Transcript Antidotes

REVIEW ON POISONING IN
CHILDREN
Nerissa M. Dando, MD, FPPS, FPSCOT
Department of Pediatrics
The Medical City
September 18, 2013
General Approach to the
Poisoning Patient
 Emergency stabilization
 Clinical evaluation
 Minimizing absorption of the poison
 Enhancing elimination of the absorbed
poison
 Administration of antidotes
 Supportive therapy and observation
 Disposition
Clinical Evaluation:
Check for Toxidromes
 Signs and symptoms taken collectively
can characterize a suspected toxicant
 These groups of manifestations are
observed to occur consistently with
particular poisons
 Seizures
+ coma + metabolic acidosis =
Triad of INH Poisoning
A patient is admitted to the emergency room with the
following symptoms: dry skin, weak rapid pulse, fever
and mydriasis. He is excited and disoriented. In his
pocket is a bottle of pills labeled: “take one as
necessary for stomach pain. This patient is most likely
to be suffering from an overdose of
A. A narcotic analgesic
B. An anticholinergic agent
C. An antacid
D. A benzodiazepine tranquilizer
Anticholinergic/Antidepressant Toxidrome
 Hyperthermia: “hot as a hare”
 Dry mucosa: “dry as a bone”
 Flushed skin: “red as a beet”
 Dilated pupils: “blind as a bat”
 Confusion/delirium: “mad as a hatter”
Cholinergic Toxidrome
 Diarrhea, diaphoresis
 Urination
 Miosis, muscle fasciculations
 Bradycardia, bronchoconstriction
 Emesis
 Lacrimation
 Salivation
 Mydriasis
 Tachycardia
 Hypertension
 Miosis
 Hyperthermia
 Bradycardia
 Seizures
 Hypotension
 Hypoventilation
 Coma
Shabu (Methamphetamine)
intoxicated patients present with the
following symptoms EXCEPT:
A. Miosis
B. Hypertension
C. Tachycardia
D. Hyperthermia
Tinnitus or “ringing of ears” is the first
sign of toxicity in overdose of this drug
A. Aspirin
B. Paracetamol
C. Mefenamic Acid
D. Morphine
The most common and serious
consequence of crude oil or kerosene
ingestion is
A. hepatotoxicity
B. aspiration pneumonia
C. renal failure
D. central nervous system stimulation
Usual doses of chloramphenicol
given to newborns may cause:
A. retinal toxicity
B. gray-baby syndrome
C. renal damage
D. hyperbilirubinemia
All of the following may cause
metabolic acidosis EXCEPT:
A. Isoniazid
B. Methanol
C. Salicylates
D. Diuretics
TRUE in the interpretation and use of
serum paracetamol levels
A. Blood should be extracted immediately postingestion.
B. Levels greater than10 ug/ml taken 4 hours
post-ingestion is toxic.
C. Plot levels in the Rummack-Matthew
nomogram to assess severity of toxicity
D. Levels plotted below the line of the nomogram
needs administration of antidote.
Lavage with activated charcoal may be
beneficial to the following poisoning
EXCEPT:
A. Pyrethroid pesticide
B. Salicylates
C. Sodium hypochlorite
D. Benzodiazepine
Baking soda solution can limit the
absorption of which poison or drug
overdose?
A. Shellfish saxitoxins
B. Snake venoms
C. Digoxin
D. Salicylates
Management for amphetamine toxicity
a. acidify the urine by giving ammonium chloride
because amphetamines are weak bases
b. alkalinize the urine with sodium bicarbonate
c. peritoneal dialysis
d. hyperbaric oxygen
Management for salicylate overdose
a. Acidify urine
b. N- acetylcysteine
c. Alkalinize the urine
d. Penicillamine
A lethargic 18 year-old female was
brought to the ER who intentionally
took an unknown number of sedatives.
What would be an appropriate
antidote?
a. Methylene blue
b. Flumazenil
c. 100% oxygen
d. Naloxone
Antidotes
 Methylene blue (antioxidant) – nitrates,
herbicides poisoning
 100% or hyperbaric oxygen – cyanide
and carbon monoxide poisoning
 Naloxone – opioid toxicity
A comatose teen believed to have
attempted suicide has received initial
stabilization of her airway, breathing and
circulation. The next consideration is
A. CT of brain and toxicology screen
B. GI decontamination with activated charcoal lavage
C. Administration of hypertonic dextrose, thiamine and
naloxone
D. Determination of serum electrolytes and anion gap
Antidotes for Patients With Coma of
Unknown Etiology
 Naloxone
 Glucose
 Thiamine
Antidote for Patients With
Seizure of Unknown Etiology
• Pyridoxine (Vitamin B6)
Antidote for acetaminophen toxicity
a. Deferoxamine
b. Glucagon
c. Pralidoxime
d. N – acetylcysteine
Antidotes
 Deferoxamine (Desferal) – Iron toxicity
 Glucagon – Beta blockers toxicity
 Pralidoxime – pharmacologic antidote
for organophosphate toxicity
 Atropine – physiologic antidote for
organophosphate toxicity
 N – acetylcysteine – paracetamol
toxicity
Antidote for organophosphate toxicity
a. Physostigmine
b. Atropine
c. Penicillamine
d. Flumazenil
Antidotes
 Physostigmine – anticholinergic toxicity
 Penicillamine – heavy metal poisoning
(lead, arsenic, mercury)
 Flumazenil – Benzodiazepine overdose
What do you give for an individual who
intentionally ingested an unknown
substance but has antimuscarinic
manifestations?
a. Physostigmine
b. Atropine
c. Pralidoxime
d. N-acetylcysteine
Which of the following is incorrect
regarding lead poisoning?
a. has lead lines on gingival and on epiphyses
of long bones on X-ray
b. shows erythrocyte basophilic stippling
c. manifests with wrist and foot drop
d. may lead to megaloblastic anemia
Health Effects of Lead
 Clinical Lead
Poisoning
 Coma
 convulsions
 peripheral
neuropathy
 Kidney failure
 anemia
 Subclinical Lead
Poisoning
 Decreased
IQ
 altered behavior
 slowed nerve
conduction
Lead Poisoning
Lead Lines
Gingival Lines
Antidote for severe lead poisoning
a. Dimercaprol
b. Succimer
c. Penicillamine
d. Deferoxamine
A stuporous 18 year-old male was found
locked inside a car in their enclosed garage.
He presented with cherry-red lips and
mucous membranes. The appropriate
management would be:
a. Hydroxocobalamin
b. Naloxone
c. Hyperbaric oxygen
d. Methylene blue
Antidote for digitalis toxicity
a. Glucagon
b. Dimercaprol
c. Anti-dig Fab fragments
d. Atropine
If an acid drain cleaner has been
ingested
A. Immediately induce vomiting to remove
offending agent
B. Insert NGT and do gastric lavage even beyond
one hour post-ingestion
C. A strong base such as NaOH should be used
to neutralize the acid.
D. Give H2 blocker or proton pump inhibitor (PPI)
Antidote for iron toxicity
a. EDTA
b. Succimer
c. Penicillamine
d. Deferoxamine
A 2 year-old male was rushed to the ER
after his mother could not wake him up.
Beside him was an upturned container of
silver jewelry cleaner. The appropriate
management would be:
a. give Atropine
b. give nitrite and thiosulfate
c. give methylene blue
d. give aminocaproic acid
Antidote for heparin toxicity
a. Protamine
b. Vitamin K
c. Warfarin
d. Aminocaproic acid
Antidotes
 Vitamin K – warfarin toxicity
(coumatetralyl in rat poisons)
 Aminocaproic acid – hemostatic agent
Antidote for opioid toxicity
a. Atropine
b. Naloxone
c. 100% Oxygen
d. Flumazenil
Which of the following has the correct
combination of the antidote and its
mechanism of action?
A. Pralidoxime – inert complex formation
B. Ethanol – reduction in conversion to more toxic
compounds
C. N-acetycysteine - bypassing the effect of poison
D. Pyridoxine – competitive inhibition at receptor
site
Pediatric Specific ADRs
(Craig, CR et al, Modern Pharmacology, 6th ed., 2004)
Drug
Reaction
Furosemide (Lasix)
Nephrocalcinosis
Indomethacin (Indocin)
RF, Bowel perforation
Adrenocorticoids
Delayed development, growth
suppression
Tetracycline
Discolored teeth
Phenobarbital
Hyperactivity, impaired intelligence
Phenytoin (Dilantin)
Thickened skull, coarse features
Chloramphenicol
Gray baby syndrome
Phenothiazines
Extrapyramidal reaction
Valproic acid (Depakene)
Hepatotoxicity
Aspirin
Reye’s Syndrome in patients with
chickenpox or influenza