Toxicology

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giddyupp
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54618
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Toxicology
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2011-01-13 13:18:32
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Toxicology PHPR522
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Toxicology
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  1. What is the number to the Poison Control Center?
    1-800-222-1222
  2. What are the names of 4 toxicology references?
    • Casarett & Doull's Toxicology: The Basic Science of Poisons
    • Ellenhorn's Medical Toxicology: diagnosis & Treatment of Human Poisoning
    • Goldfrank's Toxicology Emergencies
    • Poisindex (Micromedex)
  3. What is the first thing you should do when there is a patient with some sort of toxic exposure?
    • (Determine if it's safe to approach)
    • stabilize the patient (ABC's)
  4. After stabilizing the toxicology patient, what is the next step?
    • Gather a history:
    • substance
    • time of exposure
    • dose
    • duration of exposure
    • past medical history
  5. After gathering a toxicology patient's history, what is the next step?
    Evaluate the situation - read the toxidromes if present
  6. What is a toxidrome?
    a constellation of s/sx that suggest a specific class of poisoning
  7. What are the effects of sympathomimetics?
    • increase BP
    • increase HR
    • slight increase in temp
    • dilate pupil
    • hyper alert
    • increase reflexes
    • tremor
  8. What are the effects of anticholinergics?
    • may increase BP
    • increase HR
    • increase temp
    • dilate pupil
    • altered mental status
    • decrease bowel sounds
    • decrease urine output
  9. What are the effects of cholinergics?
    • may decrease BP
    • decrease HR
    • same temp
    • pinpoint pupil
    • altered mental status
    • increase bowel sounds
    • increase bronchial sounds
  10. What are the effects of opioids?
    • decrease BP
    • decrease HR
    • decrease temp
    • pinpoint pupils
    • decrease level of consciousness
    • decrease bowel sounds
    • rales (late)
  11. What are the effects of sedative/hypnotics?
    • decrease BP
    • decrease HR
    • decrease temp
    • miosis or mydriasis
    • altered mental status
    • decrease resp. rate
    • decrease peristalsis
    • hyporeflexia
  12. What labs should you look at in a toxicology patient?
    • anion gap: Na, Cl, HCO3
    • osmol gap: Na, glucose, BUN
    • blood gases
    • albumin
    • INR
    • (Methadone does not show up on opioid tests)
  13. How do you remove the toxic source from the patient?
    • Ipecac
    • gastric lavage
    • single-dose activated charcoal
    • multi-dose activated charcoal
    • cathartics
    • whole-bowel irrigation
    • diuresis
    • hemodialysis/hemoperfusion
    • antidotes
  14. Who should not recieve ipecac?
    • no gag reflex
    • lethargic, comatose, convulsing
    • expected to become unresponsive in 30 min
    • caustic, corrosives, ammonia, bleach
    • children
    • erlderly
    • debilitated
    • pregnant
  15. What are the limitations of gastric lavage?
    • ingestion of corrosive or hydrocarbon
    • must have been ingested in last hour
    • aspiration pneumonitis
    • laryngospasm
    • injury to esophagus and stomach
    • hypothermia
    • fluid and electrolyte imbalance
  16. What are the risks of activated charcoal?
    emesis and aspiration
  17. What substances does single-dose activated charcoal not work for?
    • iron
    • lead
    • lithium
    • simple alcohols
    • corrosives
  18. What substances can multi-dose activated carbon work for?
    • CBZ
    • dapsone
    • phenobarb
    • quinine
    • theophylline
  19. When does whole-bowel irrigation ever get used?
    • when pts swallow condoms containing cocaine:
    • GoLytely for 4-12 hours
  20. For which medications is hemodyalisis life-saving?
    • methanol
    • ehylene glycol
    • salicylates
    • ethanol
    • theophylline (usually use charcoal)
    • lithium (<4 = chronic, <6 = acute, <2.5 = with sx)
  21. What is the antidote for acetaminophen toxicity?
    • N-acetylcysteine
    • maintains or restores hepatic concentrations of glutathione
  22. What is the antidote for anticholinesterase insecticides?
    atropine
  23. What is the antidote for rattlesnake, cottonmouth, and copperhead poisoning?
    crotalidide antivenin
  24. What is the antidote for black widow poison?
    Latrodectus mactans antivenin
  25. What is the antidote for coral snake poisoning?
    Micrurus fulvitus antivenin
  26. What is the antidote for Calcium Channel Blockers?
    • calcium gluconate - increases intracellular levels of Ca
    • calcium choloride - increases intracellular levels of Ca
    • glucagon - increases production of cAMP in increased intracellular Ca
  27. What is the antidote for lead poison?
    • Calcium disodium EDTA
    • dimercaprol
  28. What is the antidote for plutonium poisoning?
    calcium trisodium pentate
  29. What is the antidote for cyanide?
    cyanide antidote kit
  30. What is the antidote for iron?
    • deferoxamine
    • chelation
  31. What is the antidote for digoxin?
    • digoxin immune Fab
    • binds digoxin
  32. What is the antidote for arsenic?
    dimercaprol
  33. What is the antidote for mercury?
    dimercarol
  34. What is the antidote for gold?
    dimercaprol
  35. What is the antidote for ethylene glygol?
    • ethanol
    • fomepizole - inhibits alcohol dehydrogenase
  36. What is the antidote for methanol?
    • ethanol
    • fomepazole inhibits alcohol dehydrogenase
  37. What is the antidote for Beta blockers?
    • glucagon
    • increases production of cAMP in increased intracellular Ca
  38. What is the antidote for methemoglobinemia?
    methylene blue
  39. What is the antidote for opioids?
    • naloxone
    • antagonize opioid receptors
  40. What is the antidote for sulphonyl urea?
    • octreotide acetate
    • lowers insulin levels
  41. What is the antidote for organophosphate insecticides?
    pralidoxime
  42. What is the antidote for anticholinergics?
    • physostigmine
    • inhibits cholinesterase
  43. What is the antidote for radioactive iodine?
    potassium iodide
  44. What is the antidote for isoniazid?
    • pyridoxine HCl
    • replaces vitamin B6
  45. What is the antidote for TCA's?
    • sodium bicarb
    • increases clearance of acidic meds
  46. What is the antidote for salicylates?
    • sodium bicarb
    • increases clearance of acidic meds
  47. What is the antidote for benzodiazepines?
    • flumazenil
    • antagonizes BDZ receptors
  48. What is the classic symptom triad of salicylate toxicity?
    • hyperventilation
    • tinnitus
    • GI disturbances (N,V)
  49. What are the sx of mild-moderate salicylate toxicity?
    • acid-base abnormalities
    • fever
  50. What are the sx of severe salicylate toxicity?
    • hyperthermia
    • altered mental status
    • non-cardiac pulmonary edema
    • hypoglycemia
    • seizures
    • coma
  51. What level of salicylates causes toxicity?
    >40 mg/dL
  52. At what point should you refer a patient to the hospital for salicylate toxicity (dose)?
    • 150mg/kg or more
    • 6.5g of aspirin
    • more than a lick of oil of wintergreen in <6yo
    • more than 4mL of oil of wintergreen in 6yo and up
  53. Should emesis by induced in cases of salicylate overdose?
    no
  54. When should blood levels of salicylate be checked?
    • at least 6h after ingestion
    • continue checking q 2h until level starts to decline
  55. What should be monitored in salicylate overdose?
    • salicylate levels after 6h, then q 2h
    • BUN/SCr
    • blood glucose
    • blood gases
    • electrolytes
  56. What supportive care should be given to salicylate overdoses?
    • ABCs@!!!!
    • correction of volume depletion
    • correction of metabolic abnormalities
  57. When should gastric lavage/multi-dose activated charcoal be used for salicylate overdose?
    • if pt presents within 1-2h post-ingestion
    • for ACUTE toxicity only, not chronic
  58. How do you treat salicylate toxicity?
    • sodium bicarbonate
    • also need to replace K+ loss
    • hemodialysis if:
    • acidosis unresponsive to alkalinization
    • renal failure
    • salicylate level > 100 mg/dL
    • persistent, severe CNS symptoms
    • pulmonary edema
  59. How do you administer sodium bicarb for salicylate overdose?
    • 1-2 mEq/kg IV bolus, then
    • continuous infusion of D5W + NaHCO3 until urine pH reaches 7.5-8.0 and plasma pH= 7.45-7.55
    • (increases renal clearance by 10-20 fold and significantly reduces half-life)
  60. What are the sx of benzodiazepine toxicity?
    • general depression of the CNS
    • drowsiness
    • slurred speech
    • ataxia
    • respiratory arrest
    • coma
  61. How do you manage BZD toxicity?
    • determine time and dose of OD
    • duration of BZD use
    • Co-ingestants
    • ABC's (often the only thing done to manage BZD overdose, especially with mixed ingestions, unknown hx, or CI exist)
    • Gastric lavage:
    • large amount ingested or co-ingestions
    • most effective in first hour post-dose
    • activated charcoal:
    • effectively binds BZDs and should be administered in most situations
    • Flumazenil
  62. How does flumazenil work?
    • competetive inhibition of BZD receptors
    • onset 1-2 min
  63. How is flumazenil dosed?
    • 0.2 mg IV over 30s
    • if no response:
    • 0.3 mg IV over 30s
    • if still no response:
    • 0.5 mg IV over 30s q 1min up to 3mg
    • if partial response at 3mg, keep dosing up to 5mg
    • repeat doses may be given q 20min if re-sedation occurs
  64. When is Flumazenil CI?
    • hypersensitivity
    • pt using BZD for life-threatening condition
    • TCA co-administration (increases risk of seizures)
  65. What are some cautions for the use of flumazenil?
    • always ensure proper airway mgmt
    • take necessary measures to secure airway, ventilation, and IV access - some pts may attempt to pull them out upon arousal
    • use w/ caution in alcoholics
  66. What should be monitored during flumazenil tx?
    • re-sedation and respiratory depression for up to 120 min
    • withdrawal sx or seizures
  67. What are the SE of flumazenil?
    • dizziness
    • injection site pain
    • diaphoresis
    • HA
    • abnormal or blurred vision
  68. What are the sx of CCB toxicity?
    • bradycardia
    • hypotension
    • N
    • V
    • dizziness
    • lethargy
    • seizures
    • coma
    • unresponsiveness
    • depressed reflexes
    • AV block
    • intraventricular conduction defects
    • ventricular dysrhythmias
  69. What should be monitored in CCB OD?
    • arterial blood gases
    • electrolytes
    • BUN/SCr
    • ECG
    • pulse
    • hypoxia
    • pneumonia
  70. How much diltiazem, nifedipine, or verapamil may be life-threatening?
    1g
  71. What should be avoided in treating CCB OD?
    ipecac - risk of seizures and coma
  72. How do you manage CCB OD?
    • ABC's
    • gastric lavage with a single dose of charcoal (if within 1-2h of ingestion)
    • whole-bowel irrigation w/ polyethylene glycol electrolyte solution (SR tablet OD)
    • adjunctive tx for hypotn, bradycardia, and shock
    • CaCl bolus test dose of 10-20 mg/kg up to 1-3g preferred for serious toxicity
    • glucagon bolus of 0.05-0.20 mg/kg, 3-5mg over 1-2 minutes initially
  73. What are the brand and generic names of 2 short-acting BZD's?
    • oxazepam (Serax)
    • alprazolam (Xanax)
  74. What are the brand and generic names of 2 long-acting BZD's?
    • chlordiazepoxide (Librium)
    • diazepam (Valium)
  75. What are 3 ASA-containing drugs?
    • Fiorinal
    • Aggrenox
    • Percodan
  76. What are the 3 underlying mechanisms of cardiac toxicity in CCB OD?
    • vasodilation through relaxation of smooth muscles
    • decreased contractility by action on cardiac tissue
    • decreased automaticity and conduction velocity through slow recovery of Ca channels
  77. What are the brand and generic names of 4 CCB's?
    • diltiazem (Cardizem)
    • verapamil (Isoptin)
    • nifedipine (Procardin)
    • nicardipine (Cardine)
  78. What are the concurrent factors that may worsen CCB-induced cardiac complications?
    • concurrent ingestion of BBL, digoxin, class I antiarrhythmics
    • pt on chronic CCB tx and overdoses
    • elderly or pt w/ underlying cardiac disease
  79. Which elimination measures have not proven effective for CCB OD?
    • hemodialysis
    • multi-dose activated charcoal
    • ipecac
  80. How is acetylcysteine dosed?
    • PO:
    • 140 mg/kg loading dose
    • 70 mg/kg q 4h x 17 doses
    • 72h total timeframe
    • IV:
    • 150 mg/kg in 200ml D5W over 1h
    • 50 mg/kg in 500ml D5W over 4h
    • 100 mg/kg in 1L D5W over 16h
    • 21h total timeframe
  81. How is digibind dosed?
    • (serum concentration x wt)/100 = #vials
    • - or -
    • (mg ingested x bioavailability)/0.5mg of digoxin bound per vial
    • unknown amount = 10 vials, repeat with 10 vials as needed
    • life threatening = 20vials STAT

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