Toxicological Jeopardy

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Toxicological Jeopardy
2
Street Drugs And Salicylates
Picture That
Toxic Tidbits
Antidotes And Anecdotes
Name That Toxidrome
100
100
100
100
100
200
200
200
200
200
300
300
300
300
300
400
400
400
400
400
500
500
500
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750
750
750
750
750
Final Jeopardy
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Toxic Tidbits

• Acute Lithium toxicity is characterized
• by which of the following?
• Seizures, hypotension, arrhythmias
• Rotary nystagmus, Agitation, hypertension
• GI symptoms, tremor, hyprerreflexia
• Hypoglycemia, tremor, AMS

Toxic Tidbits 100 (1 of 1)
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Toxic Tidbits

• Overdose of which of the following is
• most likely to result in a metabolic
• acidosis?
• Captopril
• Furosemide
• Acetaminophen
• Metformin

Toxic Tidbits 200 (1 of 1)
5
Toxic Tidbits

• Alkaline diuresis enhances the excretion
• of all of the following substances
• Except?
• Phenobarbital
• Chlorpropamide
• Salicylate
• Pentobarbital

Toxic Tidbits 300 (1 of 2)
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Pentobarbital

• All the other substances except pentobarbital can
  be enhanced by urinary alkalinization
• Increasing the ionized form of weak acids
  increases their water solubility, therefore, more
  eliminated in urine rather than distributing to
  tissues

H A -
HA
Toxic Tidbits 300 (2 of 2)
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Toxic Tidbits

• After an overdose of captopril, which of
• the following electrolyte disturbances
• Is most likely to occur?
• Hypokalemia
• Hypocalcemia
• Hypercalcemia
• Hyperkalemia

Toxic Tidbits 300 (1 of 2)
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Angiotensinogen
Substance P
Renin
PG synthesis
Bradykinin
Angiotensin I
X
X
ACE I
Angiotensin II
NE release
Inactive Peptide
Vasodilation
Aldosterone
ADH
Peripheral Vascular Resistance
H2O Resorption
Na Resorption K Excretion H2O Resorption
Na Resorption
Vasoconstriction
Blood Pressure
Blood Pressure
Toxic Tidbits 300 (2 of 2)
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Toxic Tidbits

• Serotonin Syndrome is most likely to
• occur with combination of which of
• the following?
• Prozac and Ambien
• Lexapro and Demerol
• Linezolid and Etomidate
• Lithium and Valproic Acid

Toxic Tidbits 400 (1 of 1)
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Toxic Tidbits

• A 3 y/o female presents with a BG level
• of 14mg/dl. Labs show an elevated
• prolactin, GH, insulin and C peptide,
• UDS (-) What was the child exposed to?
• Rosiglitazone
• Metformin
• Glyburide
• insulin

Toxic Tidbits 500 (1 of 2)
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Sulfonylurea Mechanism
sulfonylurea
Ca
KATP
Sulfonylurea receptor
I
K
I
I
I
Pancreatic ? cell
insulin
Toxic Tidbits 500 (2 of 2)
12
Toxic Tidbits

• () anion gap, (-) osmol gap, ()
• ketones is seen with which of the
• Following?
• Alcoholic Ketoacidosis
• Ethylene Glycol
• Isopropanol
• Methanol

Toxic Tidbits 750 (1 of 1)
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Antidotes And Anecdotes

• A 48 year old male develops chest pain,
• dyspnea and cyanosis shortly after the
• administration of Benzocaine. Which of the
• following should be administered?
• A) Nitroglycerin
• B) Methylene Blue
• C) Physiostygmine
• D) Narcan

Antidotes And Anecdotes 100 (1 of 2)
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Antidotes And Anecdotes

• Medications
• Amyl nitrite
• Benzocaine
• Dapsone
• Lidocaine
• NTG
• Nitroprusside
• Phenacetin
• Phenazopyridine
• Prilocaine
• Quinones
• Sulfonamides

• Chemical Agents
• Anline dyes
• Butyl nitrite
• Chlorobenzene
• Fires
• Nitrates
• Isobutyl nitrite
• Napthalene
• Nitrophenol
• Nitrous gases
• Silver nitrate
• Trinitrotoluene

Antidotes And Anecdotes 100 (2 of 2)
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Antidotes And Anecdotes

• A 16 year old male ingested 20 (200mg)
• INH tablets prior to ED arrival. He is
• actively seizing, what course of action
• should be taken?
• Administer IV valium 5mg
• Administer IV pyridoxine 2 grams
• Administer IV PHB 20mg/kg IV
• Administer IV pyrodoxine 4 grams

Antidotes And Anecdotes 200 (1 of 2)
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MECHANISM OF INH TOXICITY
GLUTAMIC ACID DECARBOXYLASE
GLUTAMIC ACID
GABA
PYRIDOXAL 5 PHOSPHATE
INH INHIBITS
INH INACTIVATES
PYRIDOXINE PHOSPHOKINASE
INH ENHANCES
URINARY ELIMINATION
PYRIDOXINE
Antidotes And Anecdotes 200 (2 of 2)
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Antidotes And Anecdotes

• Which of the following is NOT a
• mechanism by which N-acetylcysteine
• works to prevent APAP induced
• hepatotoxicity?
• Precursor for Glutathione synthesis
• A substrate for sulfonation
• Directly Binds NAPQUI
• Increase CYP2E1 activity

Antidotes And Anecdotes 300 (1 of 2)
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Antidotes And Anecdotes 300 (2 of 2)
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Antidotes And Anecdotes

• Which of the following is not a
• component of the cyanide antidote kit?
• Amyl nitrate
• Amyl nitrite
• Sodium nitrite
• Sodium thiosulfate

Antidotes And Anecdotes 400 (1 of 2)
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Antidotes And Anecdotes 400 (2 of 2)
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Antidotes And Anecdotes

• Side effects of administration of
• Deferoxamine include which of the
• Following?
• A) Hypotension
• B) ARDS
• C) Increased risk or Yersinia Infections
• D All of the above

Antidotes And Anecdotes 500 (1 of 2)
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Deferoxamine Challenge
Dose Administered
Antidotes And Anecdotes 500 (2 of 2)
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Antidotes And Anecdotes

• How many vials of Digibind should be
• given to a 70kg male with acute digoxin
• Toxicity and a level of 7ng/mL?
• A) 4 vials
• B) 5 vials
• C) 6 vials
• D) 10 vials

Antidotes And Anecdotes 750 (1 of 2)
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Inhibition of Na-K-ATPase
skeletal muscle
heart
baroceptors
rise in Nai and Cai
Nai
rise in Nai and Cai
Ko
automoticity
Cai
firing
hyperkalemia
premature beatsescape rhythmsV-tach, V-fib
vagal tone
bradycardia, AV blocks, asystole
contractility
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Picture That
Name the toxin
Picture That 100 (1 of 4)
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• Picture That

Name the toxin
Picture That 100 (2 of 4)
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• Picture That

Name the toxin
Picture That 100 (3 of 4)
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Jimson Weed(datura stramonium)

• Anticholinergic Plants
• Atropa belladonna (deadly nightshade)
• Cestrum nocturnum (night blooming jessamine)
• Datura suaveolens (angels trumpet)
• Datura stramonium (jimson weed)
• Hyoscyamus niger (black henbane)
• Lantana camara (red sage)
• Solanum carolinensis (wild tomato)
• Solanum dulcamara (bittersweet)
• Solanum pseudocapsicum (Jerusalem cherry)
• Solanum tuberosum (potato)
• Arctium lappa (burdock root)

Picture That 100 (4 of 4)
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• Picture That

Name the toxin
Picture That 200 (1 of 5)
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• Picture That

Name the toxin
Picture That 200 (2 of 5)
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• Picture That

Name the toxin
Picture That 200 (3 of 5)
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• Picture That

Name the toxin
Picture That 200 (4 of 5)
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• Picture That

Name the toxin
Picture That 200 (5 of 5)
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• Picture That

Picture That 300 (1 of 3)
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Picture That

• Ingestion/exposure to the previously
• pictured plant is most likely to result in?
• Hyponatremia
• Contact Dermatitis
• Arrhythmias
• Flatulence

Picture That 300 (2 of 3)
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Picture That
Picture That 400 (1 of 2)
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Picture That

• Which of the following should be
• administered to the patient after an
• unknown overdose with the previous
• EKG?
• Physiostigmine
• Calcium Salts
• Glucagon
• Sodium Bicarbonate

Picture That 400 (2 of 2)
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Picture That
Picture That 500 (1 of 2)
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Picture That

• Which toxin is found in the pictured
• mushroom?
• Ibotenic acid
• Psilocybin
• Gyromitrin
• muscarine

Picture That 500 (2 of 2)
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Picture That
Picture That 750 (1 of 2)
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Picture That

• What is the name of the toxin found in
• the pictured fish?
• Cigutoxin
• Domoic acid
• Tetrodotoxin
• Scrombroid

Picture That 750 (2 of 2)
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Salicylates

• The minimal toxic dose (mg/kg) of
• salicylates is?
• 100
• 50
• 25
• 150

Salicylates 100 (1 of 2)
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Salicylates Toxic Dose

• Therapeutic Range 1015 mg/kg
• Mild Toxicity 150 mg/kg
• Moderate Toxicity 150-300 mg/kg
• Severe Toxicity gt 300 mg/kg

Salicylates 100 (2 of 2)
44
Street Drugs

• An 18 year old female presents to the
• Emergency Department obtunded. She is
• intubated but self extubates shortly after. She
• is now awake, alert and appropriate. Which of
• the following may be responsible?
• GHB
• Gamma-butyrolactone
• 1,4-butanediol
• All of the above may be responsible

Street Drugs 200 (1of 3)
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GHB dehydrogenase GABA transaminase GABA
transaminase Succinic semialdehyde reductase
Tissue lactonases Nonenzymatic hydrolysis
B-oxidation
GABAB Receptor
Trans-4-hydroxycrotonic acid
GHB-receptor
Street Drugs 200 (2of 3)
46
Alcohol Dehydrogenase
HO
NAD
NADH
NAD
Aldehyde dehydrogenase
NADH
B-oxidation
Trans-4-hydroxycrotonic acid
GHB-receptor
GABAB Receptor
Street Drugs 200 (3of 3)
47
Salicylates

• As a salicylate poisoned patient becomes
• more acidotic, more salicylate will exist in
• the ____ form and the volume of
• distribtuion ____.
• Ionized, decreases
• Unionized, increases
• Unionized, decreases
• Ionized, increases

Salicylates 300 (1 of 3)
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Salicylates 300 (2 of 3)
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• Volume of distribution (Vd)
• Apparent volume the drug is dissolved in
• Measured in Liters or Liters/Kg
• not a real volume

Salicylates 300 (3 of 3)
50
Salicylates

• Hyperthermia, occuring in salicylate
• toxicity, is secondary to?
• Inhibition of the krebs cycle
• Uncoupling of oxidative phosphorylation
• Stimulation of lipid metabolism
• Increasing capillary permeability

Salicylates 500 (1 of 1)
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Street Drugs

• A patient presents to the Emergency
• Department with agitation, a sense of
• persecution and rotary nystagmus. Exposure
• to which of the following can cause theses
• symptoms.
• A preparation containing Camphor
• A preparation containing Pseudophed
• A preparation containing DXM
• A preparation containing Ethanol

Street Drugs 400 (1of 2)
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Street Drugs 400 (2of 2)
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Salicylates

• Which of the following is more likely to
• be seen in acute vs chronic salicylate
• toxicity?
• Neurological symptoms
• Gastrointestinal Symptoms
• Renal insufficiency
• Elevated LFTs

Salicylates 500 (1 of 2)
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ACUTE CHRONIC
INCIDENCE 85 15
AGE YOUNG OLD
INTENTION OD OFTEN RARE
COINGESTION OFTEN RARE
PSYCH. HX COMMON UNCOMMON
COMORBIDITY RARE COMMON
TIME TO DX EARLY LATE
ABNORMAL PROTIME YES YES
RENAL FXN NORMAL OFTEN ABNORMAL
HEPATIC FXN NORMAL OFTEN ABNORMAL
NEUROLOGIC SYMPTOMS OCCASSIONALLY COMMON
PULMONARY SYMPTOMS RARE COMMON (50)
GI SYMPTOMS VERY COMMON RARE
MORBIDITY 16 30
MORTALITY 2 25
Salicylates 500 (2 of 2)
55
Street Drugs

• A patient presents to the Emergency
• Department with profound hyponatremia and
• seizures after attending a RAVE party. Which
• of the following is the most likely cause
• GHB
• Cocaine
• MDMA (Ectascy)
• Rohypnol

Street Drugs 750 (1 of 1)
56
Name That Toxidrome

• An increased heart rate, dry flushed
• skin, dilated pupils agitation and urinary
• retention are seen in which of the following?
• Cholinergic Toxidrome
• Anticholinergic Toxidrome
• Sympathomimetic Toxidrome
• Sedative Hypnotic Toxidrome

Name That Toxidrome 100 (1 of 1)
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Name That Toxidrome

• Ingestion of which of the following is
• most likely to cause dilated pupils?
• Risperdal
• Meperidine
• Amytriptylline
• Lexapro

Name That Toxidrome 200 (1 of 1)
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Name That Toxidrome

• The most reliable way to differentiate
• the difference between anticholinergic
• and sympathomimetic toxidrome are
• A) Dilated pupils, agitation
• B) Diaphoresis, urinary retention
• C) Flushed skin, hyperthermia
• D) Visual hallucinations, pressured speech

Name That Toxidrome 300 (1 of 1)
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Name That Toxidrome

• Which of the following is capable of
• producing a toxdrome similar to the
• opioid toxidrome?
• Geodon
• Clonidine
• Reglan
• Propofol

Name That Toxidrome 400 (1 of 1)
60
Name That Toxidrome

• The odor described in a patient exposed
• to Organophosphate insecticides is?
• Bitter Almonds
• Burnt Rope
• Garlic
• Sulfur

Name That Toxidrome 500 (1 of 1)
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Name That Toxidrome

• Exposure to which of the following
• is capable of producing muscle
• fasiculations, weakness and respiratory
• distress?
• China-Berry Tree
• Germanium
• Nicotine containing plants
• Grayanotoxin containing plants

Name That Toxidrome 750 (1 of 1)
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Final Jeopardy

• In the course of treatment of a patient with
• Ethylene Glycol Toxicity, which of the
• following may be used as an adjunct to
• decrease the production of Oxalic Acid?
• Thiamine
• Folic Acid
• Niacin
• Magnseium

63
(CH2OH)2
Ethylene glycol
ADH
CH2OHCHO
Glycoaldehyde
ADH
CH2OHCOOH
Glycolic Acid
ADH
Glyoxylic Acid
CHOCOOH
thiamine
B6
Oxalic Acid
Mg
Glycine Benzoic Acid
Alpha-hydroxy-beta-ketoadipic acid
Hippuric Acid