Toxidromes 3

Question 1

Sympathomimetics Toxidrome: Signs and Symptoms (4)

Answer 1

1. Cardiovascular
   a. Hypertension
   b. Tachycardia
   c. Hyperthermia
   d. Tachypnea
2. GI - Bowel sounds present
3. CNS
   a. Dilated pupils
   b. Psychomotor agitation
   c. Mydriasis (large pupils)
4. Skin- Diaphoresis

Question 2

Sympathomimetic Responses (2)

Answer 2

1. Increased catecholamine surge will typically produce Hypokalemia, Hyperglycemia, Metabolic acidosis, low bicarbonate
2. Potential rhabdomyolysis due to extreme agitation
   i. CK LEVELS – to test for rhabdomyolysis
   ii. Do CK levels with a sympathomimetic ingestion

Question 3

Cocaine Abuse (3)

Answer 3

1. Insufflation
   a. (snorting)
   b. Reasonable high
   c. Drug has short life and user seeks more
   d. Safer but less efficient
2. Smoking (free basing)
   a. Stronger and faster
   b. Pulmonary complications
3. Injecting (speed balling)
   a. User cut cocaine with heroin

Question 4

How can children get cocaine? (5)

Answer 4

1. Mother in child abuse
2. Breast milk
3. Accidentally: leaving around
4. Intentional exposure from parents blowing it into child face
5. Unintentional exposure from passive smoke

Question 5

Cocaine Effects (7)

Answer 5

1. Interacts with alcohol creating new compound in liver causes euphoria 45-60 minutes later
2. Increased risk for seizure if using nifedipine (Calcium channel blocker)

Central venous effects:

3. Vasoconstriction
4. Tachycardia (200 range)
5. BP increase (systolic in 200)
6. Cocaine can lead to Coronary syndrome and Pulmonary hemorrhage
7. TEMPERATURE IS HIDDEN VITAL SIGN

Question 6

Adolescence and Cocaine Use (3)

Answer 6

1. Pneumomediastinum from inhaling smoke and performing valsalva maneuver
2. Screening: look form metabolites of cocaine
3. In OD: pale, clammy and cool, cardiac rhythm abnormalities

Question 7

Summary of sympathomimetic effects (4)

Answer 7

Ex: cocaine

1. Large pupils
2. Elevated HR
3. Wet skin
4. Decreased GI motility

Question 8

Summary of cholinergic effects (4)

Answer 8

Ex: organophosphate

1. Small pupils
2. Decreased HR
3. Wet skin
4. Elevated GI motility

Question 9

Summary of anticholinergic effects (4)

Answer 9

Ex: diphenhydramine

1. Large pupils
2. Increased HR
3. Dry skin
4. Decreased GI motility

Question 10

Summary of opioid effects (4)

Answer 10

Ex: heroin

1. Decreased HR
2. Normal HR
3. Normal skin
4. Decreased GI motility

Question 11

New toxidromes (4)

Answer 11

1. Case of l7 year old woman who had a witnessed seizure at home
2. Woke up complaining of bi-temporal headache
3. Patients have bizarre interest in light
4. Serum Na: ll4

Question 12

MDA (6)

Answer 12

1. Similar effects to MDMA
2. MDA is a metabolite of
3. MDMA
4. Acts on the CNS by releasing norepinephrine and blocking its reuptake
5. Oral or IV
6. Frequently adulterated with other drugs

Question 13

MDA Signs and Management (2)

Answer 13

1. Hypertension –> IV nitro, nitroprusside or alpha blocker such as phenotolamine
2. Rhabdomyolysis –> Strict attention for fluids and electrolyte balance with alkalization of urine
   * Need to fluid restrict

Question 14

Amphetamine Analogue (MDA, MDMA, MDEA) Effects (18)

Answer 14

1. Increased CNS and hallucinogenic effects

Cardiovascular:

2. Tachycardia
3. Hypertension
4. Dysrhythmia
5. Flushing
6. Angina

Neurologically:

7. Diaphoresis
8. headache
9. altered mental status
10. seizures
11. Intracranial hemorrhage
12. mydriasis
13. BRUXISM: pacifier around neck: ectasy
14. Severe fatigue following use
15. Hyperthermia – Fluid and electrolyte imbalance due to water intake
16. Marathon dancing is associated with its use
17. Death associated with amphetamine use
18. Subarachnoid hemorrhage and ruptured aneurysm

Question 15

Acute overdose of amphetamine analogues (5)

Answer 15

1. Airway, breathing
2. Control of agitation and sedation is needed
3. Control hyperthermia
4. Rhabdomyolysis can be a control.
5. Benzodiazepines such as Ativan for seizure

Question 16

Gamma Hydroxybutyrate (GHB) (date rape drug) (10)

Answer 16

1. Rapid progression to flaccid areflexic coma
2. Preserved pulse and BP
3. CNS depression and respiratory depression
4. ‘DATE RAPE’ drug (liquid ecstasy, liquid X, Grievous bodily harm)
5. GHB used until l990 as an OTC sedative
6. Severe reactions including seizures and coma
7. Produces dopamine release in substantia nigra producing euphoria
8. GHB may be protective against hypoxic tissue injury
9. Can have mild hypothermia and asymptomatic bradycardia
10. Hypotension can occur if alcohol is used with this

Question 17

Treatment of GHB (5)

Answer 17

1. Watch and stimulate patient
2. Must really determine that respirations can’t be stimulated
3. May respond to naloxone
4. Produces pattern of normal rapid eye movement
5. Best sleep the patient has had

Question 18

Salicylates (ASA) (7)

Answer 18

1. Weak acid, rapidly absorbed
2. Enteric coated has delayed absorption
3. Toxic dose: 160 mg/kg
4. Lethal dose 480 mg/kg
5. Mixed respiratory alkalosis-metabolic acidosis
6. Stimulates respiratory drive causing hyperventilation, but limits ATP production → metabolic acidosis
7. Oil of wintergreen, 1ml = 1400mg of aspirin

Question 19

Salicylates overdose etiology (6)

Answer 19

1. Stimulate the respiratory center of medulla
2. Hyperventilation and respiratory alkalosis (compensatory for metabolic acidosis)
   a. Blowing off the ingested acid
3. Compensatory bicarbonates excretion
4. Increased pyruvate and lactate cause metabolic acidosis
5. Toxic if >/=150 mg/kg
6. Found in antihistamine/decongestant combos, anti-diarrheal, herbal meds, oil of wintergreen, sunscreens

Question 20

Salicylates signs and symptoms (10)

Answer 20

1. Nausea and vomiting
2. Tinnitus
3. Tachypnea and hyperpnea
4. Hypotension
5. Oliguria
6. Pulmonary edema
7. Minor rise in temperature
8. Respiratory alkalosis and metabolic acidosis
9. Ketones in urine
10. 1-2 drops of ferric chloride solution turns pink is positive for ASA

Question 21

Salicylates Dif Dx (7)

Answer 21

1. Other causes of anion gap metabolic acidosis
2. MUDPILES
3. Reye syndrome
4. Sepsis
5. Encephalopathy
6. Diabetic ketoacidosis
7. Renal failure

Question 22

Salicylates Clinical Presentation (9)

Answer 22

1. Tachypnea, tachycardia, hyperthermia
2. Respiratory alkalosismetabolic acidosis
3. Altered serum glucose
4. AG metabolic acidosis (MUDPILES)
5. Dehydration (vomiting, tachypnea, sweating)
6. Abd. pain/n/v
7. Tinnitus, hearing loss
8. Lethargy, seizures, altered mental status
9. Noncardiogenic pulmonary edema

Question 23

Metabolic Acidosis with High Anion Gap: Causes (MUDPILES)

Answer 23

METHANOL
UREMIA
DIABETIC KETOACIDOSIS
PARALDEHYDE AND PHENORMIN
ISONIAZID AND IRON
LACTIC ACIDOSIS
ETHANOL AND ETHYLENE GLYCOL
SALICYLATES

Question 24

Evaluation of ASA Overdose (6)

Answer 24

1. Lytes, ABG, LFTs, CBC, pregnancy test, urine PH
2. Serum salicylate levels (toxicity at 25mg/dl)
3. Toxicity correlates POORLY with levels
4. Evaluation with DONE normogram based on single ingestion of regular
5. ASA at levels drawn 6 hrs. after ingestion
6. Underestimates toxicity in cases of severe academia or chronic ingestion

Question 25

Therapy of ASA Overdose (5)

Answer 25

1. ABC’s 2. Activated charcoal 3. Urinary alkalinization -- Use of Bicarbonate 4. By increasing urinary pH to greater than 8, ASA gets trapped in tubes and cannot be reabsorbed 5. Dialysis for severe acidemia, volume overload, pulmonary edema, cardiac or renal failure, seizures, coma, levels >100mg/dl in acute ingestion, or > 60-80 mg/dl in chronic ingestion

Question 26

Disposition for ASA overdose (4)

Answer 26

1. Pt. gets charcoal and remain asymptomatic after 6-8 hours = 2. Possible D/C 3. Sustained release requires longer observation period 4. Pts. with toxic levels, symptomatic, or develop symptoms = Admission

Question 27

Acetaminophen Overdose (3)

Answer 27

1. Usually metabolized almost entirely in liver where it is converted to nontoxic form 2. Excreted in urine 3. Severe toxicity in adolescents in doses as low as 10-15 grams

Question 28

Acetaminophen Overdose Epidemiology (3)

Answer 28

a. Accidental overdose in children over 6 b. Adults and adolescents more likely to develop toxicity c. Peak level 4 hours post ingestion

Question 29

Rumack-Matthew Nomogram (4)

Answer 29

1. Sensitive predictor of hepatotoxicity 2. Failure rate approaches zero over the past 25 years of use 3. Useful only with levels obtained between 4 - 24 hours post ingestion 4. Single acute ingestion

Question 30

Signs and Symptoms of Acetaminophen Overdose (5)

Answer 30

1. Initially asymptomatic 2. Malaise, nausea, vomiting Liver injury: 3. Abdominal pain, 4. Persistent vomiting 5. Jaundice --> Appears 14-48 hours post ingestion

Question 31

Acetaminophen Overdose Treatment (3)

Answer 31

1. GI decontamination with activated charcoal 2. Rumack-Matthew nomogram a. Patients with acetaminophen levels within safety range: no RX b. If at 4 hours post ingestion > 150 microgram/ml need N acetylcysteine c. Every 4 hours 3. Psychiatric evaluation

Question 32

Optimum timing to obtain levels: acetaminophen

Answer 32

4 hours

Question 33

Optimum timing to obtain levels: iron

Answer 33

4 hours

Question 34

Optimum timing to obtain levels: salicylates

Answer 34

2-4 hours