Toxicology

Toxidrome:constellationofsigns/symptomsthatsuggestaparticular
classofpoison.(Thereare5typesofclasses)
o Anticholinergicdilatedpupils,dryskin,fever,hallucinations
o Cholinergicbradychardia,diarrhea,increased
salivation/urination,vomiting,wheezing
o Opioidalteredmentalstatus,bradycardia,constrictedpulpils,
decreasedbowelsounds,hypothermia,slowrespiration
o Sedativeblurredvision,confusion,coma,nystagmus,
sedation,slurredspeech
o Stimulanthallucinations,insomnia,restlessness,tachychardia,
tremors
Poison
o Protectyourself
o ABCDEsofemergencymanagement
Airway
Mostcommonfactorcontributingtodeathfrom
drugoverdoseorpoisoning
Patientlosesairwayprotectivereflexes,airway
obstructionbyflaccidtongue,pulmonary
aspirationofgastriccontents,respiratoryarrest
Breathing
Circulation
Disability
Exposure
Cathartics
o UsedtospeedremovaloftoxinsfromGIT
o Sorbitolisarecommendedagentintheabsenceofheart
failure
o Magnesiumsulfatecanbeusedintheabsenceofrenalfailure
Antidotes
o Modeofaction
Neutralizethepoisonbychangingchemicalnature
Preventsabsorption

 Countertheeffectsbyproducingoppositephysiological
action
Poison
Antidote
Acetaminophen
Acetylcysteine
Organophosphates
Atropine/Pralidoxime
Ironsalts
Deforoxamine
Digoxin
Digibinds
Methanol,ethylene
Ethanol/Fompizole
glycol
Opioid/Narcotics
Naloxone
Carbonmonoxide
Oxygen
Benzodiazepine
Flumazenil
CarbonMonoxide
o GreatImitator
o BindingaffinityofCOforhemoglobinis250timeshigherthan
oxygen
o CNSeffectsvenousstagnation,edema,hemorrhage
o Headache,dizziness,weakness,nausea,vomiting,chestpain,
confusion,cardiacarrhythmias,highHbCO,cherryredcolor
totheskin&mucousmembranes
NitrogenOxides
o SiloFillersdiseasedelayedonsetpulmonarytoxicity
experiencedbyfarmworkerswhouponentranceintoapoorly
ventilatedsiloareexposedtohighconcentrationsofNO2
producedbyfermentinggrain
Dyspnea,cough,hypoxia,possiblewheezesandraleon
exam
NitrousOxide
o WhipitprepackagedcartridgefilledwithNO2
Inhaledforeuphoriceffects
Pneumoconiosis
o Anylungdiseaseduetopermanentdepositionofsubstantial
amountsofparticulatematterinthelungs
o Coaldust,silicone,asbestos,irondust,tinoxide,bauxite,etc.
Anthracosis

o Blacklungdisease;Coalminerspneumoconiosis(formfrom
blackcoal)
CaplansSyndrome
o CombinationofRAandpneumoconiosis
o DX:lungfunctiontest,rheumatoidfactor;chestxray
Silicosis
o Causedbyinhalationofsilicadust
Asbestos
o Fibrousmineralformofmagnesiumsilicate
o Insulation,fireproofingmaterial,andbrakeliningsnolonger
usedinU.S.
o Lungcancer,mesothelioma,gastrointestinalcancer
o Asbestosisinterstitialfibrosingoflungs
Inflammatoryrxn
SOB,decreasedvitalcapacity,&totallungcapacity
TX:nocure;supportive(O2,bronchodilators,
percussion,etc.)
o Mestheliomacancercausedbyasbestosexposure
Mostcommoninpleura,butcanalsooccurin
pericardium,peritoneum,andtunicavaginalis
FarmersLung
o Allergicdiseaseusuallycausedbybreathingindustfrom
moldyhay(oranymoldycropstraw,corn,silage,grainor
eventobacco)
Byssinosis
o Formofreactiveairwaydisease
o Cotton,flax,yarn,hempworkers;unknownetiology
o MondayFeverduetoexposure
bronchoconstriction,chesttightness,cough,wheeze,and
dyspnea;worseonthe1stdayofworkweek
Bagassosis
o Hypersensitivitypneumonitis;cough,SOB
o Duetoinhalationofdustfromresidueofcaneafterextraction
fromsugar
o CaneJuice

o Dustscontainingsporesofthermophilicactinomycetes
(Micropolysporafaeni)thatgrowinstored,moldybagasse
o DX:chestxray
o TX:steroidsandreducedexposure
o India,Argentina,Louisiana
Lead(Pb)Poisoning
o Paint,gasoline,pipes,jewelryandpottery,recyclingplants,
leadacidbatteries,metalalloys,solders,somefolkremedies
o Greaterthan90%ofleadburdeninadultsandmorethan2/3rd
oftheburdeninyoungchildrenoccurintheskeleton
o Chroniclowlevelexposuresleadtopica,decreased
intelligence,impairedneurobehavioraldevelopment,stunted
growth,anddiminishedauditoryacuity
o NucleatedRBCscontainsbasophilicstipplingofthe
cytoplasm
o Depositedinbone
o Toxicityandnervoussystem
Peripheralneuropathy,paraesthesia
Wrist/footdrop
Impairedconcentration
Headache
Visualmotorincoordination
Tremor,delirium,lethargy,lowIQ
Ataxia
Convulsions,coma
Burtonslines
Musclewasting
Bluish/pallordepositonfingers
o TX:chelationtherapychelatingagentsbindtootheragents
tofacilitatetheirexcretion
Severeexposures:calciumdisodiumEDTAor
dimercaprol(BAL)
Arsenic
o Sources:drinkingwaterandrice,seafood,coalcombustion,
drugs,smelting,environmental
o Inhibitspyruvatedehydrogenase
o Garlicbreath&ricecoloredstools
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o AldrichMeeslines
o Raindroppigmentation
o INORGANICARSENIC:TX:chelationtherapywith
dimercaprol
o ORGANICARSENIC:chelationtherapyisINEFFECTIVE,
TERATOGEN
Mercury
o Sources:coalplantexhasts,volcanoes,goldmines,seafood,
thermometers,fluorescentlightbulbs,somevaccines
(preservative),topicalantiseptics,folkmedicine
o OrganicMercury
Methylmercury:viabioaccumulation,crossesBBB,fish
(tuna,swordfish,shark,kingmackerel,tilefish);worstof
theorganic.
Ethylmercury:topicalantiseptics,vaccinepreservative
(thimersol),shorterhalflife,doesNOTcrossBBB
o Chelationtherapywithdimercaprol
o Erethism
Redfingers/toes/cheeks,sweating,bleedingfrom
ears/mouth,lossofhair/fingernails
o Madhatters
o Acrodynia
Samesxaserethism,exceptinchildren
OrganophosphorusPesticides
o Cholinesteraseinhibitors
o Muscarinicsymptoms:
SLUDGEM(salivation,lacrimation,urination,
diarrhea/defecation,GIupset,emesis,miosis)
MUDDLES(miosis,urination,diaphoresis&diarrhea,
lacrimation,excitation,salivation)
o Nicotinicsymptoms:
Diaphragmfailure
Musclefasciculations,cramping,weakness
Hypertension,tachycardia,mydriasis,pallor
o TX:Pralidoxime(2PAM)
Atropinerevesesallmuscariniceffects
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o Persistsonfruits&veggies
CarbametInsecticides
o InhibitACHbycarbamoylation
o Atropineasanantidote
Cyanide
o Almonds,pitsofcherries,apricots,apples,oranges,cassava
roots,bambooshoots,tobaccosmoke,vitB12as
hyroxocobalamin,leavesofcherrylaurel
o Brightredvenousbloodandodorofbitteralmonds
Dioxins
o Tampons
o AgentOrange(TCDDmosttoxic)
o UsedtomurderPresidentYushchenkoofUkraine
Snakevenom
o Inhumanvictims,venom(complexmixtureof50+
componentsusedtokill,immobilize,predigestprey)produce
localdigestiveorcytotoxiceffectsontissues
Hematotoxic
Neurotoxic
Mixed
o Timeistissue
o Washbite,keepbelowheart,immobilizelimb
o Donotcutintobite,suckvenomorapplysuctiondevice,apply
heat/ice,tourniquet
Spiders
o Brownrecluse
Deepblueorpurpleareaaroundthebite,surroundedbya
whitishringandlargeredouterring(bullseye)
Mayturnblack
Applycoldpackandelevate
o BlackWidow
Crampingpainandmusclerigidityofstomach,chest,
shoulders,back
StingRay
o Immerseaffectedbodypartinhotwater(3090minutes)
Scorpions

o Severecases:drooling,hypo/hypertensionarrhythmia,
tachy/bradycardia,difficultybreathing,laryngealspasm,
swellingoftongue,nausea,vomiting,sweating,diarrhea,
convulsions,shock,coma,death
o SXmoresevereinchildren
Hymenoptera
o Yellowjacketsmayattackwithoutprovocation;mostcommon
causeofinsectinducedanaphylacticrxn
DrugAbuse
o Drugabuse:nonmedical,selfadministereduseofadrugthat
isharmfultotheuser
o Drugaddiction:drugabusersoverwhelmingpreoccupation
withtheprocurementanduseofthedrug
o Tolerance:decreasedintensityofaresponsetoadrug
followingitscontinuedadministration
o Physiologicaldependence:biologicneedtocontinuetotake
thedrug
o Psychologicaldependence:whenanindividualhaschanged
theirlifetoensurecontinueduseofaparticulardrugsuchthat
alltheiractivitiesarecenteredonthedruganditsuse
o Crosstolerance:tolerancetoonedrugconfersatleastpartial
tolerancetootherdrugsinthesamedrugclass(i.e.between
heroineandmethadone;ethanolanddiazepam)
o Crossdependence:abilityofonedrugtosubstitutefor
anotherdruginthesamedrugclasstomaintainadependent
stateortopreventwithdrawl
Alcohol
o Acutetoxicity
CNSdepression:decreasedanxiety,disinhibited
behavior,slurredspeech,ataxia,impairedjudgment
Hypoglycemia:impairedgluconeogenesisinpatientwith
depletedorlowglycogenstores
Respiratorydepression
Diuresis
Decreasedmyocardialcontractility,cutaneous
vasodilation,hypothermia
o Bingedrinking
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 Consuming5ormoredrinksinabout2hoursformen
Consuming4ormoredrinksforwomen
Excitotoxicityglutamaterelease
o FetalAlcoholsyndrome
Characterizedbyretardedgrowth,microencephaly,
poorlydevelopedcoordination,mentalretardation,
congenitalheartabnormalities
o TX:aversivetherapywithdisulfurum(anabuse)causes
nausea,sweating,flushing,headache,sweating,hypotension,
confusion
Psychomotorstimulants
o Methylxanthines(theophylline,theobromine,caffeine)
o Amphetamines
Benzedrine,Dexedrine,Ritalin,adderall,vyvance
Releaseofstoredcatecholamines(norepinethrine,
serotonine,dopamine)
Noantidote
HighBP,highbodytemp,tachycardia,pupildilation,
rhabdomylolysis,dehydration,libido,delusions,
anorexia
o Nicotine
o Cocaine
Use:euphoria,senseofwellbeingandcompetence,
paranoia,agitation,anorexia,dilatedpupils,
dehydration,bruxism
Noantidote
Hallucinogens
o Synesthesia/ideasthesia,alteredsenseoftime,hallucinations,
euphoria,trancelikestate,psychedeliceffects
o Synesthesiaseeingsoundortastingcolor
o Class1&Entheogens:
LSD(lysergicacid)mostlydopamine,someserotonin,
flashbacks
Mushrooms(psilocybin)serotoninanddopamine
indirectly
Mescalinepeyote,serotoninanddopamine
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 AyahuascaDMT+MOAI
PCP
o Phencyclidine(Angeldust)
o Hallucinogen,stimulant,depressant,dissociativeanesthetic
o Violentandbelligerent,unpredictablebehavior
Depressants
o GHB:(gammahydroxybutricacid)liquidX;daterapedrug
Amnesia,impairedmovement,drowsiness,sleep,slurred
speech
Marijuana
o Cannabissativamostpotent
o C.indicachillhigh
o C.ruderalis
o THC(tetrahydrocannabinol):psychoactivecomponent
o Shorttermuse:mildeuphoria,analgesia,lackofmotivation,
increasedappetite,redeyes,confusiondisorientation,paranoia,
psychosisinvulnerableindividuals
o CharlottesWebrecalcitrantseizuredisorders
OpiatesandOpioids
o Opiatederivedsemisynthetics:Heroine,Demerol,dilaudid,
Vicodin/lortab/norco(hydrocodone),Pecocet/Prcodan
(oxycodone)
Heroine
o Speedball:cocaine&heroineormorphine;falselowhigh
o Effectsofwithrawl:severepain,musclespasms,sweating,
tachycardia,mydriasis,vomiting
o Naloxoneforoverdose,clonidineforsymptomaticrelief
Krokodil
o Desomorphine;synthetic
o Gangrene/amputation,phlebitis,thrombosis,pneumonia
Pharmacology
Pharmacodynamicswhatthedrugdoestothebody
Pharmacokineticswhatthebodydoestothedrug(absorption,
metabolism,distribution,excretion)

 Pharmacotherapeuticsstudyofdrugsusedtoprevent,treator
diagnoseadisease
Effectivedoseamountofdrugthatproducesatherapeuticresponse
in50%ofpeopletakingit
Toxicdoseamountofdrugthatproducesadverseeffectsin50%of
thepeopletakingit
Entral:entersviaGIT
Parenteral:entersthroughadifferentmeans(otherthanGIT)
Chemicalnamedescribesdrugsanatomicstructure
Genericnameinternationallyrecognized;nonproprietarynameof
adrug;thereisonlyasinglegenericnameforeachdrug
Proprietarynamebrandortradenameofadrugthatispatentedby
drugmanufactuerer
Drugschedule
o 1:highabusepotential;notlegal;noacceptablemedicaluse;no
prescriptionsavailable(cocaine,heroin,LSD,marijuana)
o 2:highabusepotentialandseveredependenceliability;
current,acceptedmedicaluse,norefills,30daysupply(opium,
morphine,methadone,coca,amphetamines)
o 3:lessabusepotential,lowmoderatephysicaldependence
(codeine,barbiturates,anabolicsteroids,suboxone)
o 4:lessabusepotentialthanC3(Phenobarbital,ultram,soma,
ambient)
o 5:limitedabusepotential,acceptedmedicaluse(codeine,
atropine,pseudophedrine)
Antiinfectives
o Aminoglycosides
Adverserxns:ototoxicity&nephrotoxicity
o Cephalosporins
Indications:seriousinfectionsofthelung,skin,soft
tissue,bones,joints,UTI,septicemia,endocarditis,
meningitis,Lymedisease
Cefazolin
Ancef
Cephalexin Keflex
Cefuroxime Ceftin
Cefixime
Suprax
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Ceftriaxone
Cefepime

Rochepin
Maxipime

o Fluroquiolones
Adverserxns:tendonrupture
Ciprofloxac Cipro
in
o Penicillins

Advers
Amoxicillin
Augmentin,
erxns:
trihydratew/
clavulin
sun
clavulanate
potassium
Ampicillin
sensitivity/hypersensitivity
o Sulfonamides
Adverserxns:photosensitivity
Cotrimoxazole
Bactrim,septra
o Tetracyclines
Adverserxns:photosensitivity
Usedtotreatacne
Doxycycline
Antihypertensives
o Alphaadrenergicblockers
o Aceinhibitors
Endinpril
Adverserxn:drycough
Angiotensinconvertingenzymeinhibitors
o AngiotensinII
o Betablockers
Fatigue
Reduceheartrate
ololorlolendings
o Calciumchannelblockers
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Diltiazem:cardizem
Relaxessmoothmuscletoprovidevasodilationand
affectscardiacmuscletoreduceHR
o Diuretics
Furosemide:lasix
Hydrochlorothiazide(HCTZ)
HighCholesterol
o Statinsandbileacidsequestrants
o Statins:HMGCoAreductaseinhibitors
Livertoxicity
Endinstatin
Lipitor
Diabetes
o Metaformin&sulfonylureas
o Metaformin
Type2diabetes
Adversernx:flatulence
o Sulfonylureas
Type2diabetes
Sedatives
o Narcotics(akaopioids),Benzodiazeprines,Barbituates
o Opioids:Lomotril(fordiarrhea)
o Talwin(mixedagonistantagonistopioids)
o Benzodiazeprines
Enhance/facilitateactionsofGABA
Adverserxn:drowsiness
EndinPamorlam
Xanax
Diazepam:valium
Ativan
Versed
MuscleRelaxants
o Polysynapticinhibitors,indirect/direct,anxiolytic
o Skeletalmusclerelaxants1
Carisoprodol:soma
Parafonforte
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Flexeril
Robaxin
Norflex
o SkeletalmusclerelaxantsII
Valium
Antidepressants
o SSRI,Tricylics,phenothizines
SSRIProzac,Paxil,Zoloft
Respiratory
o Antihistamines,adrenergics,adrenocorticoids,
anticholinergics,Leukotrienereceptorblockers
Antihistaminesdiphenhydramine:benadryl
Vertigo/nausea
Bonineformotionsickness
Adrenergics:Sudafed(pseudoephedrine)
Mimicnaturallyoccurringcatecholamines
Beta2adrenergics:albuterol:proventil,ventolin
HIV/AIDS
o Nucleosidereversetranscriptaseinhibitors
Retroviral
o Proteininhibitors
Anticoagulants
o Anticoagulants,VitKinhibitors,Thrombolyticenzymes
Anticoagulants:heparin(safeforpregnant)
VitKinhibitors:warfarinratpoison
NSAIDs
o Livertoxicity,GIupset
Ibuprofen
Advil,motrin
Indomethacin
Indocin
Naproxen
Aleve
mobic
Meloxicam
Histaminereceptorantagonists
o Pepcid,Zantac
o Indications:duodenal/gastriculcer,acidreflux,GI
hypersecretion
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 Nitrates
o Nitroglycerin
Anticholinergics
o Nausea/vomiting:Scopace
o Parkinsonsandotherspasticconditions,myscledystonia,
motionsickness
AdverseDrugRxns,Teratogens,Vitamins,ToxicPlants
Cheeseeffect:interactionbetweenmonoamineoxidase(MAO
inhibitor)andtyraminecontainingfood
o Agedcheese,redwine,beer,chickenliver
Grapefruit
o Altersdrugmetabolizedbycytochromep450isoforms
o Some(butnotall):antihistamines,benzodiazepines,
amphetamines,caffeine,statins,selectedcalciumchannel
blockers,estrogens,HIVproteaseinhibitors,alsosomemisc
drugs(cyclosporine)
Sulfurcontainingantibiotics
o Bactrim:antibioticcombinationoftrimethoprimand
sulphamethoxazole
o StevensJohnsonSyndrome:toxicepidermalnecrosis
Teratogenicdrugs
o Anyagentthatleadstocongenitalanomalyorincreases
incidenceofanomaly
o ClassD:knownrisk
o ClassX:notprescribed
o Knownteratogens:
Alcohol
Cocaine
Mercury
Ibuprofen(prematureclosingofductusarteriosus,
prematureorprolongedlabor)
Tetracycline
Streptomycin(deafness)
ACEinhibitors
Anticoagulants
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Lithium
Andogens
DES
Phenytoin(Dilantin)
Mentalretardation,poorgrowth,microcephaly,
dysmorphicface,hypolasiaofdigits/nails
Fetalhydantoinsyndrome
Thalidomide
Limbdefectmeromelia/phocomelia*seallimb
Eardefect
Cardiovascularanomalies
Warfarin/coumadin
Anticoagulant,rodenticide
o Ototoxicity
Drugaccumulatesinendolymphandperilymphand
damageshaircells
Aminoglycosides(streptomycin,neomycin,gentamycin,
amikacin,tobramycin)
VitaminPoisoning
o Fatsoluble(A,D,E,K)
MostteratogenicvitaminA
Dryskin,increasedintracranialpressure
VitD:mosttoxicofallvitamins
w/vitCcalciumoxalatecrystals
o WaterSoluble(folicacid,vitb12,etc)
Niacin/B3toxicity:abuseinbodybuilders
Plants
o Foxglove
Digitoxin
Digitalis(digoxin;leftventricularheartfailure)
o Oleander
Digitoxin
Barbequingoverbranches,dogschewingonbranches
o Datura
Atropine,scopolamine
Anticholinergictoxidrome***

15

 TX:physostigmine

16