Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
151 Cards in this Set
- Front
- Back
|
What percent of pt's taking lithium develop toxicity during therapy?
|
75-90%
pg 1211 |
|
|
Lithium competes with other cations (Na, K, Mg, Ca) displacing them from ___ and ___ sites.
|
intracellular and extracellular
pg 1211 |
|
|
What happens to pts on lithium when RSI is performed with succ's, vecuronium or pancuronium?
|
prolonged neuromuscular blockade
pg 1212 |
|
|
T/F: Lithium levels correspond to central nervous system effects.
|
False. Lithium distro is slow in and out of the brain and generally lags behind serum levels.
pg 1212 |
|
|
What are the most common side effects seen with lithium therapy?
|
Hand tremor, fatigue, poluria, decreased concentration of urine, anorexia, N/V/D
pg 1212 |
|
|
Acute lithium ingestions generally produce more __ side effects and less neuro toxicity.
|
GI
pg 1213 |
|
|
Lithium induced seizures that are refractory to benzos should be treated with what?
|
Phenobarbital, Phenytoin decreases lithium excretion and is ineffective
pg 1213 |
|
|
Severe toxicity (>4mEq/L acute, 3.5mEq/L chronic) should be treated how?
|
hemodialysis
pg 1213 |
|
|
24yo M admits to taking 30 of sibling's Lithium SR 400mg capsules after breakup with girlfriend. Level is 0.8mEq/L. IVF given and pt is doing well. At what hr can you send pt home?
|
Don't! Any acute ingestion of sustained release must be admitted regardless of level.
pg 1214 |
|
|
The duration of action for barbiturates depends on ____.
|
the distrobution into the tissues rather than half life, due to their lipid solubility
pg 1214 |
|
|
Mild to moderate barbiturate intoxification resembles ____ intoxification.
|
ETOH
pg 1215 |
|
|
What are the most common signs of barbiturate overdose?
|
hypothermia, respiratory depression, and hypotension
pg 1215 |
|
|
Early deaths from barbiturate overdose result from what?
|
respiratory arrest
pg 1215 |
|
|
What are barbiturate serum levels good for in the toxic pt?
|
establishing the diagnosis. Serum levels do not correspond to brain levels and are not reliable for txmt purposes
pg 1215 |
|
|
What are the txmt goals of barbiturate overdose?
|
ABCs, Activated Charcoal, Urinary Alkalization, and/or hemodialysis
pg 1215 |
|
|
T/F: Dialysis is recommended for all types of barbiturate overdoses if not responding to other txmts.
|
False: only good for phenobarbital
pg 1216 |
|
|
T/F: Urinary Alkalization is only useful for long acting barbiturate overdoses.
|
True. it is not effective for short acting barbiturates.
pg 1216 |
|
|
Because of rapid development of tolerance in barbiturates, what is the concern during the txmt process?
|
Withdrawal symptoms
pg 1216 |
|
|
Which nonbenzo sedative has been associated with serotonin syndrome?
|
Buspirone
pg 1220 |
|
|
Which nonbenzo sedative has been associated with myoclonic jerks?
|
Carisoprodol
pg 1220 |
|
|
Which nonbenzo sedative has been associated with gastric bezoars and prolonged coma?
|
Meprobamate
pg 1220 |
|
|
Which nonbenzo sedative has been associated with cardiac instability and ventricular arrhythmias?
|
Chloral Hydate
pg 1220 |
|
|
What med should be used for Chloral Hydrate overdose induced ventricular arrhythmias?
|
Beta Blockers
pg 1220 |
|
|
T/F: GHB has a short duration of action, low dependence/abuse, and little withdrawal symptoms.
|
False. 2 Step withdrawal syndrome. First stage, 2hrs after last dose - insomnia, confusion, anxiety, GI distres
Second stage - 2 days - 3 weeks, tachycardia, confusion, hallucinations pg 1221 |
|
|
The nonbenzo's for insomnia (Zolpidem, Zaleplon, Zopiclone) produce dependence and withdrawal. Which has the least?
|
Zaleplon (Sonota)
pg 1222 |
|
|
Which 3 commonly abused hallucinogens can result in hyperthermia requiring active cooling?
|
LSD, PCP, and MDMA
pg 1238 (chart) |
|
|
What clinical features are more commonly seen in hallucinogen overdoses?
|
Mydriasis, tachycardia, muscle tension
pg 1238 |
|
|
What are the main treatment options for hallucinogen toxicity?
|
ABCs, Supportive, benzos, hydration and cooling
pg 1238 |
|
|
Methylxanthines posses similiar clinical effects, which is likely the most potential for significant toxicity?
|
Theophylline - increases endogenous adrenergic stimulation, and adenosine antagonism
pg 1257 |
|
|
Most common side effects of methylxanthine toxicity?
|
GI (N/V), Neuro (tremor, agitation, seizure), Cardiovascular (HoTn, tachycard, arrhythmias), Metabolic (hypoK, acidosis, hyperthermia, rhabdo)
pg 1257 |
|
|
The best predictor of theophylline toxicity is ____, whereas the best predictor in chronic exposure is _____.
|
peak serum concentration, increased pt age
pg 1258 |
|
|
Methylxanthine txmt includes?
|
ABCs, GI decon, and enhanced elimination
pg 1258 |
|
|
What seizure txmt medication is contraindicated in theophylline overdose?
|
Phenytoin - increase seizure risk
pg 1259 |
|
|
When is dialysis considered in methylxanthine toxicity? (2)
|
1) acute ingestion, symptomatic, serum level >90mcg/mL;
2) chronic ingestion, symptomatic, serum level >40mcg/mL pg 1259 |
|
|
T/F: Txmt options for nicotine overdose includes: activated charcoal w/in 1hr, soap/water dermal exposure, urine acidification, and benzos.
|
False: activated charcoal and urine acidifcation not recommended.
pg 1260 |
|
|
What is the first line txmt option in antihypertensive overdoses?
|
Fluid restoration
pg 1273 |
|
|
Which antiHTN overdose may respond to naloxone (max 10mg)?
|
ACE-I and Clonidine
pg 1276 |
|
|
Thiosulfate should be administered in the overdose of this antiHTN.
|
Sodium nitroprusside
pg 1274 |
|
|
Corticosteroids, diphenhydramine, epi, and zantac may be administered for these overdoses.
|
ACE-I and ARBs
pg 1274 |
|
|
Even a single tablet can cause significant symptoms in a child due to alpha-2 stimulation; causing bradycard, HoTn?
|
Clonidine
pg 1275 |
|
|
What is the most consequential adverse effect associated with ACE-I and ARBs?
|
angioedema
pg 1276 |
|
|
What is the safest course after an episode of angioedema?
|
D/C all ACE-I and ARBs
pg 1276 |
|
|
Which antiHTN can you see "Steal Syndrome" in?
|
Hydralizine - peripheral vasodilation with reflex tachycardia
pg 1276 |
|
|
In severe HoTn, using hydralizine or minoxidil, which vasopressor is recommended?
|
phenylephrine (alpha-1) minimizes tachycardia and prevents myocardial ischemia, unlike dopamine (B agonist)
pg 1276 |
|
|
The most important predictors of toxicity in nitroprusside use are _____ and _____.
|
rate of infusion (production) and rate of elimination (renal fxn).
pg 1277 |
|
|
Most phenytoin related deaths have been caused by what two causes?
|
Rapid administration and hypersensitivity reactions
pg 1277 |
|
|
Why is Fosphenytoin preferred over Phenytoin?
|
less irritating in parenteral form (ie doesn't percipaitate in IV soln)
pg 1277 |
|
|
Oral absorption is slow, variable, and often incomplete with Phenytoin, so what is needed in overdose patients?
|
serurm serial measurment to determine peak levels.
pg 1277 |
|
|
T/F: Phenytoin is highly protein bound (90%) therefore hemodiaylsis is required for treatment.
|
False: highly protein bound means hemodialysis will be ineffective
pg 1278 |
|
|
Toxic effects of Phenytoin vary with route. Which route carries the greatest risk?
|
IV admin due to proplene glycol and ethanol in the mixture
pg 1278 |
|
|
34yo F presents with confusion, dizziness and diplopia after an intentional suicide attempt. EMS reports finding empty bottle of Phenytoin. What cardio risks are your concerned with?
|
None. Cardio risk limited to IV administration.
cardio risks- HoTn, brady, conduction delays, AV block, wide QRS, V-fib, asystole pg 1279 |
|
|
What soft tissue effects can IV Phenytoin have?
|
localized crystallization, abscess, necrosis, compartment syndrome, bluish discoloration of extremity ("purple glove snydrome")
pg 1279 |
|
|
Is cardiac monitoring necessary after oral overdose of phenytoin?
|
No. cardiac toxicity limited to IV admin
pg 1280 |
|
|
T/F: The decision to discharge or medically clear a pt for psych eval after oral overdose of phenytoin can be based on a single serum level.
|
False: Can Not due to long and erratic absorption
pg 1280 |
|
|
Cardiac arrythmias are rare, but carbamazepine is one of the few drugs that can cause both ___ and seizures.
|
wide QRS
pg 1280 |
|
|
Txmt options for carbamazepine overdoses are?
|
activated charcoal, hemodialysis, sodium bicarb for conduction delays
pg 1280 |
|
|
What medication has been shown to increase valproate metabolism?
|
1-carnitine 50mg/kg/d
pg 1281 |
|
|
Disposition for Phenytoin, Carbamazepine, and Valproate should be based on?
|
monitor serum drugs levels every few hours until they decline and pt is asymptomatic
pg 1281 |
|
|
Which of the second generation anticonvulsants are most toxic?
|
Topiramate, Levetiracetam, Lamotrigine
pg 1282 |
|
|
What are the three methods of abusing hydrocarbons?
|
1)huffing - a rag
2)bagging - plastic bad 3)sniffing - inhaled thru nostrils pg 1287 |
|
|
Toxic potential of hydrocarbons depends on their physical characteristics like ___, ____, and ____.
|
Viscosity, surface tension, volatility
pg 1287 |
|
|
Pts ingesting substances w/ viscosities <__ SUS (Saybolt Uinversal Seconds) are at ___ risk for aspiration.
|
60 and greater risk
pg 1288 |
|
|
The initial radiograph in a hydrocarbon aspiration usually show what?
|
usually clear, changes usually appear 2-6hrs later
pg 1288 |
|
|
What is "sniffing sudden death syndrome" related to?
|
most worrisome complication from solvent abusers. Catecholamine sensitization of the heart by hydrocarbons resulting in vent dysrhythmias.
pg 1289 |
|
|
Toluene abusers of c/o muscle weakness in the ED due to what?
|
hypokalemia, usually K+ < 2.0
pg 1290 |
|
|
Hydrocarbon induced hemolysis occuring after acute ingestion usually presents with what symptoms?
|
lethargy, SOB, cyanosis
pg 1290 |
|
|
What two treatments are contraindicated in the txmt of hydrocarbon aspiration pneumonitis?
|
steroids and abx
pg 1291 |
|
|
When are catecholemines (epi, norepi, dopa) indicated during the txmt process for hypotension in a hydrocarbon overdose?
|
Never, as they may percipitate dysrhythmias.
pg 1291 |
|
|
What is the role of gastic decon in hydrocarbon overdoses?
|
limited. AC w/in 1hr may help but the risk of provoking vomiting may outweigh the benefits
pg 1291 |
|
|
Acids cause serious injury at a pH of <___.
|
pH < 3
pg 1292 |
|
|
Alkalis cause serious injury at a pH > ___.
|
pH > 11
pg 1292 |
|
|
____ acid or ____ reserve refers to the amount of acid or base needed to neutralize the agent of interest, greater the value, greater the potential for injury.
|
Titratable acid / Alkaline reserve
pg 1292 |
|
|
Alkaline injuries induce a deep tissue injury called ____ ___.
|
Liquefaction necrosis
pg 1293 |
|
|
Acid injuries induce ___ ___.
|
coagulation necrosis
pg 1293 |
|
|
Which type of acid produces a nonanion gap acidosis?
|
hydrochloric acid
pg 1294 |
|
|
Initial goal in txmt for caustic ingestion is ___.
|
first priority is airway maintence.
pg 1294 |
|
|
What type of airway is contraindicated in caustic ingestion injuries?
|
Blind nasotracheal
pg 1294 |
|
|
What should be attempted before any airway intubation attempt?
|
fiberoptic eval
pg 1294 |
|
|
Why is activated charcoal contraindicated in caustic ingestions?
|
charcoal does not adhere to most caustics and will impede visualization w/ endoscopy
pg 1294 |
|
|
Why is Ipacac syrup contraindicated in caustic ingestions?
|
inducing vomiting will result in repeated exposureof the airway and GI mucosa to the caustic agent
pg 1295 |
|
|
When should an NG tube be used after caustic ingestions?
|
after the fiberoptic scope and within 30min of ingestion
pg 1295 |
|
|
T/F: Intentional ingestions of caustic agents should undergo early endoscopy b/c suicide ingestions carry highest risk of clinically important injuries.
|
True
pg 1295 |
|
|
What are some obvious signs of caustic ingestion that require early endoscopy?
|
stridor, oropharyngeal burns, vomiting, drooling, food refusal
pg 1295 |
|
|
Most experts agree that endoscopy should be w/in the first several hrs after ingestion, ideally <__hrs and not >__hrs postingestion to avoid iatrogenic perforation.
|
<12hrs and not >24hrs
pg 1295 |
|
|
Animal models have demonstated benefit w/ steroid use in caustic ingestion injuries. what is the recommendation for steroids?
|
steroids not recommended
pg 1295 |
|
|
Role of abx in caustic ingestions?
|
None, unless pt given steroids
pg 1295 |
|
|
Laparotomy is perfered over laparscopy due to eval of the posterior gastrum. What are the emergency indications?
|
peritoneal signs, free intraparitoneal air, esophageal perf on xray, endoscopy or CT
pg 1295 |
|
|
What causes highest morbidity or death in alkaline injuries?
|
complications from direct tissue necrosis
pg 1296 |
|
|
What is the key txmt for ocular exposure to caustic agents?
|
key principle is not choice type of fluid, rather the immediacy and adequecy of irrigation
pg 1296 |
|
|
Disc batteries w/ a diameter > __ to __ are at increased risk for impaction and esophageal injury.
|
15-20mm
pg 1296 |
|
|
Which acid has the greatest potential for morbidity and death?
|
hydrofloric acid
pg 1297 |
|
|
Hydrofloric acid burns have been treated w/ intra-arterial calcium, what is calcium is contraindicated?
|
Calcium cholride
pg 1297 |
|
|
Why is it important to recognize the initial "index case" of metal poisoning?
|
prevent others from being poisoned when the metal source is enviromental or industrial
pg 1308 |
|
|
What is the most common cause of metal poisoning?
|
Lead
pg 1308 |
|
|
The combo of ___ and __ dysfxn w/ a hemolytic anemia should raise the suspicion of lead toxicity.
|
abdominal and neurologic dysfxn
pg 1310 |
|
|
Children presenting with the diagnosis of encephalopathy should be consider to have ___ toxicity as well.
|
lead
pg 1310 |
|
|
In lead toxicity, ___ is a major cause of morbidity and mortality and may begin with seizures and coma.
|
encephalopathy
pg 1310 |
|
|
Lab turnaround time for lead is days, diagnostic studies should focus on eval for ___ and exam of radiographs for lead exposure.
|
anemia
pg 1310 |
|
|
What meds are used for chelation therapy for lead toxicity?
|
Dimercaprol, edetate calcium disodium and succimer
pg 1310 |
|
|
What type of pt allergy is dimercaprol contraindicated for lead chelation therapy?
|
peanut allergy
pg 1310 |
|
|
Edetate calcium disodium can be easily confused with this medication when treating lead toxicity.
|
Edetate disodium used for hypercalcemia
pg 1311 |
|
|
Toxicologist consider ____ as the preferred chelator for lead poisoning in all but the most severe cases.
|
Succimer
pg 1311 |
|
|
This toxic metalloid is nearly tasteless, odorless, and distributes easily thruout the body, including hair, nails, and bone. Hallmark is a cholera-like diarrhea.
|
Arsenic
pg 1311 |
|
|
What are Mee's lines?
|
1-2mm wide transverse white lines in the nail due to arsenic poisoning
pg 1312 |
|
|
Arsenic poisoning should be considered in pts with HoTn of unknown etiology that was preceded by severe _____.
|
gastroenteritis
pg 1312 |
|
|
T/F: swallowing mercury in a glass thermometer produces severe adverse effects, especially if GI tract is damaged.
|
Fasle: does not produce adverse effects unless GI tract is damaged
pg 1313 |
|
|
Severe hemorrhagic gastroenteritis, ab pain, graying of oral mucosa, metallic taste, shock and rapid cardiovascular collapse are associated with ___ toxicity.
|
mercury
pg 1313 |
|
|
___ is contraindicated in methyl mercury poisoning owing to the potential for exerbation of CNS symptoms.
|
Dimercaprol
pg 1314 |
|
|
____ is defined as any chemical shown to be a health hazard or physical hazard.
|
Hazardous chemical
pg 1315 |
|
|
Why are children more sensitive to inhaltion injuries?
|
Physiologically, they have increased respiratory exposure, high minute ventilations
pg 1315 |
|
|
What are a couple of th first txmt steps in a toxic inhalation?
|
remove from source, 100% oxygen, and bronchodilators
pg 1316 |
|
|
Which toxin has an insidious onset, used in WWI, irritates the nose, eyes, throat and upper airway, forms a white cloud, and smells of freshly mown hay?
|
Phosgene
pg 1316 |
|
|
Whic toxin appears as a dense green-yellow gas, smells pungent, used in WWI, and can cause coughing, horseness, and pulm edema?
|
Chlorine
pg 1316 |
|
|
Which toxin is associated with "silo filler dz"?
|
Nitrogen oxides
pg 1316 |
|
|
This toxin is higher water soluble, colorless, alkaline, pungent odor, and results in bronchospam, pulm edema, and ocular irritation.
|
Ammonia
pg 1316 |
|
|
Which toxin was used by the Nazis in the gas chamber, found in the cassava melon, causes anxiety, palpitations, HA, and dyspnea?
|
Cyanide
pg 1316 |
|
|
What is the lethal dose of cyanide in an adult?
|
140-250mg
pg 1316 |
|
|
What are the anti-dotes for cyanide poisoning?
|
amyl nitrite for inhalation, 3% sodium nitrite, and 25% sodium thiosulfate
pg 1318 |
|
|
T/F: Sodium nitrite is a vasodilator and is contraindicated in hypotensive, bradycardic, comatose cyanide toxic pts.
|
False: Hypotension is not contraindicated in this setting
pg 1318 |
|
|
How do we adjust the sodium nitrite dose in peds?
|
according to the hemoglobin level
pg 1319 |
|
|
How does the rhodanese enzyme work with sodium thiosulfate in cyanide txmt?
|
catalyzes the transfer of sulfate from sodium thiosulfate to cyanide to form a less toxic substance excreted by kidneys
pg 1319 |
|
|
Which toxin smells like rotten eggs, rapid LOC, seizures and death in few breathes?
|
Hydrogen Sulfide
pg 1320 |
|
|
Vitamin A overdose causes blurred vision, appetite loss, skin pigmentation, loss of hair, dry skin, itching, and increase incidence of ___.
|
long bone fx
pg 1321 |
|
|
Consipation, coma, and confusion present with toxicity from which vitamin overdose?
|
Vitamin D
pg 1321 |
|
|
This vitamin in large doses can inhibit Vit K and should be monitored closely for bleeding.
|
Vitamin E.
pg 1321 |
|
|
Vitamin __ can be toxic in megadoses and produce hemolytic anemia, kernicterus, hemoglobinuria, renal tubular degeneration, and inhibit anti-coags.
|
Vit K.
pg 1321 |
|
|
Which B vitamin in high doses >5g/d over several weeks will cause nerve damage.
|
B6
pg 1322 |
|
|
Which vitamin in large doses is associated with gout and nephrolithiasis?
|
Vitamin C
pg 1323 |
|
|
This herbal is used for dementia and intermittent claudication.
|
Ginkgo Biloba
pg 1323 |
|
|
St. Johns Wort is used for ?
|
mild to moderate depression
pg 1323 |
|
|
Kava is used for ___ and saw palmetto for short term ____.
|
anxiety and prostatism
pg 1323 |
|
|
Why may herbals be dangerous to take? (3)
|
1) may contain toxic ingredients, 2) Quality and uniformity is unreliable, and 3) contaminated with drugs
pg 1324 |
|
|
Which antimicrobials have the greatest potential for toxic effects?
|
antimalarials (quinine, chloroquine, mefloquine, and primaquine)
pg 1325 |
|
|
What are the 3 classic features of isoniazid overdose?
|
seizures, metabolic acidosis, and protracted coma
pg 1326 |
|
|
Pt w/ seizures refractory to benzos, phenytoin and phenobarb should be considered to have a ___ overdose.
|
Isoniazid
pg 1326 |
|
|
What is the txmt for isoniazid seizures?
|
gram-gram equivalent of B6 to isoniazid, if unkn amount then B6 5g IV or peds 70mg/kg (max 5g)
pg 1326 |
|
|
Phenytoin has no role in treating isoniazid seizures and __ __ as little role for acidosis.
|
sodium bicar
pg 1326 |
|
|
Encephalopathy, agitation, and absence seizures have been reported in what abx?
|
ceftazidime, cefepime, and cefuroxime
pg 1326 |
|
|
____ are associated with QT prolongation and the potential for Torsades de Pointes.
|
Macrolides
pg 1326 |
|
|
Pts who have tumors that occlude the upper airway or have undergone a larnygectomy cannot be ____.
|
orally intubated
pg 1592 |
|
|
T/F: Pediatric tracheostomy tubes never have am inner cannula b/c of the small inner diameter.
|
True.
pg 1592 |
|
|
What is the issue with a tracheostomy that is <7 days old when needing to asses it?
|
tract will not be mature enough and manipulation may create a false passage.
pg 1593 |
|
|
Why must the obturator be removed quickly once the tracheostomy is in place?
|
pt cannot breath around obturator.
pg 1593 |
|
|
When attempting a trach placement you should always have an extra smaller trach in case of difficulty. What is the problem with smaller device though?
|
it will be shorter, and may not be long enough for pt's neck
pg 1594 |
|
|
What happens to the stoma if the trach is out for several hrs?
|
stoma may begin to close and dilation may be required
pg 1594 |
|
|
How can you tell the difference btwn laryngectomy and tracheostomy pts?
|
Laryngectomy pts cannot breathe or vocalize when tube is occluded
pg 1594 |
|
|
What pathogens often contaminat trach tubes?
|
staph aureus, psuedomonas, and candida
pg 1594 |
|
|
What % of pts present w/ a sentinel aterial bleed or hemoptysis with a tracheoinnominate fistula?
|
50%
pg 1595 |
|
|
If a tracheostomy pt presents with massive bleeding, what is the first maneuver?
|
control brisk bleeding by hyperinflating the cuff
pg 1595 |
|
|
Stomal hemorrhage is controlled with digital pressure of the ___ artery against the manubrium.
|
innominate artery
pg 1595 |
|
|
Who should remove stents and their associated tracheostomy tubes?
|
the surgeon familiar with the device and placement
pg 1595 |
