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Toxicology

Toxicology. Medical Student Lecture 2013. History Tox MATTERS. M edication A mount/concentration T ime T aken E mesis? R eason S igns/symptoms. Physical Exam. VITALS! General appearance Pupils Skin (Wet/dry? Flushed?) GI (bowel sounds?) Neuro (clonus? Reflexes?) MSK tone

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Toxicology

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  1. Toxicology Medical Student Lecture 2013

  2. HistoryTox MATTERS • M edication • A mount/concentration • T ime • T aken • E mesis? • R eason • S igns/symptoms

  3. Physical Exam • VITALS! • General appearance • Pupils • Skin (Wet/dry? Flushed?) • GI (bowel sounds?) • Neuro (clonus? Reflexes?) • MSK tone • Psych (hallucinating? Oriented?)

  4. Toxicology Workup

  5. Toxicology Workup • EKG • Labs: • BMP (why?), tylenol level • If suspected: • ASA, lithium, VPA, toxic alcohols, osmolality, etc

  6. 22 yo M brought in by friends 70, 110/60, 4, 70% RA, 97.8 F Case 1

  7. What do you need to know?

  8. PE • General: unresponsive • Skin: blue, dry • HEENT: pupils 2mm • MSK: decreased tone • Neuro: no clonus, not moving extremities • GI: decreased BS

  9. Antidote?

  10. Antidote? • Narcan!

  11. Antidote? • Narcan! • He wakes up immediately and wants to put his clothes on and go home. • Do you let him? • What questions can you ask to make sure that it is safe for him to leave?

  12. Case 2 • 25 yo F who presents via EMS. She was found outside running around her neighborhood without clothes on.

  13. Physical Exam • 120, 130/85, 15, 100% RA, 100.5 • General: looking around room, not engaged in conversation w/ you. • HEENT: pupils 6mm, equal • Skin: flushed on face and on chest, no sweat in axillae • GI: decreased BS • Neuro: no rigidity, no clonus • Psych: mumbles incoherently, picking at things in the air, not oriented

  14. Toxidrome?

  15. Anticholinergic Toxicity • Hot as a hare • Mad as a hatter • Red as a beet • Blind as a bad • Dry as a bone • Tachy as a $20 suit • Naked as a jaybird

  16. Usual Suspects • Antihistamines • Benadryl (Tylenol PM), Doxylamine (NyQuil) • Antipsychotics • Seroquel, clozaril, olanzapine • Cyclic antidepressants • Amitriptyline, imipramine, nortriptyline • Plants • Jimsom weed The list goes on…

  17. Treatment?

  18. Treatment? • Antidote is physostigmine. • Inhibits acetylcholinesterase • Can save an intubation

  19. Case 3 • 35 yo M who presents altered. He was found by EMS outside a club. Someone called because he was acting strangely. He is angry and has required multiple doses of benzos in the rig. • Vitals: • 140, 160/90, 18, 96% RA, 99.5 F

  20. Physical Exam • General: angry, shouting at people in the room • HEENT: pupils 6mm, equal • Skin: no flushing. +Diaphoresis • GI: normal BS • Neuro: no rigidity, no clonus • Psych: angry, delusional, but knows where he is.

  21. Toxidrome?

  22. Toxidrome? • Sympathomimetic toxicity • Symptoms: • anxiety, delusions, diaphoresis, hyperreflexia, mydriasis, paranoia, piloerection, and seizures • hypertension, and tachycardia. • Common substances: • Amphetamines/methamphetamine, cocaine, theophylline • It may appear very similar to the anticholinergic toxidrome, but is distinguished by hyperactive bowel sounds and sweating.

  23. Treatment • Benzos, benzos and…

  24. Treatment • Benzos, benzos and… MORE BENZOS!

  25. Case 4 • 45 yo Mexican migrant worker who presents from his work. He is having a lot of difficulty breathing, per EMS.

  26. Physical Exam • 50, 120/80, 30, 85% NRB, 98.6 F • General: confused male with obvious difficulty breathing • HEENT: pupils 2mm, tearing, runny nose • CV: brady • Resp: diffuse wheezing, decreased BS throughout • Skin: diaphoretic • Neuro: normal m tone, he is confused, pulling at his lines • GU: urine in pants

  27. Toxidrome?

  28. Toxidrome? • Cholinergic

  29. Toxidrome? • Cholinergic • Symptoms: • bronchorrhea, confusion, defecation, diaphoresis, diarrhea, emesis, lacrimation, miosis, muscle fasciculations, salivation, seizures, urination, and weakness, bradycardia, hypothermia, and tachypnea. • Substances that may cause this toxidrome include carbamates, mushrooms, and organophosphates.

  30. Cholinergic Toxidrome • Common mnemonic: • SLUDGE • Salivation, Lacrimation, Urination, Diarrhea, Gastrointestinal distress, and Emesis • DUMBBELLS • Diarrhea, Urination, Miosis, Bradycardia, Bronchorrhea, Emesis, Lacrimation, Lethargy and Salivation

  31. Treatment

  32. Treatment • 2-PAM (pralidoxime) and atropine • “reactivates” acetylcholinesterase so that it can again break down Ach • Atropine works in conjunction with this (competitive antagonist for M receptor)

  33. Case 5 • 66 yo Farmer who presents obtunded. Found by a family member in the garage. Family was very worried about him because he wasn’t “acting right.” Was slurring his speech initially. Per EMS, became more unresponsive in the rig.

  34. PE • 110, 100/68, 30, 100% RA, 98.7F • General: obtunded • HEENT: pupils midrange, reactive • CV: tachy, no murmurs • Resp: no wheeze/rhonchi • Skin: dry • Neuro: normal m tone, no clonus

  35. Workup • EKG: sinus tachycardia • BMP: Na 162 K 7.2 Cl 119 HCO3 4 BUN/Cr 18/3.04 Glucose 280

  36. Workup, cont’d • ABG 6.7/24.8/90/4

  37. Workup, cont’d ABG 6.7/24.8/90/4 Osmolality 391 ETOH 0.0

  38. What’s next?!

  39. Calculations • AG = Na - (Cl +HCO3) • Calculated osmolality = 2 x [Na mmol/L] + [glucose mg/dL /18] + [urea mg/dL /2.8] • Osmolar gap = measured osm - calculated • A normal osmol gap is < 10 mOsm/kg

  40. Calculations, cont’d • AG = 39 • Osmolar gap = 391 - 346 = 45 What’s causing the gap?

  41. Ethylene Glycol Toxicity • Found in antifreeze • Tastes sweet (bad for babies and animals) • Metabolites cause high AG acidosis • Ca oxalate crystals form in kidneys causing ARF • Antidote: fomepizole

  42. Other toxidromes • Sedative-hypnotics • Benzos, alcohol, GHB • Supportive care • ASA toxicity • Elevated everything (BP, pulse, RR, temp) • Bicarb gtt, dialysis

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