EM: Toxicology

A 4yo girl is seen at the ED because of possible ingestion. She was unattended for several minutes when she went through her grandmother's bag containing bottles of codeine, aspirin, clonidine, diphenhydramine, and fluoxetine. Upon arrival at the ED, her examination reveals temperature of 38°C, heart rate of 120, respiratory rate of 16, blood pressure 85/56, pupils 5 mm equal and reactive and dry/flushed skin. Exam also reveal dry mucous membranes and decreased bowel sounds. Which of the following is the most likely medication that caused the girl's findings? A. Codeine B. Aspirin C. Clonidine D. Diphenhydramine E. Fluoxetine

D. Diphenhydramine (anticholinergic toxidrome, antidote is physostigmine)

Which of the following is associated with miosis, respiratory depression, CNS depression, hypothermia, and bradycardia? A. Anticholinergic toxicity B. Cholinergic toxicity C. Salicylate toxicity D. Opioid toxicity E. Sedative toxicity

D. Opioid toxicity

A 2yo girl is brought to the ED after she was found with an open bottle of her grandfather's pills. Mom states she had a couple episodes of vomiting before arrival. In the emergency room, she is tachypneic, febrile, and diaphoretic. Laboratory results reveal sodium 140, potassium 4.0, chloride 100, and bicarbonate 12. A venous blood gas shows pH 7.29, pCO2 22, and pO2 89. Which of the following is indicated in the management of this patient? A. Flumazenil B. N-acetylcysteine C. Naloxone D. Sodium bicarbonate E. Lorazepam

D. Sodium bicarbonate (treat salicylate toxicity)

Which of the following is associated with mydriasis, agitation, tachycardia, hypertension, hyperpyrexia, diaphoresis, and seizures? A. Anticholinergic toxicity B. Cholinergic toxicity C. Salicylate toxicity D. Sympathomimetic toxicity E. Sedative toxicity

D. Sympathomimetic toxicity

All of the following are agents in the empirical treatment for a pointed patient EXCEPT: A. Oxygen B. N-acetylcysteine C. Naloxone D. Glucose E. Thiamine

B. N-acetylcysteine (not in the empirical cocktail given to all patients)

Which medication is given for alcohol withdrawal?

Benzodiazepines

Not including urine toxicology screen, what other complimentary labs do you want to order for a patient with suspected poisoning?

- Glucose - CMP - Lactate - Urine hCG - ECG - Ethanol

What is the dose of naloxone for opioid overdose?

0.1-0.4 mg IV

What are the 2 treatment option for GI decontamination?

1. Polyethylene glycol 2. Activated charcoal (adult dose 50g PO; pediatric dose 1g/kg PO)

A 49yo man presents to the ED complaining of sweating and tremors. The patient drinks a bottle of liquor per day and stopped suddenly because of a pending court case. His last alcoholic drink was 3 days ago. On PE, his blood pressure is 168/105 mm Hg, pulse rate is 106/minute, respirations are 22/minute, and temp is 99.3°F. The patient appears agitated and restless with a visible tremor of bilateral hands. The triage team ordered folic acid, thiamine, and a multivitamin. Which of the following is the most appropriate disposition? A. Admit the patient and start diazepam B. Admit the patient and start disulfiram C. Discharge the patient with a prescription for diazepam D. Discharge the patient with a prescription for disulfiram

A. Admit the patient and start diazepam

Which of the following is associated with mydriasis, urinary retention, dry mucous membranes, dry flushed skin, and ALOC? A. Anticholinergic toxicity B. Cholinergic toxicity C. Salicylate toxicity D. Opioid toxicity E. Sedative toxicity

A. Anticholinergic toxicity

A 5yo boy is brought to the ED after being found unresponsive at home. He was found lying on the floor in his parent's room with prescription medications scattered all over. His parents called 911, and he was immediately rushed to the hospital by ambulance. On exam, the boy is sedated with a respiratory rate of 15/min, blood pressure of 70/50 mm Hg, oxygen saturation of 92% on room air, miosis of the pupils, and 1+ reflexes on all extremities. His blood sugar is normal. Which of the following is the most likely medication ingested? A. Methadone B. Atropine C. Salicylate D. Organophosphate E. Amphetamine

A. Methadone (opioid toxicity)

A 42yo woman presents to the ED after a suicide attempt. The patient was depressed 2 days ago and took ab entire bottle of acetaminophen. She initially felt slightly nauseous and generally unwell but was otherwise asymptomatic. A family member convincer her to come to the ER for further evaluation. What is the best antidote for this patient? A. N-acetylcysteine B. Lorazepam C. Physostigmine D. Flumazenil E. Naloxone

A. N-acetylcysteine

What is the antidote for acetaminophen toxicity? A. N-acetylcysteine B. Lorazepam C. Physostigmine D. Flumazenil E. Naloxone

A. N-acetylcysteine

Which of the following is associated with excessive salivation/tearing/sweating, urination, vomiting, trouble breathing, and muscle fasciculations? A. Anticholinergic toxicity B. Cholinergic toxicity C. Salicylate toxicity D. Opioid toxicity E. Sedative toxicity

B. Cholinergic toxicity

A 19yo farmer presents to the ED with vomiting, diarrhea, diaphoresis, wheezing, and excessive tearing. Vital signs are BY 150/100 mmHg, HR 36 bpm, RR 28/min, and T 98.6° F. Which of the following is the most appropriate initial step in management? A. Atropine IV B. Decontamination C. Endotracheal intubation D. High-dose insulin E. Activate charcoal 50mg PO

B. Decontamination (patient presents with cholinergic toxicity from organophosphate contamination)

A 4-year-old boy presents after ingesting an unknown quantity of his mother's lorazepam. His vital signs are HR 72, BP 78/43, RR 6, oxygen saturation 91% and finger stick glucose 110. On examination, the patient moans in response to deep painful stimuli. What antidote is indicated? A. Activated charcoal B. Flumazenil C. Naloxone D. Thiamine E. N-acetylcysteine

B. Flumazenil

Which of the following agents is given for drug-induced seizures? A. Pyridoxine B. Lorazepam C. Physostigmine D. Flumazenil E. Dextrose

B. Lorazepam (NOTE: the book also says pyridoxine is given for drug-induced seizures)

A 16yo girl is brought to the ED for evaluation of nausea, hearing issues, and lethargy. Her parents report the patient vomited twice today, felt dizzy, and noted abdominal pain and "ringing in her ears". PMH includes anxiety and depression. She does not use alcohol, tobacco, or illicit drugs. Vitals are T 101.3°F, BP 120/80 mmHg, HR 110bpm, RR 25/min. The patient appears lethargic and only responds to a sternal rub. Labs show decreased bicarbonate, blood pH of 7.34, and PaCO2 of 47 mmHg. Which medication was most likely ingested? A. Ethanol B. Salicylate C. Codeine D. Tylenol E. Cocaine

B. Salicylate (treat supportively by alkalinizing the urine with sodium bicarbonate)

Which of the following toxicities has a routine screening test and should be ordered for ALL patients with suspected poisoning? A. Cocaine B. Methamphetamine C. Acetaminophen D. Ibuprofen E. Barbiturate

C. Acetaminophen (initially is asymptomatic and there is no identifiable toxidrome at the time when antidotal tx is most efficacious so important to ID via labs!)

What is the antidote for anticholinergic toxicity? A. N-acetylcysteine B. Lorazepam C. Physostigmine D. Flumazenil E. Naloxone

C. Physostigmine

Which of the following is associated with respiratory alkalosis, metabolic acidosis, tinnitus, tachypnea, tachycardia, diaphoresis, and N/V? A. Anticholinergic toxicity B. Cholinergic toxicity C. Salicylate toxicity D. Opioid toxicity E. Sedative toxicity

C. Salicylate toxicity

The smell of bitter almonds on a poisoned patient during general inspection indicates which toxicity?

Cyanide poisoning

Organophosphates will present with which type of toxidrome? A. Opioid toxicity B. Anticholinergic toxicity C. Salicylate toxicity D. Cholinergic toxicity E. Sympathomimetic toxicity

D. Cholinergic toxicity

What is the antidote for a benzodiazepine toxicity? A. N-acetylcysteine B. Lorazepam C. Physostigmine D. Flumazenil E. Naloxone

D. Flumazenil

A 42yo woman presents to the ED after a suicide attempt. The patient was depressed two days ago and took an entire bottle of acetaminophen. She initially felt slightly nauseous and generally unwell but was otherwise asymptomatic. A family member convinced her to come to the ED for further evaluation. Which of the following history or physical exam findings is most consistent with toxic acetaminophen ingestion? A. Anorexia and myalgias B. Jaundice and pruritus C. Nausea, vomiting, and diarrhea D. Right upper quadrant abdominal tenderness

D. Right upper quadrant abdominal tenderness

What is the antidote for a cholinergic toxicity? A. N-acetylcysteine B. Lorazepam C. Physostigmine D. Flumazenil E. Atropine

E. Atropine (2-5mg IV for adults)

An 18-year-old man presents to the ED in police custody after using an unknown drug. Vital signs include a BP of 170/85 mm Hg, HR 120 bpm, T 37.8°C, RR 18/min, and SpO2 99% on room air. On exam, he is agitated and diaphoretic. His pupils are 7 mm and reactive. Which one of the following substances did this patient most likely use? A. Fluoxetine B. Salicylate C. Heroin D. Acetaminophen E. Cocaine

E. Cocaine (give benzodiazepine antidote)

What is the antidote for opioid toxicity? A. N-acetylcysteine B. Lorazepam C. Physostigmine D. Flumazenil E. Naloxone

E. Naloxone

Which of the following is associated with CNS depression, ataxia, dysarthria, bradycardia, and respiratory depression? A. Anticholinergic toxicity B. Cholinergic toxicity C. Salicylate toxicity D. Opioid toxicity E. Sedative toxicity

E. Sedative toxicity

What is the most commonly abused drug in the world?

Ethanol

What is the 1st line treatment for hypotension in a poisoned patient?

IV fluid bolus 10-20 mL/kg

The priority for any poisoned patient is:

Resuscitation (ABCs)