Surgery

Front 1

Who is most likely to be affected by poison?

Back 1

½ < 6 y.o.; 1/3 <3 y.o.

Front 2

Where do most poisonings occur?

Back 2

91% occur at home

Front 3

Who is most likely to die from poisoning?

Back 3

> 1/2 of fatal victims aged 20-49; esp. 45-49 y.o.
2% deaths in children under 6 y.o.

Front 4

What is the most common route of poisoning?

Back 4

79% ingestions, 7% dermal, 5% inhal., 4.5% ocular

Front 5

MC poisionings

Back 5

Analgesics (11.7%), Cosmetics/personal care products (8.0%), Household cleaning substances (7.0%), Sedatives/hypnotics/antipsychotics (6.1%), Foreign bodies/toys/miscellaneous (4.1%)

Front 6

MC fatalities from poison

Back 6

Opioid analgesics, Sedatives/hypnotics/antipsychotics Cardiovascular agents

Front 7

*What are the effective care steps for Toxicology?

Back 7

The ABCs
Supportive Care
– Correct BP, HR, RR, Temp, O2sat, Glucose
– Oxygen
– IV Fluids
– Monitoring
– Sedation/seizure tx.
– Cooling/heating
Reduce absorption
Enhance elimination
Consider antidotes

Front 8

how do you respond to any sick victim?

Back 8

O2
IV
Monitor
Airway equipment
ABCDE (Airway, Breathing, Circulation, Defibrillate/disability/decontaminate, Expose)
Vitals

Front 9

3 conditions respond rapidly to antidotes ("3Hs")?

Back 9

hypoxia, hypoglycemia, heroin

Front 10

what is the name of the lens that is utilized to irrigate the eyes?

Back 10

Morgan lens

Front 11

what products are used to remove toxins from the gut?

Back 11

ipecac, gastric lavage

Front 12

what product is used to bind the toxin within the gut?

Back 12

charcoal

Front 13

what products are used to flush the toxin thru the gut?

Back 13

cathartic, GoLYTELY

Front 14

contraindications of ipecac

Back 14

Altered mental status
Actively vomiting
Caustic
Hydrocarbons

Front 15

indications of ipecac

Back 15

Given at time of ingestion
Long delay to medical care

Front 16

complications of ipecac

Back 16

Aspiration
Mallory-Weiss tear
Intractable vomiting

Front 17

contraindications of orogastric lavage

Back 17

Caustics were ingested
Airway is not protected
Delayed presentation

Front 18

why use orogastric lavage?

Back 18

Removes 35-56% of drug if used < 1 hr of ingestion.
Lay persons expect us to “pump the stomach”

Front 19

complications of orogastric lavage

Back 19

Tracheal insertion of tube
Esophageal/gastric perforation
Knotting

Front 20

contraindications of charcoal

Back 20

Caustic ingested
Aspiration risk
Poisons it won’t adsorb
Messy

Front 21

charcoal PHAILS to work on....

Back 21

Pesticides
Hydrocarbons
Acids/Alkalis
Iron
Lithium/Lead
Solvents

Front 22

MC cathartic

Back 22

sorbitol (combined with charcoal)

Front 23

contraindications of cathartics

Back 23

Age < 5 y.o.
Have renal failure (magnesium)
Ingested caustics
Took something that will already cause diarrhea

Front 24

4 parts of enhanced elimination

Back 24

1.Urine alkalinization
2.Forced diuresis
3.Hemodialysis
4.Enterohepatic dialysis

Front 25

urine alkalinization

Back 25

weak acids become stronger ions, can’t be re-absorbed in the tubules, go into urine

procedure: 1-2 mEq/kg (1 – 2 amps) bolus of NaHCO3, Repeat boluses or drip to maintain (Urinary pH 7.5 to 8.0, Serum pH < 7.5 to 7.55, 3 amps NaHCO3+40meqK in 1L N/S@150-250 cc/hr), Caution K and vol overload

Front 26

forced diuresis

Back 26

Combine IV fluids with diuretic (mannitol/furosemide)
At best, 2 fold increase in elimination
Complicated by cerebral and pulmonary edema
Rarely used because better options available (Phenobarbital, Bromide, Lithium)

Front 27

hemodialysis

Back 27

Life-threatening ingestions: I STUMBLE
– Isopropanol
– Salicylates
– Theophylline/caffeine
– Uremia
– Methanol
– Barbiturates/Beta-blockers
– Lithium
– Ethylene glycol/Electrolyte - K

Front 28

enterohepatic hemodialysis

Back 28

Multi-dose charcoal
Theory: Some absorbed drugs are excreted in the bile; giving a 2nd chance to bind to charcoal
Indicated: large doses of drugs with enterohepatic circulation: Carbamazepine, Dapsone, Phenobarbital, Quinine, Theophylline, Salicylates

Front 29

how are most poisoned patients decontaminated?

Back 29

dilute, irrigate, wash

Front 30

*The classic toxidromes

Back 30

Opiates
Sympathomimetics
Cholinergics
Anticholinergics
Salicylates
Hypoglycemics
Serotonergics
Sedative-hypnotics
Hallucinogens

Front 31

common opiates

Back 31

Morphine, codeine, heroin, hydromorphone,
fentanyl, hydrocodone, oxycodone

Front 32

opiates triad

Back 32

CNS depression
Miosis
Respiratory depression

other sxs: dec BP, dec HR, N/V/Constipation

Front 33

tx of opiates

Back 33

Airway
Naloxone (Narcan)

Front 34

sympathomimetics (stimulants) sxs

Back 34

Agitation
Anxiety
Mydriasis
Diaphoresis
Tachycardia
Hypertension
Hyperthermia
Seizures

Front 35

common sympathomimetics

Back 35

cocaine, amphetamines

Front 36

tx of sympathomimetics

Back 36

sedation and cooling

Front 37

cholinergic sxs

Back 37

SLUDGE BBB
– Salivation
– Lacrimation
– Urination
– Diaphoresis
– GI symptoms
– Emesis
– Bronchorrhea
– Bradycardia
– Bronchospasm
DUMBELLS
– Diaphoresis/diarrhea
– Urination
– Miosis
– Bradycardia/bronchospasm
– Emesis
– Lacrimation
– Lethargy

Front 38

common cholinergics

Back 38

insecticides, bio weapons

Front 39

mechanism of action of cholinergics

Back 39

bind to and stimulate Ach receptors

Front 40

tx of cholinergics

Back 40

airway, atropine, 2-PAM (pralidoxime)

Front 41

common anticholinergics

Back 41

Atropine
Tricyclics
Antihistamines (Diphenhydramine, Dimenhydrinate, Chlorpheniramine, Atropine, Scopolamine, Hyoscyamine, Jimson Weed)

Front 42

anticholinergic sxs

Back 42

Mydriasis, Dry/flushed skin, Urinary retention, Absent bowel sounds, Hyperthermia, Dry mucous membranes, Seizures, rhabdomyolysis

"Mad as a hatter: psychosis
Dry as a bone: dry mucous membranes
Red as a beet: flushed skin
Hot as Hades: fever
Blind as a bat: blurred vision
Seizing like a squirrel: seizure"

"Can’t see, Can’t spit, Can’t pee, Can’t sh*t"

Front 43

tx of anticholinergics

Back 43

sedation and cooling

Front 44

common salicylates

Back 44

Aspirin, Pepto-Bismol, Excedrin, Wintergreen

Front 45

salicylates s/s

Back 45

resp alkalosis, met acidosis, tachypnea, vomiting, tinnitus, tachycardia, diaphoresis

Front 46

tx of salicylates

Back 46

fluids, bicarb (alkaline urine), hemodialysis

Front 47

common hypoglycemics

Back 47

slufonylureas, insulin

Front 48

hypoglycemic sxs

Back 48

Altered mental status
Slurred speech
Paralysis
Seizures
Diaphoresis
Tachycardia

Front 49

tx of hypoglycemics

Back 49

Glucose (D10W infant, D25W child,D50W adult)
Glucagon
Oral feeding
Octreotide

Front 50

common serotonergics

Back 50

Meperidine
Dextromethorphan
SSRIs
Tricyclics
St. John’s Wort

Front 51

serotonergic sxs

Back 51

Increased muscle tone
Hyperreflexia
Hyperthermia
Tremor
“Wet dog shakes”

Front 52

tx of serotonergics

Back 52

sedation and cooling

Front 53

sedative-hypnotics sx

Back 53

Decreased reflexes
CNS depression
Nystagmus
Hypotension
Bradycardia
Respiratory depression
Hypothermia

Front 54

common sedative-hypnotics

Back 54

benzo, barb

Front 55

tx of sedative-hypnotics

Back 55

airway, avoid fluazenit

Front 56

common hallucinogens

Back 56

LSD, PCP

Front 57

hallucinogen s/s

Back 57

Agitation
Euphoria
Aggression
Paranoia
Mydriasis
Tachycardia
Hypertension
Diaphoresis

Front 58

complications of hallucinogens

Back 58

sz, rhabdomyolysis, trauma

Front 59

tx of hallucinogens

Back 59

sedation and cooling

Front 60

absinthe

Back 60

Anise, fennel and wormwood
Clear/Green
55 to 75% alcohol
As high as 144 proof

Front 61

toxins that causes withdrawal sxs

Back 61

Alcohol
Opiates
Benzos
Barbs
Centrally-acting Antihypertensives

Front 62

drug withdrawal sxs

Back 62

Diarrhea/Cramps
Gooseflesh
Mydriasis
Tachycardia
Lacrimation
Hypertension
Yawning
Hallucinations
Seizures

Front 63

toxins that cause bradycardia

Back 63

PACED
Propranolol (B blockers)/Phenobarbital
Anticholinesterases (cholinergics)
Calcium channel blockers, clonidine
Ethanol
Digoxin

Front 64

toxins that cause tachycardia

Back 64

FAST
Free base, other cocaines
Anticholinergics, antihistamines, amphetamines
Sympathomimetics, solvents
Theophylline

Front 65

toxins that cause hypothermia

Back 65

COOLS
Carbon Monoxide
Opiates
Oral hypoglycemics, insulin
Liquor
Sedatives

Front 66

toxins that cause hyperthermia

Back 66

NASA
Neuroleptic malignant syndrome, nicotine
Antihistamines
Salicylates, sympathomimetics, serotonergics
Anticholinergics, antidepressants

Front 67

toxins that cause hypotension

Back 67

CRASH
Clonidine, calcium channel blockers
Reserpine, other antihypertensives
Antidepressants, aminophylline
Sedative-hypnotics
Heroin, other narcotics

Front 68

toxins that cause hypertension

Back 68

CT SCAN
Cocaine
Thyroid supplements
Sympathomimetics
Caffeine
Anticholinergics, amphetamines
Nicotine

Front 69

toxins that cause tachypnea

Back 69

PANT
PCP, paraquat, pneumonitis (chemical)
Aspirin, other salicylates
Non-cardiogenic pulmonary edema
Toxin-induced metabolic acidosis

Front 70

toxins that cause bradypnea

Back 70

SLOW
Sedative hypnotics, including GHB
Liquor
Opiates
Weed (marijuana)

Front 71

toxins that cause hypoxia

Back 71

Barbiturates
Ethanol
Opiates

Front 72

Miosis on pupil exam

Back 72

COPS
Clonidine, cholinergics
Opiates,organophosphates
 Phenothiazines,pilocarpine
 Sedative-hypnotics

Front 73

Mydriasis on pupil exam

Back 73

AAAS
Antihistamines
Antidepressants
Atropine, other anticholinergics
 Sympathomimetics

Front 74

common toxins that make the skin WET and DRY?

Back 74

Dry – anticholinergics, antihistamines
Wet – sympathomimetics, cholinergics

Front 75

common toxins that cause seizures

Back 75

OTIS CAMPBELL
 Organophosphates
 Tricyclics
 Insulin
 Sympathomimetics
 Cocaine, camphor
 Amphetamines, anticholinergics
 Methylxanthines – Theo, caffeine
 PCP
 Benzo withdrawal, GHB
 Ethanol withdrawal
 Lidocaine, lithium
 Lead, lindane

Front 76

tx of toxin sz

Back 76

Benzodiazepines
Barbs
Pyridoxine
Propofol
No Phenytoin

Front 77

anion gap causes

Back 77

METALACID GAP
 Methanol, metformin
 Ethylene glycol
 Toluene
 Alcoholic ketoacidosis
 Lactic acidosis
 Aminoglycosides, other uremics
 Cyanide, carbon monoxide
 Isoniazid, Iron
 Diabetic ketoacidosis
 Generalized seiz. causing toxic agents
 Aspirin, salicylates
 Paraldehyde
MUDPILES
 Methanol
 Uremia
 DKA
 Paraldehyde
 INH, Iron
 Lactate
 Ethanol, ethylene glycol
 Salicylates

Front 78

significance of osmolar gap

Back 78

(2*Na) + (Gluc/18) + (BUN/2.8) + (ETOH/4.6)
 Gap > 10 is significant
 (Methanol/3.2)
 (Ethylene Glycol/6.2)
 (Isopropanol/6.0)

Front 79

reasons for increased osmolar gap

Back 79

ME DIE
Methanol
Ethylene glycol
Diuretics (osmotic ones like mannitol)
Isopropyl alcohol
Ethanol

Front 80

Insulin antidote


Back 80

Glucose

Front 81

Oral Hypoglycemics antidotes

Back 81

Glucose, Octreotide

Front 82

Narcotics antidotes


Back 82

Naloxone, nalmefene

Front 83

Cyanide antidotes


Back 83

Amyl nitrate, sodium nitrite,
sodium thiosulfate, hydroxocobalamin

Front 84

Benzodiazepines antidote


Back 84

Flumazenil

Front 85

Acetaminophen antidote


Back 85

N-acetylcysteine

Front 86

TCAs antidote

Back 86

Sodium Bicarb

Front 87

Isoniazid (INH) antidote 

Back 87

Vitamin B6 (pyridoxine)

Front 88

Methemoglobinemia (Pyridium) antidote


Back 88

Methylene Blue

Front 89

Cholinergics (Organophosph.) antidotes


Back 89

Atropine, 2-PAM

Front 90

Anticholinergics antidote


Back 90

Physostigmine

Front 91

Digitalis antidote


Back 91

Digibind FAb

Front 92

Iron antidote


Back 92

Deferoxamine

Front 93

Heparin antidote


Back 93

Protamine

Front 94

Coumadin antidotes

Back 94

Vitamin K, FFP

Front 95

Lead, mercury, arsenic, other heavy metals antidotes



Back 95

Succimer, EDTA, Dimercaprol (BAL)

Front 96

Ethylene Glycol/methanol antidotes


Back 96

Ethanol, Fomepizole

Front 97

Beta Blockers antidote


Back 97

Glucagon

Front 98

Calcium Channel Blockers antidotes 

Back 98

Glucagon and
Calcium Cl/gluconate, Combo insulin & glucose

Front 99

Copper antidote


Back 99

Penicillamine

Front 100

Valproic Acid antidote


Back 100

Carnitine

Front 101

Crotalid snakes antidote

Back 101

Antivenom Fab

Front 102

Hyperkalemia antidotes

Back 102

Push K+ into cells, drawing H+ out of cells (Glucose and Insulin, Nebulized albuterol, Sodium Bicarb)

Stabilize the cardiac cells membranes (Calcium gluconate)

Bind K and eliminate it (Kayexalate)

Dialysis to eliminate it

"CB DIAL K" = Ca, bicarb, dialysis, insulin, albuterol, lasix, kayexalate

Front 103

Vomiting < 6 hr of ingestion of mushrooms indicates?

Back 103

limited hepatotoxicity

Front 104

Vomiting > 6 hr of ingestion of mushrooms indicates?

Back 104

more hepatotoxicity

Front 105

Wet Thiamine deficiency Beriberi indicates?

Back 105

Cardiovascular dysfunction

Front 106

Dry thiamine deficiency Beriberi indicates?

Back 106

Neurological – a.k.a. Wernicke’s
encephalopathy

Front 107

Thiamine deficiency Beriberi triad

Back 107

– Ocular-motor palsy, nystagmus
– Altered mental status – memory impairment
– Ataxia

Front 108

common TCAs (dirty rotten stinking drugs)

Back 108

Amitriptyline (Elavil)
Imipramine (Tofranil)
Doxepin (Sinequon)
Nortriptyline (Pamelor)
Desipramine (Norpramin)
Cyclobenzaprine (Flexaril – muscle relaxant)
"AID Nw DC"

Front 109

Classic EKG changes of TCA toxicity

Back 109

– Sinus tachycardia
– Rightward axis
– Prolonged PR and QT
– Widened QRS.

Front 110

TCA toxicity tx

Back 110

NaHCO3
hypotension, then the patient needs bicarb.
Dialysis ineffective – large volume of distribution.
Gastric lavage only if early on
Charcoal 1gm/kg if alert
Hyperventilation +/-
Avoid physostigmine
Use benzodiazepines for seizures
Use saline with bicarb then pressors for hypotension

Front 111

common MAOI

Back 111

– Phenelzine (Nardil)
– Tranylcypromine (Parnate)
– Isocarboxazid (Marplan)
– Selegiline (Eldepryl)

"PhIST"

Front 112

what products have high levels in MAOI (tyramine)?

Back 112

– Preserved meats/fish
– Sauerkraut
– Aged cheese
– Chianti wine
– Big beans
"P CABS"

Front 113

S/S MAOI/tyramine rxn

Back 113

– Severe h/a
– HTN
– Diaphoresis
– Mydriasis
– Neck pain
– Chest pain/Palpitations
– Neuromuscular excitation

Front 114

tx of MAOI/tyramine rxn

Back 114

Phentolamine (α-blocker) or Nitroprusside

Front 115

complication of MAOI/tyramine rxn

Back 115

serotonin syndrome

Front 116

S/S of SSRI

Back 116

GI side effects.
Fatalities (very rare)
N/V
Sedation
Tremor
Tachycardia.
Seizures or QT prolongation (very rare)

Front 117

tx of SSRI

Back 117

supportive.
NaHCO3 may be used if the QT is prolonged

Front 118

S/S of serotonin syndrome

Back 118

Altered cognition/behavior, hyperactivity
ANS dysfunction (hyperthermia, hypertension)
Muscle rigidity in lower extremities
Ataxia, myoclonus and hyperreflexia

Front 119

tx of serotonin syndrome

Back 119

Benzodiazepines
Cyproheptadine (Periactin) - more effective

Front 120

common atypical anitdepressants and their presentation

Back 120

Trazadone (Desyrel): Orthostatic hypotension, sedation, priapism, elevated LFTs, QT prolongation (high dose)

Buproprion (Wellbutrin): Seizures, OD- tachycardia, lethargy, tremor, and confusion.

Venlafexine (Effexor): OD - tachycardia, HTN, diaphoresis, tremor, mydriasis, Seizures /QT prolongation/QRS widening (rare)

Front 121

common typical antipsychotics

Back 121

Phenothiazines: Chlorpromazine (Thorazine), Prochlorperazine (Compazine), Perphenazine (Trilafon), Thiothixene (Navane)

Butyrophenones: Haloperidol (Haldol)

Dopamine receptor antagonists: Limbic system (antipsychotic), Basal ganglia (extrapyramidal SE)

Alpha adrenergic blockers: orthostatic hypoten.

Anticholinergic: hyperthermia, tachycardia, mydriasis, sedation

Front 122

common atypical antipsychotics

Back 122

Clozapine (Clozaril)
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
Risperidone (Risperdal)
Ziprasidone (Geodon)
"ROCQZ"

Front 123

S/S of atypical antipsychotics

Back 123

sedation, seizures, temperature instability, hypotension, tachycardia, and QT prolongation

Front 124

tx of atypical antipsychotics

Back 124

supportive
NaHCO3 (if QT prolonged)

Front 125

S/S of Lithium

Back 125

tremor (mc), n/v/d, cardiotoxicity (hypokalemia)

Front 126

3 grades of Lithium toxicity

Back 126

Grade I: 1.5-2.5mEq/L
– N/V/ataxia/tremor
– Tx: fluids and Kayexalate

Grade II: 2.5-3.5mEq/L
– Stupor, rigidity, hypotension
– Tx: consider dialysis

Grade III: >3.5mEq/L
– Coma and seizures
– Tx: hemodialysis

Front 127

common sedative/hypnotics

Back 127

benzo
barb
GHB
chloral hydrate
zopidem

Front 128

common benzos

Back 128

Alprazolam (Xanax)
Clonazepam (Klonopin)
Diazepam (Valium)
Lorazepam (Ativan)
Midazolam (Versed)
Flunitrazepam (Rohypnol)

Front 129

S/S benzo toxicity

Back 129

Drowsiness/Coma
Slurred speech
Ataxia
Disinhibition
Respiratory depression (if parenteral)

Front 130

tx of benzo toxicity

Back 130

supportive
charcoal (if alert)
flumazenil (rare)

Front 131

s/s of barb (-al)

Back 131

mild OD: drowsiness, disinhibition, ataxia, slurred speech

severe OD: coma, hypothermia, bradypnea, hypotension

death d/t combo: resp arrest, cardio collapse, hypoglycemia

skin bullae

Front 132

tx of barb OD

Back 132

airway, IVF, pressors, gastric lavage (<60min from ingestion), urine alkalinization, forced diuresis (not shocky), multi-dose charcoal/dialysis

Front 133

S/S of GHB

Back 133

date rape*, coma, bradycardia, bradypnea, obtunded (intubation), sudden awake/self-extubates, er vomiting

Front 134

tx of GHB

Back 134

supportive
flumazenil/naloxone (not helpful)

Front 135

what is the oldest hypno-sedative drug and was used to to sedate children?

Back 135

chloral hydrate

Front 136

s/s of choral hydrate

Back 136

CNS depression, hypotension, bradycardia, ventricular arrythmias, pear-like odor

Front 137

tx of choral hydrate

Back 137

propanolol (arrythmias)
dialysis

Front 138

what drug is a non-benzo sedative but acts on the benzo receptors in CNS?

Back 138

zopidem (ambien)

Front 139

s/s of zopidem

Back 139

drowsiness, vomiting, coma/resp depression (rare)

Front 140

tx of zopidem

Back 140

supportive
flumazenil (single drug OD)

Front 141

what poison has a higher morbidity/mortality than any other combo of poisoning?

Back 141

carbon monoxide

Front 142

S/S of carbon monoxide

Back 142

hypoxia, myocardial depression, ventricular arrhythmias

mild (<30%): HA, nausea, dizziness, weakness, poor concentration
mod (30-40%)
severe: confusion, lethargy, c/p, syncope, coma

Front 143

tx of carbon monoxide

Back 143

high flow O2
hyperbaric (controversial)

Front 144

s/s of opiates

Back 144

CNS depression, resp depression, miosis, analgesia, orthostatic hypotension

Front 145

tx of opiates

Back 145

support respiration, naloxone, combos with APAP/ASA

Front 146

terrible common opiates

Back 146

Meperidine (Demerol): sz, renal issues, serotonin syndrome

Propoxyphene (Darvon, Darvocet): sz, heart block, widened QRS, long QT, TCA like

Diphenoxylate-hydrochloride-atropine (Lomotil): anticholinergic/opiate like, bad for kids

Tramadol (Ultram, Ultracet): agitation, htn, resp depression, sz