CEN TOXICOLOGY QUESTIONS

iron toxicity phases

0-2 hrs phase one pain: caustic to GI Tract leading to bleeding, hematemesis/hematichesia 2-4 hrs phase two abatement: dehydration 48-96 hrs phase three dead: metabolic acidosis, coagulapathies, hemmorhagic shock/hepatic & renal failure IRON Settles in filtration organs

Cholinergic Drug toxicity antidote

2-PAM Atropine

Saran Gas nerve gas antidote

2-PAM Cl Atropine and pralidoxime chloride (2-PAM Cl) are antidotes for nerve agent toxicity; however, 2-PAM Cl must be administered within minutes to a few hours (depending on the agent) following exposure to be effective. There is also generally no benefit in giving more than three injections of 2-PAM Cl.

Initial Management of Severe OD - ABCDE

A - Antidote B - Basics ; ABCs C - Change catabolism D - Distribute differently; Decontamination E - Enhance elimination In the patient with an ingestion, remember the basics (Airway, Breathing, Circulation), but also start thinking early about antidote and eliminating the toxin if indicated. Time matters.

intractable SZE [aka "uncontrolled" or "refractory"]

A disorder in which a patient's seizures fail to come under control with treatment.

OPIATES TREATMENT

Acute Naloxone Chronic Methadone Catapres Naltrexone

Tricyclic Antidepressants (TCAs)

Amitriptyline. Amoxapine. Desipramine (Norpramin) Doxepin. Imipramine (Tofranil) Nortriptyline (Pamelor) Protriptyline (Vivactil) Trimipramine (Surmontil)

cocaine

Anticholinergics Sympathomimetics

OPIATES POSSIBLE COMPLICATIONS

Aspiration Pulmonary edema Withdrawal symptoms Need for repeated doses

anticholinergic over dose examples

Atropine antihistamines [benadryl] TCAs Tricyclic antidepressants (Amitriptyline) Cyclobenzapine (muscle relaxant)

Cholinergics: i.e., Acetylcholine

BETHANACOL CARBAMATE INSECTICIDES MYASTHENIA GRAVIS DRUGS EDROPHONIUM PHYSOSTIGMINE PILOCARPINE NICOTINE

Organophosphate poisoning Cholinergics {see, spit, pee, shit] used in pesticides b/c

BUGS DROWN with Cholinergic [producing fluids: saliva, urine, digestive enzymes] Organophosphates are used as insecticides, medications, and nerve agents. Symptoms include increased saliva and tear production, diarrhea, vomiting, small pupils, sweating, muscle tremors, and confusion.

tx of ventilate/Bag/Bolus IS THE SAME FOR OD of what two drugs

Benzos and opiates

tricyclic antidepressants OD S/S

CARDIOTOXICITY QRS Widened [QT Syndrome] Symptoms may include elevated body temperature, blurred vision, dilated pupils, sleepiness, confusion, seizures, rapid heart rate, and cardiac arrest.

anticholinergic COCAINE TREATMENT

CNS sedation Labetolol Treat hyperthermia ?Parlodel or desipramine 1

Vital Signs Toxicity - Temperature Hypothermia (COOLS)

Carbon monoxide, Clonidine Opiates Oral hypoglycemics, Insulin Liquor Sedative-hypnotics

Agents that Affect Pupil Size Miosis [SMALL PUPILS] (COPS)

Cholinergics ;rest & digest], Clonidine Opiates, organophosphates Phenothiazines, pilocarpine Sedative-hypnotics, SAH MydriASis (A3S) Antihistamines, Antidepressants, Atropine Sympathomimetics

Vital Signs Toxicity - BP Hypotension (CRASH)

Clonidine, CCBs (and B-blockers) Reserpine or other antihypertensives Antidepressants, Aminophylline, Alcohol Sedative-hypnotics Heroin or other opiates

Vital Signs Toxicity - BP Hypertension (CT SCAN)

Cocaine Thyroid supplements Sympathomimetics Caffeine Anticholinergics, Amphetamines Nicotine

CHOLINERGICS: CLINICAL PRESENTATION

DEFECATION URINATION MIOSIS BRONCHO- CONSTRICTION BRADYCARDIA EMESIS LACRIMATION SALIVATION

metformin OD

Dialysis

Digitalis antidote

Digibind assess potassium just in case they are low K could cause toxicity

extrapyramidal effects are?

Extrapyramidal symptoms are most commonly caused by typical antipsychotic drugs that antagonize dopamine D2 receptors. The most common typical antipsychotics associated with EPS are haloperidol and fluphenazine. drug-induced movement disorders that include acute and tardive symptoms

nerve gas tx

FIRST RESPONDERS AT THE SCENE atropine until they stop pouring fluid out of their face Pulmonary Edema Needs Positive Pressure Airway

BENZODIAZIPINES TREATMENT

Flumazenil

OD/Chronic use of benzodiapines : szes tx

Flumazenil (Romazicon} GABA receptor antagonist It can treat drowsiness caused by sedatives following surgery or drug overdose.

BAC Def

For example, a BAC of 0.1% is one part alcohol per 1,000 parts blood. Though it doesn't sound like much, this level of alcohol in the body can cause serious side effects. Two to three drinks in an hour, depending on body weight, age, gender, and other factors, increases BAC to 0.1%.

Vital Signs Toxicity - Pulse Tachycardia (FAST)

Free base or other forms of cocaine Anticholinergics (+ flight or fight), antihistamines, amphetamines Sympathomimetics (ephedrine, amphetamines), Solvent abuse Theophylline, Thyroid hormone Anticholinergic medications: antidepressants like amitriptyline furosemide digoxin nifedipine

CYCLIC ANTIDEPRESSANTS TREATMENT amitriptyline

Gastric decontamination Treat cardiac dysrhythmias Treat seizures The drug class possesses anticholinergic, α-adrenergic and adrenergic uptake inhibition properties. Inhibition of α-adrenergic receptors decreases vascular resistance and results in hypotension related to tricyclic antidepressant overdose. Tricyclic antidepressants also inhibit fast sodium channels that influence cardiac conduction, which may result in prolonged QRS complex.4 Time from ingestion to life-threatening toxicity or seizure can be as little as an hour, with cardiotoxicity being the primary culprit for mortality. One gram of ingested drug can result in plasma levels >1000ng/mL and QRS complex of >100ms.5 Inhibition of fast sodium channels lead to slowing of phase 0 depolarization. This slowing produces QRS prolongation and development of arrhythmias.

alkaline OD

Gastric emptying and activated charcoal are contraindicated. Perforation is treated surgically.

Dimercaprol is the antidote for

Heavy metal toxicity medication It can treat arsenic, gold, and mercury poisoning. It can also treat lead poisoning when given with other medications

Anticholinergics [not producing fluids/blood to heart, lungs and brain] syndrome (antihistamines, bronchodilators, cyclic antidepressants, SLEEP AIDS)

Hot as a hare (hyperthermia) Red as a beet (flushed) Dry as a bone [ANHYDROSIS (dry skin, urinary retention) Blind as a bat (mydriasis) Mad as a hatter (hallucinations, delirium, myoclonic jerking) The antidote for anticholinergic toxicity is physostigmine salicylate. Physostigmine is the only reversible acetylcholinesterase inhibitor capable of directly antagonizing the CNS manifestations of anticholinergic toxicity; it is an uncharged tertiary amine that efficiently crosses the blood-brain barrier

Hallucinogens Stimulation of serotoninergic system

Illusions, visual hallucinations, sweating, tachycardia, pupillary dilatation

OD/Chronic use of benzodiapines (clonazepam diazepam, lorazepam)

Intractable Szes Special care should be taken in withdrawing benzodiazepines, as delirium, psychosis, and withdrawal seizures have been reported with

sympathomimetic [fight or flight/shunt blood going to heart/brain/lungs]

MIMIC SYMPATHETIC a drug that stimulates the sympathetic branch of the autonomic nervous system Epinephrine, adrenaline

CYCLIC ANTIDEPRESSANTS CLINICAL PRESENTATION

Most are combination anticholinergic and sympatholytic Coma Seizures Hypotension Cardiac dysrhythmias

Carbon Monoxide Poisoning

Most common cause of death by poisoning Symptoms vary: Mild: HA, mild dyspnea Mod: HA, dizziness, N/V,dyspnea, irritability Severe: Coma, seizures, CV collapse

SLUDGE-bbb

Muscarinic Cholinergic syndrome Salvation lacrimination urination defecation gastric emesis bronchoria bronchospasm bradycardia miosis increased bowel sounds

Acetaminophen Toxicity - Antidote

N-acetylcysteine (NAC) Glutathione precursor and glutathione substitute Increases substrate supply for the non-toxic sulfate conjugation pathway Available as oral and IV form Extremely effective if initiated within 8 hours Standard of care to treat patients up to 24 hours

ACIDIC OD NBM

NBM: Nothing by mouth

Negative Inotropes drugs

Negative inotropes include beta-blockers, calcium channel blockers, and antiarrhythmic medicines and they all work in different ways: Beta-blockers "block" the effects of adrenaline on your body's beta receptors. This slows the nerve impulses that travel through the heart.

inotropic NEGATIVE VS POSITIVE

Negatively inotropic agents weaken the force of muscular contractions. Positively inotropic agents increase the strength of muscular contraction. The term inotropic state is most commonly used in reference to various drugs that affect the strength of contraction of heart muscle (myocardial contractility).

Vital Signs Toxicity - Temperature Hyperthermia (NASA)

Nicotine, Neuroleptic malignant syndrome (muscle rigidity caused by antipsychotics] Antihistamines Salicylate [aspirin], Sympathomimetics Anticholinergics, Antidepressants

Antihyperglycemics/Sulfonylurea OD Antidote

Octreotide [tiny dose of 50mcg] [80 mg/bolus if used for GI Bleed]

how to tell a patient OD on either benzo or opiates by assessing the pupils?

Opiates constrict pupils (pinpoint) Benzos do not

Vital Signs Toxicity - Respirations Rapid Respiration (PANT)

PCP, Paraquat, Pneumonitis (chemical) ASA [salicylates], Amphetamines Non-cardiogenic pulmonary edema Toxin-induced metabolic acidosis Paraquat is used in pesticides

ANTICHOLINERGIC: ATROPINE TREATMENT

Physostigmine Gut decontamination Supportive care

0PIATES CLINICAL PRESENTATION

Pinpoint pupils Respiratory depression Bradycardia Hypotension Hypothermia Pulmonary edema Seizures

Vital Signs Toxicity - Pulse Bradycardia (PACED)

Propranolol or other Beta blockers, Poppies (opiates) Anticholinesterase drugs Clonidine, CCBs, Ethanol or other alcohols Digoxin

cholinergic cells that use which neurotransmitter

Referring to cells that use acetylcholine as their synaptic transmitter.

BENZODIAZIPINES CLINICAL PRESENTATION

Respiratory depression Drowsiness Coma

Vital Signs Toxicity - Respirations Slow Respirations (SLOW)

Sedative-hypnoptics, Strychnine, Snakes Liquor Opiates, OPs Weed (marijuana) Other causes: Nicotine, Clonidine, Chlorinated HC

Tricyclic Antidepressants (TCAs) overdose antidote

Sodium bicarbonate UNTIL GOAL pH of 7.45-7.55

Antihyperglycemics ARE Sulfonylurea AGENTS

Sulfonylurea agents are widely used as therapy for hyperglycemia in type 2 diabetes mellitus [glipizide, glyburide and glimepiride]

Chronic ETOH TX

Thiamine d/t Wernicke-Korsokoff

phytonadione [tx for vit K defcy] vitamin K antidote for

Warfarin [long acting anticoagulant]

Saran Gas [nerve gas]

Within seconds of exposure to sarin gas (or liquid, which evaporates easily), we start to notice the immediate effects of acetylcholine buildup. First, our smooth muscles and secretions go crazy. The nerves to those areas keep firing, keep telling them to go

theophylline is an antidote for

adenosine poisoning

Ethylene glycol

antifreeze coolants causing renal failure tx hemodialysis

BAL

blood alcohol level

isoprop

cleanser mega ethanol harmful metabolites after liver metabolization CAUSES DEATH

in pts exposed to radiation: all body fluids are considered?

contaminated like oncology patients

CHOLINERGICS TREATMENT Gastric

decontamination Respiratory support Atropine Pralidoxime Cardiac monitoring Tx seizures with benzodiazipine

Antidote for Iron toxicity

deferoxamine - iron chelator "de":removal "fer" iron "ox": amino GIVE MEDICINE UNTIL URINE IS CLEAR

clinical decontamination

eyewash with neutral fluid 7.4-7.5

CaChannel Blocker [-pine] & BETA blockers [-olol] Antidote

insulin along with glucose supplementation high-dose insulin has been established as an effective therapy for calcium channel blocker overdose with cardiogenic shock

Chronotropic drugs

may change the heart rate and rhythm by affecting the electrical conduction system of the heart [at the SA node] and the nerves that influence it, such as by changing the rhythm produced by the sinoatrial node. Positive chronotropes [INCREASES HR] increase heart rate; negative chronotropes [DECREASES HR] decrease heart rate

Cholinergics {see, spit, pee, shit] pathway

muscuric and nicotinic receptors that use acetylcholine neurotransmitters

OD of Negative Inotropes drugs: antidote Digoxin

negative Chrontropes Betablockers -olol Amiodrone

EtOH toxicity Wernicke-Korsakoff syndrome (WKS) is a

neurological disorder. Wernicke's encephalopathy and Korsakoff's psychosis are the acute and chronic phases, respectively, of the same disease. WKS is caused by a deficiency in the B vitamin thiamine. Thiamine plays a role in metabolizing glucose to produce energy for the brain.

Antimuscarinic (e.g. Atropine) is an antidote for:

organophosphate and carbamate insecticides, nerve agents, some poison mushrooms

What does muscular rigidity cause

rhabdomylosis syndrome due to a direct or indirect muscle injury. It results from the death of muscle fibers and release of their contents into the bloodstream (myoglobin). This can lead to renal (kidney) failure.

aspirin overdose antidote Aspirin is a derivative of salicylic [salt] acid - and is also known as acetylsalicylic acid.

salicylate poisoning Sodium bicarbonate is given in a significant aspirin overdose (salicylate level greater than 35 mg/dL 6 hours after ingestion) regardless of the serum pH, as it enhances elimination of aspirin in the urine. It is given until a urine pH between 7.5 and 8.0 is achieved.

Drug classification of alcohol

sedative

COCAINE CLINICAL PRESENTATION

tachycardia, HTN arrhythmia can get hypotension and reflex bradycardia CNS stimulation

beta blocker is an antidote for

theophylline

These three principles are called the Cardinal Rules of radiation protection; they are:

time, distance, and shielding from ionizing radiation.

#1 drug used in suicide overdose

tricyclic antidepressants

what is a brightly colored liquid made of methanol, a poisonous alcohol

windshield wiper fluid solvents Methanol poisoning may result in metabolic acidosis, blindness, and death. The inhibition of alcohol dehydrogenase is fundamental to the treatment of methanol poisoning.