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WICM 2014 Toxicology Quiz


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The slides used for the toxicology quiz at the Wellington Intensive Care Medicine 2014 Exam Preparation Course

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WICM 2014 Toxicology Quiz

  1. 1. WHO wants to be a TOXICOLOGIST? Chris Nickson The Alfred
  2. 2. How this WORKS
  3. 3. YOU form 8 teams 3 rounds of competition Quarter-finals x 4 Semi-finals x 2 The GRAND final WE find out who wants to be toxicologist!
  4. 4. The PRIZE
  5. 5. F.UCEM then FCICM
  6. 6. Round One MATCH 1
  7. 7. Team A Q1 What does DEAD in the Resus-RSI- DEAD mnemonic for the approach to the poisoned patient stand for?
  8. 8. Team A A1 Resuscitation Risk assessment Supportive care and Monitoring Investigations Decontamination Enhanced elimination Antidotes Disposition
  9. 9. Team B Q1 What are 4 of the 5 components of a risk assessment in toxicology?
  10. 10. Team B A1 Agent(s) Dose(s) Time since ingestion Current clinical status Patient factors
  11. 11. Team A Q2 What is the mechanism of paracetamol hepatotoxicity?
  12. 12. Team A A2 (1) glucuronidation & sulphation pathways are rapidly saturated (2) NAPQI production (3) glutathione depletion (4) excess NAPQI causes hepatocellular necrosis
  13. 13. Team B Q2 What are the criteria for liver transplantation in paracetamol hepatotoxicity?
  14. 14. Team B A2 The King’s College Criteria: pH < 7.3 or In a 24h period, all 3 of: INR > 6 (PT > 100s) + Cr > 300mmol/L + grade III or IV encephalopathy (modification adds lactate) toxicity/
  15. 15. Tie Breaker
  16. 16. Tie Breaker 1Q What is the antidote for isoniazid toxicity?
  17. 17. Tie Breaker 1A Pyridoxine
  18. 18. Round One MATCH 2
  19. 19. Team C Q1 What is gastrointestinal decontamination?
  20. 20. Team C A1 Removal of a toxic agent from the GI tract before complete absorption into the systemic circulation
  21. 21. Team D Q1 What is enhanced elimination?
  22. 22. Team D A1 Using techniques to increase the rate of removal of an agent from the body so as to reduce the severity and duration of clinical intoxication
  23. 23. Team C Q2 Name 3 specific therapies for severe propanolol overdose (not including catecholamines or mechanical/ extracorporeal supports)
  24. 24. Team C A2 NaHCO3 Hyperventilation High dose insulin euglycemic therapy …not glucagon(e)…
  25. 25. Team D Q2 A patient presents 10 hours after an overdose with bradycardia, cardiogenic shock, vasodilation & HYPERglycemia. What is the most likely causative agent?
  26. 26. Team D A2 Calcium channel blocker such as verapamil or diltiazem (often SR)
  27. 27. Tie Breaker
  28. 28. Tie Breaker What are the indications for digibind in acute digoxin poisoning?
  29. 29. Tie Breaker cardiac arrest life-threatening dysrhythmia K >5 mM >10 mg ingested (adult) >15 nM level (>12ng/mL)
  30. 30. Round One MATCH 3
  31. 31. Team E Q1 What two screening tests should be performed in every acutely poisoned patient? (excluding a BSL)
  32. 32. Team E A1 ECG serum paracetamol level
  33. 33. Team F Q1 What are 5 complications of activated charcoal administration?
  34. 34. Team F A1 Vomiting Pulmonary aspiration/ direct administration to lung via NGT Impaired absorption of meds Corneal abrasions Constipation / bowel obstruction Distraction from resuscitation
  35. 35. Team E Q2 Name 5 agents that can be removed by hemodialysis or hemoperfusion?
  36. 36. Team E A2 Anticonvulsants* Lithium Metformin KCl Salicylates Theophyline* Toxic alcohols selection-for-rrt/
  37. 37. Team F Q2 Name two agents where urinary alkalinisation is appropriate ?
  38. 38. Team F A2 Salicylates Phenobarbitone
  39. 39. Tie Breaker
  40. 40. Tiebreaker What are the 5 stages of iron toxicity?
  41. 41. Tiebreaker GI symptoms (0-6h) Redistribution phase (6-12 hours) Distributive shock, HAGMA, MODS (12- 48h) Liver failure(2-5 days) Cirrhosis and strictures (2-6 weeks)
  42. 42. Round One MATCH 4
  43. 43. Team G Q1 Which types of agent do NOT bind activated charcoal?
  44. 44. Team G A1 Alcohols Metals (eg. Fe, Li, K) Acids Alkalis Hydrocarbons
  45. 45. Team H Q1 What is the usual mode of death from hydrofluoric acid (HF) toxicity?
  46. 46. Team H A1 Dysrhythmias from: hypocalcemia, hypomagnesemia and acidosis
  47. 47. Team G Q2 Name 5 agents that can be treated with whole bowel irrigation
  48. 48. Team G A2 Iron Slow release potassium Slow release calcium channel blocker Arsenic trioxide Lead Body packer
  49. 49. Team H Q2 Name 4 agents that can be treated with multi-dose activated charcoal (MDAC)
  50. 50. Team H A2 Carbamazepine dapsone phenobarbitone quinine salicylate* theophyline
  51. 51. Tie Breaker
  52. 52. Tie Breaker 4Q Name 3 antidotes that can used to treat cyanide toxicity
  53. 53. Tie Breaker 4A Cyanide binders (dicobalt edetate and hydroxocobalamin) Sulfur donors (sodium thiosulfate) Methemoglobin generators (amyl nitrite and sodium nitrite)
  54. 54. Round Two SEMI-FINAL 1
  55. 55. Team AB Q1 What overdose does a high osmolar gap, hypocalcaemia and renal failure suggest?
  56. 56. Team AB A1 Ethylene glycol
  57. 57. Team CD Q1 For which poison does GI decontamination override all other management priorities?
  58. 58. Team CD Q1 Paraquat
  59. 59. Team AB Q2 What is the likely cause of this ECG in a conscious, mildly hypotensive patient?
  60. 60. Team AB A2 Sotalol overdose (sinus bradycardia, long QTc 600ms)
  61. 61. Team CD Q2 What is the likely cause of this ECG in a comatose patient with miosis and hypotension?
  62. 62. Team CD A2 Quetiapine overdose (sinus tachycardia, long QTc)
  63. 63. Team AB Q3 A comatose child in Australia with miosis, marked bradycardia, respiratory depression and hypotension has most likely overdosed on what drug?
  64. 64. Team AB A3 Clonidine
  65. 65. Team CD Q3 Name 3 features required for the diagnosis of propofol infusion syndrome (PRIS)? (not including propofol!)
  66. 66. Team CD A3 acute refractory bradycardia progressing to asystole and 1+ of: (1) metabolic acidosis (2) rhabdomyolysis (3) hyperlipidaemia (4) enlarged or fatty liver
  67. 67. Tie Breaker
  68. 68. Tie Breaker S1Q Outline your management (RSI-DEAD) of severe theophyline overdose
  69. 69. Tie Breaker S1A Resus with fluids for low BP B-blockers* for SVT Rx seizures Rx N&V Rx hypokalemia Activated charcoal* HAEMODIALYSIS
  70. 70. Round Two SEMI-FINAL 2
  71. 71. Team EF Q1 Name 4 features that help distinguish a serotonin syndrome from neuroleptic malignant syndrome?
  72. 72. Team EF A1 Both High BP, HR, RR, T; Sweaty; CK Serotonin syndrome Mydriasis Ocular clonus, limb clonus, Increased lower > upper limb tone, Agitated delirium, <24h Neuroleptic malignant syndrome Sweaty, mottled, lead pipe rigidity, staring, mutism, low serum Iron, Response to bromocriptine & dantrolene, Lasts days-weeks
  73. 73. Team GH Q1 Name 3 features that help distinguish a sympathomimetic syndrome from an anticholinergic syndrome?
  74. 74. Team GH A1 Both High BP, HR, RR, T; Mydriasis; Treated with benzos; Agitated delirium; N tone and reflexes Sympathomimetic syndrome Sweaty; Complications: ischemia, hemorrhage and dissection Anticholinergic syndrome Dry, flushed; Ileus; Urinary retention; Response to physostigmine
  75. 75. Team EF Q2 What is the likely cause of this ECG in a patient with decreased level of consciousness?
  76. 76. Team EF A2 Sodium channel blockade due to tricyclic antidepressant (broad QRS, dominant R’ in aVR)
  77. 77. Team GH Q2 What is the likely cause of this ECG in a depressed elderly man?
  78. 78. Team GH A2 Digoxin toxicity (Atrial flutter with slow ventricular response)
  79. 79. Team EF Q3 What are the clinical manifestations of valproate overdose?
  80. 80. Team EF A3 Mitochondrial toxin delayed coma HAGMA, high NH3, low glucose high Na, low Ca bone marrow suppression MODS, cerebral edema
  81. 81. Team GH Q3 What are the clinical manifestations of salicylate overdose?
  82. 82. Team GH A3 Tinnitus, hyperpnea, vomiting metabolic acidosis coma + seizures hypoprothrombinaemia
  83. 83. Tie Breaker
  84. 84. Tie Breaker S2Q The triad of GI symptoms, hair loss and peripheral neuropathy suggests what?
  85. 85. Tie Breaker S2A Thallium toxicity
  86. 86. Round Three GRAND FINAL
  87. 87. Team ABCD Q1 Venlafaxine, buproprion and tramadol all cause seizures — what anti-epileptic drug should you NOT use?
  88. 88. Team ABCD A1 Phenytoin
  89. 89. Team EFGH Q1 Name 4 agents (different classes) that cause hypoglycemia
  90. 90. Team EFGH A1 Insulin Oral hypoglycemic agents Alcohol Quinine Beta-blockers
  91. 91. Team ABCD Q2 What are the antidote(s) for organophosphate toxicity and how do they work?
  92. 92. Team ABCD A2 atropine (acetylcholine receptor antagonist) pralidoxime (prevents AChEsterase inhibtion by OP)
  93. 93. Team EFGH Q2 What is your approach to an asymptomatic child who ate a couple of his grandad’s gliclazide tablets 4 hours ago?
  94. 94. Team EFGH A2 D/C if asymptomatic with normal BSL at 8h If hypoglycemia then start octreotide Only stop octreotide in the morning and monitor for 4h after
  95. 95. Team ABCD Q3 Name the 4 essential antidotes to have available for a cardiotoxic overdose, and the agents they neutralise
  96. 96. Team ABCD A3 digibind (cardiac glycosides) high dose insulin euglycemic therapy (CCBs, B-blockers) NaHCO3 (NCBs) intralipid (local anaesthetics +) nickson-on-cardiotoxic-overdoses
  97. 97. Team EFGH Q3 Name 4 metal poisonings and a specific antidote for each
  98. 98. Team EFGH A3 arsenic, lead, mercury – BAL/ dimercaprol, succimer (DMSA), unithiol (DMPS) copper – penicillamine, BAL iron - desferrioxime
  99. 99. Team ABCD Q4 What are the features of colchicine toxicity?
  100. 100. Team ABCD A4 GI Symptoms Bone marrow depression Shock, ARDS, renal failure, coagulopathy
  101. 101. Team EFGH Q4 What are the features of paraquat poisoning?
  102. 102. Team EFGH A4 GI symptoms, corrosive +ve urinary dithionate metabolic acidosis MODS, shock, ARDS pulmonary fibrosis
  103. 103. Team ABCD Q5 What specific measures are recommended for treatment of dapsone toxicity?
  104. 104. Team ABCD A5 MDAC Treat methemoglobinemia: methylene blue, exchange transfusion, hyperbaric oxygen
  105. 105. Team EFGH Q5 What specific measures are recommended for treatment of paraquat poisoning?
  106. 106. Team EFGH A5 Intubation if airway compromise Immediate GI decontamination ?hemodialysis (if <2h) ? NAC, Vit C, cyclophosphamide, steroids Supportive care or palliation
  107. 107. Tie Breaker
  108. 108. Tie Breaker GF Q A patient with a history of multiple sclerosis appears to be brain dead. What overdose must be excluded?
  109. 109. Tie Breaker GF A Baclofen
  110. 110. LEARN MORE Suggested resources
  111. 111. The END
  112. 112. Additional unused questions
  113. 113. Team A Q2 Name 3 risk factors for propofol infusion syndrome (PRIS)?
  114. 114. Team A A2 >4mg/kg/hr propofol for 48 hours younger age acute neurological injury low carbohydrate intake catecholamine infusion corticosteroids infusion
  115. 115. Tie Breaker What agent may controversially be used as an antidote for valproate overdose and propofol infusion syndrome (PRIS)?
  116. 116. Tie Breaker Carnitine
  117. 117. Team D Q3 What are the ECG features of digoxin toxicity?
  118. 118. Team D Q3 AV conduction blocks Increased automaticity classically SVT with slow ventricular response …not reverse tick ST segments!
  119. 119. Team F Q3 Outline the management (Resus-RSI-DEAD) of iron overdose?
  120. 120. Team F A3 ABCs, fluids Supportive care + monitoring WBI (if >60mg/kg) or retrieval Desferrioxamine (if >90uM, HAGMA, shock)
  121. 121. Tie Breaker 3Q What is the best specific antidote to use in severe beta-blocker overdose?
  122. 122. Tie Breaker 3A High dose insulin euglycemic therapy …not glucagon(e) 
  123. 123. Team H Q3 A patient with GHB overdose should regain consciousness within what period following ingestion?
  124. 124. Team H A3 6 hours
  125. 125. Team CD Q1 What are the clinical manifestations of carbamazepine overdose?
  126. 126. Team CD A1 Nystagmus, Ataxia, Delirium Anticholinergic effects Coma VT/VF in massive overdoses
  127. 127. Team CD Q3 A comatose adult in Australia with miosis, tachycardia, long Qtc and hypotension has most likely overdosed on what drug?
  128. 128. Team CD A3 Quetiapine or olanzepine (clozapine if hypersalivating)