Royal College: Emergency Medicine > Toxicology > Flashcards

Toxicology Flashcards

This deck covers Chapters 139-159 in Rosens, compromising all of toxicology. (112 cards)

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1
Q

Outline treatment for BB/CCB poisoning.

A
  • MOVID
  • ABCs
  • Charcoal/WBI
  • Fluids, Pressors
  • Calcium
  • Glucagon 5 mg IV
  • Insulin R 1-10 units/kg/hr
  • Intralipid
  • ECMO
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2
Q

Identify the following:

A

Water Hemlock

Signs/Symptoms

  • N/V
  • Seizures (GABA antagonism)

Treatment

  • Charcoal
  • Seizure control
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3
Q

Outline the metabolism of ethylene glycol.

A

Ethylene glycol

  • Alcohol dehydrogenase
  • NAD as cofactor

Glycoaldehyde

  • Aldehyde dehydrogenase
  • NAD as cofactor

Glycolic acid

  • NAD as cofactor

Glycoxylic acid

  • Pyridoxine as cofactor (glycine)
  • Thiamine and Mg as cofactor (a-hydroxy-…)

Oxalic acid + Glycine + a-hydroxy-b-ketoadipate

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4
Q

List 6 radio-opaque drugs.

A

CHIPES

  1. CaCO3
  2. Heavy metals
  3. Iron
  4. Potassium
  5. Enteric-coated pills
  6. Solvents
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5
Q

List 5 benefits of fomepizole over alcohol.

A
  1. Ease of administration
  2. Standardized
  3. Predictable
  4. Safer
  5. Longer duration of action
  6. No CNS effect
  7. ADH has higher affinity to fomepizole than alcohol
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6
Q

In asymptomatic or minimally symptomatic children, what guides lead chelation therapy?

A

Leads sucks (69)

  • BLL >69 - hospitalize
  • BLL 45-69 - OP oral succimer
  • BLL <45 - no chelation
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7
Q

List 5 non-selective and 4 selective beta-blockers.

A

Non-Selective

  • PLaNTS
  • Propranolol
  • Labetalol
  • Nadolol
  • Timolol
  • Sotalol

Selective

  • BEAM
  • Bisoprolol
  • Esmolol
  • Atenolol
  • Metoprolol
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8
Q

Differentiate the type of injury caused by acids/alkalis.

A

Acids

  • Coagulative necrosis
  • Concern re: systemic absorption

Alkalis

  • Liqufactive necrosis
  • Deeper penetration
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9
Q

What is the mechanism of action of CN and H2S?

A

Binds Complex IV in the electron transport chain

Uncouples oxidative phosphorylation

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10
Q

Outline management of ASA poisoning.

A
  • IV fluids
  • U/O at 2-3 cc/kg
  • Alkalinize the urine
  • NaHCO3 infusion
  • Target urine pH >7.5
  • Replace potassium
  • KCl in fluids
  • Maintain glucose
  • Target >5.5 mmol/L
  • Consider dialysis
  • Coma, Seizure
  • Renal failure
  • Hepatic failure
  • Respiratory failure
  • Severe acidosis
  • Rising ASA level
  • Acute level >7.2
  • Chronic level >3.6
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11
Q

List 6 drugs that intralipid is indicated for.

A
  1. BB
  2. CCB
  3. Local anesthetic
  4. Buproprion
  5. TCAs
  6. Seroquel
  7. Diphendydramine
  8. Class I antiarrhythmics
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12
Q

List the antidote and dose for the following drugs/poisons:

  • Iron
  • Isoniazid
  • Lead
  • Local anesthetics
  • MDMA-related hyperpyrexia
  • Neuroleptics (NMS)
  • Methanol
  • Methemoglobin
  • Opioids
A
  • Iron - Deferoxamine 15 mg/kg/hr IV
  • Isoniazid - Pyridoxine 5g IV
  • Lead - DMSA 10 mg/kg PO
  • Local anesthetics - Intralipid 1.5 mL/kg IV
  • MDMA-related hyperpyrexia - Dantrolene 2.5 mg/kg IV
  • Neuroleptics (NMS) - Dantrolene 2.5 mg/kg IV
  • Methanol - Fomepizole 15 mg/kg, Folate 50 mg IV
  • Methemoglobin - Methylene blue 1-2 mg/kg
  • Opioids - Narcan 0.4 mg IV
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13
Q

Pulmonary irritants react with water to cause damage. Give 4 examples.

A
  1. Chlorine –> HCl
  2. Phosgene –> HCl
  3. Ammonia –> Ammonium hydroxide
  4. Sulfur dioxide –> H2SO4
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14
Q

When do you initiate lab testing (AST + APAP) in chronic APAP ingestion (3)?

A
  • Ingestion >10g/day x24h
  • Ingestion >6d/day x48h
  • Symptomatic (N/V, RUQ pain, Jaundice)
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15
Q

List 7 drugs which enhance lithium toxicity.

A

Renal Toxins

  1. NSAIDs
  2. Diuretics
  3. ACEi
  4. ARB

Neuro/Psych Meds

  1. SSRI
  2. Antipsychotics
  3. Carbamazepine
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16
Q

List 5 drugs that induce CYP P450.

A
  1. Sulfonylureas
  2. Phenobarbital
  3. Rifampin
  4. INH
  5. Phenytoin
  6. Carbamazepine
  7. HIV medications
  8. St. John’s wart
  9. Chronic EtOH
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17
Q

List 7 causes of a toxin-induced bradycardia.

A
  1. CCB
  2. BB
  3. Opiate
  4. Clonidine
  5. Digoxin
  6. Barbiturates
  7. Organophosphates
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18
Q

List 5 reasons why the Done nomogram is not useful in all patients.

A
  1. Derived in pediatric population
  2. Assumes 1st order kinetics
  3. pH must be >7.4
  4. Toxicity correlates poorly with serum levels
  5. Used after 6h from single, non-EC ASA dose
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19
Q

How do you approach the following patients with iron ingestion?

  • Asymptomatic, Ingestion <20 mg/kg, Level <60
  • Asymptomatic, Ingestion >20 mg/kg, Pills on Xray
  • Symptoms and level 60-90 umol/L
  • Ingestion >60 mg/kg, level >90 umol/L
A

Asymptomatic, Ingestion <20 mg/kg, Level <60

  • Observe x6h, then psych vs home

Asymptomatic, Ingestion >20 mg/kg, Pills on Xray

  • Get level at 4h and 8h
  • WBI
  • If level >60 or systemic symptoms = chelate
  • If level <60 and decreasing = don’t chelate

Symptoms and level 60-90 umol/L

  • Chelate (DFO 15 mg/kg/hr)

Ingestion >60 mg/kg, level >90 umol/L

  • Chelate (DFO 15 mg/kg/hr)
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20
Q

List 8 indications for DigiFab.

A

Adult

  1. Cardiac arrest
  2. Ventricular dysrhythmia
  3. Symptomatic, refractory bradycardia
  4. Progressive rhythm disturbance
  5. Potassium >5
  6. Increasing potassium
  7. Co-ingestion with CCB, BB, TCA
  8. Ingestion of plant containing drug AND dysrhythmia
  9. >10 mg ingestion with any of above
  10. Digoxin level >6 with any of above

Children

  1. Same as adults except K >6 and level >5
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21
Q

What kinetics does ASA undergo in therapeutic vs toxic ranges?

A

Therapeutic = 1st order

Toxic = zero order

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22
Q

List 10 indications for HD in ASA toxicity.

A
  1. Coma
  2. Seizure
  3. Renal failure
  4. Hepatic failure
  5. Respiratory failure
  6. Severe acidosis
  7. Rising ASA level
  8. Acute level >7.2
  9. Chronic level >3.6
  10. Pregnant
  11. Intubated
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23
Q

List the antidote and dose for the following drugs/poisons:

  • Organophosphates/Carbamates
  • Rattlesnake bite
  • Serotonin syndrome
  • Sulfonylureas
  • TCAs
  • Valproate
A
  • Organophosphates - Atropine 1 mg then double
  • Rattlesnake bite - CroFab 5 vials
  • Serotonin syndrome - Cyproheptadine 4 mg PO
  • Sulfonylureas - Octreotide 50 ug SC
  • TCAs - Bicarb 1 mEq/kg, Intralipid 1.5 mL/kg
  • Valproate - Carnitine 100 mg/kg IV
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24
Q

Outline the degree of IRON toxicity in terms of the amount ingested and serum iron level.

A

No Toxicity

  • Ingested <20 mg/kg
  • Serum <30 umol/L

Mild

  • Ingested 20-40 mg/kg
  • Serum 30-60 umol/L

Moderate

  • Ingested 40-60 mg/kg
  • Serum 60-90 umol/L

Severe

  • Ingested >60 mg/kg
  • Serum >90 umol/L
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25
Name 4 different **chelators**.
1. Deferoxamine 2. BAL 3. DMSA 4. EDTA 5. D-Penicillamine
26
List 3 reasons to start NAC in **chronic ingestions**.
1. AST \>2x normal 2. AST elevated + APAP \>66 umol/L or symptomatic 3. APAP greater than expected/toxic
27
List contraindications to **activated charcoal**.
* Can't absorb toxin * Caustic ingestion * Aspiration * Ileus * Perforation * Airway not protected
28
What 5 hydrocarbons have **increased toxicity**?
**CHAMP** * Camphor * Halogenated Hydrocarbons * Aromatic hydrocarbons * Metals * Pesticides
29
List 6 ingested overdoses in which you would consider **WBI**.
Basically, anything that is very toxic 1. Heavy metals 2. BB 3. CCB 4. TCA 5. Iron 6. Lithium 7. Extended-release formulations 8. Bezoar forming drugs
30
**Differentiate** acute and chronic lithium overdose by: * Cause * Presenting symptoms * Usefulness of WBI * Levels for HD
**Cause** * Acute - overdose * Chronic - AKI, dehydration, drug interaction **Presenting symptoms** * Acute - GI, Cardiac * Chronic - Neuro **Usefulness of WBI** * Acute - helpful * Chronic - not helpful **Levels for HD** * Acute - \>4 mEq/L * Chronic - \>2.5 mEq/L
31
What is the dose of **deferoxamine**? Indications (3)? Adverse effects (4)?
**Dose** * 15 mg/kg/hr x24h **Indications** * Systemic toxicity * Level \>90 umol/L * Ingestion \>60 mg/kg **Adverse Effects** * Hypotension * Anaphylactoid reactions * Pink urine * Ototoxic * ARDS * Yersinia sepsis
32
Name 5 drugs that could be used to treat a **hypertensive emergency secondary to cocaine**.
1. Benzodiazepines 2. Phentolamine 3. Nitroglycerin 4. Nitroprusside 5. Hydralazine 6. Diltiazem AVOID BETA-BLOCKERS --\> Unopposed alpha
33
List 6 causes of a '**double gap**' (Anion + Osmolar).
1. DKA 2. AKA 3. Ethylene glycol 4. Methanol 5. Propylene glycol 6. Lactate 7. MODS 8. Chronic renal failure
34
List three types/forms of **mercury**.
1. Elemental * Not absorbed * Inhaled 2. Inorganic salt * GI/GU toxin 3. Organic * GI/Skin toxic * Neuro symptoms
35
How are **inhaled toxins** classified (4)?
1. Asphyxiant (simple) * Takes up space, so no oxygen * CO2, N2, Helium 2. Asphyxiant (chemical) * Inhibits oxygen utilization * CN, CO 3. Irritant (high solubility) * Danger quickly (laryngospasm, bronchospasm, eyes) * Ammonia, HF, HCl 4. Irritant (low solubility) * Danger later (pneumonitis, ARDS) * Phosgene
36
What drugs require **urinary alkalinization**?
**STAMP CAME** 1. Sulfonamides 2. TCAs 3. ASA 4. MTX 5. Phenobarbital 6. Cocaine 7. Antihistamines 8. Methanol 9. EG
37
What is the mechanism of action of **physostigmine**? Adverse reactions? Contraindications?
MOA = AChEi A/E = Cholinergic excess (Seizures) CI = QRS \>100 ms, TCAs
38
What are the 5 Hunter Criteria for **serotonin syndrome**?
Known exposure to serotonergic drug: 1. Spontaneous clonus 2. Inducible clonus AND Agitation or diaphoresis 3. Ocular clonus AND Agitation or diaphoresis 4. Tremor AND Hyperreflexia 5. Tone AND Temperature AND Clonus
39
Name 8 drugs with **primarily anticholinergic toxicity**.
1. Atropine 2. Scopolamine 3. Homatropine 4. Cyclopentolate 5. Glycopyrrolate 6. Atrovent 7. Benztropine 8. Diphenhydramine
40
A patient thought to be inhaling hydrocarbons arrives in VT. How do you alter ACLS?
* Add esmolol or lidocaine * Avoid epinephrine
41
Outline your management of **stimulant-induced hyperthermia**.
1. Identification 2. MOVID 3. ABCs 4. Benzos 5. Ketamine if necessary 6. Ice packs 7. Cold IV fluids 8. Intubate/Paralyze if necessary 9. Antibiotics 10. B/W including BCx, CK/urine myoglobin
42
What are the 3 treatment goals for **EG/Methanol toxicity**.
* Correct acidosis * Bicarb to pH 7.45-7.5 * Aggressive in Methanol (save sight) * Careful in EG (worsen hypoCa) * Enhance clearance * HD * Prevent metabolism * Alcohol/Fomepizole * Thiamine 100 mg/Pyridoxine 50 mg + Folate 50 mg
43
Name the 3 binding sites on a **GABA receptor**.
1. GABA 2. BZD 3. EtOH/Barbituates/GHB
44
List 4 indications for HD in **lithium poisoning**.
1. Acute \>4, Chronic \>2.5 2. CNS symptoms (seizure, decreased LOC) 3. Renal insufficiency 4. Can't tolerate volume
45
What is the mechanism for sudden death with **hydrocarbon abuse**?
Sensitization of myocardium to catecholamines
46
What is the clinical picture of **GHB toxicity**?
**Sedative Hypnotic Toxidrome** * Respiratory depression/Apnea * Miosis * Hypothermia * Bradycardia/Hypotension Fluctuating between agitation and deep coma Vomiting Myoclonic movements
47
What 2 types of **NSAID overdoses** are dangerous?
1. Mefanamic acid * Seizures 2. Phenylbutazone * Aplastic anemia + Agranulocytosis
48
Outline the management of **TCA overdose**.
* MOVID * Charcoal 1 g/kg * Airway management * IVF + Pressors * Bicarb/3% saline boluses until narrow QRS * Na 155 or pH 7.55 limit * Seizures with BZD * Intralipid 1.5 mL/kg * Lidocaine 1 mg/kg * ECMO
49
Name & Describe the Stages of **APAP Toxicity**.
**Stage 1 (0-12 hours)** * N/V * Elevated APAP level **Stage 2 (8-36 hours)** * N/V + RUQ pain * Elevated LFTs **Stage 3 (2-4 days)** * Fulminant liver failure * Coags, Glucose, Bili, Acidosis **Stage 4 (\>4 days)** * Death/Recovery
50
List 6 signs of **serotonin syndrome**.
**FARMED** 1. Fever 2. Autonomic instability 3. Rigidity 4. Myoclonus 5. Encephalopathy 6. Diaphoresis
51
What are 3 mechanisms of **action of cocaine**?
1. Forces release of NE, Dopamine, Serotonin into synapse 2. Blocks reuptake from the synapse 3. Sodium channel blockade
52
How do you calculate the dose for a **naloxone INFUSION**?
⅔ the initial effective total dose / hr Initial effective dose = dose needed to achieve RR = 12
53
What are the toxic effects of **lithium**?
**LITHIVM** * **L**eukocytosis * **I**nsipidus diabetes * **T**remor * **H**ypothyroidism/Hyperparathyroidism * **I**ncreased weight * **V**omiting/Nausea/Diarrhea * **M**isc. * ECG (long QT) * SS * NMS
54
List 8 risk factors for increased risk of **digoxin toxicity**.
1. Renal failure 2. Heart disease * CHF, Myocarditis, Ischemic disease 3. Electrolyte imbalance * HypoK, HyperK, HypoCa 4. Hypothyroidism 5. Sympathomimetic drugs 6. Alkalosis 7. Elderly women 8. Cardiac drugs * CCBs, BB, TCAs 9. Drug interactions * Captopril, CCBs, Erythromycin
55
Outline 3 approaches to calculating and administering **DigiFab**.
**Empirical** * Cardiac arrest = 20 vials * Life-threatening dysrhythmia = 10 vials **Ingested Dose** * Digoxin is 80% bioavailable * One vial binds 0.5 mg of digoxin **Steady-State Concentration** * Vials = (Serum concentration x Weight in kg) / 100
56
List 2 adverse effects of **Levamisole**.
**Antihelminthic agent** 1. Agranulocytosis 2. ANCA-positive vasculitis
57
List 6 admission criteria for **cocaine-related chest pain**.
1. Persistent pain 2. ECG changes 3. Dysrhythmia 4. Elevated Troponin 5. Pre-existing CAD 6. CAD risk factors 7. ACS 8. CHF 9. Requiring IV anti-hypertensives
58
List 8 causes of **stimulant-induced chest pain**.
1. ACS 2. Endocarditis 3. Pericarditis 4. Aortic dissection 5. PE 6. Pulmonary infarction 7. PTX 8. FB 9. Pneumomediastinum
59
Describe the timing and clinical characteristics of each stage of **ethylene glycol toxicity**.
**Stage 1 (0-12h)** * Acute Neurologic stage * Drunk +/- ocular findings **Stage 2 (12-24h)** * Cardiopulmonary stage * Tachycardia, HTN, Tachypnea * Myositis * Hypocalcemia **Stage 3 (24-72h)** * Renal stage * Flank/abdominal pain, hematuria w/ AKI * Calcium oxalate crystalluria **Stage 4 (6-12d)** * Delayed Neurologic stage * Cranial neuropathy * Cognitive/Motor deficits
60
What is the universal antidote for **decreased LOC NYD**?
**DONT** 1. Oxygen 2. Thiamine 3. Dextrose 4. Narcan
61
What is the mechanism of action of **organophosphates**?
Bind and inhibit AChE Leads to cholinergic toxidrome
62
What **toxicities** are specific to: * Toluene * Benzene * Chlorinated HC * Methylene Chloride
Toluene - HAGMA, RTA Benzene - Cancer, Aplastic anemia Chlorinated HC - Hepatic necrosis Methylene Chloride - CO poisoning
63
List 4 acid-base disturbances with **ASA toxicity**.
**Metabolic Acidosis (AG)** * Uncouples oxidative phosphorylation **Respiratory Acidosis** * Eventually tire **Metabolic Alkalosis** * Volume contraction **Respiratory Alkalosis** * Stimulates resp center in medulla
64
List the **antidote and dose** for the following drugs/poisons: * Tylenol * Anticholinergics * Arsenic/Lead/Mercury * Benzos * Black Widow * Beta-Blockers * CCBs * Cyanide * Digitalis * Ethylene glycol * Hydrofluoric acid
* APAP - NAC 150 mg/kg x1h, 50 mg/kg x4, 100 mg/kg x16h * Anticholinergics - Physostigmine 1-2 mg IV * Arsenic/Lead/Mercury - BAL 3-5 mg/kg IM * Benzos - Flumazenil 0.2 mg * Black Widow - one vial Latrodectus antivenin by slow IV infusion * BB - Glucagon 5 mg IV, Insulin R, Intralipid 1.5 mL/kg * CCBs - Calcium 1g, Glucagon 5 mg IV, Insulin R * Cyanide - Hydroxycobalamin 5g IV * Digitalis - 10-20 vials if VF, otherwise dose * EG - Fomepizole 15 mg/kg, B1 100 mg IV, B6 100 mg IV * Hydrofluoric acid - calcium gluconate top/IV/IA
65
List 5 **differences** in acute and chronic digoxin intoxication.
1. Chronic is more lethal 2. Chronic has more ventricular dysrhythmias 3. Chronic is usually older patients 4. Chronic often need Fab 5. Chronic often have worse underlying heart disease
66
Name 4 classes of **hydrocarbons**.
1. **Aliphatic HC** * Methane, Butane 2. **Aromatic HC** * Benzene 3. **Halogenated HC** * Chloroform 4. **Wood distillates** * Toluene
67
What 4 characteristics determine the toxicity of a **hydrocarbon**?
1. Viscosity 2. Volatility 3. Side chains (Halogenated/Metals) 4. Surface tension
68
List 5 properties that make a **drug dialyzable**.
1. Small Vd (\<1L/kg) 2. Low protein binding 3. Small size 4. Low endogenous clearance 5. Severe toxicity without antidote
69
What are the main symptoms of a **nicotinic CHOLINERGIC toxidrome**?
Days of the Week * **M**uscle cramps * **T**achycardia * **W**eakness * t**H**ypertension * **F**asciculations
70
What are the main symptoms of a **muscarinic CHOLINERGIC toxidrome**?
**DUMBBELS** * **D**iarrhea * **U**rination * **M**iosis * **B**ronchorrhea * **B**radycardia * **E**mesis * **L**acrimation * **S**alivation
71
List 4 indications for **HBOT in CO poisoning**.
**Best if started within 6 hours of exposure** 1. COHb \>25% 2. COHb \>15% (pregnant/children) 3. Altered LOC 4. Neuro deficits (motor, visual) 5. CV Instability (ischemia/arrhythmia) 6. pH \<7.2
72
How can you **differentiate** isopropyl alcohol ingestion from EG/Methanol?
1. Ketosis without acidosis 2. Osmolar gap without anion gap 3. Often get gastritis 4. Breath
73
**Differentiate** serotonin syndrome from neuroleptic malignant syndrome.
**Serotonin Syndrome** * Exposure to serotoneric drug * More clonus * Mydriasis * Acute **NMS** * Exposure to dopaminergic drug * More rigidity * Rhabdo * Subacute
74
Name 4 mechanisms of action of **NAC**.
1. Glutathione precursor 2. Glutathione substitute 3. Enhance sulfation 4. Free radial scavenger 5. Alters hepatic microcirculation 6. Reduces cerebral edema
75
Outline your treatment of a **suspected barbituate overdose**.
* MOVID * MDAC - 25g q2h x3 * Airway protection * IVF + Pressors * Dialysis
76
What does a VBG sample look like in someone with **CN poisoning**?
Looks arterial Due to lack of utilization of oxygen
77
Outline the **metabolism of methanol**.
**Methanol** * Alcohol dehydrogenase * NAD as cofactor **Formaldehyde** * Aldehyde dehydrogenase * NAD as cofactor **Formic acid** * Folate as cofactor **CO2 + H20**
78
List 6 drugs not absorbed by **charcoal**.
1. Alcohols 2. Acids 3. Bases 4. Heavy metals 5. Halogens 6. Lithium 7. Solvents
79
List 4 ECG findings in **TCA overdose**.
1. Tachycardia 2. QRS long 3. QT long 4. R'R in aVR
80
What are the clinical features of **PCP ingestion**?
* Extreme agitation/violence * Blank/Catatonic stare * Nystagmus * Ataxia * Rigidity * Hyperreflexia * Hyperthermia * Rhabdomyolysis * Bronchospasm
81
List 3 different methods of predicting the need for liver transplant or death in **APAP toxicity**.
1. APACHE \>20 2. Lactate \>3.5 3. Modified King's College * pH \<7.3 * Or all of: * Cr \>300 * INR \>6.5 * Encephalopathy \> Grade 3
82
What are the 3 components of the **Lily kit**? What is the mechanism of action of each?
1. **Amyl Nitrite IN** * Causes methemoglobinemia * CN leaves ETC to form CNMetHb 2. **Sodium Nitrite IV** * Causes methemoglobinemia * CN leaves ETC to form CNMetHb 3. **Sodium Thiosulfate IV** * Rhodanese uses sulfur to catalyze: * CNMetHb --\> Thiocyanate (SCN)- + Hb
83
List 6 causes of **increased osmolar gap**.
1. Alcohol 2. Methanol 3. Ethylene glycol 4. Isopropyl alcohol 5. Sorbitol 6. Mannitol 7. Hypertriglyceridemia 8. Multiple Myeloma
84
Outline your treatment for **amanita phalloids toxicity**.
* MOVID * Anti-emetics * MDAC - 0.5 g/kg PO q4h * Penicillin G 1M units/kg, div q6h * Slows toxin uptake into liver * NAC - same as APAP * Antioxidant * Transfer to liver transplant center
85
List 8 dysrhythmias found with **digoxin toxicity**.
1. Atrial tachycardia 2. **Junctional tachycardia\*** 3. Ventricular tachycardia 4. **Atrial fibrillation - slow\*** 5. Ventricular fibrillation 6. **Bidirectional VT\*** 7. PVCs 8. Ventricular bigeminy/trigeminy 9. Heart block 10. Sinus bradycardia
86
List 10 toxins/medications that can cause **delirium**.
1. Alcohol/WD 2. Anticholinergics 3. Anticonvulsants 4. Antidepressants 5. Antihypertensives 6. Antiparkinsons 7. Antipsychotics 8. Cardiac medications 9. Cocaine 10. Lithium 11. MAOIs 12. Mushrooms 13. LSD 14. Opiates 15. PCP 16. ASA 17. Steroids 18. Sympathomimetics
87
List 2 **antipsychotics** from each of: * 1st generation (low potency) * 1st generation (high potency) * 2nd generation
**1st generation (low potency) - controls + symptoms** * Chlorpromazine * Prochlorperazine * Hydroxyzine **1st generation (high potency) - controls + symptoms** * Loxapine * Haloperidol * Droperidol **2nd generation - controls +/- symptoms** * Quetiapine * Risperidone * Olanzapine * Ziprasidone
88
When would you use **multi-dose activated charcoal** (6)?
**D**rink **T**his **C**harcoal **Q**uickly **P**lease or **A**n **OG** * **D**apsone/Digoxin * **T**heophylline * **C**arbamazepine * **Q**uinine * **P**henobarbital * **A**manita * **O**leander * **G**liclazide
89
List 7 receptors that **TCAs** work on.
1. Serotonin 2. NE 3. Alpha 4. Na 5. K 6. GABA 7. Histamine 8. Cholinergic
90
What 2 drugs should be given in **organophosphate poisoning**?
1. Atropine 1 mg, then doubled q5min until dry 2. Pralidoxime 1g IV
91
List the **associated toxin** with the following odours: * Bitter almonds * Carrots * Fishy * Fruity * Garlic * Glue * Pears * Rotten Eggs * Shoe Polish * Wintergreen
* Bitter almonds - cyanide * Carrots - water hemlock (cicutoxin) * Fishy - zinc * Fruity - ethanol, acetone, isopropyl alcohol * Garlic - arsenic, organophosphate * Glue - toluene * Pears - chloral hydrate * Rotten Eggs - disulfiram, hydrogen sulfide, NAC * Shoe Polish - nitrobenzene * Wintergreen - methyl salicylate
92
What 2 receptors does **GHB** bind?
1. GHB * Excitatory 2. GABA * Sedating This explains the cycling somnolence and agitation
93
List 8 drugs that are **dialyzable**.
**IVC STUMBLE NASA** * **I**sopropyl alcohol * **V**alproate * **C**arbamazepine * **S**alicylate * **T**heophylline * **U**remia * **M**ethanol * **B**arbituates * **L**ithium * **E**thylene glycol * **N**adolol * **A**cebutolol * **S**otalol * **A**tenolol
94
List 10 drugs implicated in **serotonin syndrome**.
1. SSRI 2. SNRI 3. Buproprion 4. TCAs 5. MAOIs 6. MDMA 7. Cocaine 8. LSD 9. Amphetamines 10. Linezolid
95
List 7 factors that influence the extent of a **caustic injury**.
1. Type of agent 2. Concentration 3. Volume 4. pH 5. Duration of contact 6. Viscosity 7. Presence of food in stomach
96
Describe the metabolism of **isopropyl alcohol**.
**Isopropyl alcohol** * Alcohol dehydrogenase **Acetone**
97
List 4 indications for **pralidoxime administration**.
In the context of organophosphate poisoning: 1. Respiratory depression 2. Fasciculations 3. Seizures 4. Arrhythmias 5. CV instability 6. \>4mg of atropine given **NOT HELPFUL IN CARBAMATES**
98
List 4 indications to start **NAC**.
1. 4 hour APAP level above treatment line 2. APAP \>60 umol/L and unknown ingestion time 3. Elevated AST 4. Presents after 8 hours
99
What findings are prognostic of **seizures and dysrhythmias** in TCA overdose?
QRS \>100 ms = Seizures QRS \>160 ms = Ventricular dysrhythmia
100
What are the stages of **iron toxicity**?
**Stage 1 (0-6h)** * GI * N/V, abdo pain, hematemesis/melena **Stage 2 (6-24h)** * Latent **Stage 3 (\>24h)** * Systemic * Coma, Acidosis, Hypoglycemia, AKI, Coags **Stage 4 (2-5d)** * Fulminant liver failure **Stage 5** * Consequences * GI strictures/obstruction
101
List 8 '**one dose kills**' for children.
1. Sulfonylureas 2. CCB 3. BB 4. Clonidine 5. Methyl salicylate 6. Methadone 7. Antimalarials 8. TCAs 9. Camphor 10. Lomotil 11. Opiates 12. Theophylline
102
List 6 risk factors that increase the risk of hepatotoxicity with **chronic APAP ingestion**.
**Glutathione Depletion** 1. Chronic EtOH use 2. Malnourishment 3. Liver disease 4. HIV/AIDS **P450 Induction** 1. Induced P450 2. Smoking 3. Febrile \<5 yo
103
What is meant by the term "aging" **re: AChE**?
Aging is when the bond between the AChE and an organophosphate becomes permanent Starts at 48h, then become resistant to treatment
104
What are the diagnostic criteria for **NMS**?
1. A) Rigidity + Hyperthermia 2. B) Two or more of: * Diaphoresis * Tremor * Tachycardia * HTN * Leukocytosis * Mutism * Altered LOC * Incontinence * Dysphagia 3. A and B not caused by another substance, neurologic condition, or another mental disorder
105
Name 3 management options for **opioid withdrawal**.
1. Clonidine 2. Buprenorphine 3. Methadone 4. Opioids
106
What is the mechanism of action of **PCP**?
* NMDA antagonist * Inhibits reuptake of NE, Dopamine, Serotonin * Opioid receptor agonist * Cholinergic receptor agonist
107
Name 4 opioids that can precipitate **serotonin syndrome**.
1. Methadone 2. Demerol 3. Dextromethorphan 4. Tramadol 5. Oxycodone 6. Buprenorphine
108
List 5 differences between adults and children for **digoxin poisoning**.
1. Adults are toxic at lower levels 2. Adults have more N/V and visual symptoms 3. Adults have more tachy-, children more brady- 4. Adults have more allergic reactions to DigiFab 5. Adults have less variable Vd
109
List cofactors that you should give in **toxic alcohol ingestions**.
* Ethylene Glycol * Thiamine 100 mg * Pyridoxine 50 mg * Magnesium sulfate 2 g * Methanol * Folinic acid 50 mg
110
List 4 indications for **starting fomepizole**.
1. Serum methanol \>6.2 mmol/L (20 mg/dL) 2. Serum ethylene glycol \>3.2 mmol/L (20 mg/dL) 3. Known Ingestion + Elevated osmolar gap 4. Strong suspicion of ingestion and 2+ of: 1. pH \<7.3 2. Bicarb \<20 3. Osm gap \>10 4. End organ damage (ocular, renal, CNS) 5. Urinary oxalate crystals (for EG)
111
List 4 indications for dialysis in **toxic alcohol ingestion**.
1. Methanol \>16 mmol/L 2. Ethylene glycol \>8 mmol/L 3. Metabolic acidosis + end-organ damage (ocular, renal, CNS) 4. Elevated osmolar gap if toxic alcohol levels not available
112
How much **elemental iron** is present in 100 mg of: * Ferrous gluconate * Ferrous sulfate * Ferrous fumarate * Iron polysaccharide
* Ferrous gluconate * 10% = 10 mg * Ferrous sulfate * 20% = 20 mg * Ferrous fumarate * 30% = 30 mg * Iron polysaccharide * 100% = 100 mg
Royal College: Emergency Medicine
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