Toxicological Jeopardy

ToxicologicalToxicological JeopardyJeopardy

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Street Street Drugs And Drugs And SalicylatesSalicylates

Picture Picture ThatThat

ToxicToxic

TidbitsTidbits

Final JeopardyFinal Jeopardy

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Antidotes Antidotes And And

Anecdotes Anecdotes

Name That Name That ToxidromeToxidrome

400400

Toxic TidbitsToxic Tidbits

Acute Lithium toxicity is characterized Acute Lithium toxicity is characterized

by which of the following?by which of the following?

A)A) Seizures, hypotension, arrhythmiasSeizures, hypotension, arrhythmias

B)B) Rotary nystagmus, Agitation, Rotary nystagmus, Agitation, hypertensionhypertension

C)C) GI symptoms, tremor, GI symptoms, tremor, hyprerreflexiahyprerreflexia

D)D) Hypoglycemia, tremor, AMSHypoglycemia, tremor, AMS

Toxic Tidbits $100 (1 of 1)


Overdose of which of the following isOverdose of which of the following is

most likely to result in a metabolic most likely to result in a metabolic

acidosis?acidosis?

A)A) CaptoprilCaptopril

B)B) FurosemideFurosemide

C)C) AcetaminophenAcetaminophen

D)D) MetforminMetformin


Alkaline diuresis enhances the Alkaline diuresis enhances the excretionexcretion

of all of the following substancesof all of the following substances

Except?Except?

A)A) PhenobarbitalPhenobarbital

B)B) ChlorpropamideChlorpropamide

C)C) SalicylateSalicylate

D)D) PentobarbitalPentobarbital



PentobarbitalPentobarbital

All the other substances except All the other substances except pentobarbital can be enhanced by pentobarbital can be enhanced by urinary alkalinizationurinary alkalinization

Increasing the ionized form of Increasing the ionized form of weak acids increases their water weak acids increases their water solubility, therefore, more solubility, therefore, more eliminated in urine rather than eliminated in urine rather than distributing to tissuesdistributing to tissuesH + + A -HA



After an overdose of captopril, which After an overdose of captopril, which ofof

the following electrolyte disturbancesthe following electrolyte disturbances

Is most likely to occur?Is most likely to occur?

A)A) HypokalemiaHypokalemia

B)B) HypocalcemiaHypocalcemia

C)C) HypercalcemiaHypercalcemia

D)D) HyperkalemiaHyperkalemia


Angiotensinogen

Angiotensin I

Angiotensin IINE release

Aldosterone

Na+

Resorption

ADH

Blood Pressure

Renin

ACE I

Bradykinin

Inactive Peptide

PG synthesis

Vasodilation

Peripheral Vascular

ResistanceVasoconstriction Na+ Resorption K+ Excretion H2O Resorption

H2O Resorption

X X

Blood Pressure

Substance P



Serotonin Syndrome is most likely toSerotonin Syndrome is most likely to

occur with combination of which ofoccur with combination of which of

the following?the following?

A)A) Prozac and AmbienProzac and Ambien

B)B) Lexapro and DemerolLexapro and Demerol

C)C) Linezolid and EtomidateLinezolid and Etomidate

D)D) Lithium and Valproic AcidLithium and Valproic Acid



A 3 y/o female presents with a BG level A 3 y/o female presents with a BG level

of 14mg/dl. Labs show an elevated of 14mg/dl. Labs show an elevated

prolactin, GH, insulin and C peptide, prolactin, GH, insulin and C peptide,

UDS (-) What was the child exposed to?UDS (-) What was the child exposed to?

A)A) RosiglitazoneRosiglitazone

B)B) MetforminMetformin

C)C) GlyburideGlyburide

D)D) insulininsulin


Sulfonylurea Sulfonylurea MechanismMechanism

Pancreatic cell

Sulfonylurea receptor

sulfonylurea

KATP

Ca

I I

I

I

insulin

K+



(+) anion gap, (-) osmol gap, (+)(+) anion gap, (-) osmol gap, (+)

ketones is seen with which of the ketones is seen with which of the

Following?Following?

A)A) Alcoholic KetoacidosisAlcoholic Ketoacidosis

B)B) Ethylene GlycolEthylene Glycol

C)C) IsopropanolIsopropanol

D)D) MethanolMethanol


Antidotes And Antidotes And AnecdotesAnecdotes

A 48 year old male develops chest pain, A 48 year old male develops chest pain,

dyspnea and cyanosis shortly after the dyspnea and cyanosis shortly after the

administration of Benzocaine. Which of the administration of Benzocaine. Which of the

following should be administered?following should be administered?

A) NitroglycerinA) Nitroglycerin

B) Methylene BlueB) Methylene Blue

C) PhysiostygmineC) Physiostygmine

D) NarcanD) Narcan

Antidotes And Anecdotes $100 (1 of 2)

Antidotes And Antidotes And AnecdotesAnecdotes MedicationsMedications

– Amyl nitriteAmyl nitrite– BenzocaineBenzocaine– DapsoneDapsone– LidocaineLidocaine– NTGNTG– NitroprussideNitroprusside– PhenacetinPhenacetin– PhenazopyridinePhenazopyridine– PrilocainePrilocaine– QuinonesQuinones– SulfonamidesSulfonamides

Chemical AgentsChemical Agents– Anline dyesAnline dyes– Butyl nitriteButyl nitrite– ChlorobenzeneChlorobenzene– FiresFires– NitratesNitrates– Isobutyl nitriteIsobutyl nitrite– NapthaleneNapthalene– NitrophenolNitrophenol– Nitrous gasesNitrous gases– Silver nitrateSilver nitrate– TrinitrotolueneTrinitrotoluene



A 16 year old male ingested 20 (200mg) A 16 year old male ingested 20 (200mg)

INH tablets prior to ED arrival. He is INH tablets prior to ED arrival. He is

actively seizing, what course of action actively seizing, what course of action

should be taken?should be taken?

A)A) Administer IV valium 5mgAdminister IV valium 5mg

B)B) Administer IV pyridoxine 2 gramsAdminister IV pyridoxine 2 grams

C)C) Administer IV PHB 20mg/kg IVAdminister IV PHB 20mg/kg IV

D)D) Administer IV pyrodoxine 4 gramsAdminister IV pyrodoxine 4 grams


MECHANISM OF INH MECHANISM OF INH TOXICITYTOXICITY

GLUTAMIC ACID GABA

GLUTAMIC ACID DECARBOXYLASE

PYRIDOXAL 5` PHOSPHATE

PYRIDOXINE

PYRIDOXINE PHOSPHOKINASE

INH INHIBITSINH INACTIVATES

URINARY ELIMINATION

INH ENHANCES



Which of the following is NOT a Which of the following is NOT a

mechanism by which N-acetylcysteine mechanism by which N-acetylcysteine

works to prevent APAP induced works to prevent APAP induced

hepatotoxicity? hepatotoxicity?

A)A) Precursor for Glutathione synthesisPrecursor for Glutathione synthesis

B)B) A substrate for sulfonationA substrate for sulfonation

C)C) Directly Binds NAPQUIDirectly Binds NAPQUI

D)D) Increase CYP2E1 activityIncrease CYP2E1 activity




Which of the following is not a Which of the following is not a

component of the cyanide antidote component of the cyanide antidote kit?kit?

A)A) Amyl nitrateAmyl nitrate

B)B) Amyl nitriteAmyl nitrite

C)C) Sodium nitriteSodium nitrite

D)D) Sodium thiosulfateSodium thiosulfate




Side effects of administration of Side effects of administration of

Deferoxamine include which of the Deferoxamine include which of the

Following?Following?

A) HypotensionA) Hypotension

B) ARDSB) ARDS

C) Increased risk or Yersinia InfectionsC) Increased risk or Yersinia Infections

D All of the aboveD All of the above


DeferoxamineDeferoxamine Challenge Challenge

Dose Administered



How many vials of Digibind should be How many vials of Digibind should be

given to a 70kg male with acute given to a 70kg male with acute digoxindigoxin

Toxicity and a level of 7ng/mL?Toxicity and a level of 7ng/mL?

A) 4 vialsA) 4 vials

B) 5 vialsB) 5 vials

C) 6 vialsC) 6 vials

D) 10 vialsD) 10 vials


Inhibition of Na-K-ATPase

[Nai+]

[Ko+]

hyperkalemia

[Cai++]

skeletal muscleheart

contractility

premature beatsescape rhythmsV-tach, V-fib

firing

baroceptors

vagal tone

bradycardia, AV blocks, asystole

automoticity

rise in Nai+

and Cai++

rise in Nai+

and Cai++

Picture ThatPicture That

Picture That $100 (1 of 4)

Name the toxin



Name the toxin



Name the toxin

Anticholinergic PlantsAnticholinergic Plants– Atropa belladonnaAtropa belladonna (deadly nightshade) (deadly nightshade) – Cestrum nocturnumCestrum nocturnum (night blooming jessamine) (night blooming jessamine) – Datura suaveolensDatura suaveolens (angel’s trumpet) (angel’s trumpet) – Datura stramoniumDatura stramonium (jimson weed) (jimson weed) – Hyoscyamus nigerHyoscyamus niger (black henbane) (black henbane) – Lantana camaraLantana camara (red sage) (red sage) – Solanum carolinensisSolanum carolinensis (wild tomato) (wild tomato) – Solanum dulcamaraSolanum dulcamara (bittersweet) (bittersweet) – Solanum pseudocapsicumSolanum pseudocapsicum (Jerusalem cherry) (Jerusalem cherry) – Solanum tuberosumSolanum tuberosum (potato) (potato)– Arctium lappaArctium lappa (burdock root) (burdock root)

Jimson Weed(datura stramonium)



Name the toxin



Name the toxin



Name the toxin



Name the toxin



Name the toxin


Picture That Picture That



Ingestion/exposure to the previously Ingestion/exposure to the previously

pictured plant is most likely to pictured plant is most likely to result in?result in?

A)A) HyponatremiaHyponatremia

B)B) Contact DermatitisContact Dermatitis

C)C) ArrhythmiasArrhythmias

D)D) FlatulenceFlatulence






Which of the following should be Which of the following should be

administered to the patient after an administered to the patient after an

unknown overdose with the previous unknown overdose with the previous

EKG? EKG?

A)A) PhysiostigminePhysiostigmine

B)B) Calcium SaltsCalcium Salts

C)C) GlucagonGlucagon

D)D) Sodium BicarbonateSodium Bicarbonate




Which toxin is found in the pictured Which toxin is found in the pictured

mushroom?mushroom?

A)A) Ibotenic acidIbotenic acid

B)B) PsilocybinPsilocybin

C)C) GyromitrinGyromitrin

D)D) muscarinemuscarine





What is the name of the toxin What is the name of the toxin found in found in

the pictured fish?the pictured fish?

A)A) CigutoxinCigutoxin

B)B) Domoic acidDomoic acid

C)C) TetrodotoxinTetrodotoxin

D)D) ScrombroidScrombroid


SalicylatesSalicylates

The minimal toxic dose (mg/kg) of The minimal toxic dose (mg/kg) of

salicylates is?salicylates is?

A)A) 100100

B)B) 5050

C)C) 2525

D)D) 150150

Salicylates $100 (1 of 2)

Salicylates: Toxic DoseSalicylates: Toxic Dose

Therapeutic Range: 10–15 mg/kgTherapeutic Range: 10–15 mg/kg Mild Toxicity:Mild Toxicity: 150 mg/kg150 mg/kg Moderate Toxicity: 150-300 Moderate Toxicity: 150-300

mg/kgmg/kg Severe Toxicity: > 300 mg/kgSevere Toxicity: > 300 mg/kg


Street DrugsStreet Drugs

An 18 year old female presents to theAn 18 year old female presents to theEmergency Department obtunded. She is Emergency Department obtunded. She is intubated but self extubates shortly after. intubated but self extubates shortly after.

She She is now awake, alert and appropriate. Which is now awake, alert and appropriate. Which

of of the following may be responsible?the following may be responsible?A)A) GHBGHBB)B) Gamma-butyrolactoneGamma-butyrolactoneC)C) 1,4-butanediol1,4-butanediolD)D) All of the above may be responsibleAll of the above may be responsible

Street Drugs $200 (1of 3)

Tissue lactonases

Nonenzymatic hydrolysis

B-oxidation

Trans-4-hydroxycrotonic acid GHB-receptor

GHB dehydrogenaseGABA transaminaseGABA transaminase

Succinic semialdehyde reductase

GABAB

Receptor


NAD NADH

Alcohol Dehydrogenase

HO

Aldehyde dehydrogenase

NAD

NADH

Trans-4-hydroxycrotonic acid B-oxidation

GHB-receptor GABAB Receptor


Salicylates Salicylates

As a salicylate poisoned patient becomes As a salicylate poisoned patient becomes

more acidotic, more salicylate will exist in more acidotic, more salicylate will exist in

the ____ form and the volume of the ____ form and the volume of

distribtuion ____.distribtuion ____.

A)A) Ionized, decreasesIonized, decreases

B)B) Unionized, increasesUnionized, increases

C)C) Unionized, decreasesUnionized, decreases

D)D) Ionized, increasesIonized, increases



Volume of distribution (VVolume of distribution (Vdd))– Apparent volume the drug is dissolved inApparent volume the drug is dissolved in– Measured in Liters or Liters/KgMeasured in Liters or Liters/Kg

not a real volumenot a real volume



Hyperthermia, occuring in salicylate Hyperthermia, occuring in salicylate

toxicity, is secondary to?toxicity, is secondary to?

A)A) Inhibition of the krebs cycleInhibition of the krebs cycle

B)B) Uncoupling of oxidative Uncoupling of oxidative phosphorylationphosphorylation

C)C) Stimulation of lipid metabolismStimulation of lipid metabolism

D)D) Increasing capillary permeabilityIncreasing capillary permeability



A patient presents to the Emergency A patient presents to the Emergency Department with agitation, a sense of Department with agitation, a sense of persecution and rotary nystagmus. Exposure persecution and rotary nystagmus. Exposure to which of the following can cause thesesto which of the following can cause thesessymptoms. symptoms. A)A) A preparation containing CamphorA preparation containing CamphorB)B) A preparation containing PseudophedA preparation containing PseudophedC)C) A preparation containing DXMA preparation containing DXMD)D) A preparation containing EthanolA preparation containing Ethanol




Which of the following is more likely to Which of the following is more likely to

be seen in acute vs chronic salicylatebe seen in acute vs chronic salicylate

toxicity?toxicity?

A)A) Neurological symptomsNeurological symptoms

B)B) Gastrointestinal SymptomsGastrointestinal Symptoms

C)C) Renal insufficiencyRenal insufficiency

D)D) Elevated LFT’sElevated LFT’s


ACUTEACUTE CHRONICCHRONIC

INCIDENCEINCIDENCE 85%85% 15%15%

AGEAGE YOUNGYOUNG OLDOLD

INTENTION ODINTENTION OD OFTENOFTEN RARERARE

COINGESTIONCOINGESTION OFTENOFTEN RARERARE

PSYCH. HXPSYCH. HX COMMONCOMMON UNCOMMON UNCOMMON

COMORBIDITYCOMORBIDITY RARERARE COMMONCOMMON

TIME TO DXTIME TO DX EARLYEARLY LATELATE

ABNORMAL PROTIMEABNORMAL PROTIME YESYES YESYES

RENAL FXNRENAL FXN NORMALNORMAL OFTEN ABNORMALOFTEN ABNORMAL

HEPATIC FXNHEPATIC FXN NORMALNORMAL OFTEN ABNORMALOFTEN ABNORMAL

NEUROLOGIC NEUROLOGIC SYMPTOMSSYMPTOMS

OCCASSIONALLYOCCASSIONALLY COMMONCOMMON

PULMONARY PULMONARY SYMPTOMSSYMPTOMS

RARERARE COMMON (50%)COMMON (50%)

GI SYMPTOMSGI SYMPTOMS VERY COMMONVERY COMMON RARERARE

MORBIDITYMORBIDITY 16%16% 30%30%

MORTALITYMORTALITY 2%2% 25%25%



A patient presents to the Emergency A patient presents to the Emergency

Department with profound hyponatremia and Department with profound hyponatremia and

seizures after attending a RAVE party. Whichseizures after attending a RAVE party. Which

of the following is the most likely causeof the following is the most likely cause

A)A) GHBGHB

B)B) CocaineCocaine

C)C) MDMA (Ectascy)MDMA (Ectascy)

D)D) RohypnolRohypnol

Street Drugs $750 (1 of 1)

Name That ToxidromeName That Toxidrome

An increased heart rate, dry flushed An increased heart rate, dry flushed

skin, dilated pupils agitation and urinary skin, dilated pupils agitation and urinary

retention are seen in which of the retention are seen in which of the following?following?

A)A) Cholinergic ToxidromeCholinergic Toxidrome

B)B) Anticholinergic ToxidromeAnticholinergic Toxidrome

C)C) Sympathomimetic ToxidromeSympathomimetic Toxidrome

D)D) Sedative Hypnotic ToxidromeSedative Hypnotic Toxidrome

Name That Toxidrome $100 (1 of 1)


Ingestion of which of the following Ingestion of which of the following is is

most likely to cause dilated pupils?most likely to cause dilated pupils?

A)A) RisperdalRisperdal

B)B) MeperidineMeperidine

C)C) AmytriptyllineAmytriptylline

D)D) LexaproLexapro


The most reliable way to differentiate The most reliable way to differentiate

the difference between anticholinergic the difference between anticholinergic

and sympathomimetic toxidrome are:and sympathomimetic toxidrome are:

A) Dilated pupils, agitationA) Dilated pupils, agitation

B) Diaphoresis, urinary retentionB) Diaphoresis, urinary retention

C) Flushed skin, hyperthermiaC) Flushed skin, hyperthermia

D) Visual hallucinations, pressured D) Visual hallucinations, pressured speechspeech



Which of the following is capable of Which of the following is capable of

producing a toxdrome similar to the producing a toxdrome similar to the

opioid toxidrome?opioid toxidrome?

A)A) GeodonGeodon

B)B) ClonidineClonidine

C)C) ReglanReglan

D)D) PropofolPropofol




The odor described in a patient The odor described in a patient exposedexposed

to Organophosphate insecticides is?to Organophosphate insecticides is? Bitter AlmondsBitter Almonds Burnt RopeBurnt Rope GarlicGarlic SulfurSulfur



Exposure to which of the following Exposure to which of the following

is capable of producing muscle is capable of producing muscle

fasiculations, weakness and respiratory fasiculations, weakness and respiratory

distress?distress?

A)A) China-Berry TreeChina-Berry Tree

B)B) GermaniumGermanium

C)C) Nicotine containing plantsNicotine containing plants

D)D) Grayanotoxin containing plantsGrayanotoxin containing plants


Final JeopardyFinal Jeopardy

In the course of treatment of a patient with In the course of treatment of a patient with

Ethylene Glycol Toxicity, which of the Ethylene Glycol Toxicity, which of the

following may be used as an adjunct to following may be used as an adjunct to

decrease the production of Oxalic Acid?decrease the production of Oxalic Acid?

A)A) ThiamineThiamine

B)B) Folic AcidFolic Acid

C)C) NiacinNiacin

D)D) MagnseiumMagnseium

(CH2OH)2

CH2OHCHO

Ethylene glycol

Glycoaldehyde

CH2OHCOOH Glycolic Acid

CHOCOOH Glyoxylic Acid

Glycine + Benzoic Acid

Hippuric Acid

Oxalic Acid

Alpha-hydroxy-beta-ketoadipic acid

thiamine

Mg++

B6

ADH

ADH

ADH

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Toxicological Jeopardy