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Questions and Answers
Which of the following is a hallmark sign of toxic alcohol poisoning?
What is the primary initial treatment for patients with acetaminophen toxicity?
In cases of aspirin toxicity, what is the first acid-base imbalance observed?
Which symptom is commonly associated with beta blocker toxicity?
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Which of the following treatments is NOT recommended for TCA toxicity?
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What is a common clinical finding in a benzodiazepine overdose?
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For which of the following toxicities is flumazenil administration risky?
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Which of the following can indicate severe progression in acetaminophen toxicity?
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What effect does high-dose insulin have in cases of calcium channel blocker toxicity?
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Which of the following is a potential effect of kratom at high doses?
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Which condition is associated with Fomepizole poisoning?
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What is the first acid/base derangement noted in Aspirin poisoning?
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Which of the following is a characteristic feature of TCA overdose?
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Digitalis poisoning is likely to result in which of the following?
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Ethylene glycol toxicity primarily leads to which type of metabolic derangement?
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What complication can arise from severe beta-blocker overdose?
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In the context of toxic alcohol ingestions, which metabolic change is most frequently observed?
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Which organ system is primarily affected by chronic digitalis toxicity?
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Aspirin poisoning can lead to which of the following respiratory changes?
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What is a common treatment for ethylene glycol toxicity?
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Which condition is most likely to result from Fomepizole poisoning?
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In the context of digitalis poisoning, which of the following symptoms is most characteristic?
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Which of the following conditions is primarily characterized by metabolic acidosis?
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In cases of ethylene glycol toxicity, which metabolic derangement is most likely to occur?
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Which of the following is a common complication associated with TCA overdose?
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Which symptom is typically observed in patients with aspirin toxicity and relates to respiratory function?
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What is the most significant risk factor associated with beta-blocker toxicity?
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Which of the following antidotes is commonly used for treatment in cases of ethylene glycol ingestion?
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What type of acid-base derangement is expected in the early stages of aspirin poisoning?
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Which clinical feature is most likely linked to acute salicylate overdose?
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What is the primary goal of managing beta blocker toxicity?
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What occurs during the early phase of acetaminophen toxicity?
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In the context of opiate toxicity, what is most likely to cause respiratory depression in children?
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What is a significant risk associated with the administration of flumazenil for benzodiazepine overdose?
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Which of the following is a common effect of toxic alcohols?
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Which treatment is primarily effective for managing aspirin toxicity?
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What symptom is commonly seen in tricyclic antidepressant (TCA) overdose?
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Which condition strongly suggests the need for a liver transplant in acetaminophen toxicity?
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What should be prioritized in the management of stimulant overdoses such as cocaine and methamphetamine?
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In the case of digitalis toxicity, what visual disturbance might a patient experience?
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Study Notes
Toxicosis Effects
- Can speed up or slow down metabolism
- Can increase or decrease pH
- May cause alterations in mental status
Initial Patient Care Priority
- In all toxic exposures and overdoses, supportive care should be the priority.
- Poison Control Center: 1-800-222-1222
- Contact poison control for every toxic exposure/overdose patient.
Acetaminophen Toxicity (Tylenol)
- N-acetylcysteine is the antidote for acetaminophen overdose.
- It binds with toxic acetaminophen metabolites for maximum effectiveness.
- Should be administered within 8-10 hours of ingestion.
- Dosage is based on serum acetaminophen levels, time since ingestion, and patient weight.
Acetaminophen Toxicity: Outcomes
- 7.2% of overdoses cause acute liver failure
- 10% of acute cases advance to severe liver failure.
- Most patients recover with n-acetylcysteine (NAC).
- Death is rare with early NAC administration.
-
Factors requiring liver transplant:
- Arterial pH >7.3
- INR >6.5
- Creatinine >3.4
- High grade encephalopathy
Acetylsalicylic Acid Toxicity (Aspirin)
- No antidote exists for aspirin overdose.
- Management focuses on preventing further absorption and increasing elimination.
-
Acid-base imbalances:
- Early: respiratory alkalosis
- Late: metabolic acidosis
-
Symptoms:
- Early: burning mouth, malaise, nausea/vomiting, dizziness, tinnitus
- Moderate: tachypnea, hyperpyrexia (high fever), sweating, dehydration, ataxia, restlessness
- Severe: hallucinations, stupor, cerebral edema, seizures, renal failure, cardiovascular collapse
-
Treatment:
- ICU: sodium bicarbonate
- Hemodialysis
Beta Blocker Toxicity
- Isolated beta blocker toxicity is uncommon.
- Isolated overdose is usually intentional.
- Hallmark symptoms are cardiovascular: the most common are bradycardia and hypotension.
- Check blood glucose, as beta-blockers may cause hypoglycemia.
Calcium Channel Blocker Toxicity
- Directly inhibits voltage in myocardial calcium channels.
- Causes vasodilation.
- Can lead to distributive shock.
- Onset can be delayed by hours.
- May impair insulin release and cause hyperglycemia.
Beta Blocker and Calcium Channel Blocker Overdose: Treatment
- Pharmacotherapy aims to improve bradycardia and myocardial contractility.
- High-dose insulin: for positive inotropy
- Catecholamines: complementary therapy
- High-dose glucagon: potential benefit
Benzodiazepine Toxicity
- Affects the use of GABA (gamma-aminobutyric acid).
- Isolated benzo overdose is rare.
-
Hallmark clinical findings of isolated benzodianzepine overdose:
- CNS depression
- Normal or near-normal vital signs
- Altered mental status with slurred speech and ataxia, but arousable.
- Children: Signs and symptoms appear within 4 hours of ingestion.
- Most common sign of benzodiazepine overdose in children: ataxia
Benzodiazepine Toxicity: Treatment
- Supportive care
-
Flumazenil (Romazicon):
- Competitive antagonist for benzodiazepines
- Risky to administer
- May cause precipitous withdrawal
- Risks usually outweigh the benefits
Opiate Toxicity
- Heroin epidemic
- Synthetic opioids: 70% increase in mortality
-
Buprenorphine: Recovery medication unlikely to cause respiratory depression.
- Pediatrics: May see respiratory depression and delayed onset.
-
Loperamide:
- Binds to opiate receptors in the gastrointestinal tract.
- High doses produce a “high”.
- Causes QT prolongation.
-
Gabapentin:
- Often used in conjunction with chronic opiate use.
- 15% of opiate users report getting high from gabapentin.
-
Kratom:
- Opiate-like in high doses
- May cause seizures
- Responds to naloxone and benzodiazepines
Stimulants: Cocaine and Methamphetamine
- Clinical findings: Cardiovascular complications, psychosis, delirium.
- Cocaine users: More likely to present to the ED with trauma.
- Methamphetamine users: More likely to present with altered mental status.
-
Average vital signs in stimulant intoxication:
- Heart Rate: 106
- Blood pressure: 142/90
- Higher BNP in methamphetamine users.
Toxic Alcohol Poisoning
- Hallmark sign: Wide gap metabolic acidosis
- High serum osmolality
- Toxic alcohols are:
- Hepatic Toxic: Liver metabolizes them
- Renal Toxic: Kidneys excrete them
- Dialysis is highly effective at toxic alcohol elimination.
Methanol
-
Symptoms:
- Visual disturbances
- Abdominal pain, pancreatitis
Ethylene Glycol
- Identification is often delayed.
- Autopsy findings: Calcium oxalate crystals in brain, heart, and lung tissue.
- Kussmaul's breathing: Seen in all stages.
-
Symptoms:
- Cerebral edema
Isopropanol (Rubbing Alcohol)
-
Effects: Directly toxic to organ tissue.
- Toxic to gastric tissue
Toxic Alcohol Treatment
-
Ethanol alcohol or Fomepizole: Both inhibit alcohol dehydrogenase (ADH).
-
Fomepizole:
- Greater affinity for ADH than ethanol
- Does not cause slowing of metabolism
-
Fomepizole:
Ethanol Alcohol
- Beer Potomania: Dilutional hyponatremia from drinking too much beer.
-
Alcoholic Ketoacidosis:
- Lethargy
- Tachycardia
- Dehydration
- Abdominal pain
- Agitation, lethargy
- Ketone odor
- Tachypnea
Tricyclic Antidepressant (TCA) Toxicity
-
Toxic Effects:
- Inhibits norepinephrine reuptake
- Direct alpha block
- Membrane stabilizing effect on myocardium (too much)
- Anticholinergic reaction
-
Clinical Features of TCA Overdose:
- Wide QRS
- Hyperthermia with impaired sweating
- Hypotension
- Coma in 17%
-
Treatment:
- Sodium bicarbonate: Cardiac stabilization
- Norepinephrine
- ECMO
- Activated charcoal (ineffective)
Cardiac Glycosides: Digitalis
- First symptom: GI distress
- Symptoms: Often vague, may experience green or yellow halos around objects.
- Treatment: Digibind (digoxin immune fab)
-
Characteristic EKG Changes:
- Slowing heart rate
- ST depression described as “ice cream scoop” in appearance
Questions
-
Your patient has a wide-gap metabolic acidosis with AMS of unknown etiology. You suspect:
- Ethylene glycol toxicity
-
The first acid/base derangement noted in Aspirin poisoning is:
- Respiratory alkalosis
Toxicology
- Initial patient care priority in all toxic syndromes is supportive care.
- Poison Control Center number: 1-800-222-1222
- Poison control should be contacted for every toxic exposure/overdose patient.
- Patient demographics, history, current status, offending agent, time of exposure, route of exposure, and amount ingested are crucial information.
Acetaminophen Toxicity (Tylenol)
- N-Acetylcysteine (NAC) is an antidote that binds with toxic metabolites.
- NAC should be given within 8-10 hours of ingestion for maximal effectiveness.
- Dosage is based on serum acetaminophen levels, time from ingestion, and patient weight.
- 7.2% of acetaminophen overdoses cause acute liver failure, and 10% of these cases advance to severe liver failure.
- Most patients recover with NAC.
- Death is rare with early NAC administration.
- Indications for liver transplant:
- Arterial pH >7.3
- INR >6.5
- Creatinine >3.4
- High-grade encephalopathy
Acetylsalicylic Acid Toxicity (Aspirin)
- There is no antidote.
- Management focuses on preventing further absorption and increasing elimination.
- Initial acid-base imbalance: respiratory alkalosis.
- Late acid-base imbalance: metabolic acidosis.
-
Early Symptoms:
- Burning in the mouth
- Malaise
- Nausea/Vomiting
- Dizziness
- Tinnitus
-
Moderate Symptoms:
- Tachypnea
- Hyperpyrexia
- Sweating
- Dehydration
- Ataxia
- Restlessness
-
Severe Symptoms:
- Hallucinations
- Stupor
- Cerebral edema
- Seizures
- Renal failure
- Cardiovascular collapse
-
Treatment:
- ICU: sodium bicarbonate
- Hemodialysis
Beta Blocker and Calcium Channel Blocker Toxicity
Beta Blocker Toxicity
- Isolated beta blocker toxicity is uncommon.
- Isolated overdose is usually intentional.
- Hallmark symptoms are cardiovascular.
- Most common: bradycardia and hypotension.
- Monitor blood glucose as it can cause hypoglycemia.
Calcium Channel Blocker Toxicity
- Directly inhibits voltage in myocardial calcium channels.
- Causes vasodilation leading to distributive shock.
- Onset may be delayed by hours.
- Can impair insulin release causing hyperglycemia.
Treatment for Beta Blocker and Calcium Channel Blocker Overdose
- Treatment is aimed at improving bradycardia and myocardial contractility.
- High-dose insulin for positive inotropy.
- Catecholamines are complementary therapy.
- High-dose glucagon may be beneficial.
Benzodiazepine Toxicity
- Alters the use of GABA.
- Isolated benzo overdose is rare.
- Hallmark clinical findings of isolated benzo OD:
- CNS depression
- Normal or near-normal vital signs
- Altered mental status with slurred speech and ataxia but arousable.
- Children show signs and symptoms within 4 hours of ingestion.
- Ataxia is the most common sign of a benzodiazepine overdose in pediatrics.
- Treat with supportive care.
Flumazenil (Romazicon) for Benzodiazepine Overdose
- Competitive antagonist for benzodiazepines.
- Very risky to administer.
- May cause precipitous withdrawal.
- Risks usually outweigh the benefits.
Opiate Toxicity
- Heroin epidemic.
- Synthetic opioids: 70% increase in mortality.
-
Buprenorphine:
- Recovery medication.
- Unlikely to cause respiratory depression.
- In pediatrics, may see respiratory depression and delayed onset.
-
Loperamide:
- Binds to opiate receptors in the GI tract.
- High doses produce a high.
- Causes QT prolongation.
-
Gabapentin:
- Chronic opiate use and gabapentin often go hand-in-hand.
- 15% of opiate users report using gabapentin to get high.
-
Kratom:
- Opiate-like in high doses.
- May cause seizures.
- Responds to naloxone and benzodiazepines.
Stimulants: Cocaine, Methamphetamine
- Clinical findings: CV complications, psychosis, delirium.
- Cocaine users more likely to present to ED with trauma.
- Methamphetamine was more likely to present with altered mental status.
- Average heart rate: 106
- Average blood pressure: 142/90.
- BNP higher with meth users.
Toxic Alcohol Poisoning
- Hallmark sign is wide-gap metabolic acidosis.
- High serum osmolality.
- Hepatic toxic: liver metabolizes toxic alcohols.
- Renal toxic: kidney excretes them.
- Dialysis is highly effective at toxic alcohol elimination.
Methanol
- Visual disturbances.
- Abdominal pain, pancreatitis.
Ethylene Glycol
- Identification is often delayed.
- Calcium oxalate crystals found in brain, heart, lung tissue on autopsy.
- Kussmaul's breathing seen in all stages.
- Cerebral edema.
Isopropanol (Rubbing Alcohol)
- Direct effects on organ tissue.
- Toxic to gastric tissue.
Treatment of Toxic Alcohols
- Administration of ethanol alcohol or Fomepizole.
- Both inhibit alcohol dehydrogenase (ADH).
- Fomepizole has a greater affinity for ADH than ethanol.
- Fomepizole does not cause slowing of metabolism.
Ethanol Alcohol
- Beer Potomania: dilutional hyponatremia from drinking too much beer.
-
Alcoholic Ketoacidosis:
- Lethargy.
- Tachycardia.
- Dehydration.
- Abdominal pain.
- Agitation, lethargy.
- Ketone odor.
- Tachypnea.
Tricyclic Antidepressant (TCA) Toxicity
-
TCA Toxic Effects:
- Inhibits norepinephrine reuptake.
- Direct alpha block.
- Membrane stabilizing effect on myocardium (too much).
- Anticholinergic reaction.
-
Clinical Features of TCA Overdose:
- Wide QRS
- Hyperthermia with impaired sweating
- Hypotension
- Coma in 17%
-
TCA Overdose Treatment:
- Sodium bicarbonate for cardiac stabilization.
- Norepinephrine.
- ECMO.
- Do not give activated charcoal (ineffective).
Cardiac Glycosides: Digitalis
- GI distress is usually the first symptom.
- Symptoms often vague.
- May see green or yellow halos around objects.
- Treated with Digibind (digoxin immune fab).
- Characteristic EKG changes:
- Slowing heart rate.
- ST depression described as "ice cream scoop" in appearance.
Questions:
-
What is the most likely diagnosis for a patient with wide-gap metabolic acidosis and AMS of unknown etiology?
- Answer: d. Ethylene glycol toxicity.
-
What is the first acid/base derangement noted in Aspirin poisoning?
- Answer: d. Respiratory alkalosis.
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Description
This quiz covers the effects of acetaminophen toxicity, including its impact on metabolism and pH levels. It highlights the initial patient care priorities such as supportive care and the role of N-acetylcysteine as an antidote. Key outcomes and factors necessitating liver transplants are also discussed.
