Week 11 - Chemical Injuries

Question 1

what conditions happen/occur at phase 3 acetaminophen overdose?

Answer 1

Encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition (such as viral infection or toxins in the blood).

, renal failure,

cardiomyopathy (Cardiomyopathy is a disease that affects your myocardium (heart muscle). Cardiomyopathy can make your heart stiffen, enlarge or thicken and can cause scar tissue. As a result, your heart can’t pump blood effectively to the rest of your body.)

Question 2

When do Serum acetaminophen levels peak after injestion?

Answer 2

Serum acetaminophen levels peak at 4 hrs after injestion?

Question 3

Classic symptoms for Downers? (what substances to these apply to?) (5 of them)

Answer 3

Applies to opioids, benzos, alcohol

Respiratory depression
Pupil constriction
Bradycardia
Hypothermia
Coma

Question 4

What is something that was found to be a key contributing factor to overdose deaths?

Answer 4

polysubstance use was found to be a key contributing factor to overdose deaths.

Question 5

What kind of symptoms do “All Arounders” produce when they are used/abused? What is an example of an “All Arounder”?

Answer 5

These drugs produce mixed symptoms when used or abused!

*Ecstasy, for example, is chemically very similar to cocaine and particularly methamphetamine (is a derivative of meth), but ecstasy produces hallucinogenic symptoms in addition to those on the “uppers: classic symptoms slide!

Question 6

What do we need to watch for when using Cathartic/emetic methods to prevent the absorption of a substance?

Answer 6

*Electrolyte imbalances/dehydration

Question 7

What is the main guide and basic principles of managing overdoses?

Answer 7

Remember, ABCDEs are still the guide and basic principles of managing overdoses still apply

Question 8

Examples of substances that are combined/used as polysubstance? (think more street drugs)

Answer 8

Some substances named included “alcohol, fentanyl, methadone, cocaine, carfentanil, hydromorphone, benzodiazepines, morphine, heroin, and methamphetamines (note that this is not an exhaustive list)”

Question 9

What do we need to watch for when using Gastric suctioning or lavage to prevent the absorption of a substance?

Answer 9

*Electrolyte imbalances/dehydration because we are removing fluids from the body

Question 10

Why would we use Benzos + IV sodium bicarbonate to treat Salicylate Overdoses?

Answer 10

Benzodiazepines (prevent seizures)

IV sodium bicarbonate - Alkalinization of Urine – promote urine excretion and correct acidosis- NaHCO3 +/- potassium to promote urinary excretion and correct acidosis (watch for alkalosis!)

Question 11

With any suspected overdose what is/are still our main initial focus?

Answer 11

With any suspected overdose, the principles of ABCDE still apply and are still our main initial focus

-Management of ABCDE!!!

Question 12

For Salicylate overdoses, what does Free drug in extracellular space lead to/cause? (think of 4 S+S)

Answer 12

Free drug in the extracellular space can lead to confusion, delirium, seizures, coma

Question 13

With acetaminophen overdoses, when is Hepatotoxicity/overdose more likely to occur?

Answer 13

Hepatotoxicity is more likely to occur with:
-Older adults
-Children/adults <50kg
-Malnourished patients
-Higher doses of ingestion
-Doses taken over shorter time frame
-Prexisting liver disease
-Taken with other hepatotoxic meds (amoxi-clav, carbamazepine, erythromycin

Hepatotoxicity is more likely with older adults, children and adults <50kg, malnourished patients, higher doses of ingestion, doses taken over a shorter time frame, patients taking medications that are also hepatotoxic, or preexisting liver disease.

Question 14

Treatment for opioid overdose?

Answer 14

Treatment: activated charcoal and naloxone (IM or IV, intermittent or continuous)

Question 15

S+S of a MILD Salicylate Overdose? (4 main ones), what is the Amount of ASA in Bloodstream at this level?

Answer 15

ASA Blood level: >150mg/kg

S+S: Nausea, vomiting, dizziness, tinnitus

Question 16

What makes polysubstance ( multiple substance) use dangerous for overdoses? What do they pose for health care providers?

Answer 16

Combining these substances makes fatal overdoses more likely and poses a significant treatment challenge for practitioners

Question 17

For Salicylate overdoses, what does the patients prognosis depend on?

Answer 17

Prognosis depends on patient age and amount consumed over time

Question 18

Examples of uppers, downers, and all arounders?

Answer 18

-“Uppers”
Cocaine, methamphetamine, caffeine, nicotine

-“All Arounders”
Ecstasy, marijuana, psilocybin (magic mushrooms), LSD, PCP, peyote

-“Downers”
Alcohol, opioids, benzodiazepines, tranquilizers

Question 19

what is the #1 reason for liver transplantation?

Answer 19

Acetaminophen overdoses

Question 20

What key intervention do we do if acetaminophen levels OR liver function tests increase? (does it need to be both tests?) When is it especially important we do these?

Answer 20

Key: Mucomyst IV initiated if acetaminophen levels OR liver function tests increased (doesn’t need to be both—esp important if time of ingestion is unknown)

Question 21

Example of Cathartic/emetic methods (medications) we can use to prevent the absorption of a substance?

Answer 21

-Epecac (vomiting) / Magnesium Citrate/sulfate (laxative)

Question 22

S+S of acetaminophen overdose? (Phase 4) how long does this phase last for?

Answer 22

Fourth phase: 5-7 days
Resolution of liver function, or Death

-You wither get better or die!

Question 23

What are Important questions to ask when trying to identify the substance for an overdose patient?

Answer 23

Important questions to ask: what was ingested, how much, at what time, have they taken this before?

Question 24

Treatment for Salicylate Overdoses? (what kind of treatment is necessary?) (6 different interventions)

Answer 24

Aggressive treatment necessary!!!
1.) Address ABCDEs
Possible intubation - Protect airway or control respirations

2.) IV fluids
Dehydration and dextrose (for decreased glucose levels) and possible dextrose containing fluids for glucose depletion

3.) IV sodium bicarbonate
Alkalinization of Urine – promote urine excretion and correct acidosis
-NaHCO3 +/- potassium to promote urinary excretion and correct acidosis (watch for alkalosis!)

4.) Activated charcoal (prevent further absorption) - Can be administered several times!

5.) Benzodiazepines (prevent seizures)

6.) Hemodialysis possible but uncommon

Question 25

What phase of acetaminophen overdose do the most sevre and worst symptoms come out? (how does the liver play a centeral role?)

Answer 25

Phase 3 - This is where the most severe symptoms come out!!!! The liver plays a central role in this process by balancing the uptake and storage of glucose via glycogenesis and the release of glucose via glycogenolysis and gluconeogenesis.

Question 26

Examples of overdoses with multiple substances!

Answer 26

Many patients overdose on multiple substances, intentionally or unintentionally E.g. high on cocaine and drunk on alcohol E.g. ecstasy laced with methamphetamine E.g. polypharmacy in the elderly

Question 27

S+S of phase 1 of an acetaminophen overdose? (7 of them) how long does this phase last for? What intervention do we do here to confirm acetaminophen levels?

Answer 27

First Phase – 1st 24 hrs -Nonspecific -Nausea, vomiting, anorexia, pallor, lethargy, diaphoresis, OR -Asymptomatic -Liver Function Tests usually normal -Blood levels of acetaminophen confirmed

Question 28

What does Acetaminophen overdoses result in?

Answer 28

Results in profound hepatotoxicity!!! -Metabolized in liver -Reactive/toxic metabolites that damage liver -#1 reason for liver transplantation

Question 29

S+S of a SEVERE Salicylate Overdose? (think of the big one!), what is the Amount of ASA in Bloodstream at this level? (7 main ones we went over in class)

Answer 29

ASA Blood level: >500mg/kg S+S: Hypotension, *metabolic acidosis*, cerebral edema, oliguria (low urine output), renal failure, coma, seizures

Question 30

What are some interventions we can do to prevent absorption? (what is the best timeframe for these interventions to be done ? Why?)

Answer 30

1.) Activated charcoal: NG into stomach Binds with substances to prevent absorption 2.) Gastric suctioning or lavage (pump the patients stomach) NG to suction (can’t remove large pills) Can instill fluids before suctioning *Electrolyte imbalances/dehydration 3.) Cathartic/emetic Give meds to induce vomiting or GI motility (emptying stomach of unabsorbed substances) -Epecac (vomiting) / Magnesium Citrate/sulfate (laxative) *Electrolyte imbalances/dehydration All best done within 60-minutes of ingestion - any longer and there is limited clinical benefit since the drug has been absorbed

Question 31

How does the liver play a centeral role with acetaminophen overdoses?

Answer 31

The liver plays a central role in this process by balancing the uptake and storage of glucose via glycogenesis and the release of glucose via glycogenolysis and gluconeogenesis.

Question 32

How do we Identify the Poison/Substance for an overdose?

Answer 32

Health history – what was ingested, how much, at what time, have they taken this before? Blood levels – etoh, THC, cocaine, etc.

Question 33

S+S of a MODERATE Salicylate Overdose? (7 of them), what is the Amount of ASA in Bloodstream at this level?

Answer 33

ASA Blood level: >250mg/kg S+S: Tachypnea, hyperpyrexia (>41C), sweating, dehydration, agitation, ataxia (poor muscle control), restlessness

Question 34

Ex of unintentional overdose?

Answer 34

Unintentional are more common, but not exclusive to, the elderly. Sometimes the patient can tell us what they took (especially if it is intentional), or at least give us clues (e.g. “I take a medication for my heart rate”—what is it and does their clinical picture correlate to taking too much of it?). Sometimes family members find empty bottles—more clues for us.

Question 35

What are important blood tests we run for acetaminophen overdoses?

Answer 35

Important blood tests: acetaminophen levels (illustrated on slide), AST/ALT (liver function)

Question 36

What are some interventions we can do to enhance excretion of a substance? (3 of them)

Answer 36

1.) Hemodialysis Rare Filter the blood to remove toxins Dialysis is rare and generally only for the critically ill, but it can filter the blood and potentially remove toxins 2.) Fluid loading Enhance kidney/liver function Excrete drug quicker (if via kidneys) Dilute drug Maintain kidney function 3.) Sodium bicarbonate -Salicylate and Phenobarbital overdoses -Alkalinazation of urine enhances excretion of acidic drugs -Given via IV In a select few cases, alkalinazation of the urine with sodium bicarbonate can enhance the excretion of acidic drugs. Aspirin overdose and phenobarbital overdose are the two cases where this could be used. Would be given IV with the goal of urine pH >7.5

Question 37

General S+S of Salicylate overdose?

Answer 37

Hyperventilation, sweating, and GI losses from vomiting/diarrhea cause dehydration (think metabolic acidosis), confusion, delirium, seizures, coma

Question 38

When looking at enhancing excretion, what kind of drugs does the alkalization of urine enhance?

Answer 38

Alkalinazation of urine enhances excretion of acidic drugs

Question 39

What medication/drug is the leading case of of intentional and unintentional overdose in adults? Why? (4 reasons why)

Answer 39

Acetaminophen!!!! Why: Because it's so common 1.) Found in many cough, cold, flu and decongestant medication 2.) Over the counter—easily available and accessible in overdose amounts 3.) Patients sometimes think that if 2 pills are good, 4 pills must be better 4.) Lack of recognition of the name acetaminophen (e.g. cold medicine without Tylenol in the name)

Question 40

What levels usually rise later in the course of an acetaminophen overdose?

Answer 40

LFTs (liver function tests) usually rise later in the course of overdose as acetaminophen levels decrease / are undetectable

Question 41

S+S of acetaminophen overdose? ( 5 of them) (Phase 3) how long does this phase last for?

Answer 41

Third phase: 72-96 hrs (3-5 days) -Acute hepatic necrosis -Fulminant hepatic failure -Most severe symptoms: 1.) Jaundice, 2.hypoglycemia, 3.stupor (Stupor is an excessively deep state of unresponsiveness, People can be aroused from it only briefly by vigorous stimulation, such as repeated shaking, loud calling, or pinching) , 4.hemorrhage, 5.liver failure 3 major conditions: Encephalopathy, renal failure, cardiomyopathy

Question 42

In Salicylate and Phenobarbital overdoses, what is given/what intervention is done to enhance excretion?

Answer 42

Sodium bicarbonate

Question 43

What is the main condition that Salicylate overdoses lead to/cause? Why?

Answer 43

METABOLIC ACIDOSIS due to the inhibiting of the Krep cycle which then leads to lactic acid build-up which then causes us to hyperventilate

Question 44

For Salicylate overdoses, what does the inhibit/interference with the Kreb cycle impact? (think outside/other then metabolic acidosis) What does it result in?

Answer 44

Liver can only metabolize so much salicylate per hour, eventually becomes overwhelmed and damaged by metabolites Interference with Kreb’s cycle also impacts glucose homeostasis: -glycogen depletion Gluconeogenesis, Catabolism of proteins and free fatty acids as a result - Low serum glucose clinically (hypoglycemia)

Question 45

What makes acetaminophen over doses unique/different?

Answer 45

Acetaminophen overdose is an interesting phenomenon, because it isn’t the drug itself that kills the person, and it doesn’t kill them right away—they actually start to feel better in the 1-3 day range, However, they may have caused irreparable liver damage at this point, and so they start to decline a few days later and may still die.

Question 46

What is the max daily dose for acetaminophen? At what does does overdose symptoms begin to occur?

Answer 46

4g max daily dose Overdose symptoms start at 10g – as few as 15 Tylenol Arthritis pills (650mg each).

Question 47

For Salicylate overdose, can we administer activated charcoal several times?

Answer 47

YES

Question 48

What are the 5 goals/Phases of Treating Overdoses / Chemical Injuries?

Answer 48

1.) Assess and manage ABCDE’s 2.) Identify poison/substance 3.) Prevent absorption 4.) Counteract the substance 5.) Enhance excretion

Question 49

Why is activated charcoal called activated charcoal?

Answer 49

If they ask, it’s called activated charcoal because it is treated with oxygen to open up microscopic pores in the carbon that act like a sponge

Question 50

What are Toxidromes?

Answer 50

Toxidromes : a group of signs and symptoms constituting the basis for a diagnosis of poisoning/overdose *A toxidrome is a constellation of findings, either from the physical examination or from ancillary testing, which may result from any poison/overdose. group of symptoms based on below classifications -Acetaminophen -Salicylates -“Uppers” Cocaine, methamphetamine, caffeine, nicotine -“All Arounders” Ecstasy, marijuana, psilocybin (magic mushrooms), LSD, PCP, peyote -“Downers” Alcohol, opioids, benzodiazepines, tranquilizers

Question 51

Other than Respiratory depression, Pupil constriction, Bradycardia, Hypothermia, and Coma, what is "other" S+S are there for alcohol intoxication? (7 main ones and also think about CIWA!!)

Answer 51

-euphoria, -Inhibition (a feeling that makes one self-conscious and unable to act in a relaxed and natural way) -loss of coordination, -poor judgment, -memory loss, -nausea/vomiting, -lethargy

Question 52

What intervention is essential to enhance liver and kidney function? (Hint: it enhances excretion)

Answer 52

In order to enhance liver and kidney function, ensuring adequate hydration (oral or more likely IV fluids) is essential

Question 53

Classic S+S for Uppers? (7 main ones) What other drug are these symptoms true for as well?

Answer 53

-Tachycardia -Hypertension -Dilated pupils -Diaphoresis -Hyperthermia -Agitation -Combativeness -(these are true of ecstasy as well)

Question 54

For Salicylate overdoses, what blood tests would we run? Why do we need to use blood level tests cautiously?

Answer 54

Use blood test levels cautiously—they do not always accurately reflect toxicity. You will do a series of blood salicylate levels and ABGs to watch that results are trending towards normal

Question 55

What does Salicylate overdoses inhibit/lead to? What else occurs?

Answer 55

Inhibition of Kreb’s cycle -> this activates anaerobic metabolism  lactic acid buildup -> meatabolic acidosis! Metabolic acidosis - Hyperventilation Glycogen depletion also occurs - hypoglycemia

Question 56

S+S of acetaminophen overdose? (Phase 2) how long does this phase last for? What is important to note/remeber for this stage?

Answer 56

Second phase – 24-72 hrs (1-3 days) -Patient feels better -Elevation in liver function enzymes *AST and ALT, bili, INR(PT) elevated -RUQ pain with nausea/vomiting *However, they may have caused irreparable liver damage at this point, and so they start to decline a few days later and may still die.

Question 57

Assuming there are no threats to life from ABCDE’s, what is the next thing/step we do when treating overdoses? Why?

Answer 57

Assuming there are no threats to life from ABCDE’s, the next thing to do is to try to identify the substance (or substances) that the patient has in their system. This allows us to direct our treatments more specifically

Question 58

What is the antidote for acetaminophen overdoses?

Answer 58

acetylcysteine (mucomyst)

Question 59

What are Cocaine, methamphetamine, (as well as ecstasy) considered? What do they mimic and activate? Our patients and their bodies are?

Answer 59

Cocaine, methamphetamine, as well as ecstasy, are all sympathomimetics They mimic and activate the sympathetic nervous system. Patients and their bodies are high energy

Question 60

What is the goal of the Pre-toxic, Toxic, and Resolution Phase when treating overdoses? (remeber, these apply to the 5 prinicples/goals of treating an overdose)

Answer 60

Pre-toxic phase: Goal – limit further absorption or hasten drug elimination. Toxic Phase: Goal - Minimize tissue/organ injury Resolution Phase: Goal – Regain homeostasis in organ function and prevent further drug poisoning