SUMMARY TABLE p1

💀 TOX LECTURE 1 — ONE TABLE TO RULE THEM ALL

CATEGORY	KEY INFO (WHAT TO MEMORIZE)	EXAM TRAPS / PEARLS 😈
👶 WHO DIES FROM WHAT	PEDS: opioids, CV drugs (BB/CCB), sedatives, sulfonylureas YOUTH: unregulated drugs (FENTANYL #1), antidepressants, ethanol ADULTS: polypharmacy + CNS depressants, acetaminophen, CV drugs	👉 Teen + death = pick unregulated opioids 👉 Kids = small dose → BIG effect
🏥 ADMISSIONS vs DEATHS	Oral hypoglycemics = highest admission rates	👉 NOT most common poisonings, but high severity
💊 “ONE PILL CAN KILL”	Bupropion → seizures BB/CCB/propafenone → CV collapse TCAs → arrhythmias + seizures Clonidine/guanfacine → CNS + resp depression Sulfonylureas → hypoglycemia Opioids → resp arrest Amphetamines → hyperstimulation Hydroxychloroquine → cardiac toxicity	👉 Toddler + 1 pill = ASSUME DANGEROUS 👉 ALWAYS refer/observe
🧠 CORE TOX MECHANISMS (CAUSE OF DEATH)	CNS depression (opioids, clonidine) Seizures (bupropion, TCAs) Arrhythmias (CV drugs, TCAs) Hypoglycemia (sulfonylureas)	👉 Most deaths fall into these 4 buckets
🧬 CLONIDINE TOXICITY	↓ HR, ↓ RR, CNS depression, MIOSIS Central α2 agonist → ↓ sympathetic activity	👉 Looks like opioid ❌ NOT hyperactive
🍬 SULFONYLUREA TOXICITY	Rebound hypoglycemia Even 1 pill dangerous	❌ Dextrose alone NOT enough ✅ OCTREOTIDE is KEY ❌ Don’t give prophylactic dextrose
⚡ BUPROPION TOXICITY	Delayed seizures (hours later) NE + DA reuptake inhibition QRS widening, QTc prolongation	👉 ❌ “patient looks fine” = NOT SAFE 👉 still observe
👶 WHY KIDS GET POISONED	Environment + human error Meds left out (grandparents!!) Not childproof Looks like candy Wrong dose/med	👉 Grandparent meds = CLASSIC scenario
😔 YOUTH SUICIDE RISK	Previous attempt Substance use Mental illness Stress/bullying Access to meds	👉 High-risk groups: Indigenous youth, 2SLGBTQ+, unhoused
🗣 PHARMACIST ROLE (SUICIDE)	Ask directly: “Thinking of hurting yourself?” “Do you have a plan?” “Tried before?”	✅ Asking does NOT increase risk
🚑 ACTIONS	Urgent → 911 Non-urgent → crisis line/MD Reduce access to meds	👉 Always think: refer vs manage
🛡 POISON PREVENTION	Child-resistant containers Store out of reach Original containers Separate meds/chemicals Dispose unused meds	👉 EASY MARKS
☎ POISON CALL STEPS (ORDER MATTERS)	1. Background: what, how much, who 2. Urgency: when, symptoms, stable? 3. Risk: toxicity, high-risk drug, child? 4. Recommendation: manage vs refer	👉 VERY testable sequence
🚨 WHEN TO REFER	CALL 911: unconscious, not breathing, seizing CALL DPIC: any overdose, unknown ingestion, CV drugs, multiple meds, chemicals CRISIS LINE: suicidal thoughts, no ingestion	👉 Know which = HUGE exam points
😈 EXAM TRAPS	❌ Most pediatric exposures severe → FALSE (95% mild) ❌ Asymptomatic = safe → FALSE (delayed tox!) ❌ Dextrose fixes sulfonylurea → FALSE ❌ Clonidine = hyperactivity → FALSE	👉 THESE WILL BE TESTED
⚡ 10-SECOND RECALL	Kids → 1 pill can kill Deaths → opioids, CV drugs, sedatives Bupropion → delayed seizures Sulfonylureas → hypoglycemia → octreotide Clonidine → CNS depression	👉 If panicking → recall this

💀 TOX LECTURE 2 — ONE TABLE TO RULE THEM ALL (BASIC SCIENCE GOD MODE)

CATEGORY	KEY INFO (WHAT TO MEMORIZE)	EXAM TRAPS / PEARLS 😈
🧠 DEFINITIONS	Toxicology = study of harmful effects + mechanisms Toxicity = harm depends on dose + exposure + patient	👉 NOT just overdose → patient factors matter
⚠ TERMINOLOGY	Toxin = biological (venom, botulinum) Toxicant = environmental (chemicals, metals) Xenobiotic = foreign substance (drugs, pollutants)	👉 Acetaminophen = xenobiotic (NOT toxin)
👶👵 WHO IS MORE SENSITIVE	Neonates → immature metabolism (↓ glucuronidation) Elderly → ↓ clearance (↓ hepatic blood flow) Genetics → ALDH2 deficiency (↑ alcohol toxicity) Body fat → lipophilic drugs stored → delayed toxicity Liver disease → ↑ acetaminophen toxicity	👉 Pattern: impaired clearance = ↑ toxicity
⚠ TYPES OF TOXICITY	Organ-specific → one organ (acetaminophen → liver) Systemic → whole body (cyanide) Acute → one exposure (methanol) Chronic → repeated (lead) Immediate → fast (methemoglobinemia) Delayed → later (benzene → leukemia) Dose-dependent → predictable (aspirin) Idiosyncratic → random (sulfa allergy)	👉 Predictable = dose-dependent 👉 Random = immune/genetic
🫁 ABSORPTION (VERY TESTED)	Route risk: Inhalation > injection > oral > dermal Lungs = huge surface area → rapid absorption Bypassing 1st pass → ↑ toxicity	👉 inhalation = MOST dangerous
🍽 GI ABSORPTION	Small intestine = MOST absorption Weak acids → stomach (non-ionized, lipid soluble) Weak bases → intestine	👉 BOTH weak acids/bases matter
🫁 RESPIRATORY	Small particles → go deeper → worse toxicity Alveoli = systemic absorption	👉 deeper = more dangerous
🧴 DERMAL	Intact skin = barrier (stratum corneum) Damaged skin → ↑ absorption	👉 once in dermis → ↑ absorption
🔄 DISTRIBUTION (Vd)	HIGH Vd → drug in tissues → LOW plasma levels LOW Vd → stays in blood	👉 “normal level but toxic” = HIGH Vd
🧠 STORAGE	Fat → lipophilic drugs (delayed release) Bone → metals (lead) Liver/kidney → accumulation	👉 low perfusion → delayed toxicity + chronic effects
🧱 BARRIERS	BBB blocks polar drugs Lipophilic drugs cross easily (opioids, ethanol)	👉 lipophilic = more CNS effects
🔥 METABOLISM (CORE)	Phase 1 (CYP450): oxidation, reduction, hydrolysis → can create TOXIC metabolites Phase 2: conjugation → water soluble → excrete	👉 Phase 1 = danger 👉 Phase 2 = safe
☠ ACETAMINOPHEN PATHWAY	Phase 1 → NAPQI (toxic) Glutathione detoxifies NAPQI	👉 overdose → glutathione depleted → liver failure
🚨 SATURATION (BIG DEAL)	Normal → safe pathway Overdose → toxic pathway activated	👉 “overdose changes pathway” = SATURATION
🚽 ELIMINATION	Kidney = MAIN route Lipophilic drugs → must become hydrophilic first	👉 liver → hydrophilic → kidney excretion
⚡ ION TRAPPING RULE	Ionized = excreted Non-ionized = reabsorbed	👉 alkalinize urine → ↑ salicylate excretion
📊 DOSE RESPONSE	LD50 = lethal dose 50% EC50 = effective dose NOAEL = no harm LOAEL = lowest harm	👉 humans set limits BELOW NOAEL
⚖ THERAPEUTIC INDEX	TI = LD50 / ED50 BIG TI = safer	👉 classic easy mark
🤧 IMMUNE REACTIONS	NOT dose-dependent Sensitized → small dose → BIG reaction	👉 “small dose big reaction” = immune
🧬 ALLERGY TYPES	Type I → immediate (IgE, anaphylaxis) Type II → cytotoxic (IgG/IgM) Type III → immune complex Type IV → delayed (SJS)	👉 Immediate = Type I ALWAYS
⚖ ADR vs TOXICITY	Toxicity = overdose/accumulation ADR = harm at NORMAL dose Side effect = expected AE = not necessarily drug-caused	👉 ADR = normal dose problem
🔗 DRUG INTERACTIONS	Pharmacodynamic: same system (additive, synergistic, antagonistic) Pharmacokinetic: affects ADME (CYP most common)	👉 opioid + alcohol = respiratory depression
🧪 PK INTERACTIONS EXAMPLES	statin + CYP inhibitor → toxicity lithium + diuretic → toxicity	👉 CYP interactions VERY COMMON
🧠 TOXICITY SIGNS	Hepatotoxicity → ↑ ALT/AST, jaundice, dark urine Nephrotoxicity → ↑ Cr, ↓ urine, ↑ BUN, ↓ GFR	👉 classic exam presentation
😈 BIG EXAM PATTERNS	“delayed toxicity” → redistribution / metabolism / SR “small dose big reaction” → immune “normal level but toxic” → HIGH Vd “overdose changes pathway” → saturation	👉 THESE = GUARANTEED TEST
⚡ 10-SECOND RECALL	dose + patient = toxicity inhalation = most dangerous high Vd = hidden toxicity acetaminophen = NAPQI immune ≠ dose dependent CYP interactions common	👉 if stuck → recall this

💀 TOX LECTURE 3 — ONE TABLE TO RULE THEM ALL (CLINICAL GOD MODE)

CATEGORY	KEY INFO (WHAT TO MEMORIZE)	EXAM TRAPS / PEARLS 😈
🧠 MASTER ALGORITHM (MOST IMPORTANT)	1. Stabilize 2. History 3. Diagnosis (toxidrome) 4. GI decontamination 5. Enhanced elimination 6. Antidotes 7. Disposition	👉 If you blank → WRITE THIS ORDER = free marks
🚨 STABILIZATION (ABCDE)	A airway → intubate if needed B breathing: ↓RR → opioids → naloxone ↑RR → salicylates/stimulants C circulation: ↓BP → CCB/BB ↑BP → stimulants	👉 ALWAYS FIRST STEP = stabilization
🧠 D = DISABILITY (SUPER TESTED)	Seizures → BENZOS ONLY ❌ NOT phenytoin	👉 toxin seizures ≠ regular seizures
😵 AGITATION	BENZOS FIRST	❌ avoid antipsychotics (↓ seizure threshold, ↑ toxicity)
🍬 HYPOGLYCEMIA	D50 ± glucagon ± octreotide (if sulfonylurea)	👉 sulfonylurea = always think octreotide
🌡 HYPERTHERMIA	DEADLY (>40.5°C brain damage risk) Goal: <39°C FAST (30–60 min)	👉 BEST = ICE BATH 👉 sedation to prevent shivering
⚡ TOX-SPECIFIC INTERVENTIONS	Seizures → benzos Agitation → benzos Wide QRS → sodium bicarbonate CCB/BB shock → insulin + glucose	👉 these are literally exam answers
❌ FLUMAZENIL (BIG TRAP)	DO NOT USE in overdose	👉 causes withdrawal seizures + unmasks co-ingestions
🧾 HISTORY	Kids → accidental Adults → intentional (may lie) AMS → EMS, family, pill bottles	👉 LOW effort marks
🧠 TOXIDROMES (CORE)	OPIOID: ↓LOC, ↓RR, miosis → naloxone CHOLINERGIC: SLUDGE/DUMBELS → atropine ± pralidoxime SYMPATHOMIMETIC: ↑HR, ↑BP, sweating → benzos + cooling ANTICHOLINERGIC: dry, hot, confused → benzos ± physostigmine/rivastigmine SEROTONIN: hyperreflexia, clonus → benzos + cyproheptadine	👉 Sweaty = sympathomimetic 👉 Dry = anticholinergic
🧪 LABS (MUST KNOW)	Chem-7 (lytes, glucose, renal) LFTs ASA level Acetaminophen level	👉 ALWAYS check acetaminophen
🧠 ANION GAP	Na - (Cl + HCO₃) Normal: 6–14 ↑ = metabolic acidosis	👉 “extra acids?”
☠ MUDPILES CAT (CAUSES)	methanol, ethylene glycol, salicylates, metformin, iron, INH, etc.	👉 memorize BIG ones
🍷 OSMOL GAP	detects toxic alcohols (methanol, ethylene glycol, isopropanol)	👉 anion gap = acids 👉 osmol gap = alcohols
🧽 ACTIVATED CHARCOAL	Use within 1–2 hrs life-threatening ingestion	❌ does NOT bind: lithium, iron, alcohols, cyanide
❌ IPECAC	NO LONGER USED	👉 delays charcoal
🚫 GASTRIC LAVAGE	Rare only if VERY early + life-threatening	👉 not routine
🚿 WHOLE BOWEL IRRIGATION	sustained-release lithium, iron body packers	👉 when charcoal doesn’t work
🧪 ENHANCED ELIMINATION	HEMODIALYSIS removes: methanol, ethylene glycol, lithium, salicylates, valproate	👉 works best for small, water-soluble, low Vd
💧 URINE ALKALINIZATION	↑ salicylate excretion	👉 ion trapping concept
💊 ANTIDOTES (FREE MARKS)	acetaminophen → NAC opioids → naloxone sulfonylurea → octreotide digoxin → digoxin immune Fab iron → deferoxamine toxic alcohols → fomepizole cyanide → hydroxocobalamin methemoglobinemia → methylene blue INH → pyridoxine	👉 THESE ARE STRAIGHT TEST QUESTIONS
🏥 DISPOSITION	SUPPORTIVE CARE = MOST IMPORTANT fluids, airway, monitoring, ICU if needed	👉 antidotes ≠ everything
😈 EXAM PATTERNS	seizure → benzos agitation → benzos wide QRS → sodium bicarb low BP + CCB → insulin + glucose pinpoint + ↓RR → opioid sweaty + tachy → sympathomimetic dry + hot → anticholinergic hidden acids → anion gap hidden alcohols → osmol gap	👉 THIS SECTION = EXAM KEY
⚡ 10-SECOND RECALL	ABCDE FIRST ALWAYS benzos = seizures + agitation charcoal early (not Li/iron/alcohols) dialysis = lithium/salicylates/toxic alcohols memorize antidotes supportive care > everything	👉 if panicking → recall this

💀 TOX LECTURE 4 — ONE BIG ULTRA TABLE (TOXIC ALCOHOLS)

CATEGORY	KEY INFO (WHAT TO MEMORIZE)	COMPARE / PATTERN / TRAPS 😈
🧠 CORE IDEA	Toxicity = ACID METABOLITES (NOT alcohol itself) Methanol → formic acid → blindness Ethylene glycol → glycolic/oxalic acid → kidney failure Both → anion gap metabolic acidosis	👉 They will try to trick you with “alcohol level” 👉 ALWAYS think acids
⚡ KEY PATHWAY	MeOH/EG → ADH → toxic acids → death	👉 BLOCK ADH = life-saving
💊 FIRST-LINE TREATMENT	Fomepizole (preferred) Ethanol (backup)	👉 DO NOT WAIT for labs 👉 “if thinking about it → give it”
🎯 WHY BLOCK ADH	Stops formation of toxic acids Buys time for elimination	👉 doesn’t remove toxin, just prevents damage
🧪 DOUBLE GAP (MOST TESTED PATTERN)	↑ Osmol gap + ↑ Anion gap = TOXIC ALCOHOL	👉 THIS = diagnosis clue
⏳ TIME COURSE (VERY HIGH YIELD)	EARLY: ↑ OG, normal AG, mild symptoms LATE: ↓ OG, ↑ AG, severe acidosis	👉 ❌ Normal OG ≠ safe → could be late presentation
🚨 WHEN TO SUSPECT	Unexplained acidosis Altered LOC ↑ AG + ↑ OG Alcohol use / suicide	👉 If unclear → assume toxic alcohol
🚫 DO NOT WAIT	Start treatment BEFORE confirmation	👉 VERY COMMON EXAM TRAP
🧪 TREATMENT ALGORITHM	1. Block ADH (fomepizole) 2. Fix acidosis (NaHCO₃ if pH <7.25) 3. Remove toxin (dialysis) 4. Supportive	👉 MUST know order
💉 DIALYSIS INDICATIONS	Severe acidosis High levels Renal failure Very sick patient	👉 ALSO helps correct acidosis
👁 CLINICAL DIFFERENCES	Methanol → vision loss Ethylene glycol → kidney failure Both → metabolic acidosis	👉 vision vs kidney = classic
💊 BONUS TREATMENT	Methanol → folic acid (helps metabolize formate)	👉 low yield but testable
🧠 WHEN TO GIVE FOMEPIZOLE	OG >10 + history OR suspicion + ≥2: ↓HCO₃ (<20) ↑AG (>16) ↓pH (<7.3) ↑OG (>10) OR levels: EG >3, MeOH >6	👉 LOW THRESHOLD → GIVE IT ANYWAY
🍺 AKA (ALCOHOLIC KETOACIDOSIS)	↑ AG + mild OG ↑ beta-hydroxybutyrate low/absent ethanol improves with glucose + fluids	👉 GETS BETTER with treatment
🔥 AKA VS TOXIC ALCOHOL	AKA → improves Toxic alcohol → worsens	👉 HUGE differentiation question
🧪 KETONE PEARL	Beta-hydroxybutyrate ↑ Ketone tests NOT sensitive	👉 test limitation = exam trap
🧃 ISOPROPYL ALCOHOL (IPA)	↑ OG ONLY ❌ NO anion gap ❌ NO acidosis causes ketosis (acetone) fruity breath	👉 ↑ OG without acidosis = IPA
💊 IPA TREATMENT	Supportive only	👉 NO fomepizole
⚠ EXAM TRAPS	❌ “Normal OG = no toxic alcohol” → FALSE ❌ “Wait for labs” → FALSE ❌ “All alcohols cause acidosis” → FALSE (IPA doesn’t) ❌ “All ↑ OG = toxic alcohol” → FALSE (AKA, DKA etc.)	👉 THESE ARE GUARANTEED TEST QUESTIONS

🧪 ANION GAP (AG)	AG = Na - (Cl + HCO₃) Normal: 6–14 ↑ AG → metabolic acidosis	👉 “extra acids in blood?” 👉 toxic alcohols → ↑ AG
🧪 OSMOL GAP (OG)	OG = measured – calculated Calculated ≈ 2(Na) + glucose + urea + 1.25×EtOH Normal: <10	👉 detects toxic alcohols 👉 ↑ OG = alcohols
⏳ TIME COURSE (LABS)	EARLY: ↑ OG, normal AG LATE: ↓ OG, ↑ AG	👉 ❌ normal OG ≠ safe
🧪 pH (ABG)	Normal: 7.35–7.45 ↓ pH = acidosis	👉 toxic alcohol → ↓ pH
🧪 HCO₃ (BICARB)	Normal: 22–26 ↓ HCO₃ = metabolic acidosis	👉 <20 → concerning 👉 <7.25 → treat (NaHCO₃)
🧪 WHEN TO TREAT (CUT-OFFS)	pH < 7.3 (suspect) pH < 7.25 → give bicarbonate AG > 16 OG > 10	👉 helps decide fomepizole
🧪 FOMEPIZOLE THRESHOLDS	EG > 3 MeOH > 6	👉 BUT don’t wait for levels 😈

💀 TOX LECTURE 5 — ONE ULTRA COMPARISON TABLE (APAP vs SALICYLATES vs NSAIDs)

CATEGORY	ACETAMINOPHEN (APAP)	SALICYLATES (ASA)	NSAIDs
🎯 MAIN TOXICITY	Liver failure	Mixed acid-base disorder	Usually mild (GI), severe = CNS + renal
⚡ MECHANISM	CYP2E1 → NAPQI (toxic) → covalent binding + mitochondrial damage	1. Stimulate resp center → resp alkalosis 2. Uncouple oxidative phosphorylation → metabolic acidosis	COX inhibition → ↓ prostaglandins
💀 CORE PROBLEM	Glutathione depletion → NAPQI damage	Mixed disorder + CNS effects + metabolic stress	Usually supportive, severe rare
⏳ EARLY PRESENTATION	😈 ASYMPTOMATIC (BIG TRAP)	Hyperventilation	Nausea, vomiting, drowsiness
⏳ MID (24–30 hr)	↑ AST/ALT	progressing acid-base issues	usually still mild
⏳ LATE	↑ INR → liver failure	Metabolic acidosis dominates	coma, hypotension (rare)
🧪 LAB PATTERN	↑ AST/ALT	Mixed: resp alkalosis + metabolic acidosis	usually normal unless severe
📊 ACID-BASE	metabolic acidosis (late)	MIXED DISORDER ALWAYS	metabolic acidosis (severe only)
💊 TOXIC DOSE	10 g OR 200 mg/kg	Mild: 150–200 mg/kg Severe: 300–500 mg/kg	<200 mg/kg mild >400 mg/kg severe
🧪 KEY LAB TEST	4-hour APAP level (nomogram)	Serial salicylate levels	usually none needed
❌ TRAP (LABS)	❌ cannot check before 4 hrs	❌ single level NOT enough	—
💊 FIRST STEP (EARLY)	Activated charcoal (if early)	Activated charcoal (if not vomiting)	usually none
💉 ANTIDOTE	NAC (LIFE SAVER)	❌ none	❌ none
🔥 TREATMENT CORE	NAC (replenishes glutathione)	GASP: G = glucose A = alkali (MOST IMPORTANT) S = saline P = potassium	Supportive only
⚡ MOST IMPORTANT TX	NAC ASAP (best <8 hrs but works late)	Sodium bicarbonate (alkalinization)	Supportive
🧠 KEY PEARL	“NAPQI = nuclear bomb to liver”	“Mixed disorder ALWAYS”	“Usually mild”
🧠 GLUCOSE PEARL	—	Give glucose EVEN if normal (brain starving)	—
⚡ ION TRAPPING	—	Alkalinize urine → keeps salicylate OUT of brain	—
🎯 GOAL pH	—	7.45–7.55 (serum) urine pH 7.5–8	—
⚠ POTASSIUM	—	MUST correct K⁺ to alkalinize urine	—
🚨 DIALYSIS	massive overdose	Severe acidosis, seizures, renal failure, very sick	rarely needed
💀 MASSIVE OD	Early lactic acidosis + coma	severe CNS toxicity	severe CNS depression
🚫 BIGGEST TRAP	❌ patient looks fine early	❌ DO NOT INTUBATE lightly	❌ assume severe
⚠ INTUBATION DANGER	—	↓ RR → acidosis → drug enters brain → death	—
🧠 PATTERN RECOGNITION	Initially well → later liver failure → NAC	Hyperventilation + mixed disorder → bicarb	Mild symptoms → supportive
❌ EXAM TRAPS	❌ early normal = safe	❌ normal glucose = no glucose ❌ single level enough	❌ all behave same