccine only if:

  • Animal has altered mental status/bizarre behavior
  • Attack was unprovoked or by a wild/stray animal that cannot be observed or diagnosed

Emergency (2 decks)

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