These drugs/classes cause miosis COPS Cholinergics, clonidine Opiates, organophosphates Phencyclidine, phenothiazine, pilocarpine Sedatives (barbiturates) These drugs/classes cause mydriasis AAAS Anticholinergics (atropine) Antihistamines Antidepressants (cyclic) Simpathomimetics (amphetamine, cocaine, LSD) These drugs/classes cause diaphoresis SOAP (if you're sweaty you need to SOAP up) Simpathomimetics Organophosphates Aspirin (salicylates) PCP Causes of red skin CO boric acid Causes of blue skin methemoglobinemia cyanosis Activated charcoal is ineffective or contraindicated in the following CHEMICAL CamP Caustics Hydrocarbons (and most water soluble compounds) Electrolytes Metals Iron Cyanide Alcohols Lithium Camphor Phosphorus How do you treat acetaminophen ingestion? activated charcoal check APAP level 4 hours after ingestion compare to Rumack-Matthew nomogram if toxicity possible, IV NAC or PO acetylcysteine within 8 hours of ingestion follow AST/ALT/PT/PTT (not APAP levels) consider coingestions Signs/symptoms of anticholinergic ingestion dry as a bone (decreased sweating and urine output) red as a beet blind as a bat (mydriasis) mad as a hatter (agitation, seizure) hot as a hare (hyperthermia) treatment of anticholinergic ingestion activated charcoal physostigmine is contraversial treatment of carbamazapine ingestion activated charcoal and supportive care ideally check levels 2-4 hours post ingestion follow levels and renal function (delayed peak 24-72 hours) What does clonidine ingestion mimic? How is it treated? Mimics opioid toxicity activated charcoal and whole bowel irrigation Serial ECGs and blood gases to dictate supportive measures resolves in 24 hours what doses of ibuprofen are/aren't toxic? treatement? <100mg/kg not toxic >400mg/kg causes seizures and coma Rx: activated charcoal and supportive care toxic dose of iron stages of toxicity treatment >60mg/kg of elemental iron is severe 1. GI stage (30min-6hr) 2. stability (6-24hr) 3. systemic toxicity (w/in 48 hours) (remember AG met acidosis) 4. hepoatotoxicity (2-3 days) 5. GI/pyloric scarring (2-6 weeks) treat levels greater than 500mcg/ml (drawn ideally at 4 hours) with IV deferoxamine PO deferoxamine and activated charcoal do not work How do you treat phenothiazine ingestion What type of symptoms will be seen Activated charcoal All symptoms dose dependent mild: anticholinergic, disruption of CNS, temp, BP mod: cogwheel rigidity sev: cardiac conduction abnormalities Also dose dependent dystonic reaction Treat with IV/IM diphenhydramine What topical analgesic ingrediant can cause salicylate poisoning? oil of wintergreen a few points on Dx and Rx of salicylate ingestion respiratory alkalosis AG met acidosis low glucose, low K, dehydration Ferric chloride plus any salicylate turns urine purple/brown activated charcoal (surgery if tablet bezoar) alkalinize urine with bicarb to enhance elimination consider dialysis laboratory signs of theophylline ingestion and treatment hyperglycemia hypercalcemia hypokalemia hypophosphatemia met acidosis treat with repeated activated charcoal and consider dialysis Pneumonic for tricyclic ingestion signs TriC A (CCCA) Coma Convulsions Cardiac dysrhythmias Acidosis Cardiac effects of tricyclics tachycardia, including VT hyper/hypotension widened QRS prolonged QT Treatment of TCA ingestion NaHCO3 to alkalinize serum/prevent dysrhythmias Lidocaine if dysrhythmias occur Activated charcoal symptoms of CO poisoning and clinical actions headache, malaise, nausea cherry red skin/lips check serum CO because pulse ox can be falsely normal Triad seen in methanol ingestion treatment visual complaints (snowstorm) abdominal pain metabolic acidosis (high AG without lactica acidosis or ketonuria) Rx: NaCO3, ethanol or fomepizole (to competitively inhibit alcohol dehydrogenase), folate (for formic acid metabolism), dialysis if needed. What is ethylene glycol metabolized to? glycolic and oxalic acids oxalic acid chelates calcium leading to Ca-oxalate crystals in urine (urine may flouresce with Woods lamp) signs/symptoms of ethylene glycol ingestion appears drunk: N/V, drowsiness, slurred speech AG met acidosis high osmolal gap possible hypocalcemia Treatment for ethylene glycol ingestion IV ethanol or fomepizole (competitively inhibits alcohol dehydrogenase) thiamine and pyridoxine to shunt metabolism to less toxic metabolites hemodialysis if needed treat hypocalcemia if present organophospate exposure signs/symptoms (cholinesterase inhibiters --> cholinergic toxidrome) DUMBELS diarrhea urination miosis bronchospasm/bronchorrhea emesis lacrimation salivation (miosis + all bodily fluids) confirmatory test and Rx for organophosphate poisoning decreased RBC cholinesterase activity confirms Dx (don't wait for test result) wear protective clothing decontaminate child ATROPINE Pralidoxime (2-PAM)