3rd Year Toxicology Core Facts:

Zohair A. Al Aseri MD, FRCPC EM & CCMChairman and Assistant Professor , DEMCollege of Medicine King Saud UniversityConsultant Emergency Medicine and Intensivist King Saud University, Medical City

1-Following drugs can cause Bradycardia (PACED):

Propranolol (beta-blockers), poppies (opiates), propoxyphene, physostigmineAnticholinesterase drugs, antiarrhythmicsClonidine, calcium channel blockersEthanol or other alcohol,Digoxin, digitalis

Following drugs can cause Tachycardia (FAST):

Free base or other forms of cocaine, Anticholinergics, antihistamines, antipsychotics, amphetamines, alcohol withdrawalSympathomimetics (cocaine, caffeine, amphetamines, PCP), solvent abuse, strychnineTheophylline, TCAs, thyroid hormones

Hypothermia (COOLS) may be seen in poisoning with:

Carbon monoxideOpioidsOral hypoglycemics, insulinLiquor (alcohols)Sedative-hypnotics

Hyperthermia (NASA) may seen in poisoning with:

Neuroleptic malignant syndrome, nicotineAntihistamines, alcohol withdrawalSalicylates, sympathomimetics, serotonin syndromeAnticholinergics, antidepressants, antipsychotics

Hypotesion (CRASH) may seen in poisoning with:

Clonidine, calcium channel blockersRodenticides (containing arsenic, cyanide)Antidepressants, aminophylline, antihypertensivesSedative-hypnoticsHeroin or other opiates

Hypertension (CT SCAN) may occur after poisoning with:

CocaineThyroid supplementsSympathomimeticsCaffeineAnticholinergics, amphetaminesNicotine

Poisoning with following may lead to an elevated anion gap:

Methanol, metformin, massive overdosesEthylene glycolTolueneAlcoholic ketoacidosisLactic acidosisAcetaminophen (large overdoses)Cyanide, carbon monoxide, colchicineIsoniazid, iron, ibuprofenDiabetic ketoacidosisGeneralized seizure-producing toxinsAcetylsalicylic acid or other salicylatesParaldehyde, phenformin

Cholinergic toxidrome

(caused by organophosphorus, carbamate, pilocarpine) is characterised by:

Diarrhea, diaphoresisUrinationMiosisBradycardia, bronchosecretionsEmesisLacrimationLethargicSalivation

Nicotinic toxidrome (recalled by days of the week) is characterised by:

Monday: MiosisTuesday: TachycardiaWednesday: WeaknessThursday: TremorsFriday: FasciculationsSaturday: SeizuresSunday: Somnolent

Toxins accessible to haemodialysis:

UremiaSalicylatesTheophyllineAlcohols (isopropanol, methanol), Ethylene glycolBoric acid, barbituratesLithium

Paracetamol (Acetaminophen),

Q; Acetaminophen (paracetamol) can undergo all of the following biotransformation reactions EXCEPT

a. Deaminationb. N-oxidationc. Glucuronidationd. Sulphatione. Glutathione conjugation

Answer a

N-acetyl-p-benzoquinonimine (NAPQI) is the toxic metabolic product of:

a. Acetyl-salisylic acidb. Acetamiophen (paracetamol)c. Mefanemic Acidd. Ibuprofen

Answer b

Q..N-Acetyl cystiene (NAC) is used as antidote for acetaminophen. The decision to use is ideally based on Acetaminophen blood levels measured at:

a. 2 Hours from time of ingestionb. 4 Hours from time of ingestionc. 8 Hours from time of ingestiond. 24 Hours from time of ingestion

Answer b

Salicylic acid (aspirin)

Opioids

ANTIDOTEAntidote Indication (agent)n-acetylcysteineEthanol/fomepizole (4-MP)Oxygen/hyperbaricsNaloxone/nalmefenePhysostigmineAtropine/pralidoxime (2-PAM)Methylene blueNitritesDeferoxamineDimercaprol (BAL)Succimer (DMSA)Fab fragmentsGlucagonSodium bicarbonateCalcium/insulin/dextroseDextrose, glucagon, octreotide

AcetaminophenMethanol/ethylene glycolCarbon monoxideOpioidsAnticholinergicsOrganophosphatesMethemoglobinemiaCyanideIronArsenicLead, mercuryDigoxin, colchicine, crotalidsBeta-blockersTricyclic antidepressantsCalcium channel antagonistsOral hypoglycemic