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Clinical Toxicology
Exam1, decontamination, stabilization, acid base
| Question | Answer |
|---|---|
| In general, any potential benefit from GI decontamination is very reduced once __ hours from the ingestion has elapsed. | 2 hours is generally the max time to consider decontamination. |
| 4 important variables that are likely to affect efficacy are | time from ingestion, tablet formulation, drug chemistry, intestinal motility |
| If you have to use emesis | syrup of ipecac (cephaeline stimulates the CTZ); works in 20 minutes 90% of people |
| Contraindications for ipecac | 1. non-toxic ingestions 2. prior significant vomiting 3. comatose, seizing or hypotensive patients; others |
| AE of ipecac | intractable vomiting, diarrhea, aspiration, myocardial toxicity, neuromuscular weakness, lethargy, possible abortion |
| 5 minute max Gastric lavage indications | 1.potentially life-threat poison and present w/in 1 hour 2.life-threat anticholinergic presenting within 4 hours. 3.ingestion of sustained release toxic dose |
| gastric lavage absolute CI | corosive ingestions of esophageal disease |
| Gastric lavage complications 1/2 | esophageal rupture is a very rare but potentially fatal complication |
| gastric lavage complications 2/2 | profound bradycardia, cardiac arrest, asystole may be precipitated by lavage in poisoning w/drugs affecting cardiac conduction |
| What is the acryonym for activated charcoal? | PHAILS - minimally abs by charcoal |
| PHA of PHAILS | P-pesticides H-hydrocarbons/heavy metals A-Acid/Alkali/Alcohols |
| ILS of PHAILS | I-iron L-lithium S-solvents |
| Is it better to give activated charcoal with a cathartic? | No, charcoal only is as effective |
| Indications for active charc 3/5 | 1. absorbed by AC and is toxic 2. less 1-2 hours since ingestion 3. significant enterohep circulation |
| indications for AC 4 and 5 | 4. drug delays gastric emptying and it's been <4 hours 5. controlled release drug and it's been less than 12-18 hours |
| What is the dosing for AC? | 1g/kg with a 100g max. as a premixed solution. may give in yogurt or ice cream for palatability |
| What is impt about AC admin? | goal of 50g of AC within 20 minutes of starting therapy. NG may be necessary |
| Complications of AC | charcoal aspiration; bowel obstruction; hypotension/tachycardia due to hypovolemia |
| MDAC is for what drugs? | CPDQT; Carbamazepine, Dapsone, Pheobarbital, Quinine, Theophylline |
| MOA of MDAC? | interrupts enterohepatic recirc |
| MDAC admin? | 25g q 2 hours w/max of 2-3 doses. >3 doses increases risk of bowel obstruction |
| WBI-Whole bowel irrigation | large volume of isoosmolar solution that is not absorbed |
| IND for WBI | 1. iron and lithium 2. sustained release preps 3. Salicylates and others that form pharmacobezoars |
| MOA of WBI | physically flushes tablets from the GI tract |
| Dose of WBI | 500ml/h 9mon-6year 1000ml/h 6-12year 1500-2000ml/h in adolescents and adults. All oral or NG tube |
| WBI and vomiting? | give ondansetron or metoclopramide. |
| 4 reqs for hemodialysis | 1. low MW <500 2. Highly water soluble 3. <1L/Kg volume of distribution 4. low protein binding |
| 3/6 ind for hemodialysis | 1. ethanol 2. methanol 3. ethylene glycol |
| 3/6 ind for hemodia | 4. lithium 5. salicylates 6. theophylline |
| AE of hemodia | hypotension due to volume loss |
| Diagnosis of poisoning | history, physical exam, laboratory results, recognizing toxidromes |
| physical exam | ABC, vitals, id'ing toxidromes, always get APAP levels! |
| how to calculate an anion gap | (Na+Cl)-HCO3; normally 8-12; accounts for unmeasured anions |
| ATMUDPILES - ATMUD - all cause metabolic acidosis WITH anion gap | A-alcohol T-toluene M-methanol U-uremia D-DKA |
| ATMUDPILES - PILES - all cause metabolic acidosis WITH anion gap | P-paraldehyde I-isoniazid/iron L-lactate E-ethylene glycol (antifrez acidos) S-Salicylate/Strychnine |
| Serum osmolarity and osmolar gap | freezing point depression - artifact calculated osmolal normal 290 normal is <=10, can be used to estimate alcohol levels? |
| causes of elevated osmolar gap? | ethanol, isopropanol, methanol, ethylene glycol |
| blood gases | while arterial gases are best, venous will work often, pulse oximetry can fill in the gap for venous gases |
| Hypoglycemia | complications from <40mg/dL: brain injury, seizures, coma, AMI |
| TX of hypoglycemia | immediate empirical tx if AMI, 50% dextrose in adults if <70 |
| hyperkalemia causes | acidosis, alpha agonists, beta-blockers, digitalis, fluoride, lithium, renal failure |
| hypokalemia causes | beta agonists, theophylline, caffeine, stress |
| hyperkalemia complications >5meq/L | muscle weakness, widened QRS intervals, AV block, Vfib, cardiac arrest; early sign: ECG peaked T waves!! |
| Toxicology screening | qualitative are limited value, quantitative impt when tx is guided by conc. |
| impt quant levels | APAP!, carbamazepine, Dig, ethylene glycol, iron, lithium, methanol, salicylates, theo, valproic acid |
| Toxidrome - mixed alpha/beta agonist | HTN, tachycardia, mydriasis, diaphoresis, dry mucous membranes |
| examples of mixed alpha/beta agonist | cocaine/amphetamines - sweating dialated pupils |
| Beta antagonist OD toxidrome | hypotension, bradycardia, miosis, decreased peristalsis |
| beta antagonist OD example | beta-blockers or clonidine(looks like narc OD); visine is similar to clonidine (HR 10bpm) |
| Autonomic syndrome - mixed Ach agonist | miosis, diaphoresis, pulmonary edema, increased peristalsis V/D, muscle weakness |
| mixed Ach agonist example | organophosphates - cause overstimulation of Ach and eventually cause receptors to shut down |
| antimuscarinic syndrome | red as a beet, hot as a hare, mad as a hatter, dry as a bone. tachy, flushed, mydriasis, agitation, urinary retention |
| antimuscarinic syndrome | jimson weed, diphenhydramine |
| SSRI od toxidrome | tachy, tremor, spasm, responded to benadryl, hallucinations, garbled speech |
| treat ssri od? | periactin is a serotonin receptor blocker, ativan |
| opiate toxidrome | miosis, resp depression, relative brady/hypo, analgesia. looks similar to clonidine/visine. |
| evaluation of OD? | check for mixed drugs and labs that conflict with stories. |
| normal pH / pCO2 / HCO3 | pH 7.35-7.45 pCO2 35-45mmHg HCO3 20-26mEq/L |
| given a constant HCO3, what happens when you change the pCO2 from 65 to 20? | cause pH to increase |
| given the same pCO2, what happens when you raise the bicarb from 5 to 30? | cause pH to increase |
| Base excess-How far from normal are you? | minus number indicates below normal; calc by subtracting HCO3 from theoretical normal, can help determine metabolic component |
| Step approach to acid/base: step 1 | 1. assess metabolic (CO2 of chem7) and resp (pCO2 on blood gas) |
Created by:
nickh88
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