TOXIC NA COLOGY LAB (PRELIM) (clang)

Clinical Toxicology

Significant role for scientists, analytical chemists, industrial hygienists, nurses and pharmacists

identity of the substance

routes of exposure

dose

mechanism of toxicity

pharmacokinetics or toxicokinetics data

toxic effect on organ

clinical features

recommendations

recommended treatment

Substance Information Records consists of (9)

prevention, preparedness, detection and alert, response

role of poison centers in disaster management (4)

clinical, research institutions, public health, laboratories, Industry, Medicines information, Other

Key stakeholders in poison centers (9)

Poisoning

Self-harm or suicide, Assault or homicide, Unintentional or accidental

altered level of consciousness (LOC) including coma

young patient with arrhythmia

trauma patient

patient with bizarre or puzzling clinical presentation

patients in whom Poisoning or Drug overdose should be suspected

Prehospital care

First aid, CPR, emergency telephone number access, emergency medical services, emergency medical technician and/or paramedic patient evaluation and treatment, safe and expedient patient transport to the ED, and disaster response

Triage

Sorting and ordering of patients on the basis of their need for treatment and the resources available to provide that treatment

–A-irway with cervical spine stabilization

–B-reathing and ventilation

–C-irculation with hemorrhage control

–D-isability or deficits

–E-xposure and environmental control

Give the approach of Primary Survey (5)

airway, voice and breath sounds

what to consider if A-airway is normal in a patient

head tilt and chin lift, oxygen, suction

to survey for an A-airway what should be done

RR- (12-20/min)

Chest wall movements

Chest percussion

Lung auscultation

Pulse oximetry (97-100%)

what to consider if B-breathing is normal in a patient

seat comfortably

rescue breaths

inhaled medications

bag-mask ventilation

decompress tension

pneumothorax

How to restore normal B-breathing in patients

Skin color, swearing

Capillary refill time (<2s)

Palpate pulse rate (60-100/min)

Heart auscultation

Blood pressure (systolic 100-140 mmHg)

ECG monitoring

What to consider if C-circulation is normal in a patient

Stop bleeding

Elevate legs

Intravenous access

Infuse saline

How to restore C-circulation for patients

LOC (AVPU)

Alert

Voice responsive

Pain responsive

Unresponsive

Limb movements

Pupillary light reflex

Blood glucose

What to survey if there is a D-disability in a patient

Treat ABC problems

Recovery position

Glucose for hypoglycemia

How to treat D-disability in patients

Expose skin

Temperature

What to consider for E-exposure in patients

RESUSCITATION

Applying oxygen to the patient, obtaining IV access, ECG, and continuous pulse oximetry

Exigent (airway obstruction)

Emergent (acute MI)

Urgent (asthma, poisoning)

Nonurgent or minor (simple)

Ranking patient’s conditions based on severity

SECONDARY SURVEY

Head to toe evaluation of the ED patient, including laboratory, radiographic and other needed diagnostic testing

STABILIZATION

Restoration of biologic homeostasis to the patient

DEFINITIVE CARE

Continued therapy

Continued patient evaluation

Specialty evaluation /consultation

DISPOSITION

Discharge to go home

Hospitalization –Transfer to another facility more optimally equipped

Epinephrine

Norepinephrine

Dopamine

Drugs with both vasopressor and inotropic effects (sometimes called inopressors) END

Vasopressin

Angiotensin II

Phenylephrine

Pure vasopressin with no effects on cardiac contractility (VAP)

Milrinone

Isoproterenol

Dobutamine

Purely inotropes that increase cardiac contractility

- patient’s behavior prior to arrival

- changing vital signs

- seizures

Obtain a clinical history from family/friends or paramedics

Propanolol, poppies

Anticholinesterase

Clonidine, CCBs

Ethanol

substances that cause Bradychardia (PACE)

Freebase

Anticholinergics/antihistamine/amphetamines

Sympathomimetics

Solvents

Theophylline

Substances that causes tachycardia (FAST)

Carbon monoxide

Opiates

Oral hypoglycemics

Liquor

Sedatives/Hypnotics

Substances that causes Hypothermia (COOLS)

NMS, Nicotine

Antihistamine

Sympathomimetics

Anticholinergics, Antihistamine

Substances that causes Hyperthermia (NASA)

Clonidine, CCBs

Reserpine

Antihypertensive

Antidepressants

Aminophylline

Sedative/Hypnotics

Heroin

substances that causes Hypotension (CRASH)

Cocaine

Thyroid supplements

Sympathomimetics

Caffeine

Anticholinergics

Amphetamines

Nicotine

substances that causes hypertension (CTSCAN)

Sedative/hypnotics

Liquor

Opiates

Weed

substance that causes hypoventilation (SLOW)

PCP

Pneumonitis

Noncardiogenic

pulmonary edema

Toxic met. acidosis

substances/symptoms that causes Hyperventilation (PANT)

aromatic hydrocarbon, toluene

Airplane glue breath odor

cyanide

Bitter almonds breath odor

hypochlorites

Bleach breath odor

Marijuana

Burnt rope breath odor

cicutoxin of hemlock

Carrots breath odor

ethanol

Chico breath odor

carbon monoxide

coal gas breath odor

creosote, phenol

disinfectant breath odor

bromine, lithium

foul breath odor

arsenic, dimethylsulfoxide, organophosphate, yellow phosphorous, phosphide, selenium, telurium, zinc

Garlic breath odor

naphthalene, paradichlorobenzene

mothball breath odor

coniine

mouse urine breath odor

chloral hydrate, paraldehyde

pear acid breath odor

acetone, isopropanol, salicylates

sweet breath odor

nitrobenzene

shoe polish breath odor

nicotine

stale tobacco breath odor

ammonia

urine breath odor

turpentine

Violets breath odor

methyl salicylate

wintergreen breath odor

CO

Boric acid

Anticholinergics

Ethanol

Substances that causes red skin

cyanosis

methylene blue

Nitrates

Dapsone

Sulfonamides

substances that causes blue skin

barbiturates, CO, sedative hypnotics, snake/spider bites

substances or toxins that causes blistering

APAP, poisonous mushroom, arsine gas

substances that causes jaundice

Alcohol

Endocrine/epilepsy

Intoxication

Oxygen

Uremia

Trauma/tumor

Infection

Psychological

Shock/Strokes

substances or symptoms that causes altered mental status (AEIOU TIPS)

Organophosphates

tricyclics

INH/insulin

Sympathomimetics

Camphor/cocaine

Amphetamines

Methylxanthines

PCP

Benzo withdrawal

Ethanol

Lead, Lithium

Lidocaine, Lindane

substances that causes seizures (OTIS CAMPBELL)

Sympathomimetic syndrome

Clinical appearance: diaphoresis (sweating), piloerection, mydriasis and hyperreflexia. In severe cases, seizures, hypotension (later effect) and dysrhythmias may occur.

VS: tachycardia, hypertension, hyperpyrexia

induce sedation, initiate aggressive cooling, treat HTN with phentolamine, treat tachycardia with beta blockers

Sympathomimetic toxic syndrome treatment

Anticholinergic Toxic Syndrome

Clinical appearance: Hot, dry skin, mydriasis, diminished or absent bowel sounds, urinary retention, confusion and delirium. Sinus tachycardia is most common but other cardiac conduction abnormalities may occur. Seizures may occur with agents that enter the CNS

VS: tachycardia, hypertension, hyperpyrexia

Obtain immediate ECG tracing to evaluate for poisoning with TCAs; consider physostigmine only if tricyclics are not involved.

Anticholinergic Toxic Syndrome treatment

Diphenhydramine

What is the classic antihistamine that causes anticholinergic toxicity

seizures, QRS widening with subsequent risk of ventricular dysrhythmias → Na channel blockade

What are the other features of diphenhydramine poisoning?

Diphenhydramine

used in treating symptoms of histamine excess and EPS, also used as prophylaxis against hypersensitivity.

AChE inhibitors (OP, carbamates), muscarinic agents (pilocarpine, metacholine, muscarinic, mushroom poisoning

Atropine is used to treat respiratory and GI symptoms due to poisoning with ______ inhibitors or _______ agents

Atropine

Treatment of drug-induced bradycardia secondary to parasympathetic tone or AV nodal abnormality

atropine and pralidoxime. Obtain measurements of serum and RBC cholinesterase activity

treatment for Cholinergic toxic syndrome

Pralidoxime 1g-2hrs IV over 10 mins.

treatment for acute organophosphate poisoning

Atropine and Pralidoxime

Mark 1 kit contains

Narcotic toxic syndrome

Clinical appearance: altered mental status – coma, miosis, diminished bowel sounds, needle tracks, pulmonary edema, hyporeflexia

Vital Signs: Bradycardia, hypotension, hypothermia & hypoventialation

Naloxone for suspected opioid overdose, consider flumezanil for benzodiazepine overdose

Narcotic Toxic Syndrome treatment

Naloxone

antidote for acute opioid toxicity

nalmefene

a long acting opioid antagonist

Naltrexone

for outpatient addiction management (long -term opioid detoxification)

Opiates: derived from opium poppy

Opioids: capable of producing opium-like effects

How do opiates differ from opioids

Meperidine, propoxyphene, tramadol

What are the 3 opioids that do not cause miosis

Methadone, clonidine, buspirone

What medications have been used to alleviate opioid withdrawal

FLUNITRAZEPAM

Which benzodiazepine is known as the “date rape” drug roofies

BARBITURATES

Medication that should be used to treat seizures induced by flumazenil?

LONG ACTING BARBITURATES

How do you classify phenobarbital in terms of duration of action?

DRESS SYNDROME

Drug Rash with Eosinophilia and Systemic Symptoms. Clinical appearance: rash, fever and internal organ involvement

tegretol

profound inflammation associated with allergic reaction to ___________

Sedative Hypnotics

CNS depression that may lead to respiratory depression and coma. (The pupillary reaction is usually spared in sedativehypnotic coma). This category of drugs includes barbiturates, ethanol, benzodiazepines, GHB (gamma hydroxybutyric acid) and other drugs.

Hallucinogens

Patients present with hallucinations / cognitive disorders, although they are oriented to person / place / time. Associated physical findings may include: tachycardia, hypertension and mydriasis

reuptake

SSRIs, CAs, venlafaxine, meperidine, dextromethorphan, tramadol inhibits serotonin_________

breakdown

MAOIs, linezolid inhibits serotonin ______

Act as serotonin agonists

Lithium, LSD, sumatriptan

L-tryptophan

Increase serotonin synthesis

Hemoglobinpathies

chocolate brown color of blood resulting in methemoglobinemia

Hyperthermia syndome

a genetic inborn of muscle metabolism on exposure to certain anesthetic agents, particularly halothane and succinylcholine

Malignant neuroleptic syndrome

which is an idiosyncratic reactions to neuroleptic medications

meprobamate

methadone

opiates

phenobarbital

ptopoxyphene

salicylates

substances used in imaging an chest xray (NOPsP

Anion Gap

Valuable information from a routine lab test Calculated from serum electrolytes

12 postive or negative

normal range of anion gao

(Na) -( HCO3) -Cl

Anion gap formula

Osmolar gap

Difference between measured and calculated serum osmolality • Seen in the presence of low weight toxins