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Pharm Exam 1
Set 15: The Poisoned Patient
85
Pharmacology
Graduate
10/14/2011

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Cards

Term
What are the ABCs of emergency medicine?
Definition
Airway
Breathing
Circulation
(implies nothing's more important than making sure the patient has an airway)
Term
How is airway-breathing of a poisoned patient assessed/restored?
Definition
1) remove obstruction
2) intubate early
3) ventilate if necessary
4) ABG to assess:
a) oxygenation
b) ventilation
c) acid-base status
Term
How is circulation of a poisoned patient assessed/restored?
Definition
1) Obtained BP & pulse
2) Cardiac monitoring & cardioversion
3) Fluids
4) 12 lead EKG asap
5) Vasopressors
Term
What are the "Other C's"?
Definition
1) C-spine
2) Cooling
Term
What do the ABCs help with in emergency medicine?
Definition
stabilization
Term
What 4 substances are immediately given to all ER patients with altered mental status?

Why?
Definition
1) Oxygen
2) Glucose (in case of diabetic shock)
3) Naloxone (in case of narcotic OD)
4) Thiamine (in case it's Wernicke's)
Term
What patient's would NOT get naloxone if altered mental status?
Definition
1) opiod dependent w/o apnea/severe resp. depression
2) Hx of speedball abuse
3) agitated/seizing
4) pregnant & opiod dependent
Term
What is flumazenol used for clinically?
Definition
benzo OD
Term
Why isn't flumazenol used regularly?
Definition
can precipitate benzo withdrawl
Term
What is done after a patient is stablized?
Definition
Disrobe patient and do a thourough PE (always starting with vital signs)

check for:
trauma
odors
burns/tracks
bullae
**neuro exam
Term
What Hx is obtained from the patient?
Definition
complete Hx:
HPI & PMH

(though, you will need to confirm with friends, family, police, paramedics since ~50% of the time it's inaccurate)
Term
What happens if your poisoned patient is tachycardic?
Definition
It's not very specific, but gives a general area of where to start looking
Term
What happens if your poisoned patient is bradycardic?
Definition
It's very specific and narrows the list of substances significantly, down to 4 main substances (+ some other rare substances)
Term
What are the 4 drugs you think of poisoning when your patient is bradycardic?
Definition
1) β blocker 2) Ca2+ channel blocker 3) clonidine (α2 agonist) 4) digoxin (for digitalis [cardiac glycosides made from foxgloves plants])
Term
Besides cold exposure, what is the number one cause of hypothermia?
Definition
EtOH
Term
What are the 2 common causes of hyperthermia?
Definition
1) ecstacy
2) anticholinergics (no sweat)
Term
What drugs can cause both hypothermia & hyperthermia depending on the season (no body temp regulation)?
Definition
anti-psychotics
Term
What drugs can cause HTN in OD?
Definition
same as tachycardic (usually stimulants of some kind)
Term
What 2 drugs should you think of when your patient is hypotensive?
Definition
1) opiates
2) sedative hypnotics
Term
What does hyperventilation tell you about a patient?
Definition
It's very non-specific, but it could indicate metabloic acidosis
Term
How helpful is it to notice miosis in a patient?
Definition
Very - tends to be more specific
Term
What drugs should you think of when you have a miotic patient?
Definition
1) opiates
2) cholinergics
Term
How helpful is it to notice mydriasis in a patient?
Definition
Not so helpful, unless dramatic
Term
What drugs should you think of if your patient has dramatic mydriasis?
Definition
1) LSD
2) atropine
Term
How specific is nystagmus in a poisoned patient?
Definition
Not too specific, but you do think of sedative hypnotics
Term
What drugs cause rotational nystagmus?
Definition
PCP/ketamine
Term
What odor is smelled with heavy metals?
Definition
garlic
Term
What happens if you smell bitter almonds?
Definition
run. it's probably CN.
Term
Toxidrome

Anticholinergics
(Pulse, BP, Resp., Temp., Bowel Sounds)
Definition
Pulse: ↑
BP: ↑
Resp.: ↑
Temp: ↑
Bowel Sounds: ↓
Term
Toxidrome

Anticholinergics
(Skin, Mental Status, Pupils, Other)
Definition
Skin: dry, red, hot (as a bone, as a beet, as a hare)
Mental Status: altered
Pupils: mydriasis
Other: urinary retention
Term
Toxidrome

Sympathomimetic
(Pulse, BP, Resp., Temp., Bowel Sounds)
Definition
Pulse: ↑
BP: ↑
Resp.: ↑
Temp: ↑
Bowel Sounds: normal
Term
Toxidrome

Sympathomimetic
(Skin, Mental Status, Pupils, Other)
Definition
Skin: sweaty
Mental Status: altered
Pupils: mydriasis
Other: bruxism
Term
Toxidrome

Cholinergic
(Pulse, BP, Resp., Temp., Bowel Sounds)
Definition
Pulse: ↓
BP: normal
Resp.: normal
Temp: ↓
Bowel Sounds: ↑
Term
Toxidrome

Cholinergic
(Skin, Mental Status, Pupils, Other)
Definition
Skin: sweaty
Mental Status: normal
Pupils: miosis
Other: fasciulations, weakness, odors
Term
Toxidrome

Opioids
(Pulse, BP, Resp., Temp., Bowel Sounds)
Definition
Pulse: ↓
BP: ↓
Resp.: ↓
Temp: ↓
Bowel Sounds: ↓
Term
Toxidrome

Opioids
(Skin, Mental Status, Pupils, Other)
Definition
Skin: sweaty
Mental Status: ↓
Pupils: miosis
Other: track marks
Term
What 5 options do ED doctors have to decrease further absorption in a poisoned patient?
Definition
1) skin/eye decontamination
2) gut decontamination
3) activated charcoal
4) cathartics
5) whole bowel irrigation
Term
What is the #1 decontamination rule?
Definition
Protect yourself & your staff
Term
How is eye decontamination done?
Definition
iirgate with copious amounts of saline
Term
How is skin decontamination done?
Definition
Begin with wounds and you can use:
water
mild soap
50/50 detergent/corn starch
dilute bleach
Term
How do you decontaminate GI tract from a corrosive substance?
Definition
Children: 4oz water only
Adults: 8oz water, then go to ED
Term
Function

Ipecac
Definition
induces emesis
Term
Though Ipecac is not really used anymore, when should you NOT use it for sure?
Definition
<1 yr
CNS depression (vomiting unconscious child = bad)
corrosive agent (burns on the way down & up)
Term
def

gastric lavage
Definition
placement of lg. bore orogastric tube into stomach & pump 2+ L saline
Term
When is gastric lavage used clinically?
Definition
1) patients who have come to ED within 1 hr of ingestion
2) patients who have ingested copious amounts of a sunbstance
Term
Why isn't gastric lavage used more frequently?
Definition
risk of airway blockage & aspiration
Term
When is gastric lavage contraindicated?
Definition
1) unprotected airway
2) ingestion of corrosive substance
Term
What is your "friend" when trated poisons ingested?
Definition
activated charcoal
Term
MOA

activated charcoal
Definition
1) direct absorption of material
2) interrupt enterohepatic recirculation
3) gut dialysis
Term
When in charcoal contraindicated?
Definition
1) certain substances s.a. hydrocarbons & metals (Fe, Li) that don't bind to it
2) corrosive agents
3) intestinal obstruction
Term
When would multiple doses of charcoal be needed?
Definition
drugs that have enterohepatic recirculation
Term
Why is sorbitol given when charcoal is administered?
Definition
to move the charcoal (bound to poison) through the stomach and out
Term
Function

cathartics
Definition
accelerate defication
Term
def

whole bowel irrigation
Definition
massive bowel flush
Term
When would you do a massive bowel irrigation?
Definition
When charcoal won't work, body packers
Term
When is whole bowel irrigation contraindicated?
Definition
obstruction
perforation
Term
Why are drugs that cause concretions "annoying"?
Definition
Can cause prolonged intoxication
Term
What lab diagonostic tests can be done to help with deciding on a toxicant?
Definition
1) EKG
2) UA
3) few bedside tests
Term
How do you calculate the anion gap?
Definition
AG = Na - (HCO3 + Cl) with normal ~ 12
Term
What is the mnemonic for an increaed anion gap?
Definition
MUDPILES
Term
def

MUDPILES
Definition
MeOH
Uremia
Diabetes
Paraldehyde/phenformin
Iron/isoniazid
Lactate
Ethylene Glycol
Salicylates

(anything that causes lactic acidosis)
Term
What are the 2 causes of decreased anion gap?
Definition
Li, Bromide
Term
How do you calculate osmolality?
Definition
Os = 2Na + (Glucose/18) + (BUN/2.8)
Term
How do you calculate the osmolol gap?
Definition
OG = measured os - calculated os
normal ~ 10
Term
What sm. osmols can increase the osmolal gap?
Definition
alcohols
Term
Why are drug screens unreliable?
Definition
not necessarily specific or sensitive for what was the poison
Term
How are drugs of abuse drug screened?
Definition
urine
Term
Why are urine drug tests unreliable?
Definition
Just say what the patient has used, not necessarily why they're there today
Term
What drug screens are more useful?
Definition
serum levels
Term
What tox screen method is the "gold standard" (very sensitive & specific)?
Definition
GC-mass spectrometry
Term
How is xray helpful in Dx of a toxicant?
Definition
some toxicants are radiopaque
Term
def

ion trapping
Definition
enhanced elimation where drugs that are weak acids or weak bases can be trapped alkalinization or acidification (not reccomended) of urine
Term
Why is hemodialysis not used frequently?
Definition
only a small list of drugs can be removed this way (sm. molecular wt., low protein binding, sm. volume of distribution s.a. salicylates, MeOH, Li, ethylene glycol)
Term
When would you use hemoperfusion?
Definition
when a substance meets the criteria for hemodialysis, but is highly protein bound
Term
MOA

hemoperfusion
Definition
pump charcoal cartridge thru blood
Term
What are the 2 "bread & butter" antidotes?
Definition
1) N-acetylcysteine => acetaminophen
2) Naloxone => opiates
Term
When is sodium bicarbonate given in OD situations?
Definition
cardiovascular drug OD
Term
What is the antidote for digoxin?
Definition
digibind
Term
What toxins do you think of in house fires?
Definition
CN & CO
Term
What intoxicant are you thinking for a patient passed out with a needle in their arm?
Definition
opioid
Term
What is the antidote for an opioid?
Definition
naloxone
Term
What toxicant are you thinking if someone's hands are blue & their blood is brown?
Definition
some type of oxidant s.a. methemoglobulinemia
Term
What is the antidote for methemoglobulimemia?
Definition
methyl blue
Term
What is the antidote for ethylene glycol poisoning (antifreeze)?
Definition
either EtOH or a chemical blocker antizol
Term
What is the anitdote for a rattlesnake bite?
Definition
antivenom
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