Clinical Toxicology Quiz

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Questions and Answers

What is the primary treatment for cholinergic poisoning?

N-acetylcysteine

Gastric decontamination

Fab fragments

Gastric lavage (correct)

Which of the following is NOT a clinical presentation of digoxin toxicity?

Pulmonary edema (correct)

Mental status changes

Visual changes (yellow or green)

Nausea/vomiting

Which of these symptoms are characteristic of amphetamine toxicity?

Pupil dilation and increased heart rate (correct)

Diarrhea and hypotension

Skeletal muscle relaxation and sedation

Profound drowsiness and confusion

In the scenario of cholinergic poisoning, what would you most likely observe in the patient?

Constricted pupils Signup and view all the answers

What is the role of atropine in treating cholinergic poisoning?

Antagonizes the effects of acetylcholine at receptor sites Signup and view all the answers

Which overdose situation would most likely require the use of Fab fragments?

Digoxin (Lanoxin) Signup and view all the answers

What symptom is commonly associated with barbiturate overdose?

Respiratory depression Signup and view all the answers

In the provided clinical scenario of a young male with somnolent and combative behavior, what substance is most likely involved?

Amphetamines Signup and view all the answers

Which organ systems are primarily assessed in poisoned patients to determine immediate morbidity and mortality?

Respiratory system, Cardiovascular system, Central nervous system Signup and view all the answers

What are common symptoms of methanol (wood alcohol) ingestion?

Blurred vision, seizures, cramps, nausea/vomiting Signup and view all the answers

What is one of the primary focuses of early hospital management for poisoning by ingestion?

Removing the toxin from the stomach Signup and view all the answers

Which type of poisoning primarily occurs due to household products in young children?

Accidental poisoning Signup and view all the answers

What complication is associated with low viscosity hydrocarbons?

Increased risk of aspiration and complications Signup and view all the answers

What is the first symptom commonly associated with ethylene glycol ingestion?

Similar sensation to alcohol intoxication Signup and view all the answers

Which of the following is NOT a characteristic of organophosphate and carbamate poisoning?

Typically causes delayed symptoms Signup and view all the answers

What is a common psychological condition that can lead to poisoning in adults?

Intentional poisoning/overdose Signup and view all the answers

How quickly do acids generally complete their damage after exposure?

Within 1 to 2 minutes after exposure Signup and view all the answers

During the management of a poisoned patient, what is critical to ensure?

Adequate airway, ventilation, and circulation Signup and view all the answers

What are five signs of major toxicity to assess in poisoned patients?

Coma, cardiac dysrhythmias, respiratory depression, GI disturbances, hypotension or hypertension Signup and view all the answers

Which of the following compounds is known to be misused by alcoholics as a substitute for ethanol?

Ethylene glycol Signup and view all the answers

Which of the following responses is necessary for a patient exhibiting signs of respiratory depression due to poisoning?

Administer oxygen Signup and view all the answers

What type of burns can strong acids and alkalis cause?

To the mouth, esophagus, and respiratory tract Signup and view all the answers

In what type of occupational exposure are individuals at risk of poisoning?

Handling chemicals in the workplace Signup and view all the answers

Which of the following substances is NOT commonly associated with skin absorption poisoning?

Activated charcoal Signup and view all the answers

Study Notes

Poisonings

Poison is any substance causing harmful physiological or psychological effects
Poisonings from drugs, medicines, and biological substances account for 90% of hospitalizations. Common medications include tranquillizers, antidepressants, and acetaminophen.
Poisoning effects include pathologic effects and clinical symptoms resulting from a substance's toxic effect, which can be acute or chronic. Entry point is the place the poison enters the body. Direct entry into the bloodstream leads to faster poisoning.
Poisonings can be intentional (murder, suicide), accidental, or due to carelessness.

Routes of Absorption

Poisons can enter the body through ingestion, inhalation, injection, or absorption.

Toxicology

Toxicology is the science of poisons and poisonings, focusing on general toxic effects, toxic doses, poison action, clinical symptoms and organ damage, methods of extracting/proving poisonous substances, therapy, and prophylaxis.

Types of Toxicological Emergencies

Accidental poisoning (Dosage errors, idiosyncratic reactions, childhood poisoning, environmental exposure, occupational exposure, drug/alcohol abuse)
Intentional poisoning/overdose (Chemical warfare, assault/homicide, suicide attempts)

General Guidelines

Most poisoned patients need supportive therapy.
Ensure adequate airway, ventilation, and circulation.
Obtain thorough history and focused physical examination.
Consider hypoglycemia in unconscious or convulsing patients.
Administer oxygen for respiratory depression.

Poisoning by Ingestion

About 80% of accidental poisonings in children 1–3 years old are through ingestion. Household products are the most common cause.
Adult poisonings can be intentional, but accidental exposure to workplace chemicals can occur too.
Toxic effects can be immediate or delayed.

Poisoning by Ingestion (Hospital Management)

Early hospital management focuses on removing the toxin from the stomach (gastric lavage via nasogastric tube).
Alternatively, binding the toxin to prevent absorption before it reaches the intestines (activated charcoal).

Poisoning by Absorption

Many poisons enter through the skin. Plant toxins (poison ivy, oak, sumac) are common causes.
Other substances include insecticides, industrial, lawn, and garden chemicals.
Common signs/symptoms include rash, itching, burning, swelling, skin blisters, difficulty breathing, increased pulse rate, fever, headache, and general body weakness.
Organophosphates and carbamates are common toxic pesticides, absorbed by ingestion, inhalation, and dermal routes.

Poisoning by Inhalation

Industrial processes can produce air contaminants that workers or passersby can inhale. This can lead to health problems.
Routine cleaning, painting, and preservation can produce toxic vapors, gases, and dusts. Other air contaminants can be invisible or odorless.
Intentional inhalant use includes using products like paint, glue, and everyday goods to get "high". Inhalants can include correction fluid, air-conditioning refrigerant, felt-tip markers, spray paint, air freshener, and butane/cooking spray.
"Huffing" is a common use of inhalants among young adolescents. It's inexpensive, legal, and often used socially. Common substances "huffed" on include products found in homes.

Assessment and Management

The primary goal of physical assessment is identifying the poison's effects on vital organ systems. Organ systems most likely to be affected are the respiratory, cardiovascular, and central nervous systems.
Five signs of major toxicity include coma, cardiac dysrhythmias, gastrointestinal disturbances, respiratory depression, and hypotension/hypertension.

History

Inquire about ingested substance, timing of ingestion, amount consumed, and any attempts to induce vomiting, antidote, or activated charcoal administration.
Assess for any psychiatric history related to suicide attempts or recent depression episodes.

Strong Acids and Alkalis

Strong acids and alkalis can burn the mouth, pharynx, esophagus, and upper respiratory/GI tract.
Ingestion of caustic/corrosive substances causes immediate damage to mucous membranes and intestinal tract.
Acids typically cause complete damage within 1–2 minutes of exposure. Caustic Alkalis, especially solids, can continue causing damage, or tissue liquefaction, for minutes to hours after exposure.

Hydrocarbons

Hydrocarbons are saturated/unsaturated compounds derived from crude oil, coal, or plants.
Hydrocarbons are found in many household products and petroleum distillates.
Viscosity is an important characteristic of potential toxicity. Lower viscosity substances are more likely to lead to aspiration issues.

Methanol (Wood Alcohol)

A common industrial solvent from wood distillation.
Found in gas line antifreeze, windshield washer fluid, paints, paint removers, canned fuels, turpentine, varnishes, and shellacs.
Onset of symptoms ranges from 40 minutes to 72 hours after ingestion.
Symptoms include blurred vision, cramps, nausea, vomiting, and seizures.

Ethylene Glycol

Colorless, odorless, water-soluble liquid used in deicers, detergents, paints, antifreeze, and coolants.
Alcoholics sometimes use it as a substitute for ethanol.
Initial symptoms are like alcohol consumption, but more severe issues (coma, organ failure, death) can occur with high doses of ingestion.
120 ml of ethylene glycol can be a lethal dose in an average-sized person.

Antizol (Fomepizole)

Serves as an antidote for antifreeze and methanol poisoning.

Isopropanol (Isopropyl Alcohol)

A volatile, flammable, colorless liquid with a characteristic odor and bittersweet taste.
Common household/industrial applications like rubbing alcohol, disinfectants, degreasers, cosmetics, industrial solvents, and cleaning agents.
Intentional ingestion is often a substitute for ethanol. Accidental ingestion/inhalation can occur too.
More toxic than ethanol, but less toxic than methanol or ethylene glycol.
A potentially lethal dose for adults is 150–240 mL. Higher amounts are considered toxic in children.

Metals (Iron, Lead, Mercury)

Infants and children are at high risk for accidental iron, lead, and mercury poisoning due to immature immune systems.
Iron poisoning: Symptoms include nausea, abdominal pain, vomiting after ingestion. Can cause profound shock or chemistry imbalance. 10% of ingested iron is absorbed daily.
Lead poisoning: Historical use, from paints, can cause health issues with brain development, disabilities (learning/behavioral), hearing loss, kidney damage, and coma or death in extreme cases.

Mercury Poisoning

Mercury is the only metal that's liquid near room temperature.
Used in thermometers, sphygmomanometers, and dental fillings. Compounds of mercury are found in paints, pesticides, cosmetics, and industrial processes.
All forms (except amalgam) are poisonous.
Inhalation can cause lung issues but more widespread problems can follow, including metallic taste, mouth sores, swollen gums, nausea, vomiting, abdominal pain, diarrhea, headache, weakness, confusion, shortness of breath, cough, chest tightness, bronchitis, pneumonia, and kidney damage.

Food Poisoning

Illness characterized by sudden onset (often pain, vomiting, diarrhea) within 48 hours of consuming contaminated food.
- Can be infectious (bacterial, viral) or noninfectious.

Food Poisoning - Management Guidelines

Onset of symptoms depends on cause and contamination levels
Symptoms usually develop within:
- 30 minutes in case of chemical poisoning
- 1–12 hours for bacterial toxins
- 12–48 hours for viral/bacterial infections

Plant Poisoning

Toxic plant ingestion is a common category of poisoning, often occurring in children under 6 years of age. Common plants include amaryllis, mistletoe, castor bean, chrysanthemum, daffodils, english ivy, foxglove, hydrangea, lily-of-the-valley, and many types of mushrooms and fungi.

Poisoning by Inhalation (Intentional/Accidental)

Accidental or intentional inhalation of poisons can be life-threatening.
Toxic gases are classified (simple asphyxiants, chemical asphyxiants, and irritants/corrosives)
Examples include ammonia, chlorine, bromine, and household cleaners.

General Management - Inhaled Poisons

Scene safety and personal protective measures. Rapid removal from the contaminated environment.
Adequate airway, ventilation, and circulatory support.
Initial assessment and physical examination.
Eye irrigation (if needed). Routine vital signs and ECG monitoring.
Rapid transport to appropriate medical facility.

Cyanide

Cyanide poisoning can result from inhalation of cyanide gas, ingestion of cyanide salts/nitriles/cyanogenic glycosides, or nitroprusside infusion.
Symptoms include rapid, deep breathing, shortness of breath, convulsions (seizures), and loss of consciousness.

Poisoning by Injection

Human poisonings from injection may result from drug abuse, arthropod bites and stings, reptile bites, or hazardous aquatic life (mix of substances leading to multiple toxic reactions). Prepared for simultaneous reaction management in multiple organ systems.

Tragic Death (Steve Irwin)

Steve Irwin, Australian naturalist and TV personality, was killed by a stingray during a diving expedition in Queensland's Great Barrier Reef.

Arthropod Bites and Stings

Hymenoptera (bees, wasps, ants) and Arachnida (spiders, scorpions, ticks) cause the highest incidence of need for emergency care.
Reactions can be classified as local, toxic, systemic, and delayed-care.

Hymenoptera

Hymenoptera use venom for defense and subjugation of prey.
Stings are typically inflicted on the head, and neck, followed by the foot, leg, hand, and arm.

Common Toxidromes

Anticholinergics
Cholinergics
Hallucinogens
Opioid/Narcotics
Sedative/Hypnotics
Sympathomimetics

Anticholinergic Syndrome

"Hot as a hare, Dry as a bone, Red as a beet, Mad as a hatter" describes typical symptoms (Dry Patient).
Dry mouth, flushed/hot skin, dilated/nonreactive pupils, tachycardia, hyperthermia, hypertension, hallucinations, delirium, restlessness, and seizures.
Causative agents include antihistamines (Gravol, Benadryl), antiparkinson medications, atropine, antipsychotic agents, antidepressants (tricyclics), skeletal muscle relaxants, and some plants (e.g., jimson weed and Amanita muscaria).

Cholinergic Causes

Bethanachol, carbamate insecticides, myasthenia gravis drugs, edrophonium, physostigmine, pilocarpine, nicotine, nerve agents, and some mushrooms.

Cholinergic Treatment

Specific treatment includes atropine, pralidoxime (2-PAM Chloride), diazepam (Valium), and activated charcoal.

Sympathomimetic Overdose

Causative agents include cocaine, amphetamine, methamphetamine, and over-the-counter decongestants.
Specific treatment involves minimal sensory stimulation and calming measures.
Common signs include delusions, paranoia, tachycardia/bradycardia, hypertension, diaphoresis, seizures, hypotension, and dysrhythmias.

Cocaine

One of the world's most popular illegal drugs and causes profound sympathetic discharge.
Associated with tachycardia, hypertension, arrhythmia, and can also cause hypotension and reflex bradycardia.
CNS stimulation also occurs.

Cocaine and Crack

Treatment includes CNS sedation (Lowering blood pressure), and treating hyperthermia.

Tricyclic Antidepressants (TCAs)

Prescribed for depression, they work by blocking the uptake of norepinephrine, serotonin, or both into presynaptic neurons.
Altering the sensitivity of brain tissue to these chemicals also takes place.
Often linked to a combination of anticholinergic and sympatholytic effects, leading to symptoms including coma, seizures, hypotension, and cardiac dysrhythmias.

TCA Treatment

Include gastric decontamination, treating cardiac dysrhythmias, and treating seizures.

Opioids

Common analgesic medications.
- Morphine, codeine, oxycodone, and related compounds.
- Often used pre/post surgical procedures or for other pain management.
- Street versions include heroin and opium.

Opiates

Clinical Presentation includes pinpoint pupils, respiratory depression, bradycardia, hypotension, hypothermia, pulmonary edema, and seizures.

Opiates Treatment

Acute treatment with naloxone (Narcan), a direct-acting opioid antagonist (but short-acting).
Chronic treatment approaches include methadone, catapres, and naltrexone.

Opiates Complications

Complications from opioid use can be seen, including aspiration, pulmonary edema, withdrawal symptoms, and need for repeated doses.
Among heroin withdrawal effects are dilated pupils, piloerection, watery eyes, runny nose, yawning, loss of appetite, tremors, panic, chills, nausea muscle cramps, and insomnia.

Benzodiazepines

Clinical presentation includes respiratory depression and drowsiness/coma.
Treatment typically does not require pharmacological intervention, but flumazenil can be utilized.

Carbon Monoxide

Colorless, odorless, and tasteless, making detection difficult, causing vague symptoms.
Blocks oxygen absorption in the bloodstream, leading to body tissue damage.
Early symptoms can include tightness in the forehead, headaches, throbbing in the temples, weariness or dizziness, nausea, vomiting, loss of strength, increased breathing rate, and slowing pulse. Prolonged exposure can cause death. Cigarette smokers are at higher risk.

Acetaminophen Toxicity

Hepatic necrosis following large doses of acetaminophen (overdose). Symptoms can range from initial nausea, vomiting, and malaise, leading to jaundice, confusion, somnolence, coma/death.
Hallmark is symptom onset within 24 hours of ingestion (acetaminophen products alone or in combination with other meds).
Determining acetaminophen blood levels (half-life) is essential to measure toxicity (Rumack nomogram).

Acetaminophen Poisoning

Most often linked to large single ingestions of acetaminophen-containing medications.
Toxic doses vary for adults (7.5 g) and children (150 mg/kg).
Exposure can cause acute/chronic issues, especially with people consuming alcohol, chronically malnourished, or on meds affecting acetaminophen metabolism.

Overdose Treatment (Acetaminophen)

Gastric decontamination (to cleanse stomach).
N-acetylcysteine (Muco-Myst) for treatment (via IV or oral administration).

Salicylates (ASA)

Clinical presentation includes mixed acid-base disturbances, nausea/vomiting/abdominal pain, CNS issues like tinnitus, lethargy, seizures, cerebral edema, and irritability, respiratory issues (pulmonary edema), and coagulation abnormalities.

Digoxin (Lanoxin)

Cardiac drug, with direct and indirect effects on SA and AV nodal fibers.
Toxic levels can halt impulses in the SA node, decrease AV node conduction, and increase sensitivity to catecholamines.
Possible dysrhythmias or conduction block

Digoxin Clinical Presentation

Symptoms include nausea, vomiting, mental status changes, cardiovascular symptoms, and visual changes (often yellow/green).

Digoxin Treatment

Gastric decontamination and Fab fragments.

Barbiturates

General CNS depressants that inhibit impulse conduction in the ascending reticular activating system.
Used historically for anxiety and insomnia.
Overdose signs/symptoms are related to central and cardiovascular systems (care is needed for emergency support).

Amphetamines

Commonly used to improve mood, performance, or to suppress appetite.
Structurally similar to endogenous catecholamines. Their effects on the CNS are more pronounced.

Alcohol Dependence

Characterized by chronic, excessive alcohol consumption leading to harm to physical health and social function. Withdrawal symptoms occur after cessation.
Four general categories of withdrawal syndromes include minor reactions, hallucinations, alcohol withdrawal seizures, and delirium tremens (DTs).

Acute Alcohol Intoxication

Acute poisoning (from relatively rapid intake), with symptoms that can range from minor reactions to severe issues (coma, convulsions, etc.). Signs include intoxication level depending on the individual consuming and the dosage.

Alcohol Withdrawal Syndrome

A period of relative or complete abstinence from alcohol consumption. Includes minor reactions (occurring 6–8 hours after cessation, peaking in 24–36 hours), hallucinations, seizures (most often occurring 7–48 hours after cessation, with peak incidence at 13–24 hours), and delirium tremens (DTs). DTs usually occur between 72–96 hours post-cessation, but can be delayed up to 14 days.

Clinical Scenarios (1-3)

Briefly describe multiple scenarios that cover diverse poison exposures, symptoms, and potential treatment responses.

Disulfiram-Ethanol Reaction

Medication disulfiram (Antabuse) is prescribed to some alcoholic patients to help them abstain from alcohol.
Ingesting alcohol while taking disulfiram causes an unpleasant and potentially life-threatening physiological response (acetaldehyde buildup).
Reaction starts 15–30 minutes post-alcohol ingestion and can last up to 2 hours.

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Description

Test your knowledge on clinical presentations and treatments related to various types of poisoning. This quiz covers key topics such as cholinergic poisoning, digoxin toxicity, and characteristics of alcohol and drug overdoses. Answer questions about symptoms, treatments, and management strategies in toxicology.