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37 Cards in this Set

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How do you calculate an osmolar gap?
Measured osms - [(2 x Na) + (BUN /2.8) + (Glucose/18)]
Which ingestions can cause an elevated osmolar gap?
Methanol, ethylene glycol, diuretics (such as sorbitol or mannitol), isopropyl alcohol, ethanol. mnemonic is ME DIE.
What are the indications for dialysis in an isopropyl alcohol ingestion?
Level over 400mg/dl or refractory hypotension.
How do patients who have ingested isopropyl alcohol present, and what do their labs show?
Intoxicated, hypotensive, no DTRs, occasional GI bleeding and hemolytic anemia. Odor of acetone. Classically have elevated osmolar gap with no anion gap.
An intoxicated patient presents to the ED with seizure. He complains of severe headache and flank pain. On lab evaluation he has an elevated anion gap and hypocalcemia. What is the ingestion?
Ethylene glycol. 1/3 of patients have hypocalcemia related to preciptation of oxalate crystals, which can cause kidney stones as well as damage vasculature and cause CHF, ARDS, and cerebral edema.
All of the following are causes of a cholinergic toxidrome except
a. organophosphates
b. pilocarpine
c. cyclic antidepressants
d. carbamates
c. cyclic antidepressants
Lithium intoxication is associated with what EKG findings?
Prolonged Q-T
Which of the following ingestions is associated with GI hemorrhage
a. lithium
b. iron
c. phosphorus
d. arsenic
b. iron
What is the antidote for iron poisoning?
deferoxamine
Findings that indicate a serious overdose of tricyclic antidepressants include the following except
a. ventricular dysrhythmias
b. wide QRS
c. AV block
d. hypertension
d. hypertension
A patient presents acting intoxicated, but does not smell of alcohol. His urine is fluorescent under Wood's lamp. What is appropriate treatment?
The patient has ingested ethylene glycol. He should be treated with ethanol, thiamine, and pyridoxine (which either inhibit formation of toxic metabolites or enhance production of non-toxic metabolites). Dialysis may also be indicated.
What is the most common cause of death from a toxin?
Carbon monoxide
A baby has swallowed mercury from a thermometer which broke in her mouth. What is the treatment?
None. Elemental mercury is not toxic in ingestion.
A mother brings in her 2 young children with headache, vomiting, weakness. She has a headache, as well. They don't have fevers. What toxin should you consider with this presentation?
Carbon monoxide
Which is injured more commonly in alkali ingestions, the stomach or the esophagus?
The esophagus. The stomach is more commonly injured in acid ingestions.
True or false. A child has ingested iron and has nausea, vomiting, diarrhea, and lethargy. You should give charcoal in case the child ingested other toxins.
False. Do not give charcoal to a patient who will require upper endoscopy.
An elderly patient presents with altered mentation, respiratory alkalosis, and an elevated anion gap metabolic acidosis. Her pH is 7.38. What toxin should you consider in your differential diagnosis, and how is it treated?
You should consider aspirin toxicity, and it is treated with urinary alkalinization (the kidney only resorbs unionized salicylic acid), charcoal, and dialysis
A drunk patient presents with photophobia, abdominal pain, elevated anion gap metabolic acidosis, blurry vision, and dilated pupils. What is the likely cause, and how is it treated?
Methanol poisoning. It is treated with ethanol, folic acid, and dialysis.
What are the advantages and disadvantages of fomepizole over ethanol?
Fomepizole is not sedating, but is more expensive.
What is the toxic dose of acetaminophen?
140 to 150 mg/kg
What is the 4 hour level of acetaminophen which would cause you to initiate treatment?
140 mg/dl
What is the treatment for acetaminophen toxicity?
N-acetylcysteine (Mucomyst)
What is the initial dose of the antidote for acetaminophen toxicity?
140 mg/kg followed by 70 mg/kg q4 hours for 17 doses
How does the antidote for acetaminophen toxicity work?
NAC is a precursor for glutathione. Glutathione is a sulfur donor for the conjugation of the toxic metabolite of acetaminophen (NAPQI).
Describe the symptoms associated with each phase of acetaminophen toxicity.
Phase 1 (0-24 hr) - Assymptomatic
Phase 2 (24-72 hr) - RUQ pain, N/V, elevated transaminases
Phase 3 (72-96 hr)- Coaggulopathy, jaundice, encephalopathy
Phase 4 (4d-3wk) - Resolution of symptoms or organ failure
What is traditionally used as a predictor for adverse outcomes with TCA overdoses?
Widening of the QRS duration of more than 100 ms.
What is the treatment for TCA overdoses?
GI decontamination
Sodium bicarb for prolonged QRS, seizures, acidosis, hypotension or dysrhythmias
Antidysrhythmics for arrhythmias
What is the toxic dose of TCAs?
10-15 mg/kg
A patient has been exposed to hydrofluoric acid on his hands. How can this be fatal?
hydrofluoric acid can bind calcium, resulting in terminal arrhythmias.
A patient has a hydrofluoric acid burn. You only have calcium chloride available for treatment. Can you inject it locally?
No. It produces direct injury to tissues.
A patient persents with DIC and metabolic acidosis with GI bleeding. Endoscopy shows coagulative necrosis in the stomach. What is the likely agent?
This is classic for an acid ingestion. Alkali ingestions cause liquefactive necrosis.
A child has ingested his mother's iron tablets. he had had abdominal pain and bloody stools, earlier, but he is now 12 hours out from ingestion and is asymptomatic. What should you do with him?
Admit him. Iron poisoning often has a "quiescent" phase prior to manifestation of altered mental status and metabolic acidosis. He needs iron levels checked and will likely need treatment with deferoxamine.
a child presents with altered mental status, low grade fever, dry mouth, and urinary retention. he has had recent poison ivy, being treated with a topical over the counter medication. what should you worry about?
arrhythmias. the child is likely toxic from a topical antihistamine similar to benedryl.
what is the maximum time at which charcoal may still be useful?
1 hour post-ingestion
15 y/o M is found unresponsive at a party. No history of trauma. BP 100/60, HR 40, RR 12, Temp 98.6. Physical exam is remarkable for the absences of a gag reflex with some vomit present in his mouth, normal sized reactive pupils, bradycardia, and GCS 3. Cardiac monitor reveals narrow complex sinus bradycardia; BG is nl, no response to naloxone. Pt is intubated for airway protection. CT brain is normal. Ethanol is 20 mg/dl on arrival. He remains comatose for the next 5 hours but then suddenly awakens, pulls his ET tube out and attempts to leave. Which of the following agents induces toxicity that is most consistent with this presentation?
A. Carisoprodol
B. Flunitrazepam
C. GHB
D. MDMA
E. Oxycodone, sustained release
GHB commonly presents like this.
Leads to ataxia, sedation, respiratory depression, coma, apnea, death
-Used for date rape d/t rapid coma induction
-Non-hemodynamically compromising sinus bradycardia and mild hypothermia are common
-Rapid recovery of consciousness from deep CNS sedation
A 40 y/o M passed out while using a gas-powered cement cutter in his garage with the doors closed. His wife called 911; paramedics placed him on oxygen with a non rebreather mask and transported him to the emergency department. On arrival he says he has only nausea and a mild headache. A venous blood COHb of 20% confirms carbon monoxide poisoning; detailed neurologic examination is normal. The hospital’s hyperbaric oxygen chamber is available. What is the rationale for using the hyperbaric chamber to treat this patient?

A. To correct presumed associated metabolic alkalosis more rapidly
B. To decrease the COHb level more rapidly
C. To decrease the likelihood of death
D. To decrease the likelihood of delayed neurologic sequelae
E. To prevent the development of cardiac dysrhythmias
D. Decrease neurologic sequelae

Hyperbaric oxygen:
-May prevent lipid peroxidation
-Decrease risk of developing neurologic sequelae
-No evidence that it reduces mortality or decreases risk of ventricular dysrhythmias
-More rapidly decrease COHb levels
-More rapidly corrects metabolic acidosis associated with CO poisoning
In which of the following situations of known methanol ingestion are both administration of fomepizole and performance of hemodialysis indicated?

A. pH/PCO2 7.10/10, methanol 0 mg/dl, ethanol 0 mg/dl
B. pH/PCO2 7.10/10, methanol 10 mg/dl, ethanol 300 mg/dl
C. pH/PCO2 7.10/10, methanol 30 mg/dl, ethanol 30 mg/dl
D. pH/PCO2 7.40/40, methanol 50 mg/dl, ethanol 10 mg/dl
E. pH/PCO2 7.40/40, methanol 200 mg/dl, ethanol 300mg/dl
c. pH7.1, pCO2 10, methanol 30, ethanol 30