Toxic Alcohols
What are the common toxic alcohol presentations?
Ethylene Glycol
Isopropyl Alcohol
What is the O2 sat gap?
Examples of TCA drugs?
Amitriptyine
Nortriptyline
Imipramine
Clomipramine
Desipramine
What are common manifestations of salicylate toxicity?
Tinnitis
Vomiting
Tachypnea
Altered mental status
Pulmonary Edema
Cerebral edema
What are the main symptoms of Li toxicity?
Tremor
Polyuria
Vomiting
Diarrhea
Ataxia
Delrium
How are toxic alcohols metabolized?
Alcohol dehydrgenase
What are causes for an O2 sat gap?
Carboxyhemoglobinemia
Methemoglobinemia
Cyanohemoglobinemia
Sulfahemoglobinemia
What is the hallmark EKG finding in TCA overdose?
Terminal Rightward Deflection
-Wide S wave in V3
-Terminal R wave in aVR (>3mm)
What is the classic triple acid base disorder in salicylate toxicity?
AG metabolic acidosis + metabolic alkalosis + respiratory alkalosis
What is the biggest contributor to dehydration?
Polyuria secondary to nephrogenic diabetes insipidus
What does the OG in toxic alcohol ingestions represent?
Toxic alcohol level
Antidote for carboxyhemoglobinemia?
FiO2 1.0
What side effects are related to which receptors?
Blockade of Cardiac Na channel - Prolonged QTc
Blockade of Alpha receptor - hypotension
Blockade of Muscarinic receptor - anticholinergic syndrome
Activation of Histamine receptor - somnolence
Blockade of GABA - seizures
Inhibition of Seratonin uptake - delirium
How do you explain?
Respiratory alkalosis
Metabolic alkalosis
AG metabolic acidosis
Respiratory alkalosis - respiratory center stimulation
Metabolic alkalosis - gastritis and vomiting
AG metabolic acidosis - mitochondrial dissociation leading to lactic acidosis
What are the different clinical scenarios for Li toxicity?
Acute
Subacute
Chronic
What does the AG represent in toxic alcohol ingestions?
Metabolites (often aldehyde and acid)
Antidote for methemoglobinemia?
Remove offending / precipitating agent
Methylene blue
FiO2 1.0
How do you treat cardiac toxicity?
Sodium bicarbonate infusion
Treatment of salicylate toxicity?
Alkalinization
Hemodialysis
Treatment of Li Toxicity?
Rehydration with NS - will promote renal clearance of Li (follows Na excretion in kidneys) - simple and very effective if renal function preserved
Hemodialysis
How do you block alcohol metabolism?
Block alcohol dehydrogenase
-Fomepizole (15mg/kg iv then 10mg/kg iv bid)
-10% Ethanol infusion (500cc iv bolus then 100-200cc/hr iv)
Antidote for cyanoglobinemia?
Hydroxycobolamine
Sodium thiosulphate
FiO2 1.0
How do you treat Sz?
Sodium bicarbonate infusion
Avoid dilantin (arrhythmogenic in TCA overdose)
Benzodiazepine
Indications for hemodialysis?
Acute salicylate level >7.2 (normal creatinine) or >6.5 (abnormal creatinine)
Chronic salicylate level >4.5
Cerebral edema
Pulmonary edema
Significant lactic acidosis
Renal impairment preventing renal clearance
Hemodialysis indications?
Severe symptoms
Li > 5.0 (normal creatinine)
Li > 4.0 (abnormal creatinine)