Toxicology

Answer: C

The best option for this patient right now is to admin-

ister octreotide 50–100 mcg subcutaneously (Answer C

is correct). The patient has not responded to two doses

of intravenous dextrose, as evidenced by point-of-care

glucose concentrations less than 70 mg/dL; therefore,

additional doses of dextrose are not indicated (Answer

A is incorrect). Although glucagon is also a potential

option, it is not recommended for sulfonylurea expo-

sures (Answer B is incorrect). Sodium bicarbonate

intravenously may be indicated in this scenario if the

patient had metformin-associated lactic acidosis; how-

ever, the patient is not on metformin and has no signs of

lactic acidosis (Answer D is incorrect).

Any of the options listed in this question are possible

treatments for a patient with a β-blocker overdose who is

not responding to the administration of intravenous flu-

ids and calcium. The optimal choice ultimately involves

efficacy and appropriate dosing. Glucagon is an option,

and it should be dosed at 5–10 mg intravenously ini-

tially (Answer A is correct). Atropine is an option for

the patient’s bradycardia, but the initial recommended

dose is 0.5–1 mg intravenously (Answer B is incorrect).

Hyperinsulinemic euglycemic therapy may be preferred

in this setting; however, the correct bolus dose is 1 unit/

kg intravenously (Answer C is incorrect). Dopamine

is an option for the treatment of hypotension and bra-

dycardia, but the correct dose would be the initiation

of an infusion at 5–10 mcg/kg/minute titrated to effect

(Answer D is incorrect).

Answer: B

Given the patient’s presentation and the common toxi-

dromes, the most likely scenario is a cholinergic agent

(Answer B is correct). The patient is experiencing bra-

dycardia with a normal BP and RR, has a decrease in

mental status, and is experiencing nausea. Although not

an absolute, anticholinergics and sympathomimetics are

more commonly associated with tachycardia (Answers

A and D are incorrect). Similarly, opioids are typically

associated with a decrease in respirations (Answer C is

incorrect).

Answer: A

The patient is experiencing QT prolongation after an

atypical antipsychotic overdose. It is important to sta-

bilize the patient by administering intravenous sodium

bicarbonate and electrolyte replacement (Answer A is

correct). Her potassium concentration is low, requiring

replacement. Because the time interval of the overdose

is not known, there is limited benefit for activated char-

coal (Answer B is incorrect). Although her magnesium

concentration is normal, it should be monitored; how-

ever, her magnesium concentration does not require

replacement at this time because her QTc is less than

500 milliseconds (Answer C is incorrect). Lorazepam is

not indicated for prophylaxis of seizure activity (Answer

D is incorrect).

Answer: A

This patient has the clinical signs and symptoms of

alcohol withdrawal. Management should focus on the

patient’s safety and controlling his symptoms, and

treatment should be administered using a symptom-

triggered therapy strategy. The primary agents used to

control symptoms are the benzodiazepines, and loraze-

pam is a good option (Answer A is correct). Barbiturates

such as phenobarbital are typically reserved for patients

who do not respond to benzodiazepine therapy because

of benzodiazepine’s long elimination half-life and stron-

ger sedative effects and oral dosing may be difficult with

his level of confusion (Answer B is incorrect). Propofol

should be avoided in non-intubated patients (Answer C

is incorrect). Clonidine is a potential option, especially

because this patient has borderline hypertension, but

oral dosing may be difficult with his level of confusion

(Answer D is incorrect).

Answer: B

The patient is experiencing an unintended opioid over-

dose, as evidenced by the decreased RR and decreased

consciousness. Administration of the antidote, nalox-

one, is the best option (Answer B is correct). Because 2

hours have passed since the methadone dose was given,

there is limited usefulness for activated charcoal at this

time, and it would not be advisable to administer it to

an unconscious patient without an established airway

(Answer A is incorrect). Whole bowel irrigation is also

not useful in this situation because it is too late to prevent