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Toxicology Kyle Weant, Pharm.D., FCCP, BCPS, BCCCP, BCEMP University of South Carolina College of Pharmacy Columbia, South Carolina…

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Toxicology Toxicology Kyle Weant, Pharm.D., FCCP, BCPS, BCCCP, BCEMP University of South Carolina College of Pharmacy Columbia, South Carolina…

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Learning Objectives 3 min

Toxicology Learning Objectives 1. Distinguish between the common clinical toxi- dromes associated with acute poisonings. 2. Describe the general management of a patient with an acute overdose. 3.…

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Toxicology A. Anticholinergic. B. Cholinergic. C. Opioid. D. Sympathomimetic. 4. A 38-year-old woman is admitted to the ICU after a suspected overdose of risperidone. She was initially hypotens…

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Exam Content Outline 1 min

Toxicology BPS Critical Care Pharmacy Examination Content Outline This chapter covers the following sections of the Critical Care Pharmacy Examination Content Outline: 1. Domain 1: Critical Care a.…

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Data Tables 3 min

Toxicology I.  EPIDEMIOLOGY A. Population based: The American Association of Poison Control Centers releases an annual report based on all the cases submitted by the 55 regional poison centers to th…

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Toxicology II.  EMERGENCY EVALUATION AND MANAGEMENT A. The primary treatment strategy for managing a toxic exposure should focus on stabilizing the patient, with an emphasis on airway, breathing, an…

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Toxicology 5. Common Toxidromes and Presentation (Chest 2011;140:795-806) (Crit Care Clin 2012;28:180-198) a. Anticholinergic i. Mechanism of toxicity is through competitive antagonism of the effec…

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Toxicology b. A positive test also does not necessarily confirm the diagnosis because another agent may be present but at concentrations below a detectable threshold. In addition, a positive test do…

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Toxicology C. Gastric Lavage 1. Gastric lavage is performed by inserting a larger-bore orogastric or nasogastric catheter tube (36–40 French for adults and 24–28 French for children) with several h…

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Toxicology 2. It is optimal to administer activated charcoal within 60 minutes of the toxin ingestion to maximize efficacy. 3. The use of a cathartic (e.g., sorbitol) in combination with activated…

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Data Tables 2 min

Toxicology Table 2. Common Dosage Strategies for General Decontamination and Enhanced Elimination Decontamination/ Elimination Strategy Pediatric Dosing Adult Dosing Gastric lavagea 10-mL/kg aliquots…

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Toxicology IV.  ACETAMINOPHEN A. Background 1. Acetaminophen is consistently one of the most common toxic drug exposures. 2. Accounted for 66,710 exposures (as a single agent) and resulted in 167…

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Toxicology b. Limitations to use of the Rumack-Matthew nomogram include the following (Ann Emerg Med 2007;50:292-313): i. Presentation more than 24 hours postingestion ii. An unknown or unreliable…

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Toxicology 5. Intravenous acetylcysteine is advantageous because of its decreased overall administration time (21 hours vs. 72 hours for oral) and minimal GI adverse effects. If intravenous acetylcy…

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Data Tables 2 min

Toxicology Table 4. Acetylcysteine Dosage Route Dose Oral Loading dose: 140 mg/kg Maintenance doses: 70 mg/kg every 4 hr for a total of 17 doses (72 hr) Intravenous Loading dose: 150 mg/kg (max 15 g)a…

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Toxicology Patient Case Questions 2 and 3 pertain to the following case. A 42-year-old woman (height 66 inches, weight 79.2 kg [176 lb]) presents to the ED with the chief concern of flu-like symptoms…

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Toxicology 2. Salicylates are readily absorbed in the stomach and small intestine and are then conjugated with glycine in the liver to the active component, salicylic acid. In overdoses, the liver c…

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Toxicology 8. Consider hemodialysis for any of the following (Postgrad Med 2009;121:162-8): a. Acute renal insufficiency b. End-organ damage (severe pulmonary edema, seizures, rhabdomyolysis) c. A…

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Toxicology B. Clinical Presentation 1. The most common clinical symptoms associated with opioid overdose are respiratory depression (defined as fewer than 12 breaths/minute), coma, miosis, and hypo…

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Toxicology h. Adverse effects are rare and may be more related to a return of sympathetic response to opioid withdrawal. Nausea and vomiting are common and can lead to aspiration. If the situation…

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Toxicology 3. Gastric decontamination with a single dose of activated charcoal may be considered only if patients present within 2-4 hours after a large overdose and can protect their airway. 4. An…

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Toxicology 1000 2. Early in therapy, an osmolar gap will be present, but this will diminish as the parent compound is metabolized. a. As the osmolar gap declines, the anion gap will rise, resulting…

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Toxicology 1001 4. Ethanol may be administered by diluting 95% alcohol for intravenous, oral, or per-tube administration. a. Mechanism of action is competitive inhibition of alcohol dehydrogenase. b…

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Toxicology 1002 (b) An analysis of a subset of patients in the Established Status Epilepticus Treatment Trial (ESETT) presenting with toxin-related status epilepticus found that a single dose of a…

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Toxicology 1003 2. Common symptoms include tremors, diaphoresis, nausea, vomiting, and abnormal vital signs, including hypertension, tachycardia, hyperthermia, and tachypnea (Am J Emerg Med 2013;31:…

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Toxicology 1004 9. Dexmedetomidine a. α2-receptor agonist, which may help control BP and HR; however, it will not prevent seizures. b. May reduce overall benzodiazepine requirements; however, it la…

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Toxicology 1005 B. Clinical Presentation 1. β-Blocker overdoses are characterized by hypotension, bradycardia, and prolonged atrioventricular conduction. 2. Calcium channel blocker overdoses with…

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Toxicology 1006 6. Hyperinsulinemic euglycemic therapy (HIET) a. Mechanism of action: i. Insulin increases the plasma concentrations of ionized calcium, improves the hyperglycemic acidotic state,…

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Toxicology 1007 iv. BP, HR, and other available hemodynamic parameters should be recorded at least every 15 minutes during the infusion. v. Adverse effects may include pancreatitis, jaundice, coagu…

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Toxicology 1008 B. Clinical Presentation 1. Cardiac effects associated with digoxin toxicity include second- and third-degree heart block, tachyarrhythmias, and bradyarrhythmias. More specific exam…

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Toxicology 1009 3. Additional serum digoxin concentrations are not recommended after the administration of digoxin immune Fab. Minimal change in serum concentrations will be expected as the digoxin…

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Toxicology 1010 iii. May consider a continuous infusion of hypertonic saline in patients with refractory cardiac conduction despite optimal serum alkalinization by increasing sodium load. c. Propos…

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Toxicology 1011 c. Cyproheptadine is a histamine-1 receptor antagonist and nonspecific serotonin receptor antagonist. A single dose of 8–12 mg by mouth should be administered for agitation and muscl…

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Toxicology 1012 6. Seizure activity should be managed with benzodiazepines, barbiturates, or propofol. 7. Anticholinergic symptoms can potentially be treated with IV physostigmine (or oral/patch for…

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Toxicology 1013 c. Suggested indications for the use of hemodialysis include (Chest 2008;133:1006-13): i. Severe toxicity (severe altered mental status or seizures) ii. Renal failure (cannot elimin…

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Toxicology 1014 5. For symptomatic patients or blood glucose less than 70 mg/dL, treat with glucose: a. Conscious patients: Administer 8 oz of an oral carbohydrate (such as juice, non-diet sodas, or…

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Toxicology 1015 XVI.  DRUGS OF ABUSE A. Background 1. Miscellaneous stimulants and street drugs accounted for 46,753 toxic exposures and 186 deaths in 2022. 2. The most common drugs of abuse involv…

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Toxicology 1016 D. Cocaine 1. Mechanism of action/toxicity (Intensive Care Med 2004;30:1526-36): a. Potent sympathetic nervous system stimulant b. Inhibits the presynaptic reuptake of epinephrine…

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Toxicology 1017 F. Piperazines 1. Mechanism of action/toxicity: enhances neurotransmitter release and reuptake inhibition of dopamine, serotonin, and norepinephrine release (Emerg Med Clin North Am…

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Toxicology 1018 REFERENCES Poison Control Centers Data The data contained within this chapter were published in 2023 and contain cases from 2022. The most recent annual reports can be found at https…

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Toxicology 1019 of hemodialysis on acetaminophen and acetylcyste- ine kinetics. Clin Toxicol (Phila). 2016;54(6):519-522. https://doi.org/10.1080/15563650.2016.1175006 Gosselin S, Juurlink DN, Kielst…

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Toxicology 1020 Alcohols Coralic Z, Kapur J, Olson KR, Chamberlain JM, Overbeek D, Silbergleit R. Treatment of toxin-related status epi- lepticus with levetiracetam, fosphenytoin, or valproate in pa…

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Toxicology 1021 Circulation. 2023;148(16):e149-e184. https://doi. org/10.1161/cir.0000000000001161 Patel NP, Pugh ME, Goldberg S, Eiger G. Hyperinsulinemic euglycemia therapy for verapamil…

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Toxicology 1022 Mokhlesi B, Garimella PS, Joffe A, Velho V. Street drug abuse leading to critical illness. Intensive Care Med. 2004;30(8):1526-1536. https://doi.org/10.1007/ s00134-004-2229-1 Muss…

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Answers & Explanations 4 min

Toxicology 1023 ANSWERS AND EXPLANATION TO PATIENT CASES 1. Answer: B The most important first step in all drug overdose cases is to try to stabilize the patient’s ABC (Answer B is correct). This m…

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Toxicology 1024 7. Answer: C The best treatment option for this patient is whole bowel irrigation because of the extended-release formulation of diltiazem (Answer C is correct). Activated char- coa…

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Self-Assessment 4 min

Toxicology 1025 ANSWERS AND EXPLANATIONS TO SELF-ASSESSMENT QUESTIONS 1. Answer: C The best option for this patient right now is to admin- ister octreotide 50–100 mcg subcutaneously (Answer C is cor…

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Toxicology 1026 drug absorption together with the airway safety concern (Answer C is incorrect). Administration of intravenous fluids would be beneficial to improve BP but should not be administere…

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