Updated: 6/12/2019

Toxicology

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Toxicology Drug Introduction
  • Toxicology medications can be broken down into the following categories 
    • metallic poisoning
    • gas poisoning
    • prescription drugs overdose
    • illegal drugs overdose
    • household substance overdose
 
Treatment Poison(s) Notes
Metallic Poisoning
Deferoxamine  
  • Iron
  • Used for aluminum poisoning in renal failure
  • Used in iron overload with repeat transfusions (thalssemia)
  • Iron over load, hemochromatosis
Deferasirox
Prussian blue
  • Cesium
  • Thallium
  • Used in the case of a radioactive incident
Penicillamine
  • Copper (Wilson's disease)
  • Water-soluble form of penicillin
  • Avoid in patients who have penicillin allergy
  • Chelates copper
EDTA
  • Lead
  • Can chelate and deplete calcium ions
Dimercaprol (BAL)
  • Arsenic
  • Lead
  • Mercury
  • Used in conjunction with EDTA for lead poisoning
Succimer
  • Arsenic
  • Lead
  • Mercury
  • Used more commonly in children
Gas Poisoning
100% O2 (consider hyperbaric O2)
  • Carbon monoxide (CO)
  • CO binds with much greater affinity than O2
Amyl and sodium nitrite
  • Cyanide
  • Cyanide found in rodenticides "gopher goitter", released in burning of plastics and wool, and plants such as cassava
  • Cyanide binds Fe3+ of cytochrome oxidase a3 of the electron transport chain (ETC) arresting cellular respiration
  • Nitrites create methemoglobin (Fe3+) intentionally to compete for and bind cyanide so it does not get to the ETC
Sodium thiosulfate
Hydroxocobalamin 
Prescription Drug Overdose
N-acetylcysteine 
  • Acetaminophen   
  • Best if given with 8-10 hours
  • Also a mucolytic
Sodium bicarbonate
  • Salicylates
  • Tricyclic antidepressants (TCA)
  • First sign of OD is hyperventilation and respiratory alkalosis
  • Do not give with physostigmine
  • First check an EKG for QRS prolongation, then treat with sodium bicarbonate in TCA overdose
Potassium iodide
  • Radioactive iodine (I-131)
  • Given to prevent the uptake of I-131
Ammonium chloride (NH4Cl, acidic)
  • Amphetamines (basic)
  • Eliminates amphetamines by acidifying urine which results in a charged amphetamine molecule which is excreted

Atropine

  • Anticholinesterases 
  • Organophosphates 
  • Sarin (nerve gas)
  • Removed contaminated clothing if patient was exposed to insectisides
  • Atropine as an anti-cholinergic and combats the excess Ach
  • Pralidoxime if given in a timely manner regenerates acetylcholinesterase reversing the condition (timing is critical)
Pralidoxime
Physostigmine  
  • Antimuscarinic
  • Anticholinergic agents
  • Atropine overdose
  • Do not give if patient may have TCA OD as it may lead to heart block or asystole
  • Tertiary amine that can cross the blood brain barrier and reverse anticholinergic effects in the CNS
Naloxone/naltrexone
  • Opioids  
  • Precipitates withdrawal symptoms in chronic opioid users
  • Use in patients with respiratory depression
  • Opioid withdrawal will NOT kill a patient it is just unpleasant
Flumazenil
  • Benzodiazepines
  • May cause seizures in addicted benzodiazepine users
  • Rarely used with benzodiazepine overdose unless concerned for respiratory depression
  • Otherwise let the patient "sleep off" the benzodiazepines 
Glucagon 
  • β-blockers 
  • glucagon, insulin, dextrose, calcium, lipid emulsion, and epinephrine are antidote 
β-blockers (propranolol, esmolol)
  • Theophylline
  • OD symptoms are due to β2 activation: hypotension, tachycardia, hypokalemia, hyperglycemia

Digitalis antibody, lidocaine, Mg2+

  • Digitalis
  • Visual and GI symptoms classically seen in overdose
Methylene blue
  • Methemoglobin
  • Iron in the heme molecule is Fe3+ which cannot bind oxygen until it is reduced to Fe2+ by treatment
Vitamin C
Aminocaproic acid
  • tPA
  • Streptokinase
-
Vitamin K
  • Warfarin
  • Bridge with heparin as warfarin can deplete protein C and S first (anticoagulants) leading to an initial prothrombotic state
Plasma infusion

Protamine

  • Heparin
  • Protamine is a highly positively charged peptide which strongly binds to the negatively charged heparin
Argatroban
  • Direct thrombin inhibitor 
Household Substance Overdose
Ethanol IV infusion
  • Antifreeze (ethylene glycol) 
  • Methanol 
  • Think antifreeze when ingested substance is said to be sweet and individual appears "drunk without the typical smell of alcohol"
  • Fomepizole should be followed by dialysis
Fomepizole  
Caustic fluid  
  • Perform endoscopy  
  • Irrigation x 15mins for ocular exposure
  • Do not try to induce vomiting in patient
  • Could perhaps use small amount of diluent
Other
Antivenin
  • Rattlesnake bite
-


Iron Poisoning
  • Most deaths due to iron poisoning (ingestion of iron tablets) occur in children between 12 - 24 months of age
  • Symptoms occur within 30 min to several hours 
    • abdominal pain, diarrhea, vomiting, cyanosis, drowsiness, and hyperventilation resulting from acidosis
  • Death can result in six hours, but an apparent recovery may happen from 6 - 12 hours with death ensuing in the next 12 hours
  • If not treated early, damage to the stomach can lead to pyloric stenosis or gastric scarring
  • Early treatment with deferoxamine can reduce mortality significantly from 45% to 1%
  • Mechanism of action of iron related damage
    • iron overdose results in the peroxidation of membrane lipids leading to cell death
Methanol and Ethylene Glycol Toxicity
  • Each are competitive substrates for alcohol dehydrogenase (ADH) 
  • Methanol
    • metabolized by ADH to formaldehyde followed by aldehyde dehydrogenase to form formic acid which is toxic to the optic nerve
      • early toxicity of formic acid is metabolic acidosis by formic acid itself
      • formic acid also binds to cytochrome oxidase blocking oxidative phosphorylation
      • resulting in lactic acidosis which is the latter and leading cause of the metabolic acidosis
    • signs and symptoms appear within 12 - 24 hours after ingestion
      • CNS depression
        • methanol acts similarly as ethanol as a CNS depressant
      • metabolic acidosis
      • visual changes
        • blindness occurs with as little as 30 mL and death at 100 mL ingestion
  • Ethylene glycol
    • colorless, odorless, sweet-tasting liquid
    • toxicity derives from the hepatic oxidation of ethylene glycol to oxalic acid
      • degraded by same pathway as methanol
        • the glycolic acid produced by aldehyde dehydrogenase is converted in oxalic acid
      • oxalic acid binds calcium and forms calcium oxalate crystals that damage the heart, brain, lungs, kidneys
    • signs and symptoms develop in stages after ingestion
      • first stage: 0.5 - 12 hours
        • stronger inebriant than methanol and ethanol causing mild depression of CNS resulting in seizures and coma
        • patients appear "drunk without smelling like alcohol"
        • within 4 - 12 hours, calcium oxalate crystals deposit in the brain causing CNS toxicity, cerebral edema, meningismus (nuchal rigidity, photophobia, headache without infection or inflammation)
        • hypocalcemia occurs due to binding of calcium by oxalic acid and can cause prolonged QT, arrhythmias, myocardial depression
      • second stage: 12 - 24 hours
        • tachypnea occurs to offset the metabolic acidosis due to the toxic metabolites produced
        • multiorgan failure (CHF, lung injury, myositis) due to widespread crystal deposition
        • NOTE: most deaths occur in the second stage
      • third stage: 24 - 72 hours
        • acute anuric renal failure from crystal deposition but full recovery occurs within weeks to months
  • Treatment
    • IV ethanol (used historically)
      • competitive substrate for ADH and has greater affinity for ADH than methanol and ethylene glycol
    • fomepizole (best initial therapy) 
      • inhibits ADH preventing production of toxic metabolites
      • should be followed by dialysis
Miscellaneous
  • When behavioral changes are recognized in adolescents screen for substance use 
Seafood-Associated Toxins
  • Tetrodotoxin
  • Scombroid
  • Ciguatoxin 
    • heat-stable neurotoxin
    • inhibits voltage gated sodium channels
    • symptoms
      • GI (vomiting, diarrhea, and abdominal pain)
      • neurologic (perioral paresthesias, pruritus, metallic taste, painful dentition, sensation that teeth are loose, temperature related dysesthesias, and blurry vision)
      • cardiac (bradycardia, heart block, and hypotension)
 

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Questions (28)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M2.PH.4733) A 65-year-old man arrives to the emergency department (ED) complaining of pain and swelling in his right leg. The patient reports he recently underwent a total hip replacement. His past medical history is significant for hypertension and diabetes. His current medications include aspirin, lisinopril, metformin, and atorvastatin. On arrival, his temperature is 99°F (37.2°C), blood pressure is 135/82 mmHg, pulse is 88/minute, and oxygen saturation is 99% O2. He denies chest pain or shortness of breath. On physical exam, his right leg appears moderately erythematous, swollen, and is tender to palpation. Other physical exam findings are negative.

A complete blood count (CBC) was performed with the following findings:

Hemoglobin: 13.0 g/dL
Leukocyte count: 6500/mm^3
Platelet count: 150,000/mm^3

The appropriate anti-coagulation therapy is started. Seven days later the patient arrives back to the ED complaining of crushing substernal chest pain. An electrocardiogram is performed and is shown in Figure A.

A CBC was performed with the following findings:

Hemoglobin: 13.5 g/dL
Leukocyte count: 8500/mm^3
Platelet count: 58,000/mm^3
INR: 2.5
aPTT: 34 seconds
Fibrinogen level: 200 mg/dL
Troponin T: 0.2 ng/mL

On physical exam, the right leg is again swollen and tender to palpation. However, a new lesion has also formed, as shown in Figure B. In addition to sending the patient for cardiac catherization, what is the most appropriate next step in management? Review Topic

QID: 108625
FIGURES:
1

Administer alteplase

0%

(0/19)

2

Administer a platelet infusion

0%

(0/19)

3

Start plasmapheresis

0%

(0/19)

4

Discontinue warfarin and maintain heparin

47%

(9/19)

5

Discontinue heparin and start argatroban

53%

(10/19)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(M2.PH.4817) A 32-year-old female is brought to the emergency department by her boyfriend for confusion. He reports that the patient had told him that she was staying home from work because of her allergies, which had been bothering her all week. When the patient’s boyfriend arrived home, he found the patient agitated and disoriented. He reports that when he tried to talk to her, she was "out of it" and kept asking for water. The boyfriend also reports that the patient recently received a negative evaluation at work and that she has been stressed. The patient’s past medical history is otherwise significant for ADHD, depression, and seasonal allergies. Her medications include amphetamine, desipramine, intranasal ipratropium, and diphenhydramine as needed. Her temperature is 102°F (38.9°C), blood pressure is 122/82 mmHg, pulse is 132/min, and respirations are 18/min with an oxygen saturation of 98% O2 on room air. Upon physical exam, the patient is agitated and grabbing at the air. She also appears flushed, her pupils are dilated, and she has scattered urticaria. The patient's EKG can be seen in Figure A. Which of the following is the most appropriate treatment for this patient? Review Topic

QID: 109380
FIGURES:
1

Activated charcoal

6%

(2/33)

2

Atropine

3%

(1/33)

3

Physostigmine

36%

(12/33)

4

Pyridostigmine

15%

(5/33)

5

Sodium bicarbonate

33%

(11/33)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(M2.PH.4678) A 66-year-old man presents to his primary care physician with abdominal pain in the setting of progressively worsening constipation. He complains of epigastric pain that waxes and wanes, and expressed concern that he has not defecated for the past 5 days. Upon further questioning, he relates that he has been taking three of his wife's multivitamins each day for the past three weeks to "combat a cold." Vital signs are within normal limits. Physical exam reveals an abdomen with nonspecific tenderness to deep palpation without rebound tenderness, hyperpercussion, or flank tenderness. What is the most likely cause of his symptoms? Review Topic

QID: 107272
1

Magnesium overdose

0%

(0/0)

2

Iron overdose

0%

(0/0)

3

Potassium overdose

0%

(0/0)

4

Folic acid overdose

0%

(0/0)

5

Zinc overdose

0%

(0/0)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(M2.PH.146) A mother presents to the family physician with her 16-year-old son. She explains, "There's something wrong with him doc. His grades are getting worse, he's cutting class, he's gaining weight, and his eyes are often bloodshot." Upon interviewing the patient apart from his mother, he seems withdrawn and angry at times when probed about his social history. The patient denies abuse and sexual history. What initial test should be sent to rule out the most likely culprit of this patient's behavior? Review Topic

QID: 105816
1

Complete blood count

0%

(0/0)

2

Blood culture

0%

(0/0)

3

Sexually transmitted infection (STI) testing

0%

(0/0)

4

Urine toxicology screen

0%

(0/0)

5

Slit eye lamp testing

0%

(0/0)

M2

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PREFERRED RESPONSE 4

(M2.PH.4689) A 45-year-old with a past history of being admitted for alcohol withdrawal and acute alcohol toxicity presents to the emergency department with ataxia. He is stuporous and does not respond to questions appropriately, often yelling and falling down. On exam, the patient has visual impairment and cannot read the Snellen chart correctly. Figure A shows his retina on ophthalmologic exam. His electrolytes are Na 140, K 3.0, Cl 95, HCO3 15, BUN 27, Cr 1.2. Which of the following can be administered intravenously to treat this patient in addition to intravenous fluids, thiamine, vitamin B12 and folate? Review Topic

QID: 107516
FIGURES:
1

Naloxone

0%

(0/2)

2

Sodium bicarbonate

0%

(0/2)

3

Ethanol

100%

(2/2)

4

Flumazenil

0%

(0/2)

5

Glucagon

0%

(0/2)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(M3.PH.35) A man is brought into the emergency department by the police department. The officer state that the man has been arrested multiple times for public alcohol intoxication, but recently became homeless. On exam, the man is behaving erratically. His vitals are all within normal limits. He appears confused and has a slurred speech. On gait exam, the patient is ataxic and cannot stand without support for more than a few seconds. Labs return with the following values: Na 140, K 4, Cl 106, BUN 8, Cr 2. His ABG has pH 7.3, PaCO2 13mm, PaO2 130mm, HCO3 7. His urinalysis is shown in Figure 1. Blood salicylate levels return as normal. While you await other diagnostic tests, which of the following should be administered next to treat this patient? Review Topic

QID: 102976
FIGURES:
1

Ethanol

0%

(0/0)

2

Naltrexone

0%

(0/0)

3

Naloxone

0%

(0/0)

4

Flumazenil

0%

(0/0)

5

Fomepizole

0%

(0/0)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(M2.PH.11) A 34-year-old male is brought to the emergency department by paramedics after being found down on the sidewalk. The paramedics are unable to provide any further history and the patient in unresponsive. On exam, the patient's vitals are: T: 36 deg C, HR: 65 bpm, BP: 100/66, RR: 4, SaO2: 96%. The emergency physician also observes the findings demonstrated in figures A and B. This patient most likely overdosed on which of the following? Review Topic

QID: 105648
FIGURES:
1

Cocaine

0%

(0/22)

2

Marijuana

0%

(0/22)

3

Alcohol

0%

(0/22)

4

Heroin

95%

(21/22)

5

Phencyclidine

0%

(0/22)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(M2.PH.8) A 4-year-old boy is brought to the emergency department by his mother with stomach pain and vomiting for the last 7 hours. His mother is pregnant and states that she is taking nutritional supplements prescribed by her doctor. She mentions that her son ingested some supplements after confusing them for candy. Arterial blood gas was drawn, and he is found to have a pH of 7.2. Abdominal X-ray is shown in Figure A. After starting IV fluids, what other treatments should this patient receive? Review Topic

QID: 105645
FIGURES:
1

Ipecac

4%

(1/25)

2

CaEDTA

0%

(0/25)

3

Hemodialysis

4%

(1/25)

4

N-acetylcysteine

0%

(0/25)

5

Deferoxamine

88%

(22/25)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(M2.PH.16) A 46-year-old homeless male presented to the emergency department intoxicated, but a serum ethanol level is normal. Results from a urine study are shown in Figure A. Which of the following findings would you most likely expect in this patient?

I: elevated serum anion gap
II: elevated serum osmolar gap
III: decreased serum pH Review Topic

QID: 104290
FIGURES:
1

I only

4%

(1/25)

2

I and II

4%

(1/25)

3

I and III

36%

(9/25)

4

I, II, and III

44%

(11/25)

5

II and III

4%

(1/25)

M2

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PREFERRED RESPONSE 4
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