POISONING TiKi TaKa

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. OPIOID INTOXICATION:
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. -- RESPIRATORY RATE is the most reliable & predictive sign.
. -- Bowel sounds.
. -- BP.
. -- Temp.
. H/O of heroin injection (Needle marks on extremities by P/E).
. Tx: NALOXONE.
. The goal of ttt is ++ RR from 6 to 12/min with improving Oxygen saturation.
. N.B. PUPIL EXAMINATION is NOT RELIABLE !!
. Opioid intoxication doesn't always present with miosis.
. Co-ingestions can lead to normal pupillary size or even mydriasis !!!
. OPIOID WITHDRAWAL:
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. Symptoms develop within 6-12 hs after the last dose of short acting opioid.
. H/O of heroin injection (Needle marks on extremities by P/E).
. Nausea - vomiting - Abdominal pain - Diarrhea - Restlessness - Arthralgia & m
yalgia.
. Rhinorrhea - Lacrimation.
. Mydriasis - Piloerection & hyperactive bowel sounds.
. Tx -> METHADONE.
. METHANOL INTOXICATION:
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. "ALCOHOL's SUBSTITUTE".
. H/O of homeless man.
. 1st 24 hs -> Headache, nausea, vomiting & epigastric pain.
. Later -----> Vision loss & coma.
. Optic disc hyperemia.
. ++ ANION GAP METABOLIC ACIDOSIS { (Na) - (Cl + HCO3) }. (Normal AG 8-12).
. ++ OSMOLAR GAP.
. Very low HCO3.
. ETHYLENE GLYCOL INTOXICATION:
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. "ALCOHOL's SUBSTITUTE".
. H/O of homeless man.
. 1st 24 hs -> Headache, nausea, vomiting & epigastric pain.
. Later -> Flank pain, hematuria, oliguria, Acute renal failure.
. Glycolic acid (Metabolite) injuries the renal tubules.
. Oxalic acid binds calcium & deposits in the kidneys.
. Tx: FOMEPIZOLE or ETHANOL to prevent ethylene glycol to its harmful metabolit
es.
. N.B. METHANOL & ETHYLENE GLYCOL MAY HAVE SIMILAR PRESENTATIONS ! BUT !!
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. METHANOL DAMAGES THE EYES.
. ETHYLENE GLYCOL DAMAGES THE KIDNEYS.
. BETA-BLOCKERS BB INTOXICATION:
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. -- HR.
. -- BP.

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AV BLOCK.
BRONCHOSPASM -> WHEEZES (MOST SPECIFIC).
Cardiogenic shock may occur (Cold & clammy extremities).
Neurological effects (Delirium & seizures).
1st line TTT -> ATROPINE + IV FLUIDS.
FAILED -------> GLUCAGON ++ c-AMP -> ++ Ca -> ++ cardiac contractility.

. CANNABIS = MARIJUANA INTOXICATION:

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. +++++++ APPETITE.
. DRY MOUTH.
. CONJUNCTIVAL INJECTION.
. ++ HR.
. ++ BP.
. ++ RR.
. -- concentration & short time memory.
. -- reaction time & impairs attention.
. ++ the risk of vehicle accidents.
. ALCOHOL INTOXICATION:
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. Slurred speech.
. Unsteady gait.
. Incoordination.
. Disinhibited behavior.
. Memory impairment.
. Nystagmus.
. ALCOHOL WITHDRAWAL:
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. Due to reflex hyperactivity of certain parts of the brain.
. Anxiety, insomnia, tremors & diaphoresis in the 1st 6-24 hs after alcohol ces
sation.
. Hallucinations & withdrawal seizures may occur.
. DELIRIUM TREMENS may occur in 5% of pts after 48 - 72 hs.
. Hypertension, agitation, tachycardia, hallucinations & fever.
. Tx -> CNS depressant -> Benzodiazepenes -> Chlordiazepoxide.
. BENZODIAZEPINE OVERDOSE:
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. Slurred speech.
. Unsteady gait.
. Incoordination.
. Respiratory compromise, stupor & coma.
. Distinguished from opioid overdose by lack of severe respiratory depression &
miosis.
. Distinguished from alcohol & phenytoin toxicity by lack of nystagmus.
. BARBITURATE (SEDATIVES) INTOXICATION:
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. Slurred speech.
. Unsteady gait.
. Incoordination.
. COCAINE INTOXICATION:
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. SYMPATHETIC STIMULATION (++HR, ++BP, MYSRIASIS).
. Euphoria.
. Sense of self confidence.
. ++ arousal.

. improved performance.
. CAUSTICS "LYE" (SODIUM HYDROXIDE) INGESTION:
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. A strong alkaline solution.
. Mostly due to suicidal attempt.
. SEVERE ESOPHAGEAL DAMAGE due to LIQUEFACTIVE NECROSIS.
. May lead to perforation & mediastinitis.
. Retrosternal or epigastric pain - hypersalivation - Odynophagia & dysphagia.
. Tx -> HOSPITALIZATION + IV HYDRATION.
. ENDOSCOPY IS MANDATORY to determine the extent of esophageal damage !
. If perforation is suspected -> A gastrograffin study sh'd be performed.
. NEVER to neutralize the alkali with ana acid !!
. NEVER to induce vomiting !!
. Charcoal isn't effective !!
. N.B. NO ALTERATION IN CONSCIOUSNESS.
. CARDIOLOGICAL PROBLEM RELATED TO TOXICOLOGY !
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. TORSADES DE POINTS -> Tx: MgSO4 !
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. Polymorphic ventricular tachycardia.
. Occurs in the setting of a prolonged QT interval.
. Seen in pts with familial long QT $yndrome.
. Malnourished pts predisposed to hypomagnesemia (Alcoholics).
. Pts on TCAs (Tricyclic anti-depressants).
. Pts on anti-arrhythmics (Amiodarone - Sotalol).
. Anti-infective agents (Moxifloxacin - Fluconazole).
. Tx -> Cessation of the offending drug & MgSO4.
. PHENCYCLIDINE INTOXICATION:
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. HALLUCINOGENIC STREET DRUG.
. VERTICAL NYSTAGMUS.
. VIOLENT BEHAVIOR.
. Agitation - confusion - Pupillary dilatation - tachycardia.
. Severe hypertension & hyperthermia may occur.
. Tx -> Benzodiazepines.
. CHEMICALS IN THE EYE:
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. FLUSH THE EYE WITH WATER (EYE UNDER A FAUCET OF RUNNING WATER FOR AT LEAST 15
mins) !
. DIPHENHYDRAMINE POISONING:
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. Anti-histaminic used in ttt of allergic rhinitis - insect bites & motion sick
ness.
. Mixture of anti-cholinergic symptoms.
. Drowsiness & confusion.
. Dry mouth - dilated pupils - blurred vision - Reduced bowel sounds & urine re
tention.
. Tx -> PHYSOSTIGMINE (Cholinesterase inhibitor).
. SALICYLATE INTOXICATION:
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. TINNITUS.
. Nausea & vomiting.
. Fever.
. Altered mental status & acid-base abnormalities.

. Tx -> ALKALINIZATION OF URINE with SODIUM BICARBONATE (Na HCO3).

. CARBON MONOXIDE (CO) POISONING:
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. HISTORY is the most ipmortant clue to diagnosis.
. SMOKE INHALATION - BARBEQUE PARTY !!
. CO is a colorless - odorless gas.
. Emitted by automobiles, furnaces & charcoal grills.
. When inhaled, it prevents the body from utilizing Oxygen.
. Headache - Nausea - Vomiting - Abd. discomfort - confusion - coma.
. PINKISH RED SKIN HUE.
. Dx -> Obtain CARBOXYHEMOGLOBIN levels.
. Tx -> HYBERBARIC OXYGEN.
. ACETAMINOPHEN POISONING:
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. Rumack - Matthew Nomogram is a curve used to assess its hepatotoxic effects.
. It also provides the need for N-acetylcysteine as an antidote.
. The 1st data point on the curve is at 4 hours !
. The decision of whether or not to take the antidote can be made after 4 hours
.
. Studies proved zat their is no correlation bet. z amount ingested & z toxicit
y level!
. So .. If a pt. came to u with H/O of ingestion of 14 pills 2 hours ago ,,
. You should wait 2 hours then obtain the acetaminophen level.
. ORGANO-PHOSPHATE POISONING:
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. Organophosphates antagonizes acetylcholinesterase -> Cholinergic excess.
. -- HR - miosis - muscle fasciculations.
. Bronchorrhea - salivation - lacrimation - diarrhea - urination.
. Tx -> ATROPINE (Compete with acetylcholine at the muscarinic receptors).
. IMMEDIATE REMOVAL OF THE PT's CLOTHING (SOAKED with secretions),
. thus .. preventing continued absorption of organophosphates through the skin.
. TRI-CYCLIC ANTI-DEPRESSANTS (TCA) INTOXICATION:
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. Hyperthermia - seizures - Hypotension.
. Anticholinergic effects (mydriasis - flushed dry skin - intestinal ileus).
. TCAs -> -- conductivity -> QRS prolongation -> Ventricular arrhythmia.
. THE BEST INDICATOR OF THE EXTENT OF THE OVERDOSE is the QRS COMPLEX DURATION.
. Tx -> NaHCO3 -> Narrows the QRS complex & -- the incidence of VT.
. NaHCO3 Mechanism -> Sodium load will alleviate the depressant action on Na ch
annels.
. NEUROLEPTIC MALIGNANT $YNDROME:
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. DRUG INDUCED IDIOSYNCRATIC REACTION.
. Sudden onset of confusion, fever, muscle rigidity & diaphoresis.
. Mostly caused by dopaminergic antagonists (HALOPERIDOL) for hallucinations tt
t.
. Rigidity & hyperthermia may lead to ms necrosis & ++ CPK > 50000.
. Tx -> DANTROLENE (Muscle relaxant).
. FLUPHENAZINE OVERDOSE -> HYPOTHERMIA:
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. High potency "typical" anti-psychotic drug.
. It disrupts thermoregulation & body's shivering mechanism.
. Pts sh'd be advised to avoid prolonged exposure to extreme temperatures.

Dr. Wael Tawfic Mohamed

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