WICM 2014 Toxicology Quiz

WHO wants to be
a TOXICOLOGIST?
Chris Nickson
The Alfred

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!

Team A Q1
What does DEAD in the Resus-RSI-
DEAD mnemonic for the approach to
the poisoned patient stand for?

Team A A1
Resuscitation
Risk assessment
Supportive care and Monitoring
Investigations
Decontamination
Enhanced elimination
Antidotes
Disposition
http://lifeinthefastlane.com/education/ccc/approach-to-acute-poisoning/

Team B Q1
What are 4 of the 5 components of a
risk assessment in toxicology?

Team B A1
Agent(s)
Dose(s)
Time since ingestion
Current clinical status
Patient factors

Team A Q2
What is the mechanism of
paracetamol hepatotoxicity?

Team A A2
(1) glucuronidation & sulphation
pathways are rapidly saturated
(2) NAPQI production
(3) glutathione depletion
(4) excess NAPQI causes
hepatocellular necrosis
http://lifeinthefastlane.com/education/ccc/acute-paracetamol-toxicity/

Team B Q2
What are the criteria for
liver transplantation
in paracetamol hepatotoxicity?

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)
http://lifeinthefastlane.com/education/ccc/liver-transplantation-for-paracetamol-
toxicity/

Tie Breaker 1Q
What is the antidote for
isoniazid toxicity?

Tie Breaker 1A
Pyridoxine
http://lifeinthefastlane.com/education/ccc/isoniazid-toxicity/

Team C Q1
What is gastrointestinal
decontamination?

Team C A1
Removal of a toxic agent from the
GI tract before complete absorption
into the systemic circulation
http://lifeinthefastlane.com/education/ccc/gi-decontamination/

Team D Q1
What is
enhanced elimination?

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
http://lifeinthefastlane.com/education/ccc/enhanced-elimination/

Team C Q2
Name 3 specific therapies for
severe propanolol overdose
(not including catecholamines or
mechanical/ extracorporeal supports)

Team C A2
NaHCO3
Hyperventilation
High dose insulin euglycemic therapy
…not glucagon(e)…
http://lifeinthefastlane.com/toxicology-conundrum-044/

Team D Q2
A patient presents 10 hours after an
overdose with bradycardia,
cardiogenic shock, vasodilation &
HYPERglycemia.
What is the most likely
causative agent?

Team D A2
Calcium channel blocker
such as
verapamil or diltiazem (often SR)

Tie Breaker
What are the
indications for digibind
in acute digoxin poisoning?

Tie Breaker
cardiac arrest
life-threatening dysrhythmia
K >5 mM
>10 mg ingested (adult)
>15 nM level (>12ng/mL)
http://lifeinthefastlane.com/education/ccc/digoxin-toxicity/

Team E Q1
What two screening tests should be
performed in every acutely poisoned
patient?
(excluding a BSL)

Team E A1
ECG
serum paracetamol level

Team F Q1
What are 5 complications of
activated charcoal administration?

Team F A1
Vomiting
Pulmonary aspiration/ direct
administration to lung via NGT
Impaired absorption of meds
Corneal abrasions
Constipation / bowel obstruction
Distraction from resuscitation
http://lifeinthefastlane.com/education/ccc/activated-charcoal/

Team E Q2
Name 5 agents that can be removed
by hemodialysis or hemoperfusion?

Team E A2
Anticonvulsants*
Lithium
Metformin
KCl
Salicylates
Theophyline*
Toxic alcohols
http://lifeinthefastlane.com/education/ccc/indications-timing-and-patient-
selection-for-rrt/

Team F Q2
Name two agents where
urinary alkalinisation
is appropriate ?

Team F A2
Salicylates
Phenobarbitone

Tiebreaker
What are the
5 stages
of iron toxicity?

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)
http://lifeinthefastlane.com/education/ccc/iron-overdose/

Team G Q1
Which types of agent
do NOT bind
activated charcoal?

Team G A1
Alcohols
Metals (eg. Fe, Li, K)
Acids
Alkalis
Hydrocarbons

Team H Q1
What is the usual
mode of death
from hydrofluoric acid (HF) toxicity?

Team H A1
Dysrhythmias from:
hypocalcemia,
hypomagnesemia and acidosis

Team G Q2
Name 5 agents that can be treated
with whole bowel irrigation

Team G A2
Iron
Slow release potassium
Slow release calcium channel blocker
Arsenic trioxide
Lead
Body packer

Team H Q2
Name 4 agents that
can be treated with
multi-dose activated charcoal
(MDAC)

Team H A2
Carbamazepine
dapsone
phenobarbitone
quinine
salicylate*
theophyline

Tie Breaker 4Q
Name 3 antidotes that can used to
treat cyanide toxicity

Tie Breaker 4A
Cyanide binders
(dicobalt edetate and
hydroxocobalamin)
Sulfur donors
(sodium thiosulfate)
Methemoglobin generators
(amyl nitrite and sodium nitrite)

Team AB Q1
What overdose does a
high osmolar gap, hypocalcaemia
and renal failure suggest?

Team AB A1
Ethylene glycol

Team CD Q1
For which poison does
GI decontamination override
all other management priorities?

Team CD Q1
Paraquat
http://lifeinthefastlane.com/education/ccc/paraquat-poisoning/

Team AB Q2
What is the likely cause of this ECG in
a conscious, mildly hypotensive
patient?

Team AB A2
Sotalol overdose
(sinus bradycardia, long QTc 600ms)

Team CD Q2
a comatose patient with miosis and
hypotension?

Team CD A2
Quetiapine overdose
(sinus tachycardia, long QTc)

Team AB Q3
A comatose child in Australia with
miosis, marked bradycardia,
respiratory depression and
hypotension has most likely overdosed
on what drug?

Team AB A3
Clonidine

Team CD Q3
Name 3 features required for the
diagnosis of propofol infusion
syndrome (PRIS)?
(not including propofol!)

Team CD A3
acute refractory bradycardia
progressing to asystole and 1+ of:
(1) metabolic acidosis
(2) rhabdomyolysis
(3) hyperlipidaemia
(4) enlarged or fatty liver
http://lifeinthefastlane.com/education/ccc/propofol-infusion-syndrome/

Tie Breaker S1Q
Outline your
management (RSI-DEAD)
of severe theophyline overdose

Tie Breaker S1A
Resus with fluids for low BP
B-blockers* for SVT
Rx seizures
Rx N&V
Rx hypokalemia
Activated charcoal*
HAEMODIALYSIS

Team EF Q1
Name 4 features that help distinguish
a serotonin syndrome from
neuroleptic malignant syndrome?

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

Team GH Q1
Name 3 features that help distinguish
a sympathomimetic syndrome from
an anticholinergic syndrome?

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

Team EF Q2
a patient with decreased level of
consciousness?

Team EF A2
Sodium channel blockade
due to tricyclic antidepressant
(broad QRS, dominant R’ in aVR)

Team GH Q2
a depressed elderly man?

Team GH A2
Digoxin toxicity
(Atrial flutter with slow ventricular response)

Team EF Q3
What are the clinical manifestations of
valproate overdose?

Team EF A3
Mitochondrial toxin
delayed coma
HAGMA, high NH3, low glucose
high Na, low Ca
bone marrow suppression
MODS, cerebral edema

Team GH Q3
salicylate overdose?

Team GH A3
Tinnitus, hyperpnea, vomiting
metabolic acidosis
coma + seizures
hypoprothrombinaemia

Tie Breaker S2Q
The triad of GI symptoms, hair loss and
peripheral neuropathy suggests what?

Tie Breaker S2A
Thallium toxicity

Team ABCD Q1
Venlafaxine, buproprion and
tramadol all cause seizures — what
anti-epileptic drug should you NOT
use?

Team ABCD A1
Phenytoin

Team EFGH Q1
Name 4 agents (different classes)
that cause hypoglycemia

Team EFGH A1
Insulin
Oral hypoglycemic agents
Alcohol
Quinine
Beta-blockers

Team ABCD Q2
What are the antidote(s) for
organophosphate toxicity
and how do they work?

Team ABCD A2
atropine
(acetylcholine receptor antagonist)
pralidoxime
(prevents AChEsterase inhibtion by
OP)
http://lifeinthefastlane.com/education/ccc/organophosphate-poisoning/

Team EFGH Q2
What is your approach to an
asymptomatic child who ate a
couple of his grandad’s gliclazide
tablets 4 hours ago?

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

Team ABCD Q3
Name the 4 essential antidotes to
have available for a
cardiotoxic overdose,
and the agents they neutralise

Team ABCD A3
digibind (cardiac glycosides)
high dose insulin euglycemic therapy
(CCBs, B-blockers)
NaHCO3 (NCBs)
intralipid (local anaesthetics +)
http://intensivecarenetwork.com/index.php/icn-activities/icn-podcasts/439-57-
nickson-on-cardiotoxic-overdoses

Team EFGH Q3
Name 4 metal poisonings and a
specific antidote for each

Team EFGH A3
arsenic, lead, mercury – BAL/
dimercaprol, succimer (DMSA),
unithiol (DMPS)
copper – penicillamine, BAL
iron - desferrioxime

Team ABCD Q4
What are the features of
colchicine toxicity?

Team ABCD A4
GI Symptoms
Bone marrow depression
Shock, ARDS, renal failure,
coagulopathy

Team EFGH Q4
What are the features of
paraquat poisoning?

Team EFGH A4
GI symptoms, corrosive
+ve urinary dithionate
metabolic acidosis
MODS, shock, ARDS
pulmonary fibrosis

Team ABCD Q5
What specific measures are
recommended for treatment of
dapsone toxicity?

Team ABCD A5
MDAC
Treat methemoglobinemia:
methylene blue, exchange
transfusion, hyperbaric oxygen

Team EFGH Q5
What specific measures are
recommended for treatment of
paraquat poisoning?

Team EFGH A5
Intubation
if airway compromise
Immediate GI decontamination
?hemodialysis (if <2h)
? NAC, Vit C, cyclophosphamide,
steroids
Supportive care or palliation
http://lifeinthefastlane.com/education/ccc/paraquat-poisoning/

Tie Breaker GF Q
A patient with a history of
multiple sclerosis
appears to be brain dead.
What overdose must be excluded?

LEARN MORE
Suggested resources
http://litfl.org/1lIDCrC

Team A Q2
Name 3 risk factors for
propofol infusion syndrome (PRIS)?

Team A A2
>4mg/kg/hr propofol for 48 hours
younger age
acute neurological injury
low carbohydrate intake
catecholamine infusion
corticosteroids infusion

Tie Breaker
What agent may controversially be
used as an antidote for
valproate overdose and
propofol infusion syndrome (PRIS)?

Tie Breaker
Carnitine
http://lifeinthefastlane.com/education/ccc/sodium-valproate-overdose/

Team D Q3
What are the ECG features
of digoxin toxicity?

Team D Q3
AV conduction blocks
Increased automaticity
classically SVT with slow ventricular
response
…not reverse tick ST segments!
http://lifeinthefastlane.com/ecg-library/basics/digoxin-toxicity/

Team F Q3
Outline the management
(Resus-RSI-DEAD) of
iron overdose?

Team F A3
ABCs, fluids
Supportive care + monitoring
WBI (if >60mg/kg) or retrieval
Desferrioxamine
(if >90uM, HAGMA, shock)
http://lifeinthefastlane.com/education/ccc/iron-overdose/

Tie Breaker 3Q
What is the best specific antidote to
use in severe beta-blocker overdose?

Tie Breaker 3A
High dose insulin euglycemic therapy
…not glucagon(e) 
http://lifeinthefastlane.com/education/ccc/glucagon-as-an-antidote/

Team H Q3
A patient with GHB overdose should
regain consciousness within what
period following ingestion?

Team H A3
6 hours
http://lifeinthefastlane.com/grievous-bodily-harm/

Team CD Q1
carbamazepine overdose?

Team CD A1
Nystagmus, Ataxia, Delirium
Anticholinergic effects
Coma
VT/VF in massive overdoses
http://lifeinthefastlane.com/education/ccc/carbamazepine-toxicity/

Team CD Q3
A comatose adult in Australia with
miosis, tachycardia, long Qtc and
hypotension has most likely overdosed
on what drug?

Team CD A3
Quetiapine or olanzepine
(clozapine if hypersalivating)

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