p.3
Consultation with Toxicologists and Poison Centers
What can poison centers and toxicologists assist with?
They can prognosticate outcomes, advise on decontamination strategies, and monitor lengths.
p.6
Therapeutic Targets in Poisoned Patients
What initiates depolarization in the left and right heart?
The bundle of His at the same time.
p.1
Therapeutic Targets in Poisoned Patients
What does the mnemonic 'ABCDEFG' help to address in poisoning cases?
It ensures all important aspects of a poisoning are covered.
p.9
Tricyclic Antidepressant (TCA) Overdose
What is the initial bolus dose of 20% fat emulsion for TCA overdose?
1.5 mL/kg over 2-3 minutes.
p.3
Toxidrome Identification and Patient History
What factors influence clinical decision-making in toxic exposures?
Factors include dose, ingestion time, patient factors, and substance ingested.
p.4
Tricyclic Antidepressant (TCA) Overdose
What is the significance of the R wave in AVR being greater than 3 mm?
It may indicate a serious cardiac event.
p.5
Tricyclic Antidepressant (TCA) Overdose
What is a notable ECG change in TCA overdose?
QRS widening due to sodium channel blockade.
p.6
Toxidrome Identification and Patient History
What does an elevated R wave in AVR indicate?
It indicates a shift in the net depolarizing force rightward, causing an upstroke in the R wave.
p.1
Consultation with Toxicologists and Poison Centers
Why is consultation with a toxicologist or poison center recommended?
To ensure unique aspects of a specific poisoning are appropriately addressed.
p.9
Toxidrome Identification and Patient History
What can diphenhydramine cause in relation to TCA overdose?
A false positive on urine drug screens and similar anticholinergic effects.
p.12
Management of Poisonings in Healthcare
What should be considered in cases of cardiovascular shock?
Early echocardiography to determine shock subtype.
p.13
Management of Poisonings in Healthcare
What are examples of agents that can be used for tachycardia and hypertension?
Esmolol with nicardipine, nitroglycerin, nitroprusside, or labetalol alone.
p.4
Tricyclic Antidepressant (TCA) Overdose
Which symptom is most suggestive of a potentially serious impending medical event?
A. QRS greater than 120 ms
p.6
Therapeutic Targets in Poisoned Patients
Why is the electrical path of the right ventricle shorter than the left?
Because the right ventricle is anatomically smaller.
p.1
Therapeutic Targets in Poisoned Patients
What does 'ABC' stand for in the context of poisoning management?
Airway, Breathing, Circulation.
p.8
Toxidrome Identification and Patient History
What should be avoided in treating wide QRS in poisoning cases?
Overaggressive treatment for ventricular tachycardia (VT).
p.15
Neuroleptic Malignant Syndrome vs. Serotonin Syndrome
What is Neuroleptic Malignant Syndrome (NMS)?
A life-threatening reaction to relative dopamine deficiency due to antipsychotic dopaminergic blockade or withdrawal of a dopamine agonist.
p.17
Neuroleptic Malignant Syndrome vs. Serotonin Syndrome
What is the first step in treating Neuroleptic Malignant Syndrome (NMS)?
Withdrawal of the offending serotonergic or dopamine antagonizing agent.
p.17
Neuroleptic Malignant Syndrome vs. Serotonin Syndrome
What is bromocriptine used for in NMS treatment?
It is a dopamine agonist that may reduce NMS symptom duration.
p.18
Neuroleptic Malignant Syndrome vs. Serotonin Syndrome
What is the mechanism of action of Cyproheptadine?
Serotonin antagonist that blocks 85-95% of serotonin receptors.
p.3
Consultation with Toxicologists and Poison Centers
What is the importance of consulting a toxicologist or poison center?
They provide expertise in managing specific overdoses and help in clinical decision-making.
p.5
Tricyclic Antidepressant (TCA) Overdose
What is a significant cardiovascular effect of TCA overdose?
Hypotension from alpha-1 adrenergic blockade.
p.1
Use of Antidotes and Specific Therapies
Why is it important to identify the correct toxin in poisoning cases?
The use of specific antidotes may vary and be relevant only to certain drugs or situations.
p.8
Use of Antidotes and Specific Therapies
How often can Physostigmine be repeated in adults?
Every 10 to 30 minutes until a response occurs.
p.11
Toxidrome Identification and Patient History
What common issue can arise from urine drug screens when testing for amphetamines?
Frequently causes false positives for amphetamine.
p.11
Management of Poisonings in Healthcare
What supportive care measures should be maintained in cases of toxicity?
Maintenance of airway, breathing, and circulation.
p.12
Use of Antidotes and Specific Therapies
What is the recommended treatment for seizures?
Benzodiazepines, with dosing similar to that for status epilepticus.
p.13
Management of Poisonings in Healthcare
Which agents are recommended for treating tachycardia and hypertension?
Agents with beta-1 receptor blockade and alpha-1 receptor blockade, or a combination of a beta-1 blocker with a vasodilator.
p.16
Neuroleptic Malignant Syndrome vs. Serotonin Syndrome
What makes the Hunter Criteria more effective than previous criteria?
They are more sensitive and specific for diagnosing serotonin syndrome.
p.20
Therapeutic Targets in Poisoned Patients
What does the ECG show regarding Shana's cardiac status?
PR interval 140 ms, QRS interval 91 ms, QTc interval 442 ms.
p.3
Use of Antidotes and Specific Therapies
What does 'F' stand for in focused antidotal therapy?
'F' stands for Focused antidotal therapy, which includes using antidotes to reverse receptor effects.
p.2
Enhanced elimination in Poisoning Cases
What is the role of cholestyramine in enhanced elimination?
To bind enterohepatically recirculated toxins.
p.5
Tricyclic Antidepressant (TCA) Overdose
What can cause the R wave to become a positive deflection in TCA overdose?
Changes in ventricular conduction due to sodium channel blockade.
p.1
Management of Poisonings in Healthcare
What should be done after acute exposures to toxins?
Estimate the risk of toxicity, monitor for symptoms, and provide therapies based on clinical syndrome.
p.11
Toxidrome Identification and Patient History
What are the clinical effects associated with sympathomimetic toxidrome?
Tachycardia, diaphoresis, agitation, hypertension, arrhythmia, and seizure.
p.13
Management of Poisonings in Healthcare
What are examples of vasodilatory agents for hypertension?
Nicardipine, nitroglycerin, or nitroprusside.
p.15
Neuroleptic Malignant Syndrome vs. Serotonin Syndrome
What is Serotonin Syndrome?
A life-threatening reaction to excess synaptic serotonin from serotonin-modulating drugs.
p.15
Neuroleptic Malignant Syndrome vs. Serotonin Syndrome
What differentiates the motor symptoms of Serotonin Syndrome from NMS?
Serotonin Syndrome presents with cogwheel rigidity, tremor, ankle and eye clonus, and hyperreflexia.
p.18
Neuroleptic Malignant Syndrome vs. Serotonin Syndrome
What is the suggested dosing for Dantrolene in adults?
1 to 2.5 mg/kg IV followed by 1 mg/kg IV every 6 hours.
p.21
Beta Blocker and Calcium Channel Blocker Overdose
What was the rank of beta blockers in terms of common fatalities reported to U.S. poison centers?
7th most common fatality.
p.22
Therapeutic Targets in Poisoned Patients
What initiates insulin release in beta cells?
Glucose entry causes depolarization, leading to the opening of voltage-gated calcium channels.
p.24
Decontamination Techniques in Poisoning Cases
When is activated charcoal indicated for decontamination?
If the drug is likely still in the gastric system, the patient can protect their airway, or if intubated with gastric access.
p.3
Consultation with Toxicologists and Poison Centers
What is the role of EXTRIP?
EXTRIP is a multidisciplinary work group that creates guidelines on extracorporeal elimination of poisons and drugs in overdose.
p.2
Decontamination Techniques in Poisoning Cases
What are the adult dosing guidelines for activated charcoal?
0.5-1g/kg OR 10 g per 1 g of substance ingested, with a usual dose of 25-100 g.
p.2
Enhanced elimination in Poisoning Cases
What is the purpose of using inducing agents in poisoning management?
To enhance CYP activity responsible for metabolism.
p.5
Tricyclic Antidepressant (TCA) Overdose
What central nervous system effects can occur with TCA overdose?
Anticholinergic delirium and seizures.
p.1
Consultation with Toxicologists and Poison Centers
What is the contact number for poison centers in the US?
1-800-222-1222, available 24/7.
p.7
Therapeutic Targets in Poisoned Patients
What is recommended for managing agitation in TCA overdose?
Benzodiazepines for seizures or anticholinergic delirium.
p.8
Management of Poisonings in Healthcare
What is the recommended treatment for seizures in poisoning cases?
Benzodiazepines are recommended.
p.9
Management of Poisonings in Healthcare
What monitoring is essential during TCA overdose treatment?
ECG, serum electrolytes, neurologic symptoms, and biomarkers of organ function.
p.9
Management of Poisonings in Healthcare
What patient condition may require urethral catheterization during TCA overdose treatment?
Anticholinergic urinary retention.
p.12
Management of Poisonings in Healthcare
What types of medications may be used in cardiovascular shock?
Inotropes (dobutamine, dopamine, epinephrine) and vasopressors (norepinephrine, phenylephrine, vasopressin).
p.13
Management of Poisonings in Healthcare
What should be considered for hypertension without tachycardia?
An agent with vasodilatory properties.
p.15
Neuroleptic Malignant Syndrome vs. Serotonin Syndrome
What alteration occurs in thermoregulation due to NMS?
Hyperthermia due to hypothalamic dopamine blockade.
p.18
Neuroleptic Malignant Syndrome vs. Serotonin Syndrome
What is the dosing range for Amantadine in adults?
200 to 400 mg orally in 2 or 3 divided doses.
p.21
Beta Blocker and Calcium Channel Blocker Overdose
What is a class effect of both DHP and non-DHP calcium channel blockers in overdose?
Prevention of pancreatic beta cell insulin release.
p.23
Use of Antidotes and Specific Therapies
What is the recommendation for lipid-emulsion therapy?
Administer if not previously given, even in cardiac arrest.
p.10
Bupropion Toxicity and Management
What are some common routes of abuse for bupropion?
Insufflation or injection.
p.2
Management of Poisonings in Healthcare
What is symptom-triggered care in the context of poisoning?
Medications to manage nausea, vomiting, pain, constipation, or other symptoms as needed.
p.2
Decontamination Techniques in Poisoning Cases
What is the consensus recommendation for administering activated charcoal?
Completion within 1 hour, but may be beneficial later for certain cases.
p.2
Decontamination Techniques in Poisoning Cases
What are the contraindications for whole bowel irrigation?
Bowel obstruction, perforation, ileus, hemodynamic instability, or compromised unprotected airways.
p.2
Enhanced elimination in Poisoning Cases
What is an example of enhanced elimination in poisoning management?
Intermittent hemodialysis, plasmapheresis, or charcoal hemoperfusion.
p.5
Tricyclic Antidepressant (TCA) Overdose
What type of receptors do TCAs antagonize?
Alpha-1 and -2 receptors, H1 receptors, and muscarinic acetylcholine receptors.
p.5
Tricyclic Antidepressant (TCA) Overdose
What clinical effects should be anticipated in TCA overdose?
Anticholinergic toxidrome, seizures, hypotension, and tachycardia.
p.6
Tricyclic Antidepressant (TCA) Overdose
What does prolonged right-sided depolarization due to TCA binding cause?
It causes the right ventricle to take longer than the left to depolarize.
p.6
Decontamination Techniques in Poisoning Cases
What is whole bowel irrigation considered for?
For large ingestions at risk for severe morbidity or those presenting more than 2 hours after ingestion.
p.1
Use of Antidotes and Specific Therapies
What is an example of a nuanced antidote use?
Chelation for acute mercury poisoning but not for chronic mercury poisoning.
p.7
Therapeutic Targets in Poisoned Patients
What is the preferred vasopressor for managing TCA induced shock?
Norepinephrine is preferred to dopamine.
p.4
Tricyclic Antidepressant (TCA) Overdose
What medications does Ella's brother take?
Guanfacine and desipramine.
p.5
Tricyclic Antidepressant (TCA) Overdose
What was the 25th most common poisoning fatality in 2020?
Tricyclic Antidepressant (TCA) overdose.
p.6
Decontamination Techniques in Poisoning Cases
When should activated charcoal be administered?
If the drug is likely still in the gastric system and the patient can protect their airway.
p.7
Therapeutic Targets in Poisoned Patients
What factors indicate that physostigmine may be reasonable to use?
Clear anticholinergic symptoms, no conduction delay, no seizure-causing or cardiovascular drug co-ingestion, no coronary artery disease, and no bradycardia.
p.8
Use of Antidotes and Specific Therapies
What is a common protocol for administering sodium bicarbonate in wide QRS?
1-2 mEq/kg IV every 3-5 minutes until QRS narrows.
p.9
Toxidrome Identification and Patient History
What are the key toxic effects of TCA overdose?
Sodium channel blockade, antimuscarinic effects, and alpha blockade.
p.13
Management of Poisonings in Healthcare
What is the goal of administering sodium bicarbonate?
To hypertonically overwhelm potential sodium channel blockade, not to achieve alkalemia.
p.17
Neuroleptic Malignant Syndrome vs. Serotonin Syndrome
When can a dopaminergic agonist be potentially restarted in NMS treatment?
If NMS is related to dopamine agonist withdrawal.
p.16
Neuroleptic Malignant Syndrome vs. Serotonin Syndrome
What is the purpose of the expert consensus scoring system for NMS?
To help identify Neuroleptic Malignant Syndrome (NMS) based on the relative value of symptoms present.
p.18
Neuroleptic Malignant Syndrome vs. Serotonin Syndrome
What is the suggested adult dosing for Cyproheptadine?
12 mg PO initially, then 2 mg every two hours if symptoms continue.
p.22
Beta Blocker and Calcium Channel Blocker Overdose
What are common clinical effects of beta-blockers?
Bradycardia, cardiogenic shock, and hypoglycemia.
p.24
Therapeutic Targets in Poisoned Patients
What is a proposed mechanism of high-dose insulin therapy for cardiotoxicity in CCB or BB overdose?
Reduced glucose requirement for myocardial cells.
p.10
Bupropion Toxicity and Management
What vital sign abnormalities were noted in David's case?
HR 175, BP 125/63, RR 25, T 99 F.
p.3
Use of Antidotes and Specific Therapies
What are examples of antidotal therapies?
Examples include naloxone, flumazenil, and physostigmine.
p.4
Tricyclic Antidepressant (TCA) Overdose
What are the notable physical exam findings for Ella?
Mydriasis, flushed skin, and cracked lips.
p.5
Tricyclic Antidepressant (TCA) Overdose
What is one mechanism of toxicity associated with TCAs?
Increase synaptic norepinephrine and serotonin.
p.6
Tricyclic Antidepressant (TCA) Overdose
What is the binding preference of TCAs regarding sodium channels?
They bind preferentially to inactive sodium channels.
p.1
Toxidrome Identification and Patient History
What is a toxidrome?
The clinical manifestations of a poisoning in overdose.
p.8
Use of Antidotes and Specific Therapies
What salvage therapies may be considered for TCA toxicity?
Lidocaine or phenytoin may be used to reverse conduction disturbance.
p.11
Toxidrome Identification and Patient History
How long can seizure onset be delayed in cases of sympathomimetic toxicity?
Seizure onset may be very delayed, with times varying based on product type.
p.12
Management of Poisonings in Healthcare
What is recommended to reduce sympathetic outflow in cases of CNS agitation or sympathomimetic toxicity?
Benzodiazepines (i.e., IV lorazepam, midazolam, or diazepam).
p.13
Management of Poisonings in Healthcare
What monitoring is essential in cases of poisoning?
Vital signs, neurologic symptoms, ECG, telemetry, arterial pH, lactate, and biomarkers.
p.17
Management of Poisonings in Healthcare
What is one method of external cooling for NMS patients?
Cold water poured or misted over skin with a fan directed at the patient.
p.16
Neuroleptic Malignant Syndrome vs. Serotonin Syndrome
Which symptom has the highest score in the NMS diagnostic criteria?
Hyperthermia (18 points).
p.20
Therapeutic Targets in Poisoned Patients
What significant lab result indicates Shana's metabolic state?
Lactate level of 4.2 mmol/L.
p.21
Beta Blocker and Calcium Channel Blocker Overdose
What is the mechanism of toxicity for beta blockers?
Blockade of cardiac beta-adrenergic receptors reduces cyclic AMP and calcium stores, decreasing automaticity and contractility.
p.23
Use of Antidotes and Specific Therapies
What therapy is recommended for refractory shock or peri-arrest?
Incremental doses of HIE and lipid-emulsion therapy.
p.24
Therapeutic Targets in Poisoned Patients
What characterizes vasoplegic shock?
Low afterload with normal cardiac output, often seen in DHP overdose or pure alpha-blocker overdose.
p.10
Bupropion Toxicity and Management
What is the significance of bupropion in terms of pediatric exposure?
Accidental exposure in infants has caused fatalities.
p.2
Management of Poisonings in Healthcare
What is the purpose of maintaining euvolemic and normal electrolytes in poisoning cases?
To provide nutrition support, electrolyte repletion, diuretics, and hemodialysis as indicated.
p.2
Decontamination Techniques in Poisoning Cases
When is whole bowel irrigation recommended?
For sustained-release or enteric-coated drugs, particularly if ingestion was more than 2 hours ago.
p.6
Tricyclic Antidepressant (TCA) Overdose
What must happen to the sodium channels on the right ventricle during depolarization?
They must remain inactive longer while waiting for the left side to finish depolarizing.
p.6
Use of Antidotes and Specific Therapies
What is an appropriate initial treatment for a patient who is tachycardic and hypotensive?
Direct current cardioversion for hypotensive wide QRS tachycardia.
p.1
Management of Poisonings in Healthcare
What should be considered when a patient reports a specific substance ingestion?
The patient may be mistaken or intentionally misleading; a detailed history and toxidrome should be assessed.
p.1
Therapeutic Targets in Poisoned Patients
What is an example of supportive care for maintaining a patent airway?
Supplemental oxygen or endotracheal intubation.
p.7
Therapeutic Targets in Poisoned Patients
What is the role of physostigmine in anticholinergic delirium?
It is used to manage anticholinergic delirium, despite past concerns about safety.
p.8
Use of Antidotes and Specific Therapies
What is the role of hypertonic sodium in treating wide QRS?
It can overcome slowed sodium current from sodium channel blockade and narrow QRS.
p.9
Management of Poisonings in Healthcare
Why is potassium monitoring especially important during TCA overdose treatment?
To maintain normal status and prevent arrhythmia, especially if undergoing alkalization.
p.11
Toxidrome Identification and Patient History
What CNS effects can be observed in cases of sympathomimetic toxicity?
Agitation, hallucination, tremor, somnolence, and seizures.
p.12
Management of Poisonings in Healthcare
What is the approach to treating malignant hypertension causing end organ damage?
Use of antihypertensives based on patient factors.
p.13
Management of Poisonings in Healthcare
What is the dosing for sodium bicarbonate in conduction abnormalities?
1-2 mEq/kg as a bolus, may repeat until QRS interval narrows.
p.15
Neuroleptic Malignant Syndrome vs. Serotonin Syndrome
What are the neurologic symptoms of NMS?
Altered mental status, agitation, confusion.
p.17
Management of Poisonings in Healthcare
What measures may be needed for thermoregulation in NMS?
External and internal cooling measures.
p.16
Neuroleptic Malignant Syndrome vs. Serotonin Syndrome
What is required alongside a negative work-up for other causes in NMS diagnosis?
Exposure to a DA antagonist or DA agonist withdrawal within 72 hours.
p.18
Neuroleptic Malignant Syndrome vs. Serotonin Syndrome
What is the pediatric dosing for Cyproheptadine for children less than 2 years old?
0.0625 mg/kg every 6 hours.
p.19
Neuroleptic Malignant Syndrome vs. Serotonin Syndrome
What is the primary treatment approach for NMS and SS?
Supportive treatment, including withdrawal of the offending agent and benzodiazepines to control agitation and motor dysfunction.
p.20
Management of Poisonings in Healthcare
What are Shana's vital signs upon arrival?
HR 94 bpm, BP 123/75 mm Hg.
p.24
Use of Antidotes and Specific Therapies
What adjunctive therapies can aid in cardiovascular drug overdose?
Administration of atropine for bradycardia, fluids for hypovolemia, and vasopressors or inotropes.
p.7
Therapeutic Targets in Poisoned Patients
What therapy may reverse hypotension in TCA overdose?
Sodium bicarbonate or sodium acetate along with colloid therapy.
p.7
Therapeutic Targets in Poisoned Patients
What is the benefit of using physostigmine in low-risk anticholinergic toxicity?
It reduces the likelihood of ICU admission or need for intubation and controls delirium better than non-antidotal therapy.
p.8
Use of Antidotes and Specific Therapies
What is the initial pediatric dose of Physostigmine?
0.02 mg/kg, with a maximum of 0.5 mg/dose.
p.8
Use of Antidotes and Specific Therapies
When might IV lipid emulsion be considered?
In patients experiencing cardiac arrest or life-threatening toxicity after standard therapies fail.
p.12
Use of Antidotes and Specific Therapies
What is the suggested initial dosing of lorazepam for adults?
IV: 1-4 mg as needed (not to exceed 2 mg/min) until symptom resolution; IM: 2-4 mg.
p.15
Neuroleptic Malignant Syndrome vs. Serotonin Syndrome
What causes the muscle rigidity and motor disorders in NMS?
Blockade of nigrostriatal dopamine.
p.15
Neuroleptic Malignant Syndrome vs. Serotonin Syndrome
What are the motor symptoms of NMS?
Lead pipe rigidity, tremor, bradykinesia.
p.16
Neuroleptic Malignant Syndrome vs. Serotonin Syndrome
What are the Hunter Serotonin Toxicity Criteria used for?
To diagnose serotonin syndrome.
p.19
Consultation with Toxicologists and Poison Centers
Who should decisions on salvage therapies be made in conjunction with?
A toxicologist or poison center.
p.20
Toxidrome Identification and Patient History
What is Shana's mental status upon arrival at the emergency department?
AOx2 with depressed affect.
p.21
Beta Blocker and Calcium Channel Blocker Overdose
What additional effects does propranolol have?
Sodium channel blockade and high CNS penetration.
p.23
Use of Antidotes and Specific Therapies
What is the recommended treatment during cardiac arrest for calcium channel blocker overdose?
Standard ACLS, IV calcium, and lipid-emulsion therapy.
p.22
Beta Blocker and Calcium Channel Blocker Overdose
What are the effects of dihydropyridines (DHP) like amlodipine?
Tachycardia (reflex from vasodilation) or bradycardia (in large overdose) and shock.
p.24
Therapeutic Targets in Poisoned Patients
What should be done if bedside cardiac ultrasound shows low ejection fraction?
Administer an inotropic agent such as dobutamine or epinephrine.
p.7
Therapeutic Targets in Poisoned Patients
What are the potential risks associated with physostigmine use?
Asystole and bradycardia, although causation is not confirmed.
p.8
Use of Antidotes and Specific Therapies
What is the adult dosing range for Physostigmine?
0.5 to 2 mg IM or IV, with a maximum infusion rate of 1 mg/min.
p.8
Use of Antidotes and Specific Therapies
What is VA-ECMO?
A salvage therapy option for severe toxicity cases.
p.9
Use of Antidotes and Specific Therapies
What is the role of sodium bicarbonate in TCA overdose treatment?
To treat wide QRS and aid in alkalinization.
p.11
Decontamination Techniques in Poisoning Cases
What is the recommended decontamination method if the drug is still in the gastric system?
Activated charcoal, if the patient can protect their airway or is intubated with gastric access.
p.12
Management of Poisonings in Healthcare
What is important to consider when determining the right dose of benzodiazepines?
Exploration of a patient's 'dose response curve' and individualization.
p.15
Neuroleptic Malignant Syndrome vs. Serotonin Syndrome
What are the dysautonomia symptoms associated with NMS?
Tachycardia, hyperthermia, flushing, diarrhea.
p.17
Consultation with Toxicologists and Poison Centers
What should be done in conjunction with a toxicologist when considering salvage therapy for NMS?
Select the use of agents, dosing regimens, and duration of use.
p.16
Neuroleptic Malignant Syndrome vs. Serotonin Syndrome
What is the significance of an increasing score in NMS diagnosis?
It increases the likelihood of NMS.
p.18
Neuroleptic Malignant Syndrome vs. Serotonin Syndrome
What is a significant consideration when using Dantrolene?
Monitor biomarkers of liver injury due to potential transaminase elevations.
p.22
Therapeutic Targets in Poisoned Patients
What role does calcium play in insulin vesicle exocytosis?
Calcium binds to SNARE proteins on insulin vesicles, allowing for membrane fusion and exocytosis.
p.24
Decontamination Techniques in Poisoning Cases
What is the purpose of whole bowel irrigation?
To prevent severe outcomes and continued absorption from extended-release products, generally initiated prior to symptom onset.
p.10
Bupropion Toxicity and Management
What symptoms is David likely to experience due to bupropion toxicity?
Tachycardia, hypotension, anticholinergic delirium, and seizures.
p.11
Toxidrome Identification and Patient History
What cardiovascular effects are associated with sympathomimetic toxicity?
Hypertension, tachycardia, conduction abnormalities, and cardiogenic shock.
p.12
Management of Poisonings in Healthcare
What may be required for patients with sympathetic toxicity?
Higher than normal dosing of benzodiazepines.
p.15
Neuroleptic Malignant Syndrome vs. Serotonin Syndrome
What is a common drug combination that increases the risk of Serotonin Syndrome?
Monoamine Oxidase Inhibitor (MAOI) + Selective Serotonin Reuptake Inhibitor (SSRI).
p.17
Management of Poisonings in Healthcare
What is a key component of supportive care in NMS treatment?
Maintenance of airway, breathing, and circulation.
p.18
Neuroleptic Malignant Syndrome vs. Serotonin Syndrome
What caution should be taken when using Cyproheptadine?
Use cautiously in unclear toxidromes that may be anticholinergic or NMS.
p.19
Neuroleptic Malignant Syndrome vs. Serotonin Syndrome
How are NMS and SS differentiated?
Based on history, onset, duration, and symptoms (bradykinesia with NMS vs hyperreflexia and clonus with SS).
p.20
Management of Poisonings in Healthcare
What medications is Shana currently taking?
Lithium carbonate, Sertraline, and Olanzapine.
p.21
Beta Blocker and Calcium Channel Blocker Overdose
What was the rank of calcium channel blockers in terms of common fatalities reported to U.S. poison centers?
6th most common fatality.
p.23
Use of Antidotes and Specific Therapies
What is suggested as a monotherapy in the presence of myocardial dysfunction?
HIE (High-dose Insulin Euglycemia).
p.22
Beta Blocker and Calcium Channel Blocker Overdose
What is a potential effect of nonselective alpha/beta blockers like carvedilol?
Vasodilatory hypotension from alpha-1 blockade.
p.24
Management of Poisonings in Healthcare
What is important to recognize in BB and CCB overdoses?
They can present as diverse shock subtypes.
p.10
Bupropion Toxicity and Management
What is the mechanism of toxicity for bupropion?
It is a norepinephrine and dopamine reuptake inhibitor.
p.15
Neuroleptic Malignant Syndrome vs. Serotonin Syndrome
How does the onset and duration of NMS differ from Serotonin Syndrome?
NMS has a delayed onset (days to weeks) and can last weeks after stopping, while Serotonin Syndrome may have rapid onset and dissipates when the medication clears the body.
p.17
Neuroleptic Malignant Syndrome vs. Serotonin Syndrome
What is the suggested IV lorazepam dosing for adults?
IV 0.5-2 mg every 6-8 hours.
p.16
Neuroleptic Malignant Syndrome vs. Serotonin Syndrome
What is one cause for a new increase in serotonin according to the Hunter Criteria?
Recent addition of a serotonergic agent.
p.18
Neuroleptic Malignant Syndrome vs. Serotonin Syndrome
What is the suggested adult dosing for the first medication?
2.5-7.5 mg orally every 6 to 12 hours, maximum dose 45 mg/day.
p.20
Toxidrome Identification and Patient History
What is the significance of the empty amlodipine bottle found?
It suggests a possible overdose or suicide attempt.
p.21
Beta Blocker and Calcium Channel Blocker Overdose
What happens in large overdoses of dihydropyridine calcium channel blockers?
They can block cardiac calcium channels, similar to non-DHP effects.
p.10
Bupropion Toxicity and Management
What is the fatality rate associated with bupropion compared to all TCAs?
42 deaths involving bupropion compared to 36 for all TCAs.
p.19
Neuroleptic Malignant Syndrome vs. Serotonin Syndrome
What are the key neurologic symptoms to monitor in patients?
Neurologic symptoms, markers of autonomic function (e.g., heart rate, blood pressure, temperature), and biomarkers of organ function.
p.23
Use of Antidotes and Specific Therapies
What is the first line therapy for adult calcium channel blocker overdose?
IV fluids, IV calcium, norepinephrine and/or epinephrine in the presence of shock.
p.22
Therapeutic Targets in Poisoned Patients
What effect does calcium channel blockade have on insulin release?
It prevents calcium entry after depolarization, thus preventing insulin vesicle exocytosis and release.
p.24
Management of Poisonings in Healthcare
What should be maintained as part of supportive care?
Airway, breathing, and circulation.
p.10
Bupropion Toxicity and Management
What notable physical exam findings were observed in David?
Inconsolable agitation, mydriasis, diaphoresis, flushed skin, hyperreflexia, and possible clonus or tremor of the ankles.
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Beta Blocker and Calcium Channel Blocker Overdose
What is the effect of non-dihydropyridine calcium channel blockers?
They block L-type and T-type calcium channels, reducing calcium current and contraction.
p.23
Use of Antidotes and Specific Therapies
What should be done if evidence of myocardial dysfunction is present?
Incremental doses of HIE (up to 10 U/kg/hr).
p.24
Therapeutic Targets in Poisoned Patients
What is the role of norepinephrine in shock management?
To initiate afterload increasing therapy in cases of normal cardiac output.
