Toxidromes 2 Flashcards
(38 cards)
1
Q
GI Decontamination and Simple Dilution
A
Controversies around best way to do this
Simple dilution – Best used when the toxicant produces local irritation or corrosion
- Water or milk is acceptable dilutions
- Best used for the first few minutes but only if no airway compromise –
- Not good for drug ingestion
2
Q
GI Decontamination and Gastric Emptying (5)
A
- Most effective within 30 minutes to one hour
- Delayed gastric emptying with anticholinergic may mean that you can do this after one hour
- Syrup of ipecac no longer in favor
- Gastric lavage limited use
- Must pass very large due 24 French for toddler, 36 French for adolescent, empty then lavage with NS
3
Q
Activated Charcoal (7)
A
PHAILS to be effective in:
- Pesticides
- Hydrocarbons
- Alcohols
- Iron (controversial in some texts)
- Lithium
- Solvents
- Watch CNS status to prevent aspiration
4
Q
When to use Activated Charcoal (5)
A
- Best used in first hour post ingestion
- Ingestion expected to produce toxicity
- Substance known to adsorb to charcoal
- Benefits felt to exceed risks
a. 1 gram/kg typical dose + sorbitol - Multidose or late charcoal for:
a. Theophylline overdose
b. Evidence of continuing absorption late
i. Aspirin or SR preparations
c. Cocaine body packers
5
Q
Whole Bowel Irrigation: Use of GoLytely (4)
A
- Makes the gut go faster so that you can’t absorb as much
- Useful in iron overdoses (metals do not bind with charcoal)
- Used for lead, sustained release medication (lithium theophylline, bupropion, verapamil) ingested patches, ingestions of vials or packages or illicit drugs
- 500 ml per hour in toddler
6
Q
Supportive Care (7)
A
- Monitor fluids – Urine output, Foley catheter
- Accucheck, treat hypoglycemia
* Dextrose: IV push - If opiod, naloxone: 0.01 mg/kg IV
- Closely monitor electrolytes
- Treat Seizures – Lorazepam, Dilantin 10
- Control agitation – Haldol, Ativan 2-4 mg IM or IV
- Think about trauma
7
Q
Sympathomimetics (7)
A
- Cocaine
- Amphetamine
- LSD
- Theophylline
- Caffeine
- Phenylpropanolamine
- Beta-2-agonist
8
Q
Anticholinergics (9)
A
- Antihistamines
- Atropine
- Scopolamine
- Antipsychotics
- Antidepressants
- Antisposmodics (bella donna)
- Mydriatics
- Mushrooms
- Jimson weed
9
Q
Cholinergics (6)
A
- Organophosphate
- Cardamate
- Physostigmine
- Edrophonium
- Mushrooms
- Acetylcholine
10
Q
Opiates (7)
A
- Narcotics
- Barbiturate
- Benzodiazepine
- Ethanol
- Clonidine
- Chloral hydrate
- Methaqualone
11
Q
Odors and Toxidromes (9)
A
- Bitter almonds = cyanide
- Carrots = cicutoxin (water hemlock)
- Fruity = diabetic ketosis, isopropanol
- Garlic = organophosphates arsenic, selenium
- Gasoline = chronic toluene
- Mothballs = naphthalene, camphor
- Oil of wintergreen = methyl salicylate
- Rotten eggs = sulfur dioxide
- Pears = chloral hydrate
12
Q
Old Toxidromes (6)
A
- Opioids
- Anticholinergic
- Cholinergics
- Sympathomimetics
- Salicylates
- Tricyclic’s
13
Q
What are opioids? (5)
A
- Natural: Codeine, morphine
- Semisynthetic: heroin, oxycodone
- Synthetic: fentanyl, meperidine,
- Well absorbed with analgesia within minutes.
- Hepatic metabolism is the first pass effect after oral ingested
14
Q
Opiate and pharmacology (2)
A
- Opiate interaction with specific receptors in CNS determines analgesic euphoric, sedative and respiratory depression
- Toxicity will depend on:
a. POTENCY
b. DOSE
c. TOLERANCE
15
Q
Opioid Toxidrome (3)
A
- Stimulation of opioid receptors
- Triad of: Miosis, CNS depression, and hypoventilation
- Agents that cause this include: heroin, morphine, hydrocodone and oxycodone
16
Q
Opioids clinical presentation (9)
A
- Analgesia to painful stimuli
- Dry mucous membranes
- Facial flushing
- Diaphoresis
- Nausea and vomiting – May also see diarrhea
- Muscle flaccidity
- Bronchospasm
- Bradycardia
- Later, constipation
17
Q
Toxidromes and additional manifestations (3)
A
- Seizures: meperidine, propoxyphene
- Mydriasis: meperidine, diphenoxylate
- Noncardiogenic pulmonary edema
18
Q
Opioids: Additional Manifestations and co-intoxicants (5)
A
- Mydriasis should never rule out opiate poisoning
- Hypoxia, hypoglycemia
- Post-ictal state
- Co-intoxicants
- Meperidine
19
Q
Treatment: Opioid-Naloxone therapy (7)
A
- Short half life: 30-l00 minutes
- Initial dose: .l mg/kg up to 20 kg to .4mg
- If no response, 2 mg every 3 minutes
- Maximum initial dose: l0 mg
- Can go to 20
- May need to be repeated every 20-60 minutes depending on what opioid was ingested
- IV, IM, intranasal
20
Q
Failure or partial response to Naloxone Therapy (5)
A
- Inadequate dose
- Co-ingestion
- Medical illness or injury
- Prolonged hypoxic insult
- Partial positive Naloxone response: Ethanol, benzodiazepine, clonidine, chlorpromazine
21
Q
What is uncommon in pure narcotic poisonings (3)
A
- Persistent seizures
- hypotension
- unresponsive arrhythmias
22
Q
Anticholinergics Toxidrome – DRY (6)
A
- Vital Signs – Hypertension (systolic ranges in150/100range) and mild tachycardia (120-140 range), Slight hyperthermia and tachypnea
- CNS signs
a. Psychomotor agitation or somnolence
b. Psychosis/seizures
c. Mydriasis - Skin: Hot, dry, flushed skin
- GI: Absent bowel sound
- Urinary retention (Jimson weed)
- If severe, treat with physostigmine 0.5 to 1.0 mg slow
a. Has a lot of very bad side effects, so only use it if the overdose is severe
23
Q
Anticholinergic Syndrome (7)
A
- Dry mouth
- Flushed appearance
- Dilated pupils
- Fever
- Ileus
- Urinary retention
- Disorientation
24
Q
Examples of Anticholinergic (5)
A
- Antihistamines - Benadryl
- Antiparkinson agents: Artine, Cogentin, Kemadrin
- Antidepressants like Elavil (Amitriptyline, Tofranil (Imipramine)
- Antispasmatics_ (Probanthine) belladonna alkaloids: Atropine, scopolamine), Librax,
- Toxic Plants: Mushrooms, jimson weed, deadly night shade
25
Anticholinergic Treatment (3)
1. GI with activated charcoal drug of choice
2. Sedation and monitor in PICU
3. Controversial Use: Physiogmine (child 0.02 mg/kg) slow IV may repeat in 15 minutes until desired affects is achieved, then every 2-3 hours prn
a. Side effects
i. Seizures
ii. Asystole
26
Cholinergic Excess Epidemiology: Organophosphate poisonings; insecticides (4)
a. Children < 6 who are playing in areas treated in insecticides
b. Occupational exposure
c. Suicidal ingestion
d. Nerve gas
27
Cholinergic Excess Etiology: Organophosphate poisonings; insecticides (5)
a. Organophosphates act as acetylcholinesterase inhibitors
b. Prevent normal breakdown and removal of Ach from post synaptic junction
c. Use: pesticides and chemical warfare
d. Absorbed through skin, respiratory, GI tract, and conjunctiva
e. If inhaled or injected, quickest onset
28
Acetylcholine (3)
1. Needs cholinesterase to cleave acetylcholine and stop stimulation
a. Into acetyl and choline
2. Excess acetylcholine at muscarinic receptor sites
3. Presents as vagal stimulation (up high vagus)
a. Bradycardia, bronchoconstrictor, glandular secretion, miosis
b. Sacral Parasympathetic: bladder and bowel incontinence
c. Vagal stimulation leads to parasympathetic responses
29
Cholinergic Drugs: Muscarinic Events (7)
a. Salvation
b. Lacrimation
c. Urination
d. Defecation
e. Bronchorrhea
f. Bradycardia
g. Miosis with blurry vision
30
Cholinergic Drugs: Nicotinic Events (7)
1. Muscular weakness
2. Fasciculation
3. Paralysis
4. Hypertension
5. Tachycardia
6. Mydriasis
7. Garlic breath
31
Cholinergic Rxns: DUMBBELLS (Wet)
* D Diarrhea
* U Urination
* M Miosis, muscle fasciculation
* B Bradycardia, bronchorrhea,
* Bronchospasm
* E Emesis
* L Lacrimation
* S Salivation
32
Organophosphates: SLUDGE (8)
1. Salivation
2. Lacrimation
3. Urinary frequency
4. Diarrhea
5. GI cramping
6. Emesis
7. Can have bradycardia, bronchorrhea, bronchoconstriction, miosis
8. Atropine for muscarinic effects (.02 to .05mg/kg every l5 minutes
33
Organophosphates: Treatment (7)
1. Healthcare worker MUST wear protective gear
```
2. Immediate decontamination
– Remove patient from exposure
– Remove clothes
– Wash down skin
i. 1% hypochlorite on skin, not eyes
ii. Iodophors (providone iodine)
```
3. Maintain proper airway
4. Atropine + Pralidoxime (synergistic)
5. Valium if CNS manifestation
6. How does Pralidoxine chloride
7. (Prussian blue) act: Regenerate acetylcholinesterase by reversing phosphorylation
– Onset an be in minutes, depends on the dosage
– Secrete the ingestion
34
Terrorists arsenal or Organophosphates (4)
1996 Sarin gas exposure
1. Patient excretes pesticides through sweat, urine and stool
2. Onset minutes to 12 hours
3. Duration days to months
4. Treatment is Pralidoxime (2-PAM) approved Prussian blue
35
Nerve Gas (4)
1. Tubun (GA)
2. Sarin (GB)
3. Soman (GD)
4. VX
a. All are cholinesterase inhibitors
b. Found in WWII in Germany
i. GA, GB, GD, GF (declassified)
ii. Phosphate linkage
36
Cholinergic Excess: SLUD (3)
1. SLUD: (salivation, lacrimation, urination, defecation)
2. Bronchorrhea is what will kill you
3. Muscle paralysis or muscle fasciculation
37
Cholinergic Excess: Atropine auto injectors to counteract (3)
1. Competitively block the action of acetylcholine on postganglionic parasympathetic cholinergic receptors
2. Decrease secretions
3. Inhibit bradyarrhythmias
38
Delayed Clinical Presentation (4)
Delayed peripheral neuropathy
a. Neurotoxic esterase in peripheral neurons leads to axonal degeneration
b. Patient has motor weakness, sensory abnormalities and extremity pain
c. 1-3 weeks after acute poisoning
d. Recovery in weeks to month and not always complete
e. Personality changes
