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200 Cards in this Set
- Front
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What toxic causes an increased osmolol gap? (6)
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1. Acetone
2. Isopropanol 3. Methanol 4. Ethylene glycol 5. Mannitol 6. Ethanol (MOST COMMON_ |
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How do you calculate the osmolal gap?
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2Na + BUN/2.8 +Glu/18 +EtOH/4.6
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What is the 'saying' for anticholinergics?
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"Mad as a hatter, hot as a hare, dry as a bone, blind as a bat, and red as a beat"
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What are the symptoms for anticholinergics?
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Increased HR and possible Increased BP
Dry flushed skin Dilated pupiles (Mydriasis) Agitation Hyperthermia Hallunications/ seizures/sedation/ coma Urinary retnation |
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How does anticholinergic differ from sympathomymetic toxidrome?
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Urinary retention and lack of diaphoresis
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Types of drugs in anticholinergic toxidrome?
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Antihistamines, jumsonweek, atropine, TCAs, antiparkisonian agens, some antipsychotis, skeletal muscle relacants, and certain mushrooms
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Treatment for anticholinergic toxidrome?
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supportive care with benzodiazepines, physostigmine (except TCA), sodium bicarbonate for widened QRS
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What two medications do you avoid in anticholinergic toxicity?
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Phenothiazines and butyphenones (haldol)
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How do you treat ventricular dysrhthmias in anticholinergics and what medicine do you avoid?
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Give: amiodarone or lidocaine
NO: Procainaminde |
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What is the pathophysiology in sympathomimetic toxidrome?
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Catecholamine excess
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What are the symptoms in sympathomimetic toxidrome?
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Increased heart rate/ BP
Diaphoresis Dilated pupils Agitation Seizures/ AMS Hyperthermia Piloerection Cardiac dysrhytmias |
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Whater are causes of sympathomimetic toxidrome?
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Cocaine, amphetamines, theophylline, OTC decongestants, caffeine
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What are treatments for sympathomimetic toxidromes?
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Benzodiazepines, hydration, and cooling
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How do you distinguish an anticholinergic toxidrome from a sympathomimetic one?
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Anticholinergic = dry skin
Sympathomimetic = diaphoresis |
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What are the symptoms of an opioid toxidrome?
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Miosis, AMS, respiratory depression
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Causes of opioid toxidrome?
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Heroid, Morphine, codeine, diphenoxylate, and fentanyl
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Treatment for opioid toxidrome?
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Naloxon 0.05 - 0.1mg IV with incremental dose as needed until respiratory rate ≥12
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What toxidrome dose clonidine mimic?
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opioid toxidrome
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What is the pneumonic for cholinergic toxidromes?
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SLUDGE (salivation, lacrimation, urination, defication, GI upset, emesis) PLUS killer Bs (bronchorrhea, bradycardia, and bronchospasm)
DUMBBELS (diarrhea, urination, miosis/muscle waisting, bradycardia, bronchorrhea, emesis, lacrimation, salivation) |
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What are the four systems (pathophysiology) of the cholinergic toxidromes?
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1. Parasympathetic system (muscarinic) - leaders to SLUDGE and bradycardia
2. Sympathetic (due to AcH nicotine crepetos in sympathtis ganglion and adrenal medulla 3. Skeletal Muscles (nicotinic): muscle fasciculations, weakness, respiratory paralysis => failure 4. Brain: delirium, seizures, confusion |
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What are causes of cholinergic toxidromes?
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organophosphates, insecticides, physostigmine, pilocarpine, mushrooms, nerve agenst
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Treatment for cholinergic toxidromes?
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secure airway/ventilate
atropin (muscarninc symptoms) until secretions are dry 2 PAM (nicotinic symptoms) |
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What is helpful in diagnosing a cholinergic toxidrome?
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Cholinesterase level
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What is considered a toxic dose ingestion of acetaminophen?
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>150 mg/kg
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What is the Rumack-Matthew nomogram?
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Nomogram used in tylenol toxicity - asses risk of toxicity in acute single ingestion with serum level and known time of ingestion
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What is the treatment for tylenol overdose?
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NAC (>140 mg/kg every 4 hours)
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What is the mechanism for NAC
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NAC provides a cofactor needed to make inert metabolites of APAP
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What type of acidosis does ethanol produce?
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IT DOES NOT!!!
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What is the triad of delirium tremens
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Confusion, fever, tachycardia
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What is the treatment for ethanol intoxication?
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Fluids, thiamine (B1), Multivitamins, MG, folic acid, and benzudiazapiens
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Symptoms of Wernicke's encephalopathy?
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Oculomotor crises, CN VI palsy (lateral rectus), nystagmus, ataxia, global confusion
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Korsakoff's psychosis
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retrograde amnesia and confabulation
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What type of acidosis does methanol produce?
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anion gap acidosis
increased osmolal gap |
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Examples of methanol
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paint thinner, window washer solvent, wood alcohol, gas tank additive
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What are the symptoms of methanol ingestion?
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(delayed 12-18hrs) Seizures, respiratory failure, N/V, pancreatitis, and blindness
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What is the toxic metabolite of methanol?
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Alcohol dehydrogenase
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Treatment for methanol?
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Fomepizole (4-methypyrazole)
EtOH Dialysis and bicarbonate with severe acidosis refractory to 4-MP or ethanol therapy |
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Examples of ethylene glycol?
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Antifreeze, pain, solvents
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Symptoms of ethylene glycol ingestion?
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CNS depression, intoxication w/o alcohol odar, anion gap acidosis, anuria, and increased osmolol gap
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Two metabolite producs of ethylene glycol breakdown?
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Oxalic acid (precipitates into stones)
Glycolic acid (produces profound acidosis) |
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Treatment for ethylene glycol
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Formepizole
IV alcohol Dialysis for severe acidosis or high blood levels >25 mg/dL |
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Examples of isopropyl alcohol?
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Rubbing alcohol
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Type of acidosis produced by isopropyl alcohol?
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none! +osmolol gap and +ketones
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What does the body convert isopropyl alcohol too?
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Acetone
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Treatment for Isopropyl alcohol?
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supportive care and hemodialysis if needed
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Symptoms for isopropyl alcohol?
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Gastritis, CNS depression, hypotension (severe cases)
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Symptoms and toxic syndrome from cocaine/amphetamine overdose?
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Sympathomimetic syndrome
Hypetension, tachycardia, seizures, dilated pupils, hyperthermia, agitation, DIAPHORESIS |
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Treatment for cocaine overdose
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Benzodiazepines, lorazepam/ cooling
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Disulfiram reaction
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Alcohol + metronidazole
Flushed face, neck, and trunk; marked diaphroesis, N/V/ headache. Severe - hypotension, seizures, dysrrhytmias.; |
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Physostigmine is used as a treatment in what toxidrome and how does it work?
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Anticholinergic toxidrome
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When would you NOT use physostigmine?
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TCA overdose
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Who do you diagnose arsenic poisoning?
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24 hour urine
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Treatment for arsenic poisoning?
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BAL and DMSA (chelation)
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Chronic effects of arsenic toxicity?
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Anemia, metallic taste, neuropathy, and horizonal Meis lines in nails, and alopecia.
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Meis lines
Arsenic, thallium, and other heavy metal toxicity |
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Symptoms of barbiturate overdose?
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Miosis, hypotension, CNS depression, cutaneous bullae (bad prognosis)
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Treatment for barbiturate overdose?
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Lavage, charcoal, urine alkalinzation for longer-acting agents, and hemodialysis
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Symptoms of benzodiazepine overdose
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Respiratory depression, ataxia, hypotension, hypothermia, and coma
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Beta-blocker overdose symptoms
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Hypotension, bradycardia, AV block
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Antidote for beta-blocker overdose:
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glucagon 5-10 mg IV, Insulin +dextrose therapy;
Others: pressors, atropine, pacemakers |
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Calcium channel overdose
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Bradycardia, hypotension, conduction delay
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Therapy for calcium channel overdose
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calcium carbonate/calcium gluconate ; insuline and glucose rescue therapy
other treatments: fluids, pacemaker, and pressors |
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What systemic symptoms can timolol eye drops cause?
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Hypotension, bradycardia, AV block
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What type of cardiovascular drug is the leading cause of death in an overdose situation?
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Calcium channel blockers
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What should be avoided in hypertensive crises in cocaine chest pain?
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Beta blockers - can cause unooposed alpha effect and worsen vasoconstriction
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Carbamazepine
a. classic triad of symptoms (3) b. severe symptoms (3) |
a. Dizziness, ataxia, and nystagmus
b. Coma, Seizures, and arryhthmia |
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Treatment for carbamazepine overdose?
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Multidose charcoal, hemoperfusion, and sodium bicarbonate for widened QRS
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Leading cause of toxic death?
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Carbon Monoxide poisoning
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Carbon Monoxide shifts the oxyhemoglobin dissociation curve which direction?
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Left
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Symptoms of Carbon Monoxide
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Headache, nausea, confusion, coma, seizures, no cyanosis (family with dog)
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Measure Carbon Monoxide toxicity? (lab)
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carboxyhemoglobin level
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Half life of Carbon Monoxide:
a. air b. 100% oxygen c. HBO |
a. 320 min
b. 90 min c. 20 min |
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What does Carbon Monoxide HBO therapy prevent?
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delayed neuropsychiatric syndrome (CNS injury)
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Treatment for Carbon Monoxide toxicity?
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100% oxygen and HBO
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What does the pulse ox and ABG show in an Carbon Monoxide poisoning?
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Both are normal!!!
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Caustic acids cause what type of necrosis?
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Coagulation necrosis
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Coagulation necrosis
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(Caustic acids): Eschar formation stops progression
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Caustic alkali cause what type of necrosis?
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Liquifaction necrosis
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What thickness injury is liquifaction necrosis?
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Full thickness
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Which is more common caustic acid or alkali ingestions?
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Alkali
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What needs to be done within the first several hours of a caustic ingestion
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Endoscopy
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What treatments are contraindicated in caustic ingestions?
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Charcoal, lavage, and blind nasotracheal intubations
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Hydroflouric acid treatment
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Milk and Magnesium citrate by NGT
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Solid alkali ingestion
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Dilute with warm water or milk
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What does chlorine gas smell like?
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Yellow-green gas that has a pungent odor
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Chlorine gas affects what part of body?
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Moist membranes
Formation of acid and oxidants on moist membranes, immediate ocular and upper airway irritation |
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Treatment for chlorine gas?
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Supportive care and humidified oxygen
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What is the mechanism of action for clonidine?
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Alpha-adrenergic agonist
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What are the central and peripheral effects of clonidine?
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Central: Hypotension/ bradycardia
Peripheral: Hypertension followed by hypotension |
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Clonidine CNS/ Cardiac symptoms in overdose?
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CNS: lethargy, apena, miosis, decreased reflexes
Cardiac: Bradycardia, hypotension, AV block |
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What cardiac drug mimics an opiate overdose?
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Clonidine : coma, miosis, respiratory depression
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Treatment for clonidine overdose
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Fluids, atropine, and pressors
Also Naloxone can be helpful |
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What is the pathophysiology behind cyanide toxicity?
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CN binds to cytochromes that cause anaerobic metabolism and lactic acidosis
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What groups are susceptable to CN toxicity?
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Jewelers, chemical labs, apricot pits, smoke inhalation (burning plastic)
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Odor of CN?
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Bitter almonds
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PaO2 and oxygen sat with CN toxicity?
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NORMAL
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Symptoms of CN toxicity?
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Abdominal pain, nausea, coma, bradycardia, acidosis, sudden CV collapse
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Lab finding in CN toxicity?
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Lactic acidosis with anion gap
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Treatment and goal of treatment of CN toxicity?
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Create a controlled state of methemoglobinemia to compete for CN
Hydoxocobalamin (Cyanokit) and nitrates that create metHgB that bind CN |
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What are the nitrates that create metHgB that bind CN?
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Amyl nitrite (inhaled)
Sodium nitrite IV Sodium thiosulfate IV |
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Pathophysiology behind digitalis toxicity?
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Inhibits Na-K-ATPase pump; causing K leaking extracellularly and Na/Ca leak intracellularly
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Symptoms of digitalis toxicity?
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Hyperkalemia, AV blocks, arrhythmias
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Antidote for digitalis toxicity?
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Digibind (FAB fragments) - start with 5 vials if level is unknown
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Most common digitalis dysrrhythia in digitalis toxicity?
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PVCs
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What is contraindicated in digoxin toxicity?
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Calcium
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Common names for GHB?
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Date rape drug and rave drug
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What are the symptoms for GHB?
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CNS depressant, rapid onset, lower gag reflex, severe repiraory depression and quick resolution within 8 hours
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Treatment for GHB?
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Airway control
NO ROLE FOR: naloxone, flumazenil, or physostigmine |
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Name common types of hallucinogens?
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LSD, mushrooms, mescaline, morning glory seeds, designer drugs
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Pathophysiology of Hallucinogens?
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Serotonin-like agents (agonist at 5-HT22 receptors)
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Hallucinogens produce similar symptoms to what toxidrome and what are they?
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Sympathomimetic (tachycardia, hyperthermia, and dilated pupils)
Other symptoms: psychosis and anxiety |
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Treatment for hallucinogens?
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Sedation, benzodiazepines, quite environment, haloperidol (haldo)
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What type of mushrooms account for most deaths?
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Amanita mushrooms
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Who are exposed commonly to HF?
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Jewelers, metal cleaning products, glass etching,
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How does HF act and what does it target?
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Weak acid that behaves like a strong alkali and can cause deepcutaneous injury and systemic HYPOCALCEMIA
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Treatment for HF?
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Calcium gluconate (NOT CA CHLORIDE) gel applied topically, intradermal infiltrate, or arterial infusion;
[Calcium binds with flouride ion that stops the pain] |
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When do you lavage in hydrocarbon exposure?
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CHAMP
Camphor Halogenated (carbon tet, PVC, vinyl chloride) Aromatic (benzene, toulene, xylene) Metals (leaded gas) Pesticides |
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When do findings of hydrocarbons typically show up on chest x-ray?
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4-6 hours post exposure
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Sudden sniffers death (hydrocarbon exposure)
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Ventricular arrhythmia cause by cardiac sensitization by endogenous catecholamines
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Lindane/ Kwell toxicity
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Treatment in scabies - a chlorinated hydrocarbon that can cause mental status changes and seizures
Avoid in young children and pregnancy |
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Hydrogen Sulfide odor
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rotten egg odor
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Pathophysiology behind Hydrogen sulfide?
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Inhibits cellular respiration, blocks cytochrome oxidase (leading to anaerobic metabolism);
H2S has a higher affinity for methemoglobin than cytochrome oxidase |
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Treatment for hydrogen sulfide?
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remove from source, increase elimination using cyanide antidote kit to generate methemoglobin (avoid thiosulfate)
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Isoniazid pathophysiology?
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inhibits production of GABA via depletion of vitamin B6
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Antidote for isoniazide toxicity?
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Pyridoxine (B6)
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_____ can cause refractory seizures (toxocology)
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INH toxicity
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what is the most common cause of poisoning in children?
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Iron
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What type of symptoms suggest a significant exposure to iron?
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Gi symptoms (abdominal pain, diarrhea, vomiting, and GI bleeding)
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What lab is not helpful in following for lead toxicity? What should you measure instead?
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TIBC (not helpful)
serum iron |
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Treatment for iron overdose?
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Whole bowel irrigation and deferoxamine chelation (activated charcoal does not bind!)
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Vin rose urine
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urine from iron toxic patients appearance after defetoxamine chelation
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Child presents with headache, encephalopathy, anorexia, abdominal pain, paint exposure, and lead lines. What toxicity is this?
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Lead
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Toxidrome that produces peripheral neuropathy (wrist drop)?
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Lead
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What toxic exposure and at what serum level is this finding produced?
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Lead; Basophilic stippling; >50 mcg/dL
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Treatment for lead toxicity?
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Chelation (BAL, EDTA, DMSA)
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Symptoms of lithium toxicity?
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Tremor, vomiting, diarrhea, confusion, slurred speach, seizure, coma, ⇑ QT, arrhythmias
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Treatment or lithium toxicity?
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1. Agressive fluid hydration
2. Hold drug, no diuretics, lavage, Kayexalate 3. Hemodialysis for severely toxic patient |
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What is a severe lithium toxicity presentation?
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Level >3.5 mEq/L; coma, seizures, myoclonus, hemodynamic collapse. At risk for renal failure with rapidly rising levels especially with sustained released formulas; Li induced seizures
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Mechanism of action for MAOI?
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Blocks degradation of catecholamines (NE, E, serotonin)
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What two drugs are contraindicated in an MAOI hyperthermic syndrome?
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Meperidine and dextromethorphan
(can cause severe hyperthermia) |
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What are common products that can cause a methemoglobinemia?
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nitrates, nitrites, benzocaine, dapsone, phenazopyridin (pyridium)
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Presenting symptoms for methemoglobinemia?
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Cyanosis that is unresponsive to oxygen
Chocolate brown bloood |
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How do you reverse methemoglobinemia?
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methylene blue
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Mushroom ingestion prognosis
a. <2 hrs of onset b. >6 hrs of onset |
a. benign course
b. toxic ingestion with risk of hepatic and renal failure |
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What cases a dystonic reaction and what is it?
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Neuroleptics/phenothiazines
dystonia: extrapyramidal reaction of tremor, torticollis, rigidity, facial grimaing, dysphagia, oculogyric crisis |
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Clinical effects of neuroleptics? (5)
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1. Dystonic reaction
2. Akathesia 3. Tardive dyskenisa 4. Anticholinergic syndrome 5. Quinidine-like anticholineric, peripheral alpha-blockage, antihistaminic, prolonged QT, and cardiac dysrhthmias Also heat stroke, hypotension, sedation, psychosis, urinary retention, and seizures |
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Treatment for neuroleptic toxicity?
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Benzotropine (cogentin), diphenhydramine (benadryl), benzodiazepines, lavage, and bicarbonate
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Treatment for neuroleptic malignant syndrome?
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fever control, benzodiazepines, dantrlene, paralysis, and bromocriptine
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Symptoms for neuroleptic malignant syndrome?
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AMS, severe hyperthermia, rigidity, opisthotonos, hypertension, tachycardia
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Name three neuroleptic agents
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haloperidol, droperidol, chlorpromazine
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Opioid symptoms?
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coma, apnea, pinpoint pupils (hypoxia can dialate pupils), hypotension
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Opioid reversal agent?
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Naloxone
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Which oralhypoglycemic agents cause prolonged hypoglycemia?
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Sulfonylureas
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What are examples of sulfonylureas
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glyburide, glipizide, glimepride, and chlopropamide
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Which oral hypoglycemic agent can cause a lactic acidosis?
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Metformin
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What toxidrome do organophosphates produce?
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Cholinergic toxidrome - inhibit cholinesterases and increase the amount of acetylcholine
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Succinylcholine should be avoided in what toxidrome?
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Organophosphates (cholinergic)
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Treatment for organophosphate?
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Atropin until secretions are dry and 2-PAM
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Symptoms for PCP?
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Rotatory nystagmus, agitation, sezirues, hyperthermia, rhabdomyolysis
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Treatment for PCM
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Hydration/cooling
Benzodiazepines Haloperidol |
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Symptoms in phenytoin overdose?
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Nystagmus, ataxia, vomiting, slurred speech, dystonias, lethargy, coma
Paradoxical seizures are rarely seen |
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Treatment of phenytoin overdose?
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Lavage and multidose charcoal
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What type of toxin is produced by: pits of apricot, cherry, peach, and plum?
Treatment? |
hydrocyanic acid (CN)
Cyanide kit and supportive care |
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Anticholinergic plants?
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Belladonna (nightshade) berries
Henbane (seeds in pod) Jimsonweed |
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What are the digitalis toxic plants?
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FOLLY
Foxglove Oleander Lilly of the Valley |
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Pediatric symptoms for ingestion of tobacco?
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Salivation, N/V/D, miosis, confusion, seizures in children
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Treatment for pediatric ingestion of tobacco?
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Lavage, charcoal, benzodiazepines for seizures
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What does warfarin block?
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Vitamin K-dependent clotting factors (II, VII, IX, and X)
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What is the treatment for warfarin?
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Lavage, activated charcoal, vitamin K, and FFP
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What type of metabolic disturbance is seen in salicylate poisoning?
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Anion gap metabolic acidosis and repiratory alkalosis
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What is the mechanism for salicylate toxicity?
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Uncouple oxidative phosphorylation, causing a metabolic acidosis
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What are the symptoms for salicylate toxicity?
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Tachypnea, coma, seizures, pulmonary edema, fever, tinnitus, and tachycardia
Hypoglycemia also is common |
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Treatment for salicylate toxicity?
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Urine alkaliniation, fluids, glucose, K and hemodialysis for severe cases
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What product contains extremely high amounts of salicylates?
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Oil of Wintergreen
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Clinical syndrome for serotonin syndrome?
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CNS: AMS, coma, seizures
Autonomic: hyperthermia, tachycardia, hypertension Neuromuscular: myoclonus, hyperkinesia |
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Treatment for serotonin syndrome?
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Cooling, cyprohepatdine (periactin
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What are the symptoms in Strychnine toxicity?
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CNS hyperstimulation of muscle twitching, facial grimacing, extensor spasm, opisthotonos (back muscle spasm and body arched)
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Treatment for strychnine poisoning?
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Airway, benzodiazepines, and may require paralytics
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TCA toxicity symptoms?
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1. Anticholinergic: flushed skin, dry mouth, mydriasis, decreased bowel sounds, urinary retention
2. CNS effects: Drowsiness, confusion, ataxia, delirium, seizures, coma 3. Cardiovascular effects: Hypotension, tachycardia, wide QRS, V-tach, torsades; right axis devation |
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Treatment for TCA overdose
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1. DO NOT USE procainamide
2. Lavage, multidose charcoal 3. Bicarbonate or lidocaine (for wide QRS) 4. Mag Sulfate for torsades 5. Benzos for delirium/seizures |
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Theophyllin toxicity lab abnormalities?
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metabolic acidosis, hypokalemia, hypomagnesium, hypophosphatemia
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Treatment of theophyllin overdose?
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Multidose charcoal, phenobarbital, betablockers, magnesium, dialysis, and hemoperfusion
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5 toxic items causing bradycardia?
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PACED
P: Propranolol (beta blockers), poppies (opiods) A: Anticholinesterase drugs C: Clinidine, calcium channel blockers E: Ethanol (other alcohols) D: Digoxin |
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4 cases of tachycardia?
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FAST
F: Freebase (cocaine) A: Anticholinergis, antihistamines, amphetamines S: Sympathomimetics, solvent abuse TL Theophylline |
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4 causes of hyperthermia
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NASA
N: NMS, Nicotine A: Antihistamines S: Salycylates, sympathomimetics, serotonin syndrome A: Anthicholinergics, Antidepressants |
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5 causes of hypothermia
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COOLS
C: Carbon monoxide O: Oral hypoglycemics, insulin O: Opiods L: Liquor S: Sedatives, Hypnotics |
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5 causes of hypotension
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CRASH
C: Clonidine, Calcium channel blockers R: Reserpine (antihypertensive agents) A: Antidepressants, amiophylline S: Sedativs, hypnotics H: Heroin (opiods) |
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6 causes of hypertension
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CTSCAN
C Cocaine T Thyroid supplements S Sympathomimetics C Caffeine A Anticholinergics, Amphetamines N Nicotine |
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4 causes of hypoventilation
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SLOW
S Sedativs, hypnotics L Liquor O Opiods W Weed (marijuana) |
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4 causes of hyperventilation
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PANT
P PCP and Pneumonitis (Chemical) A ASA (Salicylates) N Noncardiogenic pulmonary edema T Toxic metabolic acidosis |
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4 causes of miosis
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COPS
C Cholinergics, Clonidine O Opiods, organophosphates P Phenothiazines, Pilocarpine, potine bleed S Sedative Hypnotics |
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4 causes of mydriasis
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AAAS
A Antihistamines A Antidepressants A Anticholinergics, Atropine S Sympathomimetics (cocaine, amphetamines) |
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4 causes of diaphoretic skin
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SOAP
S Sympathomimetics O Organophosphates A ASA (Salicylates) P PCP |
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3 causes for red skin
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Anticholinergics, boric acid, and carbon monoxide
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2 causes for blue skin
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Cyanosis and methemoglobinemia
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4 causes of blitering skin
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barbituates, CO, spider bites, snake envenomations
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Causes for Seizures
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OTIS CAMPBELL
Organophosphates, TCAs; INH/Insulin; Sympathomimetics; Cocaine/Camphor; Amphetamines; Methylxanthins; Benzo withdrawl and botanicals; Ethanol withdrawl; Lindane, Lidocaine; Lead, Lithium |
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5 radiopaque drugs
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COINS
C Cholral hydrate, cocaine packages O Opiate packages I Iron (heavy metal: Pb, As, Hg) N Neuroleptic agents S Sustained release products, enteric coated preparations |
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4 causes of noncardiogenic pulmonary edema?
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MOPS
Meprobamate, Methadone Opiods Phenobarbital, propoxyphene Salicylates |
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What causes pink diarrhea?
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Acute lithium toxicity
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