-
What is the number to the Poison Control Center?
1-800-222-1222
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What are the names of 4 toxicology references?
- Casarett & Doull's Toxicology: The Basic Science of Poisons
- Ellenhorn's Medical Toxicology: diagnosis & Treatment of Human Poisoning
- Goldfrank's Toxicology Emergencies
- Poisindex (Micromedex)
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What is the first thing you should do when there is a patient with some sort of toxic exposure?
- (Determine if it's safe to approach)
- stabilize the patient (ABC's)
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After stabilizing the toxicology patient, what is the next step?
- Gather a history:
- substance
- time of exposure
- dose
- duration of exposure
- past medical history
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After gathering a toxicology patient's history, what is the next step?
Evaluate the situation - read the toxidromes if present
-
What is a toxidrome?
a constellation of s/sx that suggest a specific class of poisoning
-
What are the effects of sympathomimetics?
- increase BP
- increase HR
- slight increase in temp
- dilate pupil
- hyper alert
- increase reflexes
- tremor
-
What are the effects of anticholinergics?
- may increase BP
- increase HR
- increase temp
- dilate pupil
- altered mental status
- decrease bowel sounds
- decrease urine output
-
What are the effects of cholinergics?
- may decrease BP
- decrease HR
- same temp
- pinpoint pupil
- altered mental status
- increase bowel sounds
- increase bronchial sounds
-
What are the effects of opioids?
- decrease BP
- decrease HR
- decrease temp
- pinpoint pupils
- decrease level of consciousness
- decrease bowel sounds
- rales (late)
-
What are the effects of sedative/hypnotics?
- decrease BP
- decrease HR
- decrease temp
- miosis or mydriasis
- altered mental status
- decrease resp. rate
- decrease peristalsis
- hyporeflexia
-
What labs should you look at in a toxicology patient?
- anion gap: Na, Cl, HCO3
- blood gases
- albumin
- INR
- (Methadone does not show up on opioid tests)
-
How do you remove the toxic source from the patient?
- Ipecac
- gastric lavage
- single-dose activated charcoal
- multi-dose activated charcoal
- cathartics
- whole-bowel irrigation
- diuresis
- hemodialysis/hemoperfusion
- antidotes
-
Who should not recieve ipecac?
- no gag reflex
- lethargic, comatose, convulsing
- expected to become unresponsive in 30 min
- caustic, corrosives, ammonia, bleach
- children
- erlderly
- debilitated
- pregnant
-
What are the limitations of gastric lavage?
- ingestion of corrosive or hydrocarbon
- must have been ingested in last hour
- aspiration pneumonitis
- laryngospasm
- injury to esophagus and stomach
- hypothermia
- fluid and electrolyte imbalance
-
What are the risks of activated charcoal?
emesis and aspiration
-
What substances does single-dose activated charcoal not work for?
- iron
- lead
- lithium
- simple alcohols
- corrosives
-
What substances can multi-dose activated carbon work for?
- CBZ
- dapsone
- phenobarb
- quinine
- theophylline
-
When does whole-bowel irrigation ever get used?
- when pts swallow condoms containing cocaine:
- GoLytely for 4-12 hours
-
For which medications is hemodyalisis life-saving?
- methanol
- ehylene glycol
- salicylates
- ethanol
- theophylline (usually use charcoal)
- lithium (<4 = chronic, <6 = acute, <2.5 = with sx)
-
What is the antidote for acetaminophen toxicity?
- N-acetylcysteine
- maintains or restores hepatic concentrations of glutathione
-
What is the antidote for anticholinesterase insecticides?
atropine
-
What is the antidote for rattlesnake, cottonmouth, and copperhead poisoning?
crotalidide antivenin
-
What is the antidote for black widow poison?
Latrodectus mactans antivenin
-
What is the antidote for coral snake poisoning?
Micrurus fulvitus antivenin
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What is the antidote for Calcium Channel Blockers?
- calcium gluconate - increases intracellular levels of Ca
- calcium choloride - increases intracellular levels of Ca
- glucagon - increases production of cAMP in increased intracellular Ca
-
What is the antidote for lead poison?
- Calcium disodium EDTA
- dimercaprol
-
What is the antidote for plutonium poisoning?
calcium trisodium pentate
-
What is the antidote for cyanide?
cyanide antidote kit
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What is the antidote for iron?
-
What is the antidote for digoxin?
- digoxin immune Fab
- binds digoxin
-
What is the antidote for arsenic?
dimercaprol
-
What is the antidote for mercury?
dimercarol
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What is the antidote for gold?
dimercaprol
-
What is the antidote for ethylene glygol?
- ethanol
- fomepizole - inhibits alcohol dehydrogenase
-
What is the antidote for methanol?
- ethanol
- fomepazole inhibits alcohol dehydrogenase
-
What is the antidote for Beta blockers?
- glucagon
- increases production of cAMP in increased intracellular Ca
-
What is the antidote for methemoglobinemia?
methylene blue
-
What is the antidote for opioids?
- naloxone
- antagonize opioid receptors
-
What is the antidote for sulphonyl urea?
- octreotide acetate
- lowers insulin levels
-
What is the antidote for organophosphate insecticides?
pralidoxime
-
What is the antidote for anticholinergics?
- physostigmine
- inhibits cholinesterase
-
What is the antidote for radioactive iodine?
potassium iodide
-
What is the antidote for isoniazid?
- pyridoxine HCl
- replaces vitamin B6
-
What is the antidote for TCA's?
- sodium bicarb
- increases clearance of acidic meds
-
What is the antidote for salicylates?
- sodium bicarb
- increases clearance of acidic meds
-
What is the antidote for benzodiazepines?
- flumazenil
- antagonizes BDZ receptors
-
What is the classic symptom triad of salicylate toxicity?
- hyperventilation
- tinnitus
- GI disturbances (N,V)
-
What are the sx of mild-moderate salicylate toxicity?
- acid-base abnormalities
- fever
-
What are the sx of severe salicylate toxicity?
- hyperthermia
- altered mental status
- non-cardiac pulmonary edema
- hypoglycemia
- seizures
- coma
-
What level of salicylates causes toxicity?
>40 mg/dL
-
At what point should you refer a patient to the hospital for salicylate toxicity (dose)?
- 150mg/kg or more
- 6.5g of aspirin
- more than a lick of oil of wintergreen in <6yo
- more than 4mL of oil of wintergreen in 6yo and up
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Should emesis by induced in cases of salicylate overdose?
no
-
When should blood levels of salicylate be checked?
- at least 6h after ingestion
- continue checking q 2h until level starts to decline
-
What should be monitored in salicylate overdose?
- salicylate levels after 6h, then q 2h
- BUN/SCr
- blood glucose
- blood gases
- electrolytes
-
What supportive care should be given to salicylate overdoses?
- ABCs@!!!!
- correction of volume depletion
- correction of metabolic abnormalities
-
When should gastric lavage/multi-dose activated charcoal be used for salicylate overdose?
- if pt presents within 1-2h post-ingestion
- for ACUTE toxicity only, not chronic
-
How do you treat salicylate toxicity?
- sodium bicarbonate
- also need to replace K+ loss
- hemodialysis if:
- acidosis unresponsive to alkalinization
- renal failure
- salicylate level > 100 mg/dL
- persistent, severe CNS symptoms
- pulmonary edema
-
How do you administer sodium bicarb for salicylate overdose?
- 1-2 mEq/kg IV bolus, then
- continuous infusion of D5W + NaHCO3 until urine pH reaches 7.5-8.0 and plasma pH= 7.45-7.55
- (increases renal clearance by 10-20 fold and significantly reduces half-life)
-
What are the sx of benzodiazepine toxicity?
- general depression of the CNS
- drowsiness
- slurred speech
- ataxia
- respiratory arrest
- coma
-
How do you manage BZD toxicity?
- determine time and dose of OD
- duration of BZD use
- Co-ingestants
- ABC's (often the only thing done to manage BZD overdose, especially with mixed ingestions, unknown hx, or CI exist)
- Gastric lavage:
- large amount ingested or co-ingestions
- most effective in first hour post-dose
- activated charcoal:
- effectively binds BZDs and should be administered in most situations
- Flumazenil
-
How does flumazenil work?
- competetive inhibition of BZD receptors
- onset 1-2 min
-
How is flumazenil dosed?
- 0.2 mg IV over 30s
- if no response:
- 0.3 mg IV over 30s
- if still no response:
- 0.5 mg IV over 30s q 1min up to 3mg
- if partial response at 3mg, keep dosing up to 5mg
- repeat doses may be given q 20min if re-sedation occurs
-
When is Flumazenil CI?
- hypersensitivity
- pt using BZD for life-threatening condition
- TCA co-administration (increases risk of seizures)
-
What are some cautions for the use of flumazenil?
- always ensure proper airway mgmt
- take necessary measures to secure airway, ventilation, and IV access - some pts may attempt to pull them out upon arousal
- use w/ caution in alcoholics
-
What should be monitored during flumazenil tx?
- re-sedation and respiratory depression for up to 120 min
- withdrawal sx or seizures
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What are the SE of flumazenil?
- dizziness
- injection site pain
- diaphoresis
- HA
- abnormal or blurred vision
-
What are the sx of CCB toxicity?
- bradycardia
- hypotension
- N
- V
- dizziness
- lethargy
- seizures
- coma
- unresponsiveness
- depressed reflexes
- AV block
- intraventricular conduction defects
- ventricular dysrhythmias
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What should be monitored in CCB OD?
- arterial blood gases
- electrolytes
- BUN/SCr
- ECG
- pulse
- hypoxia
- pneumonia
-
How much diltiazem, nifedipine, or verapamil may be life-threatening?
1g
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What should be avoided in treating CCB OD?
ipecac - risk of seizures and coma
-
How do you manage CCB OD?
- ABC's
- gastric lavage with a single dose of charcoal (if within 1-2h of ingestion)
- whole-bowel irrigation w/ polyethylene glycol electrolyte solution (SR tablet OD)
- adjunctive tx for hypotn, bradycardia, and shock
- CaCl bolus test dose of 10-20 mg/kg up to 1-3g preferred for serious toxicity
- glucagon bolus of 0.05-0.20 mg/kg, 3-5mg over 1-2 minutes initially
-
What are the brand and generic names of 2 short-acting BZD's?
- oxazepam (Serax)
- alprazolam (Xanax)
-
What are the brand and generic names of 2 long-acting BZD's?
- chlordiazepoxide (Librium)
- diazepam (Valium)
-
What are 3 ASA-containing drugs?
-
What are the 3 underlying mechanisms of cardiac toxicity in CCB OD?
- vasodilation through relaxation of smooth muscles
- decreased contractility by action on cardiac tissue
- decreased automaticity and conduction velocity through slow recovery of Ca channels
-
What are the brand and generic names of 4 CCB's?
- diltiazem (Cardizem)
- verapamil (Isoptin)
- nifedipine (Procardin)
- nicardipine (Cardine)
-
What are the concurrent factors that may worsen CCB-induced cardiac complications?
- concurrent ingestion of BBL, digoxin, class I antiarrhythmics
- pt on chronic CCB tx and overdoses
- elderly or pt w/ underlying cardiac disease
-
Which elimination measures have not proven effective for CCB OD?
- hemodialysis
- multi-dose activated charcoal
- ipecac
-
How is acetylcysteine dosed?
- PO:
- 140 mg/kg loading dose
- 70 mg/kg q 4h x 17 doses
- 72h total timeframe
- IV:
- 150 mg/kg in 200ml D5W over 1h
- 50 mg/kg in 500ml D5W over 4h
- 100 mg/kg in 1L D5W over 16h
- 21h total timeframe
-
How is digibind dosed?
- (serum concentration x wt)/100 = #vials
- - or -
- (mg ingested x bioavailability)/0.5mg of digoxin bound per vial
- unknown amount = 10 vials, repeat with 10 vials as needed
- life threatening = 20vials STAT
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