Toxic Alcohols
How do you calculate measured osmolality?
(Na x 2) + BUN + Glucose
Iatrogenicity with Intralipid?
lipemic blood - cannot not get accurate serum chemistry
Key clinical features with seratonin syndrome?
Delirium
Fever
Hyperreflexia / Clonus
Ocular Clonus
Rigidity
Diarrhea
How useful is the Rumack-Matthew normogram for interpreting Tylenol levels?
Depends on when the patient ingested Tylenol and how much they ingested. Those 2 factors are often not clear in overdoses.
Clinical features of the hypoglycemia toxidrome?
Nausea/Vomiting
Diaphoresis
For Ethylene Glycol Toxicity, what contributes to the OG and what contributes to the AG
AG - Oxaldehyde, Oxallic Acid
Iatrogenicity with Charcoal?
Charcoal ARDS (very high mortality)
2 Hit mechanism of serotonin over expression:
How do the following medications contribute to serotonin syndrome?
SSRI
SNRI
Linezolid
SSRI - decreased serotonin reuptake
SNRI - decreased serotonin reuptake
Linezolid - decreased serotonin metabolism my MAO (Linezolid is a MAO-I)
What is the toxic metabolite that mediates fulminant liver injury?
What liver injury pattern do you see?
NAPQI
Fulminant liver failure with AST/ALT in 1000s
Causes of hypoglycemia?
Insulin overdose
Oral hypoglycemic agent overdose
Insulinoma
Addison's
Liver Failure
Septic Shock
Alcohol Binging
For Methanol toxicity, what contributes to the OG and what contributes to the AG?
OG - Methanol
AG - Formaldehyde, Formic Acid
++ risk of hypoglycemia
does not improve hemodynamics
2 Hit mechanism of serotonin over expression:
How do the following medications contribute to serotonin syndrome?
Methamphetamine
Ondansetron
Methamphetamine - sympathetic mediated increased serotonin release + decreased serotonin reuptake
Ondansetron - 5HT3 antagonist - decreased cholinergic/ increased symphathetic mediated increased serotonin release + decreased serotonin reuptake
What is the role of P450 in Tylenol toxicity?
P450 augmentation by drugs can dramatically increase NAPQI production. e.g. TB drugs and anti-epileptics
What is neuroglycopenia and how does it affect management?
CNS glucose levels do not reliably correlate with blood glucose levels.
Target a BG 8-10 to avoid neuroglycopenia
Ethylene Glycol > 15
AG > 24
pH < 7.25
Iatrogenicity with large volumes of hypotonic dextrose (D5W or D10W)
Severe hyponatremia in 24 hours
2 Hit mechanism of serotonin over expression:
How do the following medications contribute to serotonin syndrome?
Fentanyl
L Tryptophan
Lithium
Inflammatory Bowel Disease
Fentanyl - Serotonin agonist
L Tryptophan - provides more substrate for serotonin production
Lithium - increased sensitivity of serotonin receptors
Inflammatory Bowel Disease - increased expression of serotonin receptors
How is NAPQI normally detoxified by the body
Glutathione (antioxidant normally stored in the liver)
How do you treat severe hypoglycemia?
Glucose to target a BG 8-10
If D20W or D50W used then a central venous line is needed
Dialysis indications for Methanol?
Methanol > 8
AG > 24
pH < 7.25
Iatrogenicity with Cyproheptadine?
Leads to bias of realistic treatment effect and diverts attention from aggressive benzodiazepine dosing that is much more effective
Seratonin Syndrome antidote?
Benzodiazepine
Cyproheptadine
What is the antidote for Tylenol toxicity?
What is the dose?
N-acetlycysteine or NAC (antioxidant)
NAC 150 mg/kg iv over 1 hr then 50mg/kg over 4 hr then 100mg/kg iv over 16hr (keep repeating this dose till liver injury recovering)
What is hypoglycemia unawareness?
Patients stop having hypoglycemia symptoms and therefore have no warning or awareness of hypoglycemia.