Introduction to Toxicology. Medical Toxicology.... . Is a board-accredited specialty requiring at least two years of training after residency in either emergency medicine, pediatrics, internal medicine or preventative medicine.
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The question words:
- patient’s behavior prior to arrival
- changing vital signs
Propanolol, poppies Freebase
Clonidine, CCB’s Antihistamines
Carbon monoxide N.M.S., Nicotine
Oral hypoglycemics Salicylates
Clonidine, CCB’s Cocaine
Reserpine Thyroid supplements
Heroin (opiates) Nicotine
Weed (marijuana) pulmonary edema
Toxic met. acidosis
(AEIOU TIPS) (OTIS CAMPBELL)
Shock/Strokes Benzo withdrawal
Pontine bleed Sympathomimetics
DiaphoresisRed SkinBlue Skin
(S.O.A.P.) CO Cyanosis
Sympathomimetics Boric Acid MetHb
Barbituates, CO, Sedative hypnotics, snake/spider bites
Bitter almonds: Cyanide
Garlic: Organophosphates, Arsenic
Carrots: Water hemlock
Rotten eggs: Sulfur dioxide, HS
Wintergreen: Methyl salicylates
Fruity: DKA, Isopropanol
Pears: Chloral hydrate
The majority of poisonings were unintentional.... But, the majority of deaths secondary to poisoning were intentional.
Most poisonings are by ingestion and most poisonings occur at home.
The most commonly reported poison?
The least commonly reported?
Which is associated with the most deaths?
Which is associated with the least deaths?
The number one poisonous killer?
To look for conduction delays and ischemia.
(sympathomimetics, B-blockers, TCA’s, digoxin, CCB’s, CO)
To calculate anion gap and osmolality. (CAT MUD PILES and ME DIE mnemonics)
Tylenol and Aspirin levels. Why?
Because of the frequency of abuse and co-ingestion.
Serum volatiles (this tells you quantitative amounts of alcohols). Why? When?
With AMS of unknown etiology, for legal purposes, for unexplained osmolar gaps.
Drug screens. Why? When?
With urine: Screening purposes only. (This rarely changes your management)
With blood: For quantitative information regarding specific ingestants.
(Pulmonary Edema) (C.O.I.N.S.)
(M.O.P.S.) Chloral hydrate
Meprobamate Cocaine packets
Methadone Opiate packets
Opiates Iron (Heavy metals)
Propoxyphene Sustained release/
Salicylates enteric coated tabs.
“Coma cocktail” (Dextrose, Narcan, Thiamine)
Flumazenil is reserved for people who we overdose with benzos!
- Used with “moderate to severe overdoses” within an hour of ingestion. -There is a highly variable outcome with this intervention.
-Lavage is contraindicated with ingestion of corrosives.
- Purported to be superior to lavage
- Used in toxic ingestions within an hour of the ingestion.
- Dosed as 1g/kg or 10:1 ratio of charcoal to poison
- Given as single dose or multiple dose
Aminophylline Heavy metals
ASA (?) Alcohols
Barbiturates Rapid onset cyanide
B-Blockers (?) Chlorine/Iodine
Carbamazepine Other insolubles (tabs)
Dilantin (?) Laxatives
- Given with charcoal to enhance elimination
- Unproven efficacy when used alone.
Whole bowel irrigation:- May be effective for things not adsorbed by charcoal
- Used for body stuffers/packers
Hemodialysis: Urine Alkalinization:
(I.S.T.U.M.B.L.E.) ASA, Phenobarbital
Isopropanol (Alkalinizing the urine with
Salicylates NaHCO3 to trap ions of weakly
Theophylline acidic agents to promote
Methanol Titrate NaHCO3 to maintain
Barbiturates urinary pH of 7.5-8.0.
Arsenic/Lead BAL chelation
CO O2, HBO
Ethylene glycol/Methanol Fomepizole/Ethanol
Methemoglobinia Methylene blue
TCA’s Sodium bicarbonate
Mr. Smith, a 28 year old male presents in police custody complaining of chest pain. He has no other past medical history. No history of cardiac disease.
Patient further states that his chest pain began tonight about one to two hours after he was arrested by police. No history of trauma.Social history=Smokes 1 pack/day. Occasional EtOH.Family History= No cardiac deaths.
Whole Bowel Irrigation
AG: 20. Osmolar gap: 370 – (2(Na) + Glu/18 +BUN/2.8 +ETOH/4.6) = 50! (50 is greater than 10, so..... )
Is there a potential antidote for this?
We don’t have any fomepizole. But we do have ethanol!
1. Erickson TB et al. Toxicology Update: A Rational Approach to Managing the Poisoned Patient. Emerg Med Pract. 2001; 3(8): 1-28
2. Tuckler, Victor. Introduction to Toxicology handout
3. Rivers, Carol S. Preparing for the Written Board Exam in Emergency Medicine. 5th Ed. Volume II. PP 735-738
4. “Case studies in Toxicology” available at: http://www.uic.edu/com/er/toxikon/cases/allcase.htm
5. http://www.med.umich.edu/lrc/baliga/case02/images/infMI2. jpg