Study Points

Caring for the Poisoned Patient

Course #34443 - $25 • 5 Hours/Credits

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  • Participation Instructions
    • Review the course material online or in print.
    • Complete the course evaluation.
    • Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.
  1. Which of the following comprise the coma cocktail?

    ASSESSMENT AND STABILIZATION

    The coma cocktail is an informal term for four drugs that can be empirically used to treat a poisoned patient who has an altered mental status. These drugs—dextrose, oxygen, naloxone, and thiamine—are often referred to by the mnemonic DONT.

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  2. What is often the most overlooked part of caring for a poisoned patient?

    ASSESSMENT AND STABILIZATION

    When the ABCs have been evaluated and stabilized, a history and physical exam should be completed. The importance of obtaining a good history cannot be overstated. Inexperienced nurses often focus on what the patient took, but the circumstances of an overdose are just as important or more important. Knowing the circumstances of the poisoning is often the most overlooked part of caring for a poisoned patient.

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  3. Which of the following are considered to be dangerous in small amounts?

    ASSESSMENT AND STABILIZATION

    These drugs and toxins can be dangerous in amounts that are not far above the highest typically prescribed dose [6,7]:

    • Beta blockers

    • Bupropion

    • Calcium channel blockers

    • Clonidine

    • Ethylene glycol

    • Hydrofluoric acid in high concentrations

    • Isoniazid

    • Monoamine oxidase (MAO) inhibitors (e.g., phenelzine, selegiline)

    • Methanol

    • Sulfonylureas

    • TCAs

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  4. Which of the following medications/toxins has or may have delayed onset of effects when taken at toxic levels?

    ASSESSMENT AND STABILIZATION

    The following medications and toxins are associated with delayed onset of effects [2,6]:

    • Acetaminophen

    • Anticoagulant rodenticides

    • Aspirin

    • Beta blockers

    • Bupropion

    • Calcium channel blockers

    • Hydrofluoric acid

    • Lithium

    • Sulfonylureas

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  5. The anticholinergic toxidrome is characterized by

    ASSESSMENT AND STABILIZATION

    The anticholinergic toxidrome is caused by drugs that block acetylcholine from binding to cholinergic receptors. The result is central and peripheral effects that include agitation, confusion, decreased bowels sounds, delirium, dilated pupils, dry and flushed skin, dry mucous membranes, hyperthermia, tachycardia, and urinary retention [3]. In severe cases, arrhythmias, coma, and seizures are possible [4]. Drugs that can cause anticholinergic toxidrome include antihistamines, antispasmodics (such as hyoscyamine), atropine, phenothiazines, TCAs (less commonly), and psychoactive plants such as Amanita muscaria (fly agaric mushroom) and Datura stramonium (jimson weed). The duration of anticholinergic signs and symptoms after a poisoning can be several days.

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  6. Exposure to which of the following toxins can cause the cholinergic toxidrome?

    ASSESSMENT AND STABILIZATION

    The cholinergic toxidrome is caused by drugs and toxins that stimulate the cholinergic receptors. Patients with this syndrome present with bradycardia, bronchorrhea, diarrhea, emesis, lacrimation, miosis, salivation, and urinary incontinence [2,4]. Organophosphate and carbamate insecticides can cause the cholinergic toxidrome. Donepezil, a commonly prescribed drug used to treat Alzheimer disease, can cause cholinergic effects as well.

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  7. Signs and symptoms of the sympathomimetic toxidrome include

    ASSESSMENT AND STABILIZATION

    Signs and symptoms of this toxidrome include agitation, diaphoresis, fever, hypertension, mydriasis, and tachycardia [2,4]. Severe cases can cause arrhythmias, MI, and seizures. Amphetamine and cocaine are two commonly used drugs that can cause the sympathomimetic toxidrome.

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  8. Serotonin syndrome is caused by

    ASSESSMENT AND STABILIZATION

    The serotonin toxidrome, more commonly referred to as the serotonin syndrome, is caused by excessive stimulation of serotonergic receptors. Medications involved in the development of the syndrome act by inhibiting the reuptake of serotonin, causing the release of serotonin into synapses, directly stimulating serotonin receptors, or decreasing the metabolism of serotonin. It can also occur when a drug-drug interaction inhibits the breakdown of a serotonergic drug.

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  9. The best technique for detecting drug packets in the gut is

    USING THE LABORATORY AND OTHER DIAGNOSTIC TOOLS

    Imaging studies can also detect packets of illicit drugs that have been deliberately swallowed or inserted into body cavities (commonly called packing or stuffing). Intact drug packets are easily seen with a plain x-ray, but the presence of small and loosely secured drug packets that were swallowed may not be clearly visible [21,22,23,24]. There is some evidence that low-dose computed tomography (CT) is the best technique to reliably detect swallowed drug packets [22].

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  10. Which of the following drugs/toxins are NOT adsorbed by activated charcoal?

    GASTRIC DECONTAMINATION

    Activated charcoal is produced from carbonaceous substances such as peat or wood that have been pulverized and specially treated. This charcoal powder is added to a liquid (most often water and sorbitol) and delivered orally. Activated charcoal adsorbs (not absorbs) drugs or toxins in the gut, and it can also interrupt their enterohepatic and enteroenteric recirculation [25]. Most drugs and toxins are well adsorbed by activated charcoal, but acids, alkalis, alcohols, iron, and lithium are not. The adsorption bond is very strong. The charcoal-drug complex is excreted in the stool, absorbed by macrophages, or dissociated slowly enough so the drug does not cause harm. Although it is clear that activated charcoal can adsorb toxins and drugs, it is unknown if this action improves clinical outcomes [25,26,28,29,30]. However, the capacity of activated charcoal to significantly decrease drug absorption, the simplicity of the technique, and its relative lack of adverse effects have resulted in activated charcoal still being recommended for the treatment of poisoned patients.

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  11. Which of the following is a contraindication to the use of activated charcoal?

    GASTRIC DECONTAMINATION

    Contraindications to the use of activated charcoal include:

    • Ingestion of a non-toxic dose

    • Ingestion of a drug or toxin that is not adsorbed by activated charcoal (e.g., alcohols, acids, alkalis, iron, lithium, foreign body)

    • An ingestion that occurred more than one hour before arrival

    • Lack of a normal, functioning gastrointestinal tract

    • There is or may be a risk for aspiration

    • A patient who is not fully conscious or whose level of consciousness may become impaired

    • An endoscopic procedure may be needed

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  12. Multi-dose activated charcoal may increase the elimination of

    GASTRIC DECONTAMINATION

    Multiple-dose activated charcoal can increase the elimination of carbamazepine, dapsone, phenobarbital, quinine, or theophylline [31]. However, there is no proof that it offers clinical benefits, and the research on multiple-dose activated charcoal is limited and of relatively low quality.

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  13. Which of the following is a possible adverse effect of gastric lavage?

    GASTRIC DECONTAMINATION

    Gastric lavage is contraindicated if the criteria for use are not met; spontaneous emesis has occurred; it has been more than one hour since the ingestion occurred; the patient ingested an acid or alkali; the patient has a bleeding disorder; or if the patient is a body packer or stuffer. Possible adverse effects of gastric lavage include (but are not limited to) aspiration, bleeding, hypoxia, and injury to the airway, esophagus, or stomach.

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  14. The use of whole bowel irrigation should be considered for patients who

    GASTRIC DECONTAMINATION

    Indications for whole bowel irrigation include ingestion of drug packets, a foreign body, or a toxic amount of an enteric-coated medication, an extended-release medication, or iron, lithium, or potassium. Contraindications are bowel obstruction, ileus, or any condition that affects normal bowel functioning; a clinically significant gastrointestinal hemorrhage; continued vomiting; inability of the patient to protect his/her airway; and hemodynamic instability.

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  15. Fomepizole treats ethylene glycol or methanol poisoning by

    ANTIDOTES

    Ethylene glycol and methanol are commonly called the toxic alcohols. These alcohols are metabolized by alcohol dehydrogenase to acids and other compounds that can cause profound acidosis, coma, permanent ocular damage, and renal failure. Fomepizole blocks the metabolism of ethylene glycol and methanol by inhibiting the activity of alcohol dehydrogenase [59]. Fomepizole is much easier and less risky to use than hemodialysis or the traditional antidote for toxic alcohol poisoning, ethanol. Thus, it is indicated in cases of confirmed or suspected ethylene glycol or methanol poisoning [51].

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  16. Glucagon is the antidote for

    ANTIDOTES

    Beta blocker poisoning causes bradycardia, cardiac conduction delays, and hypotension. Treatment with sympathomimetics and/or vasopressors (e.g., epinephrine, norepinephrine) may not be effective because these drugs work by stimulating adrenergic receptors. In these cases, glucagon is the treatment of choice [50]. Glucagon binds to specific cell membrane receptors, bypasses the adrenergic receptors, and increases the intracellular concentration of cyclic adenosine monophosphate (cAMP). cAMP is a second messenger, and it activates intracellular enzymes that affect myocardial activity. In cases of beta blocker poisoning, glucagon increases heart rate, improves cardiac conduction, and increases contractile force. It has also been used as a second-line option for treating calcium channel blocker poisoning [43,46,50,51].

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  17. Which of the following is the antidote for acetaminophen poisoning?

    ANTIDOTES

    When a toxic dose of acetaminophen greater than 7.5 grams or 150 mg/kg is ingested, the normal metabolic pathways for the drug are overwhelmed and a large amount of a toxic metabolite is produced. This metabolite binds to the liver and can cause significant hepatic damage; acetaminophen poisoning (intentional and unintentional) is a leading cause of acute liver injury and failure and the need for liver transplant. By several complex mechanisms, N-acetylcysteine (NAC) counteracts the effects of acetaminophen poisoning.

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  18. Physostigmine should only be used to treat

    ANTIDOTES

    Physostigmine is a reversible inhibitor of acetylcholinesterase, increasing the activity and concentration of acetylcholine at cholinergic synapses. It has been used to identify and/or treat patients who have severe anticholinergic poisoning that cannot be managed with supportive care [70]. Anticholinergic poisoning can be caused by atropine, antihistamines, antipsychotics, TCAs, and some plants and mushrooms.

    Physostigmine should never be used to treat the anticholinergic effects of TCAs, and it should never be used concurrently with depolarizing neuromuscular blockers such as succinylcholine [51]. Because physostigmine increases acetylcholine concentration at synapses, it should be used cautiously or avoided if the patient has a bladder or intestinal obstruction, asthma, diabetes, gangrene, Parkinson disease, cardiac conduction defects, peripheral vascular disease, or reactive airway disease.

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  19. Sodium bicarbonate treats aspirin poisoning by

    ANTIDOTES

    Aspirin poisoning causes metabolic acidosis, and alkalinization can correct acidemia, prevent salicylate from entering the CNS, and increase renal excretion of the drug. Sodium bicarbonate should be used in patients with signs and symptoms of aspirin poisoning or serum salicylate levels of 30 mg/dL or greater. The serum pH and the patient's clinical status should be given equal importance when deciding whether or not to give sodium bicarbonate.

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  20. In cases of dermal poisonings,

    DERMAL, INHALATION, AND OCULAR POISONINGS

    For most cases of skin, respiratory tract, or ocular poisoning, toxicity is localized, and standard care is sufficient to resolve any adverse effects. For dermal exposures, all contaminated clothing should be removed. The skin is flushed with tepid water for 15 minutes, and then the level of damage can be assessed. If there are burns, provide standard burn care.

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  • Back to Course Home
  • Participation Instructions
    • Review the course material online or in print.
    • Complete the course evaluation.
    • Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.