PNP-AC Boards > Toxicologic Emergencies > Flashcards

Toxicologic Emergencies Flashcards

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1
Q

When to Gastric Lavage after poisoning

A

Suspected life-threatening toxic ingestion
Procedure can be done early after ingestions (30 min- 1hr)
Sx’s not yet apparent
Airway patency can be maintained
Supportive or antidotal not effective
Can be performed w/proper technique

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2
Q

Acetaminophen antidote

A

N-Acetylcysteine (NAC)
Oral: loading dose 140mg/kg
70 mg/kg Q 4 hr for 17 doses
IV: loading: 150mg/kg over 1 hr
50mg/kg over 4hr
100mg/kg over 16hr

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3
Q

Anticholinergics antidote

A

physostigmine-agitation/delirium
Benzodiazepines-seizures
Cold bath, sedation-hyperthermia
Vent arrhythmia-NaHCO3, BB
IVF resuscitation-rhabdomyolysis

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4
Q

Anticholinesterases Antidote

A

Atropine

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5
Q

Organophosphates Antidote
Cholinergics

A

Atropine
Pralidoxime chloride
Benzodiazepine

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6
Q

Benzodiazepine Antidote

A

Flumazenil

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7
Q

Beta blocker Antidote

A

Glucagon

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8
Q

Calcium Channel Blocker Antidote

A

Calcium

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9
Q

Cyanide Antidote

A

Amyl Nitrate

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10
Q

Iron Antidote

A

Deferoxamine for iron >500
orogastric lavage within one hour
consider whole bowel irrigation

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11
Q

Methanol/Ethylene glycol (antifreeze) Antidote

A

Fomepizole
Ethanol
reduces formation of toxic metabolites
NaHCO3 for acidosis
Pyridoxine & thiamine: ethylene
Folic Acid: methanol
Hemodialysis when levels 50.

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12
Q

Opioids Antidote

A

Naloxone-short acting
Airway maintenance

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13
Q

Tricyclic Antidepressant Antidote

A

Sodium Bicarbonate

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14
Q

Warfarin Antidote

A

Vitamin K

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15
Q

Ethanol overdose monitoring

A

Frequent glucose
LFT’s

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16
Q

Acetaminophen Overdose

A

Effects Peak after 72 hours

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17
Q

Iron Overdose Symptoms

A

0-6 hr: n/v,diarrhea, abd pain
6-12hr: Improvement
12-24hr: GI losses, shock, anion gap acidosis, depressed myocardial function, increased pulmonary vascular resistance, liver failure
2-6 wk: emesis, liver failure

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18
Q

Metformin (Glucaphage) Overdose Symptoms

A

unstable VS
hypoglycemia
fixed/dilated pupils
dysrhythmias
diaphoresis
AMS, seizures
hemiplegia,

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19
Q

Cholinergic/Organophosphate ingestion symptoms (pesticides) & nicotinic agents Sx’s

A

Somnolence, delirium
Psychosis, Seizure
tachy/bradycardia, Long QTc
hypertension
Tachypnea
decreased pupil size (mitosis)
Increased bowel sounds
defecation, incontinence
Sweaty, salivation, lacrimation
bronchorrhea, bronchospasm

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20
Q

Salicylates overdose symptoms

A

Respiratory alkalosis (1st)
mixed metabolic gap acidosis
Hyperthermia
N/V, dehydration
sweating, hyperpyrexia
Tinnitus, deafness
Tachycardia
tachypnea
pulmonary edema
hyponatremia, hypokalemia
hyper/hypoglycemia
renal failure
Coma,seizures, lethargy, agitation
Somnolence

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21
Q

Ethanol intoxication sx’s

A

hypothermia
bradypnea
bradycardia
coma
mitosis
flushed skin
hypoglycemia
increased osmolar gap

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22
Q

Carbon Monoxide poisoning sx’s

A

red, flush bullae skin, hypothermia
COHb 10%: headache
COHb 20%: dizziness, nausea, dyspnea
COHb 30%: visual disturbances
COHb 40%: confusion, syncope
COHb 50%: seizures, coma
COHb 60%: myocardial dysfunction/ischemia, death

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23
Q

Hydrocarbons ingestion sx’s
(baby oil, fuels, lighter fluid, lamp oil)

A

bronchospasm, atelectasis, poor gas exchange, surfactant inactivation, pneumonitis, edema, hemorrhages, CNS depression, arrhythmias, MI, confusion, hallucinations, slurred speech, hypokalemia, hyperchloremia, cerebral atrophy, crosses BBB. bone marrow damage: aplastic anemia.

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24
Q

Acetaminophen overdose symptoms Stage one

A

0.5 hr-24hr
Anorexia, N/V, malaise, pallor, diaphoresis

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25
Acetaminophen overdose symptoms Stage two
24-48 hrs Early ex's resolution RUQ abd pain/tendernes Oliguria elevated LFT's, PTT, Bilirubin
26
Acetaminophen overdose symptoms Stage three
72-96 hr Peak of liver function abnormal anorexia, n/v Hepatic failure Metabolic acidosis coagulatopathy renal dysfunction AMS, encephalopathy
27
Acetaminophen overdose symptoms Stage four
Hepatic failure resolution oliguric renal failure death
28
Salicylates overdose management
activated charcoal urinary alkalization (NaHCO3) hemodialysis Monitor levels for 24 hrs
29
Metformin & oral hypoglycemics overdose treatment
Give Dextrose Start Octreotide Volume expansion NaHCO3 intermittent hemidialysis Charcoal for acute toxicity
30
Caustics ex; drain cleaner) sx's
causes tissue damage/necrosis n/v, dysphagia, hematesis burns metabolic acidosis drooling stridor
31
Poisoned patient Priorities
Airway-intubation Breathing-O2, vent support Circulation-pressure support, antiarrhythmics Decontamination-charcoal, WBI Enhancement-dextrose, antidotes, hemodialysis Follow up-social work, labs, IP detox
32
Sympathomimetics toxicity Sx's (Cocaine, amphetamines)
Agitation, delirium, psychosis, Sz tachycardia, hypertension hyperthermia dilated pupils Sweaty, diaphoresis hypoglycemia
33
Anticholinergic toxicity Sx's
Somnolence, delirium Psychosis, Seizures Tachycardia, hypertension hyperthermia Pupils sluggish hypoactive bowel sounds flushed, dry skin urinary retention
34
Opioid/Clonidine toxicity Sx's
Somnolence bradycardia hypotension hypothermia bradypnea pupils sluggish hypoactive bowel sounds
35
Barbituates/sedatives toxicity sx's
Somnolence hypotension bradypnea hypothermia bullae skin (from IV use)
36
Sympathomimetics overdose TX
Benzo for tachycardia, HTN, agitation Avoid beta blockers
37
Barbiturates/sedative overdose
Naloxone
38
Common Non-Toxic Ingestions
Magic markers, Ballpoint pen ink, Crayons ,Pencils Make-up/lipstick, Play Doh, Antacids Silica gel packets
39
Highly Toxic Substances in 1 Tablet/Teaspoon
Beta blockers, Calcium channel blockers, Camphor, Hydrocarbon, Laundry pods, Methadone, Nicotine, Toxic alcohols, Tricyclic antidepressants
40
Immediate Interventions for toxic ingestion
Cardiorespiratory monitor, Establish IV access, Obtain blood samples, Electrocardiogram, * Consult poison control, toxicologist
41
Laundry Packet Ingestion
Higher concentration of surfactants and alcohol, pH approximately 7 and increases to 11 with addition of water * Clinical manifestations: nausea, vomiting, drooling, oral pain, diarrhea, respiratory distress, delayed pneumonitis, CNS depression * Refer all symptomatic patients to emergency department * Observe for at least 4 hours * Give water or milk, NPO if vomiting * Consider GI consultation * Chest radiograph for respiratory symptoms * Copious eye irrigation if exposed, ophthalmology evaluation
42
Nicotine Ingestion
Common intoxicant in pediatric ingestions * Mimics effects of acetylcholine * Early presentation includes sympathomimetic effects * Significant variability in toxicity depending on type of exposure * Referral to emergency department * Monitor for 4-6 hours, may discharge if asymptomatic * If patch ingested, monitor for 24 hours due to risk of delayed/erratic absorption * Symptomatic and supportive care
43
Tricyclic Antidepressant Ingestions
Amitriptyline, clomipramine, desipramine, doxepin, imipramine, nortriptyline * Potent CNS/respiratory depressants, extensive anticholinergic activity, marked cardiac conduction abnormalities * Referral to emergency department * Admission to PICU for pediatric patients with altered mental status or cardiovascular toxicity * Management with GI decontamination and supportive care
44
Calcium Channel Blockers
Background * Potential to be LETHAL * Appealing to children because of candy-like appearance * Several formulations; immediate, sustained release * Clinical Presentation * Hypotension, bradycardia/brady arrhythmias, SA/AV node conduction abnormalities, arrhythmias, hyperglycemia, shock, seizures, death * Diagnostic Evaluation * History, 12 lead ECG, continuous cardiopulmonary monitoring
45
Calcium Channel Blockers management
Management * No reliable antidote available * Gastric decontamination * Activated charcoal or whole bowel irrigation * Calcium administration * Volume administration for hypotension * Vasoactive agents may be required * Atropine, isoproterenol, dopamine, or cardiac pacing for bradycardia * Glucagon * Increases cyclic AMP, resulting in increased blood pressure and heart rate * Intravenous lipid administration; may absorb lipophilic drugs
46
Beta Blockers
Cause decreased contractility and AV conduction * Bradycardia, hypotension, vent arrhythmias ECG, serum electrolytes * Management: ABCs, Consider activated charcoal within one hour of ingestion, Fluid boluses for hypotension, Atropine for bradycardia, Glucagon infusion, Sodium bicarbonate
47
MDMA/Ecstasy
Psychoactive drug with stimulant properties: Metabolized primarily in the liver, produces active metabolite that is an even more potent neurotoxin * Presentation: Euphoria, increased energy, double/blurred vision, bruxism, sweating, dry mouth High doses associated with agitation, panic attacks, and hallucinations Rare cases, associated with hyperthermia, rhabdomyolysis, cerebral edema, and death
48
MDMA/Ecstasy Evaluation & Management
Diagnostic Evaluation: Vital signs; especially heart rate and temperature, Serum electrolytes, glucose, renal function, Liver function tests/coagulation panel, Creatine kinase (CK); rhabdomyolysis evaluation, Urine dipstick for myoglobin, Toxicology panel, 12 lead ECG/troponin, if complaints of chest pain Management: Supportive care, Short acting benzodiazepine for anxiety, panic attacks, hallucinations Aggressive cooling and dantrolene administration if hyperthermia Long term use can result in impaired cognitive function
49
Bath Salts/Spice
Background * Synthetically prepared drug from Khat plant * Similar affects to cocaine of amphetamines * Marketed as ‘bath salts’ or ‘plant food’ * Often labeled as ‘not for human consumption’ to avoid regulation Clinical presentation: Initial: Hypertension, tachycardia, euphoria, alertness, hyperactivity Additional effects may include: Acute coronary vasospasm, myocardial infarction, gastritis, hyperthermia
50
Bath Salts/Spice Evaluation & management
Diagnostic evaluation: No detected on standard drug screens, Advanced detection by mass spectrometry Management: Low dose benzodiazepines; agitation, * Benzodiazepines; seizures * Surface cooling and dantrolene for hyperthermia * Monitor for signs of rhabdomyolysis * Morphine, nitroglycerin, and antiplatelet medications if coronary spasm
51
An 18-month-old with profound hypotension is presumed to have ingested two calcium channel blocker pills from his grandmother’s purse. Which cardiac rhythm is most consistent with a significant calcium channel blocker ingestion? 1. Torsades de Pointes 2. Ventricular tachycardia 3. Bigemeny 4. Second degree atrioventricular (AV) block
4. Second degree atrioventricular (AV) block
52
A 17-year-old presents after an intentional TCA ingestion. Which test should be obtained immediately? A. ECHO B. Chest radiograph C. Cardiac troponin D. 12 lead ECG
D. 12 lead ECG
53
A 15-year-old female took approximately 175 mg/kg of acetaminophen as a suicide attempt after breaking up with her boyfriend. Which if the following diagnostic tests are most critical to monitor 72 hours after the ingestion? 1. Serial 12 lead ECG and troponin levels 2. Liver function tests and PT/PTT 3. Serum potassium and urine myoglobin 4. Serum osmolality and urine electrolytes
2. Liver function tests and PT/PTT
54
While waiting for the laboratory results you just requested, an appropriate action for this patient includes: A. Administer activated charcoal and plan to admit to PICU B. Administer activated charcoal and IV fluid bolus of 20 mL/kg of 0.9NaCl C. Notify poison control and obtain IV N-acetylcysteine from pharmacy D. Notify poison control and obtain Flumazenil from pharmacy
C. Notify poison control and obtain IV N-acetylcysteine from pharmacy
55
An awake toddler with a patent airway is brought to the ED with suspected calcium channel blocker ingestion. She is warm peripherally with heart rate of 60 bpm and blood pressure of 56/29 mmHg. After starting oxygen, placing her on monitors, starting an IV and and sending labs, what is the next best management strategy? A. Fluid bolus and amiodarone bolus B. Atropine dose and nitroprusside infusion C. Fluid bolus and calcium administration D. Calcium bolus and esmolol infusion
C. Fluid bolus and calcium administration
56
A toddler presents to the Emergency Department with his grandmother after a presumed ingestion. History of which missing item from the grandmother’s purse would be most concerning for a possible lethal ingestion? A. Silica packet B. Metformin tablet C. Calcium channel blocker tablet D. Antacid tablet
C. Calcium channel blocker tablet
57
What is the best test to order to evaluate for rhabdomyolysis? A. Serum creatine kinase B. Urine protein C. Coagulation studies D. Electromyogram
A. Serum creatine kinase
58
Which of the following changes in clinical examination would you expect after the initiation of deferoxamine IV? A. Vin rose urine B. Jaundice C. Oozing at catheter sites D. Maculopapular rash
A. Vin rose urine
59
How many hours after an acetaminophen ingestion is the optimal time to draw the first acetaminophen level? A. One hour B. Two hours C. Four hours D. Six hours
C. Four hours
60
Hydrocarbons ingestion Management: (baby oil, fuels, lighter fluid, lamp oil)
ABC's, oxygen. Avoid catecholamines. Correct electrolytes
61
Benzodiazepines Overdose S/S
CNS depression, bradycardia, n/v, resp depression, hypotension, hypothermia
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