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Flashcards in TOX Deck (148)
1

When should poisoning be on the ddx

• Patient with ALOC – no obvious cause
• Inexplicable vital signs
• Inexplicable lab tests, EKG
• Symptoms look like a toxidrome
• Multiple patients w/ same sx’s

2

focused Hx with poisoning should focus on

Known, suspected or reported ingestion/exposure?
1. Anticipate: What class of substance was ingested? What does it (they) do?

3

mngmt of poisoning should involve

v. REVERSE with antidote, if possible
vi. REMOVE residual poison, if possible
vii. NEUTRALIZE circulating poison
viii. ENHANCE ELIMINATION of the poison

4

poison control number

1-800-411-8080

5

initial mangement of tox pt

ii. Breathing - O2 Sat, RR – effectively ventilating?
iii. Circulation – BP low or high?
iv. Cardiac rhythm? Tachy? Brady? Wide or narrow? Is it changing?
v. D & E is for Disability/Decontamination/Exposure

6

why is considering who called 911 important

did the person who ingested this want to be saved

7

other important hx question

when was it taken
why
etoh or alcohol
PMH
has this ever happened before

8

physical exam

i. Vital signs
ii. Cardiac rhythm – do they have a dysrhythmia?
iii. Level of consciousness, gag reflex
iv. Pupils - size and reactivity
v. Skin signs – sweaty, dry, hot, rash, track marks
vi. Bowel sounds – hyper-, hypoactive, are they present at all?
vii. Bladder distention
viii. Breath/body odor
ix. Evidence of trauma, focal

9

bowel sounds

toxidrome predictable of medicines

10

management of tox

• D-stick, EKG, Upreg right away
• IV access, monitor, O2
• Acetaminophen (APAP) level
• Chem, CBC, UA, Blood
EtOH, Utox

11

why do you want to get a cmp

anion gap, electrolytes, renal, LFT’s),

12

get drug levels

• Digoxin
• Dilantin (ataxia; OD of Dilantin will make you not able to walk; they have a broad based ataxia like “drunk walking”), Carbamazepine, Valproic Acid
• Lithium


“Comprehensive” drug screens not helpful – take too long

13

• “Coma Cocktail”

• 50 cc of 50% glucose IV: (“Amp of D50”)
• Naloxone (Narcan®

14

• Naloxone (Narcan®)

reverses an opioid OD immediately. Narcan lasts about 45 mins. So if their OD is with a longer acting agent then they will come back for the 45 mins, the narcan wears off and they will go down again. Put soft restraints b/c they will wake up UNHAPPY, combative, and irritable

• 0.8-2 mg IN, IM, IV

15

when would you get a KUB

• KUB for select, ingested radiopaque substances

16

special labs you may need to order

• Calcium, Magnesium
• Total CK (rhabdomyolysis)
• PT/INR (hepatotoxic, coumadin)
• Serum osmolarity/osmolar gap

17

methods of removal

decontamination
• HAZMAT, protection for HCP
• Forced emesis**
• Surgical removal

18

Forced emesis**

b/c concerned about airway complications and esophageal rupture so don’t use this method

Rare: no syrup of ipecac

19

how do you neutralize

• 1 gm / kg administered orally
• Repeat dosing for some drugs
• Give with cathartic (Sorbitol)
• Can be given pre-hospital
• Not always useful, can be dangerous
Antidote: known ingestion/exposure

20

ENHANCE ELIMINATIONhis look like and what do we use

• Whole bowel irrigation
• Go-Lytely
• Dialysis, Hemofiltration
• Enhance urinary excretion


usually reserved for people who have ingested packets of drugs

21

i. Opiates tx

naloxone

22

ii. Acetaminophen tx

– N-acetylcysteine
1. NAC, Mucomyst

23

iii. Digoxin

– Digibind Fab-fragments

24

iv. Benzos -

flumazenil

25

v. Cyanide

- Lilly kit

26

vi. INH –

– pyridoxine

B6?

27

Carbon Monoxide

vii. Carbon Monoxide – oxygen

28

• Anticholinergics -

physostigmine

29

• Cholinergics

atropine, 2-PAM

30

• Beta blockers

glucagon (increases force and rate of contraction – chronotropic and ionotropic)

31

Ca channel blockers - TX

calcium

32

TricyclicsTX

Na bicarbonate

33

• Metals -TX

chelating agents

34

• Iron TX

deferoximine

35

• Warfarin (Coumadin TX

): Vitamin K
• Over-anticoagulation common
• Hold dose, check bleeding

36

Causes of osmolar gap

1. Methanol
2. Ethylene glycol
3. Ethanol
4. Isopropyl alcohol
5. Others....

37

normal anion gap

Calculated
1. Normal = <10

38

AG calculation

Na) – (Chloride + TCO2); Normal 5-15

39

Things that show up on a plane film




• Chloral hydrate
• Heavy metals
• Iron
• Phenothiazines; Packets of drugs (body packers)
• Enteric coated pills
• Salicylates

40

charcoal does not work on these

• Iron
• Lithium
• Cyanide
• Pesticides
• Acids and alkalis

41

why would you give someone charcoal in a NG tube

losing airway is not good with this
black slurry

42

what are toxidromes

predictable effects of particular medication

43

Anticholinergic toxidrome

a. Mad as a hatter
b. Blind as a bat
c. Red as a beet
d. Dry as a bone
e. Hot as hell


2. Flushed, dry skin

3. Elevated temp, pulse

4. Agitated delirium

5. Hallucinations

6. Dilated pupils

7. Seizures

8. ABSENT BOWEL SOUNDS

9. Distended bladder

44

what medications cause anticholinergic SE

Benadryl
scopolamine
atropine
TCA
carbamazepine
flexaril (muscle relaxer)
plants

45

plants that cause anticholinergic SE

Jimson Weed, Belladonna

46

support for anticholinergic

a. Supportive: IV fluids, monitor
b. Charcoal, Benzo’s
c. Don’t sedate with antipsychoticà enhances anticholinergic effectà seizure, sicker
d. Critical? Physostigmine

47

Cholinergic toxidrome

SLUDGE

i. Salivation
ii. Lacrimation
iii. Urination
iv. Diaphoresis
v. GI upset
vi. Emesis


b. Bradycardia ,Wheezing
c. Constricted pupils (pinpoint)
d. Lethargy

48

what can cause a toxidrome

• Pesticides
• Organophosphates
• Chemical Warfare agents
• Sarin, VX, etc

49

Tx fro cholinergic toxidrome

• Decontamination, supportive
• Atropine – muscarinic effects
• Pralidoxime (2-PAM) – both muscarinic and nicotinic effects

50

Cholinergic tx

• Decontamination, supportive
• Atropine – muscarinic effects
• Pralidoxime (2-PAM) – both muscarinic and nicotinic effects

51

sympathomemetic toxidrome

GO SPEED RACER

• Elevated BP, pulse, temp
• Can be really high
• Agitated delirium
• Seizures
• Dilated pupils
• Normal skin or sweating
• normal bowel sounds
• Bladder not distended

52

sympathomemetic drugs

• Cocaine, Amphetamines, Ecstasy
• Multiple formulations
• Caffeine
• Pseudoephedrine, Ma Huang (ephedra)
• Ritalin, Adderall, diet pills

53

sympathomemtic vs anticholinergic

NORMAL BOWEL SOUNDS
BLADDER NOT DISTENDED

54

sympathomemtic tx

a. IV fluids, Benzo’s, cooling
b. Control VS
c. Charcoal, Go-Lytely if ingested packets

55

classic triad of opiate toxidrome and 2 others

• Depressed LOC
• Lethargy to coma
• Decreased respirations (4)
• Pinpoint pupils (miosis)


• Hypotension
• Pulmonary edema

56

opiates that cause sxs

• Heroin, methadone
• Morphine, Dilaudid, Meperidine (Demerol)
• Fentanyl - patches
• Codeine, Hydrocodone, Oxycodone

57

special opiates

• Lomotil
• Dextromethorphan

58

v. Serotonergic (Serotonin Syndrome) usually happens as a result of

• Most common w/ dose increase, addition of another to tx or overdose

59

Serotonergic toxidrome

• Agitated or comatose
• Elevated temperature, pulse
• Hypo- or hypertension
• Normal pupils
• Normal skin signs
• Increased reflexes
• Clonus -hold it and bounce
• “Wet dog” shakes

60

Serotonergic meds

• SSRI’s, SSNRI’s, MAOI’s
• SSRI’s + triptans
• Combo with pain meds

61

Serotonergic treatment

a. Withdraw offender, supportive
b. Benzo’s

62

Doesn’t fit a toxidrome? consider

i. Mixed ingestion/exposure
ii. Head trauma
iii. Infection
iv. Shock
v. Metabolic imbalance


** meningitis is possible

63

i. Common, silent, deadly: order level in ALL poisoned pt’s.

h. Acetaminophen

64

what levels are toxic for acetaminophem

7.5g in adults or 150mg/kg in kids is toxic

Timing of ingestion is key – 2-4hr first level

65

what is the APAP key

timing of ingestion is key – 2-4hr first level

66

what are sxs of apap


iv. Typically few sx’s first 24hrs
v. Then: RUQ abd pain, malaise, nausea

67

labs for APAP ingestion

ASA, CBC, Chem, UA, Upreg, EKG
ix. Serial levels every 4-6hrs depending on Hx

68

Treatment for APAP

1. Charcoal if recent
2. N-acetylcysteine (NAC, Mucomyst) for 72hrs

69

Aspirin – Salicylates

i. Common, acute or chronic – slowed absorption, concretions

70

Early/mild sx’s ASA

Early/mild sx’s: tachycardia, tinnitus, n/v, abd pain, tachypnea, diaphoresis

71

Late/severe ASA sxs

Late/severe: coma, seziures, resp depression, non-cardiogenic pulmonary edema, dehydration, shock

72

how does chronic ASA tox occur

concretions

big ball of ASA hard to break up

73

severity of the ASA toxicity is directly related to the

iv. Severity = acid base imbalance

74

1. Mild toxicity/first sign

alkalosis

75

2. Progression

: resp alkalosis and AG metabolic acidosis

76

3. Severe/progression

severe AG metabolic acidosis

77

labs for ASA

v. Labs: ASA, APAP, UA/Upreg, CBC, Chem, ABG, EKG, serial ASA levels

78

TX for ASA

ABC’s, IV hydration, charcoal w/o cathartic, alkalinize urine (bicarb)

79

Pt with persistent, inexplicable tachycardia?

vii. Pt with persistent, inexplicable tachycardia? Think aspirin

80

what amount of NSAIDS is toxic

ii. 100mg/kg usually benign; co-ingestion
>400mg/kg may be life-threatening

81

NSAIDS >400mg/kgsxs

1. ALOC/coma, acidosis, seizures, pulmonary edema

82

k. Oral Hypoglycemics/Insulin sxs

i. Sx’s: ALOC, diaphoresis, tachycardia, bizarre behavior, paralysis, seizure – can mimic CVA

83

immediate dx with altered pts

ii. Immediate d-stick on ALL altered patients

84

sulfonyureas reversal

Sulfonylureas, Insulin – rapid reversal with 1 amp D50 after d-stick

85

iv. Metformin overdose

less profound hypoglycemia but lactic acidosis w/ AG present

86

The problem with oral hypoglycemics:

1. They last a long time, longer than 1 amp D50
2. Pt becomes repeatedly hypoglycemic
3. Admit these folks with glucose rich IV drips

87

Insulin OD

– admit if severe. Can correct, watch for 6hrsàhome if stable, no risks, not suicide

vii. Feed everyone with hypoglycemic toxicity

88

amitriptyline
Nortriptyline

TCA

89

amitriptyline
Nortriptyline TCAs toxidrome

iii. Anticholinergic toxidrome

90

ECG chnages with anticholinergics

1. First – sinus tach
2. Terminal R-wave in aVR
3. Widened QRS
4. Ventricular tachycardia

91

other than an anticholinergic and EKG changes what other sxs do you see

v. Coma, seizures, hypotension

92

what is the reversal agent

vi. Charcoal, whole bowel irrigation

93

sxs of iron overdose

ii. Nausea, vomiting, abd pain, diarrhea

94

sith suspected iron overdose need to figure out

iii. Estimate amount and which prep

95

sxs of iron overdose

1. AG metabolic acidosis
2. WBC’s >15k
3. Glucose >150
4. Serum iron test

96

what dx tests for suspected iron

KUB good – Charcoal does not work

97

vin rose

Dexferoxamime

antidote for iron

98

sxs of digoxin

2. N/V/D, bradyarrhythmias, hyperkalemia, CNS sx’s, EKG with specific findings
3. Dig level, Digibind Fab if arrhythmias

99

BB overdose sxs

1. Brady, hypotensive, ALOC, ventricular arrhythmias

100

labs for suspected digoxin overdose

3. Dig level, Digibind Fab if arrhythmias

101

BB overdose treatments

2. IV fluids, tx shock, charcoal if indicated

102

CCB tx

1. Sx’s/Tx much like Beta Blockers – add Calcium

103

read flags with alcohol overdose

1. EtOH level does not match sx’s
2. Not “metabolizing” (getting less drunk) with time
3. Trauma – do a good exam
4. GI bleeding, abd pain, n/v
5. Confusion, can’t walk
6. Jaundice, bruising

104

can't wait for chronic ETOH to get to 0

No need for zero level to d/c! Chronic etoh’ers will experience withdrawal sx’s at zero!

105

Refer for alcohol Tx

Benzo’s Rx for mild withdrawal sx’s

106

PE Signs:

• Tongue wag (fasiculations in the tongue), tremor
• Tachycardia
• Low grade temp

107

Red Flags fir alcohol withdraw

• Hallucinations, confusion
• Agitated delirium
• Seizure, asterixis
• Jaundice

108

tx for alcohol withdra

IV fluids, monitor, EKG, high vis bed
• Give thiamine IV
FEED THEM

109

LABS for alcohol withdraw

• Labs: CBC, Chem, PT/INR, Magnesium, Phosphorus

110

rx for alcohol withdrawal

• Benzo’s: Lorazepam 2-4mg IV until sx’s abate or need an airway
• Phenobarbital helps avoid Sz – long acting – give early
• IV 130-260mg q 30min until sedation or 1040mg

111

early sxs of mushrooms

iv. Early GI symptoms (w/in 2hrs) usually reassuring

112

delayed sxs of mushrooms

Delayed symptoms (>6hrs) associated with liver, kidney, CNS damage

113

labs for mushrooms

LFTSvi. Get LFT’s, coags, electrolytes, monitor closely

114

return to this slide

mushroom tx

. Amanita phalloides: delayed liver failure (day 3)
2. Amanita Smithiana: delayed renal failure (day 3)
3. Lepiota: delayed liver failure (day 3)

vii. Call Poison Control for ALL mushroom toxicity

115

onset of Rohypnol (flunitrazepam)

1. Rohypnol (flunitrazepam): pill form, illegal in U.S.
a. Sedation, muscle relaxation, amnesia
b. 15-30min onset, lasts 4-6hrs; tablets now dissolve with blue color

116

GHB (gamma-hydroxybutyric acid onset

1. 15min onset, lasts 3-4hrs, gone from body in 8hrs
2. Sedation, amnesia

117

ketamine

liquid/powder, onset in minutes, lasts up to 4hrs
1. Psychoactive, muscle paralysis, amnesia

118

OTC sedation

1. Visine (tetrahydrozoline), Afrin (oxymetazoline), others

119

peak ingestion of one pill kill

i. Peak age of ingestion is 1-3yr olds

120

one pill kill list

1. BIG ONE Calcium Channel Blockers – shock, brady arrhythmias
2. Clonidine – opiate toxidrome
3. Lomotil – opiate toxidrome
4. Sulfonylureas – hypoglycemia, seizures, coma
5. Cyclic Antidepressants – anticholinergic, dysrhythmias
6. Salicylates – same sx’s as adults – more serious

121

hypoglycemia, seizures, coma in children

sulfonylureas

122

pepto bismol

oil of wintergreen

6. Salicylates

123

Clonidine toxidrome

opiate toxidrome

124

Lomotil toxidrome

opiate toxidrome

125

carbon monozide poisoning seen most commonly

i. Common in winter months, cold climates – multiple sources

126

two major contributors to smoke inhalation deaths

ii. Major contributor to smoke inhalation deaths (cyanide too)

127

pathophys of CO poisoning

iv. CO binds to hemoglobin 200 times better than oxygen
1. Also binds to myoglobin, cytochromes P450 and AA3
v. Organs needing high O2 – brain, heart – affected

128

labs for CO poisoning

vii. Lab: carboxyhemoglobin (mild <20%, severe >40%)
1. Labs, lactic acid, ABG, EKG, troponin/myoglobin

129

tx for CO poisoning

viii. Tx: 100% Oxygen by non-rebreathing mask
1. Severe poisonings – hyperbaric oxygen chamber

130

near drowning

inhaling water

131

pathophysiology of near drowning

water causes loss of surfactant
Water swallowed, aspirated, alveolar flooding/loss of surfactant, hypoxia, lose airway reflexes, bradycardia, cardiac arrest, global CNS damage

132

better survival with cold water or warm water

cold better than warm

133

important questions for near drowning

a. Predisposing event: trauma, EtOH, hypoglycemia, seizure, MI, suicidal ideation, accidental
b. Clean or dirty water? Dove from height? Scuba diving?

134

labs for near drowning

ii. ABC’s first, CXR, +/- Head, C-spine CT, labs, CK, ABG

135

core temp <40.5 C (104.9) with normal mental status

1. Heat exhaustion
Normal mental status, dehydrated, sweating, weak, n/v, HA

136

heat stroke sxs

va. ALOC, ataxia, dry/hot/flushed skin, +/- sweating
b. CNS, coagulation, liver, renal damage

137

heat stroke temp

core temp >40.5 C – life threatening

138

3. Drugs associated with increased heat production

a. Cocaine, amphetamines, EtOH, salicylates

139

what do you search for with increased temp

what's tx

a. D-stick, CBC, CMP, PT/INR, CK, TSH, UA, Upreg/tox
b. Tx: ABCDE’s, cooling (ice packs, fan/wet sheet), Tylenol or NSAIDS do not work here

140

5. Malignant hyperthermia

rare, genetic, precipitated by anesthesia drugs: muscle rigidity, rhabdo

141

osborne waves are associated with hypo or hyperthermia

hypo

142

primary hypothermia

exposure, EtOH, elderly, infants, immersion

143

Secondary hypothermia

Sepsis, trauma, CVA, endocrine

144

4. Iatrogenic hypothermia

: IV fluids not warmed, ambient temp

145

kids: mammalian diving reflex

iv. Metabolism slows – kids: mammalian diving reflex

146

multi systems involved in hypotension

1. Cardiac – gentle handling to avoid dysrhythmias
a. Tach Brady, Osborn wave on EKG
2. CNS – clumsy, confusion, shivering

147

tx for hypotension

remove/tx cause, d-stick, EKG, upreg, warm IV fluids and O2, Bear-Hugger rewarming pad, feed

148

i. Snake bites**

none proven – immobilize/transport best
a. Keep the pt still