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Questions and Answers
What is the primary focus of clinical toxicology?
What should be the initial approach to managing all poisoned patients?
What is the first goal of treatment in acute poisoning?
What is essential in the supportive care of a poisoned patient?
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Which substances account for nearly half of poisoning exposures?
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What does evaluating a poisoned patient involve in the initial assessment?
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Which approach is termed as 'Routine poison management'?
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How can the progress of intoxication be judged?
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What is a critical step in managing acutely poisoned patients?
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Which of the following is NOT a vital aspect of the physical examination during the assessment of poisoning?
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Which type of antidotes directly works by competitive inhibition?
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When assessing ingested agents, what is essential before calculating the risk of toxicity?
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Which method enhances poison excretion by changing the urine pH?
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What is the primary function of chelating agents in clinical toxicology?
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Which factor is most relevant when determining the potential clinical progress of a patient after ingestion of a toxic substance?
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What is the most critical factor leading to death from poisoning?
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What should be done to prevent further poison absorption in cases of dermal exposure?
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Which of the following should be prioritized during the initial assessment of a poisoned patient?
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Which type of dialysis is particularly beneficial when renal function is impaired?
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What is the recommended approach if a patient is hypotensive during the initial evaluation?
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Why is it important to monitor the ECG in poisoned patients?
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During hemoperfusion, blood is passed through what type of material?
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What should be done if a patient presenting with seizures has a blood sugar level below 72 mg/dL?
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Which patient factor can increase the risk of significant toxicity during poisoning?
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What is the primary goal of management in cases of poisoning?
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In addition to the patient's history, what is important to gather when managing poisoning cases?
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What is the purpose of performing continuous ECG monitoring during the circulation assessment?
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What is one of the key indications of a toxic syndrome during exposure evaluation?
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Which intervention is recommended if a patient's respiratory rate is elevated, but oxygen saturation cannot be monitored?
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Which of the following is a contraindication for Whole Bowel Irrigation (WBI)?
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What is the primary goal of Whole Bowel Irrigation (WBI)?
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Which class of antidotes involves agents that form a nontoxic complex with the poison?
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What is Fomepizole primarily used for in toxicology?
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Which of the following antidotes is considered a physical antidote?
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What type of antidotes are used to interfere with poisons through their physical properties?
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Which mechanism of action is employed by Naloxone as an antidote?
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Which of the following is a detoxification accelerator used for specific poisonings?
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What is the primary purpose of gastric lavage?
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What is a key contraindication for the use of syrup of ipecac?
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Which of the following conditions does NOT allow the use of activated charcoal?
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When should activated charcoal be administered?
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What is the main function of osmotic cathartics?
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Which of the following substances should NOT be treated with cathartics?
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Which statement about emesis is incorrect?
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What procedure should be performed if emesis fails or is contraindicated?
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Study Notes
Clinical Toxicology - Initial Evaluation & Management
- Clinical toxicology focuses on the effects of drugs and chemicals on humans (and animals).
- It often involves drug overdoses and other poisonings, and identifying the substance and its amount in the body.
- It overlaps with biochemistry, pharmacology, and pathology.
- The initial evaluation of a poisoned patient should be similar in every case, regardless of the specific toxin, treating them as if a life-threatening situation.
- Common poisonings result from exposure to a variety of substances, including household cleaning products and pesticides. Prescription and over-the-counter medications account for a significant portion of poisoning exposures.
Approach to the Poisoned Patient
- All poisoned patients should be managed as if they have a potentially life-threatening condition, even if they appear normal.
- The initial approach should be consistent for all poisoning cases. This is referred to as "Routine poison management".
Important Strategies
- Treat the patient, not the poison, promptly.
- Supportive therapy is essential.
- Maintain respiration and circulation.
- Regularly measure and chart vital signs and reflexes to monitor the effects of the poison.
- The first goal in treating acute poisoning is to keep the concentration of the poison low by preventing absorption and promoting elimination.
- The second goal is to counteract toxic effects at the site of action (if possible).
Initial Evaluation (ABCDEs)
- Airway: Keep airways open and remove any obstructions. Loss of airway protection reflexes is a common cause of death in poisoning cases. Obstructions can include a flaccid tongue or aspiration of gastric contents.
- Breathing: Assess respiratory rate and oxygen saturation. If an oxygen monitor is unavailable and the respiratory rate is elevated, administer supplemental oxygen.
- Circulation: Quickly assess vital signs and hydration. Check blood pressure, pulse, and rhythm, initiate continuous ECG monitoring, secure venous access, and take blood for routine tests. If the patient is hypotensive, administer normal saline or another isotonic solution.
- Disability (Neurological): Assess level of consciousness. If seizures occur, check blood sugar. If blood sugar is below 72 mg/dL, administer 50 mL of 50% dextrose intravenously. Treat toxic seizures with IV benzodiazepines; refractory seizures can be treated with barbiturates.
- Exposure (evaluating temperature): Consider the possibility of toxic syndromes associated with hyperthermia. Certain drugs can cause significantly elevated body temperatures.
Definitive Care with Poisoning
- Identify the poison.
- Obtain an accurate history, (from family, friends, pharmacist, etc and evidence at the scene )including the time and amount ingested.
Supportive Care and Monitoring
- Acute poisoning is a dynamic illness; patient conditions can fluctuate.
- Repeat examinations and assessments are necessary.
- Ongoing management and assessment are vital.
Physical Examination
- Vital signs (Pulse Rate, Respiratory Rate, Blood Pressure, Temperature, and Oxygen saturation )
- Neurological Exam: Pupil size, Glasgow Coma Scale (GCS), mental state, tone, reflexes, and focal neurological signs.
- Skin condition (color, presence or absence of sweating)
- Dry mouth/salivation, bowel sounds, urinary retention.
- Evidence of trauma.
Risk Assessment
- An early, accurate risk assessment is crucial to managing acutely poisoned patients.
- Assessing the likelihood of significant toxicity from the ingested agent, dose, time since ingestion, clinical features, co-morbidities, and patient's weight.
- 5 steps of risk assessment include:
- Agent(s)
- Dose(s)
- Time since ingestion
- Clinical features and progress
- Patient factors (weight and co-morbidities)
Investigations
- Blood sugar level.
- ECG (check rate and rhythm).
Management
- The primary goals of management are to:
- Prevent further poison absorption.
- Increase poison elimination.
- Use antidote (if appropriate).
Prevention of Further Poison Absorption
- Dermal Exposure:
- Remove all clothing.
- Wash skin gently with soap and water for at least 30 minutes.
- Eye Exposure:
- Flush conjunctiva with running water or normal saline for 20 minutes.
- Solid corrosives should be removed with forceps.
- Gastrointestinal (GI) Exposure:*
- Induce vomiting (if appropriate, use Ipecac Syrup within 30 minutes of ingestion, see contraindications below)
- Gastric lavage (in hospital setting, if emesis failed)
- Activated charcoal
- Cathartics
- Whole bowel irrigation
Induction of Emesis (Vomiting)
- Method of choice for inducing vomiting within 30 minutes of ingestion for certain kinds of poisons.
- Syrup of Ipecac must not be used routinely as a home poison treatment intervention and has specific contraindications.
Contraindications for Inducing Emesis
- Convulsions
- Corrosive ingestions
- Hydrocarbons
- Coma
- Infants (less than 6 months – poorly developed gag reflex)
Gastric Lavage (Gastric Irrigation)
- Technique to cleanse the stomach of ingested poisons.
- Used in hospitals when emesis is contraindicated or ineffective.
- Should be performed within 4 to 6 hours of ingestion.
Activated Charcoal
- Absorbs a wide variety of ingested drugs and chemicals, not digested & remains in GI tract.
- Adult dose is 1 gram per kilogram of body weight.
- Administration within one hour of ingestion, patient at risk of significant toxic effects, and NOT at risk of airway compromise are all essential conditions for this treatment.
- Contraindications include: presence of an oral antidote, seizures, coma, and corrosive ingestion. It is not effective against hydrocarbons, alcohols, or corrosives (acids and alkalis).
Cathartics (Laxatives)
- Substances that enhance the passage of material through the GIT decreasing contact between poison and absorptive surfaces.
- Osmotic cathartics (e.g. magnesium sulfate) increase osmotic pressure in the lumen.
- Irritant cathartics (e.g. castor oil) increase GI motility.
- Contraindications include GI hemorrhage, recent bowel surgery, and intestinal obstruction.
Whole Bowel Irrigation (WBI)
- Used to clear the GI tract of non-absorbed toxins using polyethylene glycol electrolyte solutions.
- Beneficial when renal function is impaired.
- Suitable for ingested toxins that are poorly absorbed by activated charcoal and for massive ingestion of drugs or sustained-release/enteric-coated preparations.
Antidotes
- Therapeutic substances that counteract the toxic effects of specific poisons.
- Classified according to mechanism of action:
- Form a nontoxic complex to be excreted (e.g., chelators).
- Accelerate the detoxification process (e.g., N-acetylcysteine, thiosulfates).
- Decrease the rate of conversion of the poison to toxic metabolites (e.g., fomepizole).
- Competing with the poison for specific receptors (e.g., naloxone).
- Blocking receptors affected by the poison (e.g., atropine).
- Bypassing the toxic effects of the poison (e.g., oxygen in CO or cyanide toxicity).
- Antibodies to the poison (e.g., digiband, antivenoms).
Examples of Antidotes
- Listing specific examples of poisons and their respective antidotes to aid memorization
Classification of Antidotes
- Physical (e.g., activated charcoal, coating mixtures, dissolving).
- Chemical (e.g., oxidizing, reducing, precipitating).
- Physiological (or pharmacological) (e.g., competitive/non-competitive antagonism, chelating agents, antibodies).
Enhancement of Poison Excretion
- Forced Diuresis: Increasing urine production for some toxins, using manipulation of pH and osmotic diuresis methods.
- Dialysis: Removing toxins via a semipermeable membrane, peritoneal dialysis and hemodialysis suitable for impaired renal function.
- Hemoperfusion: Using a column containing an adsorbent material (charcoal or resin) to remove toxins through the blood.
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Description
This quiz focuses on the fundamentals of clinical toxicology, emphasizing the initial evaluation and management of poisoned patients. It covers the critical approach to assessing and treating cases of drug overdoses and chemical exposures, highlighting the essential protocols that should be followed in potentially life-threatening situations.
