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Pharmacology-2
Toxicology
| Question | Answer |
|---|---|
| what durgs can not be adsorbed by charcoal? | lithium, iron, alcohols, strong bases and acids |
| the half life of which drugs are decreased by as much as 50% by the use of activated charcoal? | theophylline and phenobarbitol |
| What are 2 good examples of when whole bowel irrigation is useful? | iron overdose or body packers |
| What happens if you give a polyethylene glycol at the same time you administer charcoal? | you decrease the efficacy of charcoal |
| what is the antidote for opiates? | naloxone |
| what is the antidote for methanol? | ethanol (+folate); fomepizole |
| what is the antidote for ethylene glycol? | ethanol (+ thiamine and pyridoxine); fomepizole |
| what is fomepizole? | competitive inhib of ADH (used as an antidoe for ethylene glycol and methanol poisioning) |
| what is the antidote for digoxin, digitoxin? | FAB fragments |
| what is the antidote for organophosphate poisioning? | atropine (consider adding pralidoxime when muscle weakness is present) |
| what is the antidote for carbamate insecticide poisioning? | atropine (consider adding pralidoxime if severe muscle weakness is present) |
| what is the function of pralidoxime? | it regenerates AchE, helping with muscle weakness in organophosphate/carmate insecticide poisioning |
| what is the antidote for ioniazid? | pyridoxine |
| what is the antidote for beta blockers? | glucagon |
| what is the antidote for tricyclic antidepressants? | sodium bicarbonate |
| what is the antidote for benzodiazepines? | flumazenil |
| what is the antidote for calcium channel blockers? | calcium |
| what is the antidote for acetaminophen? | N acetylcysteine |
| what is the antidote for anticholinergic agents? | physostigmine |
| what is the antidote for cyanide | sodium thiosulfate and amyl nitrate |
| what is the antidote for warfarin? | vitamin K or fresh frozen plasma if emergency with bleeding |
| naloxone is the antidote for? | opiates |
| ethanol +folate is the antidote for? | methanol |
| fomepizole is the antidote for? | methanol or ethylene glycol |
| ethanol is the antidote for? | methanol or ethylene glycol |
| ethanol + pyridoxine + thymine is the antidote for? | ethylene glycol |
| FAB fragments is the antidote for? | digoxin, digitalis |
| atropine + pralidoxime is the antidote for? | organophosphate or carbamate poisioning |
| pyridoxine is the primary antidote for _____, but can be found as an adjunct to therapy as an antidote in ____? | ioniazid, ethylene glycol |
| glucagon is the antidote for? | B blockers |
| Drugs for which serum concentrations are useful? | theophylline, ethylene glycol, acetaminophen, methanol, phenytoin, lithium, aspirin, isopropyl alcohol, iron, digoxin |
| theophylline fits into which toxidrome? | sympathomimetic |
| ethanol withdrawl fits into which toxidrome? | sympathomimetic |
| clonidine withdrawl fits into which toxidrome? | sympathomimetic |
| meprobamate fits into which toxidrome? | opiate, sedative-hypnotic |
| methyprylon fits into which toxidrome? | opiate, sed-hyp |
| methaqualone fits into which toxidrome? | opiate, sed-hyp |
| ethanol fits into which toxidrome? | opiate, sed-hyp |
| clonidine fits into which toxidrome? | opiate, sed hyp |
| antihistamines fits into which toxidrome? | anticholinergic |
| TCAs fall into which toxidrome? | anticholinergics |
| antiparkinson meds fits into which toxidrome? | anticholinergics |
| carbamazepine fits into which toxidrome? | anticholinergics |
| cyclobenzaprine (flexeril) fits into which toxidrome? | anticholinergic |
| flexeril fits into which toxidrome? | anticholinergic |
| atropine, scopalomine fits into which toxidrome? | anticholinergic |
| antipsychotic meds fits into which toxidrome? | anticholinergic |
| antispasmodic meds fits into which toxidrome? | anticholinergic |
| jimson weed fits into which toxidrome? | anticholinergic |
| organophosphate poisioning fits into which toxidrome? | cholinergic |
| insecticides fits into which toxidrome? | cholinergic |
| physostigmine fits into which toxidrome? | cholinergic |
| myasthenia gravis drugs fits into which toxidrome? | cholinergic |
| some mushrooms fits into which toxidrome? | cholinergic |
| which agents can cause a fast rate on an EKG? | theophylline, cocaine, sympathomimetics |
| which agents can cause a slow rate on EKG? | B blcokers, calcium channel blockers |
| what agents can cause a widening of QRS or QT interval? | first generation tricyclic antidepressants |
| which agents can cause torsades de pointes? | erythromycin, terfenadine, astemizole |
| which agents can cause dysrhythmias? | digoxin, antiarrhythmic agents |
| which agents can cause conduction disorders? | digoxin, antiarrythmic drugs, TCA |
| why would you look at a chest film on an overdose? | to look for aspiration or non-cardiogenic pulmonary edema |
| the safe dose of activated charcoal is (range)? | 50-100g for single dose administration |
| emesis is not suggested for OD. why? | increased chance for aspiration, Mallory Weiss tears, and prolonged emesis |
| what is the requirement for hemodialysis to work for overdose systemic drug removal? | drugs have to have a small VOD and low protein binding capacity |
| dialysis is indicated for many cases of overdose. Name some. | ethylene glycol, methanol poisioning, severe cases of lithium intoxification, severe phenobarbitol or ASA poisioning |
| when might you use hemoperfusion (filter blood thru a charcoal filter)? | severe theophylline poisioning (but no date supports improved outcomes) |
| A nun comes to the ER with an opiate poisioning. How would you treat? | 2 mg initial dose of naloxone |
| You have seen charlie in the ER before for opiate poisioning. How do you treat him today? | give naloxone in smaller dose, titrating up to avoid withdrawl symptoms (the normal dose would be to start with 2mg) |
| A patient in the ER has OD'd on a drug. You are sure it's only 1 drug. She has needle tracks. What do you give her? | You're assuming an opiate. You give naloxone in small doses titrating up (assuming she's an addict). The normal starting dose would be 2mg. |
| clonidine poisioning. antidote? | naloxone |
| what's the opiate triad? | miosis, mental status changes, respiratory depression |
| overdose with myoclonus? | anticholinergic |
| overdose with muscle fasiculations? | cholinergic |
| overdose with urinary retention? | anticholinergic? |
| overdose with dry flushed skin? | anticholinergic |
| overdose with mydriasis? | sympathomimetic, anticholinergic |
| overdose with bradycardia? | opiates, cholinergics |
| overdose with increased temp? | sympatho, anticholinergics |
| overdose with diaphoresis? | sympathomimetics, cholinergics |
| overdose with decreased bowel sounds? | anticholinergic, opiate |
| overdose with pulmonary edema? | cholinergic, opiate |
| overdose with seizure? | sympathomimetics, cholinergics |
| overdose with hypotension? | severe sympathomimetic, opiate |
| overdose with hypertension? | sympatho |
| overdose with hypothermia? | opiate |
| overdose with hyperpyrexia? | sympatho |
| overdose with hyperreflexia? | sympatho |
| overdose with tachycardia | sympatho, anticholinergic |
| overdose with pneumomediastinum? | sympatho |
| overdose with general weakness? | cholinergic |
| If the total mg ingestion of digoxin is known, how do you know how many vials to give IV? | mg/0.6=vials |
| if amount of digoxin ingested is unknown, how many vials of FAB fragments and pt has a life threatening dysrrhythmia? | give 10-20 vials IV |
| what if you know the serum digoxin level, how many vials of FAB fragments do you give? | digoxin level in ng/ml X 5.6 X kg wt /1000=answer/66.7=vials |
| what is different in the antidote for digitoxin and digoxin? | you can use FAB fragments in both, but the doses are different. |
| Your mother is poisioned with an organophosphate or carbamate insecticide. How do you tx? | give her atropine in a 2mg IV test dose, and repeat until pulmonary secretions are dry. |
| theoretically, a so-nice-kid ingests 50mg of isoniazid. How much antidote does the so-nice-kid get? | the so-nice-kid is FAIR and EQUAL. give pyridoxine in the equivalent amount of what was ingested IV |
| You grandpa is sad that his wife died and decides to swallow a whole bottle of his bp meds (beta blockers). He comes right to the ER when it starts getting hard to breathe. What to do? | give 5-10mg IV glucagon, then titrate until you see normal vital signs. MD is 2-10mg/hr |
| How much Na bicarb do you give to somne poisioned by TCA? | 1-2mEq/kg IV to start. Then you titrate arterial pH to 7.5. If pt is ventilated, can decrease CO2 as well |
| What does the change in pH to 7.5 by adding Na bicarb to a TCA poision do? | it helps to correct the delays in conduction to correct the ventricular dysrhythmias |
| when do you give flumezeril to a patient with benzodiazepine OD? | hardly ever do this: 1. bc it's difficult to change the outcome 2. risk of seizure if patient is a benzodiazepine addict 3. may cause seizure if the patient also took a seizure inducing agent |
| how do you treat calcium channel blocker poisioning? | 1g CaCl IV over 5 minutes with continued cardiac monitoring |
| You consult the Rumack nomogram and find that for a single acute ingestion your patient needs the ____ antidote for acetaminophen posioning. You should give 140mg/kd DL, then 70 every 4hours for ___doses by (IV/PO)? | NAC (N-acetylcystein), 17 doses, PO |
| Physostigmine is RARELY used to treat anticholinergic agent OD bc of risk of seizure, great increase in pulmonary secretions, and/or intractable bradycardia. When do you consider this risky tx? | You may consider if severe dysrhythmias haven't responded to sodium bicarb and antiarrhythmic agents (such as lidocaine) |
| You have a patient that OD's on a TCA. He is suffering severe dysrhythmia, even after you treated him with the suggested antidote of Na Bicarp titrated to the proper arterial ph (7.5). What can you do? | You could lidocaine and if that doesn't work, as a last resort, you could add physostigmine. |
| You need to administer physostigmine as a last result to a non-responsive TCA overdose to NaBicarb or lidocaine. What risks should you inform the decision maker about? | physostigmine comes with a risk of possible seizure, intractable bradycardia, and/or increased pulmonary secretions |
| what is the less toxic form of Cyanide, and what is required to reduce it to this? | thiocyanate (sodium thiosulfate will reduce CN to thiocyanate, which is less toxic) |
| what is the antidote for cyanide? | sodium thiosulfate and amyl nitrate; OR hydroxycobalamine |
| hydroxycobalamine can reverse which OD? | cyanide |
| sodium thiosulfate and amyl nitrate can reverse with OD? | cyanide |
| what does hydroxycobalamine do to cyanide? | hydroxycobalamine is not widely available, but it combines with cyanide to form cyanocobalamines (which is vitamine B12) |
| which toxin can be turned into a vitamin? | cyanide can be turned into vitB12 (cyanocobalamine) by hydroxycobalamine |
| how much vitamin K do you give a pt with warfarin overdose? | low doses of vitK may suffice for many patients |
| what are the disease states/drugs that may induce ANION GAP? | methanol, uremia, diabetic ketoacidosis, peraldehyde, phenformin, metformin, isoniazid overdose, idiopathic lactic acid, iron overdose, ethanol (alcoholic ketoacidosis), ethylene glycol ingestion, solvents, salicylates (also... cyanide poisioning) |
| what are the 2 ways to get an anion gap from cyanide poisioning? | cyanide poisioning from nitroprusside use or cyanide inhaled in residential fire smoke. |
| What could give you a low anion gap when it's really high? | albumin. For every gram that albumin is below 4g you should add 3 points to the anion gap. |
| What is a normal anion gap? | 3-15 |
| when is an anion gap abnormal? | when it's above 15 |
| what is the equation for the calculated (not measured) osmolal gap? | 2 Na + glucose/20 + Bun/3 + Ethanol/5 *if known |
| Why is the normal osmolal gap 10? | because a know gap is created because of lipids, Ca2+, and protein |
| When an osmolal gap is >10 what must you consider? | calculated error, lab error, hyperlipidemia, hyperproteinemia, or LMW toxins. |
| this the osmolal gap is >10, the anion gap is >15, then what should be done? | order an alcohol panel, and consider administration of antidote |
| which toxidrome doesn't allow you to depend on pupil size? | cholinergic, bc can mydriatic or miotic bc of nicotinic/muscarinic |
| what can theophylline do to ekg rate? | fast, almost always causes a rate >100 bpm |
| what can dig toxicity do to ekg rate? | slow |
| what can TCA do to ekg? | wide QRS, wide QT corrected, |
| what can fluroquinolones (grepafloxacin and sparfloxacin do to ekg? | QT prolongation |
| what can erythromycin, terfenadine, astemizole, and cisapride do to ekg? | torsades de pointes |
| of teh 4 drugs listed that can cause torsades de pointes, only 1 is still on the market. so if you see TDP, what is the most likely agent? | erythromycin |
| what ekg signs are consistent with TCA overdose? | prolonged QT interval, sinus tachycardia, rightward shift, prolonged QTcorrected |
| like dig, what is another drug that can get rid of arrythmia, but also cause a dysrhythmia? | amnioterone (sp?) |
| pt comes in with ekg showing prolonged QT interval and QT corrected, sinus tachycardia, and rightward shift. likely? tx? | TCA OD, Na Bicarb; can decrease CO2 ventilator, try to titrate to pH of 7.5 |
| which bundle of the heart is more sensitive to tricyclic antidepressant overdose? | right bundle |
| you notice pulmonary edema on an xray, but the medical hx of your patient reveals that they have no cardiac problems. likely? | could be opiods or salicylates overdose (cause leaky capillaries) |
| what can opiod narcotics and salicylates cause on xray? | noncardiogenic pulmonary edema |
| measured lab portion of the osmolal gap procedure is carried out by? | freezing point depression, which is inversely proportional to the amount of sodium. |
| The higher the osmolal gap, the _____ the measured osmolaltiy? | lower |
| what test should you order to get a anion gap? | BMP |
| what's one thing that could falsely increase the anion gap? | IVP die ( a die used in hospital settings) |
| what is a possible presentation for anion gap? | hyperrespiration, trying to blow off excess CO2 |
| A patients albumin is 2 on last visit, and their BMP shows a anion gap of 10 (the average). What is the most likely accurate AG? | 16 (3 points for every 1 point decrease from 4 in albumin) |
| why does a drop in albumin require an adjustment in the anion gap? | albumin is negatively charged, and if it's low, then it causes bicarb to increase because there's less negative charge competing for bicarb |
| How can you test for salicylates in the clinic or without drawing labs? | A urine test. Put 10% ferrous chloride into a solution of urine and it will turn purple if positive. |
| on a UDS, what if a certain drug is positive, then it's probably positive, unlike many drugs in the panel. | cocaine |
| methadone can be a false positive for ___ on a UDS? | pcp |
| quinolones may give a fp for ____ on a UDS? | opiates |
| what's a possible physiologic reason why you might get a false negative on a UDS. | decreased clearance by kidneys (indicated by increased creatinine) |
| On an EMIT (enzyme multiplied immunoassay), if a drug is present in the specimen, what will happen ? | The drug in question is bound to the active site of G6PD, which is attached to a bivalent antibody, if the rx in the specimen is like the rx in ?, it will bind to the ab, cause dissociation of ab, open active site, incr NADH and incr light absorbance=pos |
| false postives for ampthetimines? | ephedrine, some antidepressants |
| duration of amphetamines? | 2-3 days |
| duration of cocaine? | 2-3 days (light use), 8 days (heavy use) |
| false + for cocaine? | none |
| duration of marijuana? | 1-7 days (light use), 30 days (heavy) |
| false positives for marijuana? | ibuprofen, hemp seed oil |
| duration of opiates? | 1-3 days |
| false positives for opiates? | poppy seeds, morphine, codeine, fluroquinolones |
| false positives for pcp? | dextromethorphan, methadone, diphenhydramine |
| duration of pcp? | 7-14 days |
| on comprehensive drug screens, do you get more false positives or negatives? | negatives |
| what are some reasons drugs are picked up on screen? | too polar, too nonpolar, too volitile, no nonvolatile, concentration too low (high vod, or too potent), toxic anions, new drugs |
| a patient has overdosed on a synthetic narcotic (or a long acting narcotic). What must be done to compensate for this in tx with antidote? | normally with short acting or non-synthetic you give 2mg IV (except in addicts). With these, you must take 2/3 of whatever dose reveresed the symptoms and apply that per hour. |
| why is fomepizole used to treat methanol and ethylene glycol OD? | bc it occupies alc dehydrogenase without causing CNS effects |
| You have patient who OD'd on a Beta blocker. You give him the antidote. What else must you do? | keep an eye on his blood sugars, because you gave him glucagon |
| what are some of the clear contraindications for using flumazenil to reverse BENZODIAZEPINE toxicity? | bzdp + TCA; seizure hx, chronic BZDP use; hypoxia, bzap +theophylline overdose |
| what does Nacetylcystein do? | it reverses acetaminophen OD by increasing glutothione which protects against free metabolites of CYP2E1 conversion of asa to liver necrotizing substance |
| what is the fxn of amyl nitrate? | it makes methemoglobin bind the cyanide |
| why does cyanide poisioning cause an anion gap? | CN binds oxygen, so it decreases cellular respiration and increases lactic acid |
| nitroprusside is a HTN drug, when is it dangerous (like as a metabolite of CN-)? when might this be a problem? | when it's free; in the HTN medicine, the nitroprusside is bound to iron, so it's non reactive. IF a pt has impaired liver fxn, then metabolism is decreasing, incr chance for free nitroprusside |
| You have a patient being treated with warfarin prophylactly. The pt takes the wrong amount and gets a massive bleed. How would you couteract the effects of warfarin? why could this administration be a problem? | vitamin K (increase clotting cascade); vit K is fat soluble, so if you plan to give warfarin again after crisis has resolved, even though you may stop tx with vit K, you may still get inhibitory effects |
| what are the drugs that can be dialized? | EMP-SL: EMPty Small volume-Low protein: Ethylene glycol, methanol, phenobarbitol, salicylate, lithium |
| charcoal hemoperfusion? | some theophylline overdoses |
| renal ion trapping? | alkalizing urine: ASA, phenobarbitol |
| what can speed up the toxicity of digoxin? | potassium |
| If the osmolal gap is 50, how can you predict the level of EG to account for the gap. . | Take 50 x MW/10 to get answer. |
| what indicates the best outcome after using naloxone as an antidote in opiate poisioning? | an increase in RR |
| is there a risk with using naloxone as an antidote? | yes, you may precipitate narcotic withdrawl (HR will go up, along with anxiety, incr diarrhea, cramps, lacrimation, rhinitis, yawning) Flu like sympx |
| what would indicate a positive response to naloxone? | increase RR, increased mental status, increase pupil size |
| A patient who overdosed on an opiate is now stable after naloxone administration. 1 hour later she feels great. Should you send her home? | No. narcotics can outlast naloxone |
| what can be given for at home maintanence for opiate withdrawl sypm? | sublinguial buprenorphine +/- naloxone |
| TCA (fxn like anticholinergic), how does it cause heartblock. | rapid sodium channel |
| what are the 3 mechanisms of cardiotoxicity in TCA | decr reuptake of NE (like cocaine), quinidine-like mem phase (widening of action potention), mild alpha blocking properties) |
| what should the qrs be? | <100msec |
| what is a common first generation TCA? | amytriptiline |
| could you use charcoal on someone with TCA overdose? | yes |
| normal level Na? | 135-153 |
| normal K? | 3.5-5.3 |
| normal Cl? | 95-105 |
| A pt with TCA overdose is tachycardic, among other sympx. You treat with antidote Na bicarb to normalize EKG, etc. In the process, the patient is now bradycardic. What can you give her to normalize. | norepinephrine |
| sodium bicarbonate does what to they pupils in TCA overdose? | nothing; it's considered a cardiac antidote |
| You have normalized the EKG, returned respirations, normalized bp in a patient who overdosed on TCA. How long until you can release the patient? | due to the possibility of sudden cardiac death due to storage of the TCA, you must see normal vitals for 1 day after improvement, then release; need to see MMM, +bs, good heart fxn, etc. |
| What is the LD50 for TCA? at what pt are there few fatalities? at what point is death likely due to overdose? | <20mg/kg hardly any fatalities; LD50 is 35mg/kg; and death is likely at >50mg/kg |
| what is the half life in TCA overdose? | 25-80 hours |
| what is the vod in TCA? | 20-60L/kg |
| what is the PB in TCA? | 85-98% |
| why should charcoal be considered with anticholinergics? | they slow down gut motility, so they decrease their own absorption, so they can be eliminated |
| which types of antidotes are most dangerous? | cholinergics |
| what is an anion gap >20 almost always indicative of? | metabolic acidosis |
| tinnitus? | asa poisioning |
| how does asa cause a resp alk? | by hyperventilation, bc it stimulates the breathing center in the brain |
| when can you look at a DONE NOMOGRAM? | 6 hours post ingestion minimum, must be single dose OD only, (not very accurate, it over predicts toxicity) |
| explain the halflife of asa? | it goes up as serum concentration goes up |
| why is it impt that asa pka is 3.0 (which makes it a weak acid) | the more ionized, the better it will be retained at a membrane (like the renal tubule) "ion trapping" |
| what additional things do you need to give in asa overdose? | nacetylcysteine, glucose (for CNS protection), po act charcoal, vit K (decreased platelet aggregation, clotting), K+ (metabolic acidosis prod asa causes H+ into cell, K+ out), possible alkalizing of urine |
| when do you want to consider hemodialysis in an asa overdose? | if poor renal function, severe acidosis, high levels of asa, unresponsive to tx, if comorbid CHF, if pt is worsening) |
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