Toxidromes

Question 0

What are the findings in a pt with stimulant overdose?

Answer 0

Vitals signs: tachycardia tachypnea hyperthermia HTN
Eye: mydriasis
Skin: diaphoretic
MSE: agitated, hallucination, paranoia, Sz

Question 1

What are examples of stimulants?

Answer 1

Cocaine, amphetamines, pseudo ephedrine, caffeine, theophylline

Question 2

What are eg of anticholinergic meds?

Answer 2

Antihistamines
Antidepressants: TCA
Antipsychotics: phenothiazine
Atropine
Antispasmodics
Belladonna alkaloids: Jimson weed
Mushrooms
Deadly nightshade

Question 3

What are the features of anticholinergic intoxication?

Answer 3

Vitals: tachycardia, tachypnea , HTN, hyperthermia
Eyes: mydriasis
MSE: agitation, hallucination, delirium
Skin: dry and flushed

Question 4

What are eg of hallucinogens?

Answer 4

LSD
Ecstasy
Amphetamines

Question 5

What is the smell of almonds assoc with?

Answer 5

Cyanide poisoning

Question 6

What is the mnemonic for drugs causing an incr HR?

Answer 6

F reebace cocaine
A nticholinergics
S ympathomimetica
T heophylline

Question 7

What’s the mnemonic for drugs causing decr HR?

Answer 7

P ropranolol
A nticholinesterase drugs
C lonidine
E thanol
D igoxin

Question 8

Mnemonic for drugs causing miosis?

Answer 8

C holinergics, clonidine
O piates, organophosphates
P henothiazines
S edatives (barbiturates)

Question 9

Mnemonic for drugs causing mydriasis?

Answer 9

A ntihistamines
A ntidepressants
A nticholinergics
S ympathomimetics (amphetamines,PCP, cocaine)

Question 10

Blind as a bat
Hot as hare
Red as a beet
Dry as a bone
Mad as hatter 
This is a mnemonic for remembering the symptom complex assoc with what toxin? And what does each statement mean?

Mad as hatter

Answer 10

Mydriasis
Hyperthermia
Flushing
Decr sweat, decr urine
Delirium, hallucinations

These are assoc with anticholinergics (phenothiazine, antihistamines)

Question 11

What is considered a potentially toxic dose of acetaminophen?

Answer 11

Acutely:

• Minimum dose of 150 mg/kg
• In adolescents and adults: 7.5g

Chronic dose:
150mg/kg/day for >2d
4gm/d for >2d

Question 12

What is the mx of acute overdose of acetaminophen?

Answer 12

• Prevent further absorption with activated charcoal if within 1/2hr to 1hr of ingestion
• acetaminophen levels: 4hrs s/p ingestion (peak concentration)
• rumack Matthew nomogram to set likelihood of hepatic damage and need for tx w/ n-acetylcysteine (NAC) or acetylcysteine (mucomist)

Question 13

What is the effect of toxic ingestion a of ibuprofen?

Answer 13

Usu very Rarely serious.
Serious toxicity >400mg/kg
Symptoms mostly GIT

Question 14

Is iron ingestion concerning?

Answer 14

Yes!! Very serious toxicity can occur! 
Eg: pre-natal vits, fe supp
Toxic dose of elemental fe are:
- 20mg/kg GI symptoms
- 50mg/kg signif toxicity

Question 15

What are the features of Fe toxicity?

Answer 15

0-6hrs: GIT stg- nausea, d&v, abd pain, hematemesis, bloody diarrhea, direct damage to GIT mucosa
6-12: stability
W/in 48h: cvs collapse, metab acidosis (high anion gap)
2-3d: hepatic failure
2-6 wks: GIT and pyloric scarring

I 1 is indigestion
R 2 is recovery
O 3-4 oh my gosh
N 5 narrowing

Question 16

How to dx fe toxicity?

Answer 16

• abd dx: tablets may be visible, fluid and chewable tabs are not
• serum fe level 4h s/p intake: 500 severe toxicity

Question 17

How to tx fe toxicity?

Answer 17

Chelation with IV deferoxamine for

1. mod-severe symptoms regardless of fe level
2. Serum fe level >350 mcg/dl
3. Pills on radiograph

Question 18

If someone ingested oil of winter green( a baking product) what type if toxicity wud u be concerned about?

Answer 18

Salicylate toxicity

Question 19

For salicylate ingestion what dose wud be concerning for acute toxicity?

Answer 19

150mg/kg

Question 20

What are some acute signs of salicylate toxicity?

Answer 20

Nausea, vomiting, tinnitus, hyperventilation (respiratory alkalosis)
Dehydration, hypoK, metabolic acidosis (it uncouples oxidative phosphorylation),
Serious toxicity: hyperthermia, agitation, confusion, coma, renal failure, death(from pulmonary/cerebral edema, electrolyte imbalance, cvs collapse)

Question 21

What’s the monitoring and mx for acute salicylate toxicity?

Answer 21

Monitoring: q2 to 4h monitoring of salicylate levels, ABG, chem, coags

Tx: activated charcoal (drug may form a bezoar in stomach), fluid hydration, correct electrolyte disturb (hypoK), raise urine pH w/ IV bicarbonate, hemodialysis
*there is no nomogram to reference

Question 22

What are the features of acute TCA toxicity? When do symptoms usu occur?

Answer 22

Symptoms usu w/in 30mins to 6h
*CNS features are more prominent in children
*mnemonic: tri-C A
C -coma
C -cadiac dysrhythmia: incr HR, HTN, decr BP, wide QRS and prolonged Qt
C -convulsions
A -acidosis

Question 23

What is the monitoring and tx for Axute TCA ingestion?

Answer 23

W/u: chem(hypoK), ABG, ECG, urine preg, utox (usu co-ingestions), acetaminophen/salicylate/etoh levels

Tx: protect airway, activated charcoal, alkalinize serum w/ Na-bicarb (7.45-7.55) to prevent dysrhythmia, monitor, EKG monitoring, tx dysrhythmia w/ lidocaine

Question 24

What is the mechanism by which carbon monoxide poisoning is pathological?

Answer 24

Carbon monoxide has a higher affinity for Hb than O2. Once it binds to one of the 4 spots on Hb it creates carboxy-Hb which doesn't readily release O2. O2 dissociation curve shifts to the left. So in the presence of adequate O2 the tissues are unable to use it!

Question 25

What is the typical presentation of carbon monoxide poisoning?

Answer 25

*Family with flu like symptoms in winter!!! Flu like symptoms: headache, dizziness, nausea, malaise Visual changes, weakness, syncope, vomiting, ataxia, Sz, coma, death *cherry red skin

Question 26

What is the w/u and tx of carbon monoxide poisoning?

Answer 26

W/u: CO [ ] because pulse ox will be normal!! Tx: high flow O2 (1/2 life is 5h on room air and 30-90 mins on 100% O2), tx anemia, ?use of hyperbaric O2 (in pregnant/neonatal pt's)

Question 27

What is the mx of an ingested button battery in the nose, ear or esophagus vs in the stomach? What's the concern?

Answer 27

Button batteries can cause mucosal burns w/in 1h of ingestion and full thickened burns w/in 4h by caustic leakage if it's contents or by electrical current. If in the E, N or esoph remove stat if in stomach wait and watch for passage in stool w/ q3d X-rays.

Question 28

A child as ingested perfume and or mouthwash and presents w/ N&V, ataxia, slurred speech, resp depression and hypothermia. What would be you concern? What are other features of this?

Answer 28

Ethanol toxicity! Can also cause Sz and coma *in children <5 can also cause hypoglycemia, due to inhibition of hepatic gluconeogenesis

Question 29

What is the w/u and tx in a suspected ethanol toxicity?

Answer 29

W/u: ethanol level, osmolar gap (an incr >10 identifies an unknown alcohol ingestion) Tx: ABCs, IVF, tx hypoglycemia, reward as needed, +/- screen for other toxins (ethanol may mask other toxicities)

Question 30

What is a good screening tool to identify a toxic ingestion of alcohols? If abnormal what are the common offenders?

Answer 30

Serum osmolality: 2x Na (mmol/L) + glucose (mg/dl)/18 + BUN (mg/dL)/2.8 Normal is <10 Mnemonic for augmented osmolality gap: MAE DIE Methanol, acetone, ethanol, diuretics(mannitol, sorbitol), isopropranolol, ethylene glycol

Question 31

In a pt with calcium channel blocker toxicity, what is the tx?

Answer 31

Insulin and glucose