Question | Answer |
Most common overdose/Toxicity issues = ? | *analgesics... * cosmetics... * acetominophen alone |
Management of Acute Poisoning = ? | * Provide supportive care -- Prevent poison absorption -- Antidotes (when available) -- Enhance poison elimination.... * For a vst majority of drugs, there is no specific antidote |
ABCDE 's of acute poisoning management ? | * Airway -- Breathing -- Circulation -- Disability (neurological stabilization) -- Exposure |
What Dextrose, Naloxone, or Thiamine or used for ? | * For pts with altered consciousness ... * for hypoglycemia, opiate detox, or alcohol intox. |
Can provide important clues to narrow a differential diagnosis ? | * Toxidromes or toxic syndromes, that are specific to certain drug agents |
Big thing about E of the ABCDE's ? | * Don't expose yourself ! |
GI Decontamination methods = ? | * Activated charcoal -- Gastric lavage -- Induced emesis -- Whole bowel irrigation -- Cathartics |
Enhance Elimination = ? | * Urinary alkalization -- Hemodialysis |
About helping detox someone = ? | * we only help about 4% of ppl that come in, bc their body is usualy already trying to do it |
When to use GI Decontamination = ? | * Usually most beneficial:
-- Within 1-2 hr after ingestion
-and- When toxic amount ingested |
Preferred method for GI decontamination = ? | * Activated Charcoal ( need 1g/per kg of patient) ... * LOTS need to be ingested... * it binds drugs |
AC does NOT adsorb ? | * CHARCOAL: Caustics & Corrosives -- Heavy Metals -- Alcohols & glycols -- Rapidly absorbed substances -- Cyanide, chlorine -- Other insoluble drugs -- Aliphatic hydrocarbons
(gas, kerosene, liq furniture polish) -- Laxatives |
Continued... | * * PHAILS: Pesticides, potassium -- Hydrocarbons -- Acids, alkali, alcohols -- Iron, insecticides - Lithium --Solvents |
When not to us AC ? | * if over 1-2 hrs of exposure or when there is a bowel obstruction, bc these can form charcoal bricklets |
When to use/not use GASTRIC LAVAGE ? | * Use when AC is not going to work... * DO NOT USE: to remove Strong acids/bases bc of the risk of perforation and not in unconscious pts bc of aspiration risk |
Emetics - Ipecac use/when not to use = ? | * Use: only in settings of when someone can not make it to the hospital in time..... * DO NOT USE: < 6mths old, if they can't support their airway (bc they will aspirate), biggesst issue is that it can cause CNS effects |
Potential SEs of Emetics = ? | * Protracted Vomiting (cant stop, is most common SE), Aspiration, Esophageal Tearing |
Whole bowel irrigation uses = ? | *administer PEG.... * cleans out the GI system... * USE: for drugs that are sustained release drugs |
Cathartics use = ? | * Use: flushes out the GI system again... *used in AC brickets constipation issue |
Urinary alkalinization MoA and Use = ? | * changes pH to have faste rurine elim... *Uses: phenobarbital and salicylate poisoning... * SE: Can cause severe acidosis |
Hemodialysis uses = ? | * Useful for alcohols, salicylates, ethylene glycol, lithium
... * Not useful for drugs with large Vd |
A note on specific antidotes = ? | * Treat the patient, NOT the poison... * Ex. fix vitals first, then poison |
Antidote for opiate narcotics = ? | * Naloxone |
Antidote for benzodiazepine toxicity = ? | * Flumazenil |
Carbon Monoxide poisoning causes ? | * anemic hypoxia by Hb can’t carry O2 because COHb accumulates and also prevents whatever o2 is on Hb to not be able to be unloaded |
Some other things it causes = ? | * Myoglobin binding, Cytochrome binding (low Ox phos--> ROS formation), and CO stimulates guanylate cyclase (VD and cuases syncope) |
CO CxSx = ? | * Brain / CNS (fainting, h/a, confusion, coma) and myocardial injury common and Hyperpnea.... * Hb looks aturated bc CO is bound to Hb, even though it is not O2 |
What happens to to the low 02 ? | * fainting is common... * also see tissue damage due to the accumulation of lactic acid |
CO TmT = ? | * take out of exposure area, let patient rest, and give 100% O2.... * hyperbaric O2 therapy (fastest since O2 is a compet. antag of CO) |
Hydrogen Cyanide (CN), where can we get exposure from ? | * Formed when plastics burn...* see mostly in domestic fires (firefighters are common) |
CN MoA it has on the body ? | * CN- binding to Fe+3 and prevents the Fe2+ state... * can't generate ATP even though lots of O2 is there, cells then create Lactate --> Met. Acidosis |
What we see in CN poisoning ? | * histotoxic hypoxia - high O2 lvls, but thet can't use it... * So, NO cyanosis, resp distress and high O2 lvls..... * seizures, hyperpnea, gasping, convulsions |
How CN is eliminated = ? | * Thiosulfate breaks it down to a form to be excreted |
CN TmT = ? | * must be immediate !!!
-- Sodium nitrite (IV) followed by sodium thiosulfate (IV)
-- Plus positive pressure oxygen |
Nitrite MoA = ? | * promotes formation of methemoglobin (metHb, Fe+3) to detoxify cyanide to cyanmethemoglobin |
Thiosulfate MoA = ? | * facilitates enzyme-catalyzed conversion of cyanide to less-toxic thiocyanate |
Can also use to treat CN = ? | * Hydroxycobalamin (IV) - Forms harmless vitamin B12a cyanocobalamin
(eliminated in urine)..... * Works both within the intravascular space and within the cells |
Organophosphate Pesticides basics = ? | * Poisoning is common … but death is rare |
Organophosphate Pesticides MoA = ? | * Potent acetylcholinesterase inhibitors (lots of Ach builds up).... * SLUDGE/BBB or DUMBBBELS (symptom mnemonics)
.... * Muscarinic, nicotinic, and CNS effects (fasiculations, paralysis, increase in tears/urine/defication, and bradycardia) |
Organophosphate Pesticides big SE = ? | * May produce delayed neurotoxicity with sensory and motor disturbances of limbs
...... * No effective treatment |
TmT for the Acute Exposure = ? | * Respiratory support and decontamination quickly..... * Atropine
= To block muscarinic effects ... * Pralidoxime (2-PAM) = Reactivates acetylcholine esterase |
Carbamate Pesticides = ? | * Poisoning is common … but death is rare again.... * same effects as organophosphates, but effects less severe … because carbamoylation is rapidly reversible ..... * TmT = Atropine (No PAM, bc it makes it worse) |
Herbicide - Paraquat = ? | * A specific pulmonary toxicant.... * Toxicity is rare, and DEATH is likely in this one.... * if not reversed, will kill you.... * MoA= ROS in lungs damage everything |
After oral exposure = ? | * GI irritation, then Respiratory distress (hemorrhagic pulmonary edema and fatal pulmonary fibrosis) |
TmT = ? | * No specific antidote... * need to act quickly or it will kill you.... * use AC or Fullers Earth.... * NO emesis removal bc Concentrated solutions are corrosive |
Warfarin overdose tmt = ? | * lg amounts of Vitamin K |
Methyl bromide = ? | * Fumigant used to kill insects in the seed industry... * Major toxicity is on CNS
.... * TmT = symptomatic issues only |
Strychnine = ? | * Competitive antagonist of glycine (an inhibitory molecule, so get no inhibition) .... * Causes powerful & uncontrollable muscle contractions.... * See Opisthotonus = Spasm where head & heels arch backward in extreme hyperextension |
Strychnine death and TmT = ? | * Death due to respiratory paralysis
..... * Must treat immediately..... * TmT = Support respiration with diazepam |
PETROLEUM HYDROCARBONS = ? | * Gas, Kerosene, turpentine, etc… |
What we see Cx? | * CNS depression and issues in lungs from aspiration (Chemical pneumonitis) |
What we clinicians see ? | * we see Oral ingestion over inhalation from kids getting in to it.... * it is usu Charcoal lighter fluid
..... * Death is RARE |
TmT = ? | * No specific antidote ..... * DO NOT lavage or produce emetic effects (cause aspiration issues) |
Halogenated and aromatic hydrocarbons basics = ? | * Different from Pet. Hydrocarbons... * are Systemic toxicity, and readily absorbed (GI and RESP.) |
Halogenated and Aromatic Hydrocarbons = ? | * C: Camphor
--- H: Halogenated hydrocarbons (trichloroeth-ane, -ylene)
--- A: Aromatic hydrocarbons (benzene, toluene, xylene)
--- M: Metal additives (arsenic, mercury)
--- P: Pesticide additives (organophosphates) |
Lead (Pb) basics = ? | * Acute poisoning seldom a problem
.... * Chronic exposure = Long t½ of Pb enables slow accumulation to toxic concentrations |
Lead and kids = ? | * CNS of children tend to be more sensitive to Pb because it can cross BBB |
Inorganic Lead, where we get it ? | * Absorption is SLOW.... * get from Eating paint chips (pica)(ORAL) or from Industrial (refineries, manufacturers)(INHALATION) |
Inorganic Lead goes to where ? | * Initially binds to hemoglobin in RBCs, remainder goes to soft tissues..... * Later = redistributes to bone (95%), teeth, and hair (Can see on X-Ray bc of this) |
Inorganic CxSx in kids = ? | * CNS issues = Lead encephalopathy
..... * May cause lowered IQ and behavioral problems |
In Adults = ? | * GI toxicity = Lead Colic (constipation and abdom. pain)..... * Gingival lead lines (Lead-Sulfate) when lead binds (black lines on gums and teeth) |
Overall, what are some Inorganic Lead CxSx = ? | * CNS, Gingival Lead Lines, Lead Palsy, WRIST DROP, Hyperuricemia with gout, and Hematological toxicity |
Lead and Heme issues = ? | * Inhibits heme formation
..... * inhibits delta-aminolevulinic acid dehydratase and inhibits ferrochelatase (puts Fe in Heme) |
Anemia we see = ? | * Anemia (hypochromic microcytic)
... * also see basophilic stippling |
Lead poisoning - Diagnosis = ? | * Blood lead level (BLL) = most useful for screening and diagnosis...... *Urinary ALA levels and Zinc-protoporphyrin in RBCs (both from the Two Nz that are inhibited) |
Organic Lead Poisoning basics = ? | * Well absorbed … even through skin (lipophillic)
.... * see rapidly progressive CNS symptoms (without the anemia or basophilic stippling bc no effect on Heme) |
Lead poisoning – TREATMENT = ? | * Remove Exposure.... * Chelation therapy with EDTA and BAL with severe or encephalopathy.... * In Kids = Succimer |
Inorganic Arsenic where we see it and issues it causes = ? | * coal and pressure treated wood.... * absorbed in lungs/GI tract... * deposits in Hair and Nails |
Big SEs of ACUTE = ? | * projectile vomiting and rice water stool or bloody stool.... * get fluid loss and that can cause hypovolemic shock |
Chronic Arsenic Poisoning SEs = ? | *less GI issues.... * garlic odor on breath and perspiration.... * Sensorimotor Peripheral Neuropathy = pin/needle sensation in stocking/glove distribution..... * Hyperpigmentation = palms & soles
Hyperkeratosis = white lines in nails (Mee’s lines) |
Inorganic Arsenic Poisoning TmT = ? | * empty stomach.... * Chelation therapy = -- Dimercaprol (BAL)
-- Penicillamine
-- Succimer (children) |
Organic (rapidly absorbed) Arsenicals = ? | * poisonings are rare ..... * Arsine gas poisoning - industrial setting... * Produces rapid severe hemolysis --> extensive hemolytic anemia ... * Renal Failure.... * FATAL if not treated |
Organic Arsenicals TmT = ? | * Nothing really works.... * supportive care and transfusions if severe |
Mercury affects = ? | * KIDNEYS and CNS |
Acute Mercury Poisoning CxSx = ? | * get from Mercury Vapor inhalation..... * Triad of: Neuropsychiatric disorders -- Tremors
-- Gingivostomatitis |
Acute TmT = ? | * Chelation with succimer (preferred) |
Chronic Mercury Poisoning CxSx = ? | * Triad... * Erethism (Mad Hatter Syndrome) pathological shyness with explosive anger |
Inorganic Mercury CxSx and TmT = ? | * Corrosive properties = ashen-gray mucous membranes (burns places) ...... * TmT = Succimer (preferred) (NO lavage or emesis) |
Inorganic Chronic Mercury Poisoning CxSx and TmT = ? | * Acrodynia (pink disease) = Erythema of extremities – legs, hands, fingers..... * CNS CNS CNS issues..... * TmT = nothing, only supportive |
Iron poisoning and CxSx = ? | * Acute = in young kids who eat brightly colored tablets that look like candy.... * CxSx: GI damage (necrotizing gastroenteritis), If patient survives 6 hrs … apparent recovery in 12 – 24 hrs, followed by death (phases) |
Iron TmT = ? | * Empty Stomach (lavage or emesis) and X-Ray to see pill number in GI.... * Chelator: Deferoxamine (only Fe uses this drug) |
**Chelating Agents** | . |
Ethylene diamine tetraacetic acid (EDTA) MoA and uses = ? | * Give with Ca, bc can cause severe hypocalcemia w/o Ca+.... * Lead displaces Ca on EDTA... * USE: LEAD Poisoning Only |
Dimercaprol (BAL) uses = ? | * Arsenic, Mercury or Lead poisoning |
Succimer uses = ? | * Orally effective..... * Approved for use in children..... * USES: Lead, Arsenic or Mercury poisoning |
Penicillamine uses = ? | * Wilsons Disease.... * RA.... * Lead and Mercury (Not approved for Pb and Mercury though) |
Deferoxamine uses = ? | * Iron Poisoning specific drug |