Taglines and Xquestions Quiz - Gerencia Chakravyuh B-quiz 2014
WICM 2014 Toxicology Quiz
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Transcript of WICM 2014 Toxicology Quiz
WHO wants to be a
TOXICOLOGIST? Chris Nickson
The Alfred
How thisWORKS
YOU form 8 teams
3 rounds of competitionQuarter-finals x 4
Semi-finals x 2 The GRAND final
WE find out who wants to be toxicologist!
ThePRIZE
F.UCEMthen
FCICM
Round OneMATCH 1
Team A Q1What does DEAD in the Resus-RSI-DEAD mnemonic for the approach to the poisoned patient stand for?
Team A A1Resuscitation
Risk assessmentSupportive care and Monitoring
InvestigationsDecontamination
Enhanced eliminationAntidotes
Disposition http://lifeinthefastlane.com/education/ccc/approach-to-acute-poisoning/
Team B Q1What are 4 of the 5 components of a
risk assessment in toxicology?
Team B A1Agent(s)Dose(s)
Time since ingestionCurrent clinical status
Patient factors
http://lifeinthefastlane.com/education/ccc/approach-to-acute-poisoning/
Team A Q2What 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 Q2What are the criteria for liver transplantation
in paracetamol hepatotoxicity?
Team B A2The 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
Tie Breaker 1QWhat is the antidote for
isoniazid toxicity?
Tie Breaker 1APyridoxine
http://lifeinthefastlane.com/education/ccc/isoniazid-toxicity/
Round OneMATCH 2
Team C Q1What is gastrointestinal decontamination?
Team C A1Removal of a toxic agent from the
GI tract before complete absorption into the systemic
circulation
http://lifeinthefastlane.com/education/ccc/gi-decontamination/
Team D Q1What is
enhanced elimination?
Team D A1Using 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 Q2Name 3 specific therapies for severe propanolol overdose
(not including catecholamines or mechanical/ extracorporeal
supports)
Team C A2NaHCO3
HyperventilationHigh dose insulin euglycemic
therapy
…not glucagon(e)…
http://lifeinthefastlane.com/toxicology-conundrum-044/
Team D Q2A patient presents 10 hours after an overdose with bradycardia,
cardiogenic shock, vasodilation & HYPERglycemia.
What is the most likely causative agent?
Team D A2Calcium channel blocker
such as verapamil or diltiazem (often SR)
http://lifeinthefastlane.com/toxicology-conundrum-028/
Tie Breaker
Tie BreakerWhat are the
indications for digibind in acute digoxin poisoning?
Tie Breakercardiac arrest
life-threatening dysrhythmiaK >5 mM
>10 mg ingested (adult)>15 nM level (>12ng/mL)
http://lifeinthefastlane.com/education/ccc/digoxin-toxicity/
Round OneMATCH 3
Team E Q1What two screening tests should
be performed in every acutely poisoned patient?
(excluding a BSL)
Team E A1ECG
serum paracetamol level
http://lifeinthefastlane.com/education/ccc/approach-to-acute-poisoning/
Team F Q1What are 5 complications of
activated charcoal administration?
Team F A1Vomiting
Pulmonary aspiration/ direct administration to lung via NGTImpaired absorption of meds
Corneal abrasionsConstipation / bowel obstruction
Distraction from resuscitation
http://lifeinthefastlane.com/education/ccc/activated-charcoal/
Team E Q2Name 5 agents that can be
removed by hemodialysis or hemoperfusion?
Team E A2Anticonvulsants*
LithiumMetformin
KClSalicylates
Theophyline*Toxic alcohols
http://lifeinthefastlane.com/education/ccc/enhanced-elimination/http
://lifeinthefastlane.com/education/ccc/indications-timing-and-patient-selection-for-rrt
/
Team F Q2Name two agents where urinary alkalinisation
is appropriate ?
Team F A2Salicylates
Phenobarbitone
http://lifeinthefastlane.com/education/ccc/enhanced-elimination/
Tie Breaker
TiebreakerWhat are the
5 stages of iron toxicity?
TiebreakerGI 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/
Round OneMATCH 4
Team G Q1Which types of agent
do NOT bind activated charcoal?
Team G A1Alcohols
Metals (eg. Fe, Li, K)AcidsAlkalis
Hydrocarbons
http://lifeinthefastlane.com/education/ccc/activated-charcoal/
Team H Q1What is the usual mode of death
from hydrofluoric acid (HF) toxicity?
Team H A1Dysrhythmias from:
hypocalcemia, hypomagnesemia and acidosis
Team G Q2Name 5 agents that can be treated
with whole bowel irrigation
Team G A2Iron
Slow release potassiumSlow release calcium channel
blockerArsenic trioxide
LeadBody packer
Team H Q2Name 4 agents that can be treated with
multi-dose activated charcoal (MDAC)
Team H A2Carbamazepine
dapsonephenobarbitone
quininesalicylate*
theophyline
http://lifeinthefastlane.com/education/ccc/activated-charcoal/
Tie Breaker
Tie Breaker 4QName 3 antidotes that can used to
treat cyanide toxicity
Tie Breaker 4ACyanide binders
(dicobalt edetate and hydroxocobalamin)
Sulfur donors (sodium thiosulfate)
Methemoglobin generators (amyl nitrite and sodium nitrite)
http://lifeinthefastlane.com/toxicology-conundrum-038/
Round TwoSEMI-FINAL
1
Team AB Q1What overdose does a high osmolar gap,
hypocalcaemia and renal failure suggest?
Team AB A1Ethylene glycol
http://lifeinthefastlane.com/toxicology-conundrum-035/
Team CD Q1For which poison does
GI decontamination override all other management priorities?
Team CD Q1Paraquat
http://lifeinthefastlane.com/education/ccc/paraquat-poisoning/
Team AB Q2What is the likely cause of this ECG in a conscious, mildly hypotensive
patient?
Team AB A2Sotalol overdose
(sinus bradycardia, long QTc 600ms)
Team CD Q2What is the likely cause of this ECG in a comatose patient with miosis
and hypotension?
Team CD A2Quetiapine overdose
(sinus tachycardia, long QTc)
Team AB Q3A comatose child in Australia with miosis, marked bradycardia, respiratory depression and hypotension has most likely
overdosed on what drug?
Team AB A3Clonidine
http://lifeinthefastlane.com/toxicology-conundrum-041/
Team CD Q3Name 3 features required for the diagnosis of propofol infusion
syndrome (PRIS)?
(not including propofol!)
Team CD A3acute 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
Tie Breaker S1Q
Outline your management (RSI-DEAD)
of severe theophyline overdose
Tie Breaker S1A
Resus with fluids for low BPB-blockers* for SVT
Rx seizuresRx N&V
Rx hypokalemiaActivated charcoal*HAEMODIALYSIShttp://lifeinthefastlane.com/toxicology-conundrum-014/
Round TwoSEMI-FINAL
2
Team EF Q1Name 4 features that help
distinguish a serotonin syndrome from neuroleptic malignant
syndrome?
Team EF A1Both
High BP, HR, RR, T; Sweaty; CK
Serotonin syndromeMydriasis 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 Q1Name 3 features that help
distinguish a sympathomimetic syndrome from an anticholinergic
syndrome?
Team GH A1Both
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 Q2What is the likely cause of this ECG in a patient with decreased level of
consciousness?
Team EF A2Sodium channel blockade
due to tricyclic antidepressant(broad QRS, dominant R’ in aVR)
Team GH Q2What is the likely cause of this ECG
in a depressed elderly man?
Team GH A2Digoxin toxicity
(Atrial flutter with slow ventricular response)
Team EF Q3What are the clinical manifestations
of valproate overdose?
Team EF A3Mitochondrial toxin
delayed comaHAGMA, high NH3, low glucose
high Na, low Cabone marrow suppression
MODS, cerebral edema
Team GH Q3What are the clinical manifestations
of salicylate overdose?
Team GH A3Tinnitus, hyperpnea, vomiting
metabolic acidosiscoma + seizures
hypoprothrombinaemia
Tie Breaker
Tie Breaker S2Q
The triad of GI symptoms, hair loss and peripheral neuropathy
suggests what?
Tie Breaker S2A
Thallium toxicity
Round ThreeGRAND FINAL
Team ABCD Q1
Venlafaxine, buproprion and tramadol all cause seizures — what anti-epileptic drug should you NOT
use?
Team ABCD A1Phenytoin
http://lifeinthefastlane.com/toxicology-conundrum-023/
Team EFGH Q1Name 4 agents (different classes)
that cause hypoglycemia
Team EFGH A1Insulin
Oral hypoglycemic agentsAlcoholQuinine
Beta-blockers
Team ABCD Q2
What are the antidote(s) for organophosphate toxicity
and how do they work?
Team ABCD A2atropine
(acetylcholine receptor antagonist)pralidoxime
(prevents AChEsterase inhibtion by OP)
http://lifeinthefastlane.com/education/ccc/organophosphate-poisoning/
Team EFGH Q2What is your approach to an
asymptomatic child who ate a couple of his grandad’s gliclazide
tablets 4 hours ago?
Team EFGH A2D/C if asymptomatic with
normal BSL at 8hIf hypoglycemia then start
octreotideOnly stop octreotide in the morning
and monitor for 4h after
http://lifeinthefastlane.com/toxicology-conundrum-029/
Team ABCD Q3
Name the 4 essential antidotes to have available for a
cardiotoxic overdose, and the agents they neutralise
Team ABCD A3digibind (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 Q3Name 4 metal poisonings and a
specific antidote for each
Team EFGH A3arsenic, 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 A4GI Symptoms
Bone marrow depressionShock, ARDS, renal failure,
coagulopathy
http://lifeinthefastlane.com/toxicology-conundrum-042/
Team EFGH Q4What are the features of paraquat poisoning?
Team EFGH A4GI symptoms, corrosive+ve urinary dithionate
metabolic acidosisMODS, shock, ARDSpulmonary fibrosis
Team ABCD Q5
What specific measures are recommended for treatment of
dapsone toxicity?
Team ABCD A5MDAC
Treat methemoglobinemia:methylene blue, exchange
transfusion, hyperbaric oxygen
Team EFGH Q5What specific measures are
recommended for treatment of paraquat poisoning?
Team EFGH A5Intubation
if airway compromiseImmediate GI decontamination
?hemodialysis (if <2h)? NAC, Vit C, cyclophosphamide,
steroidsSupportive care or palliation
http://lifeinthefastlane.com/education/ccc/paraquat-poisoning/
Tie Breaker
Tie Breaker GF Q
A patient with a history of multiple sclerosis
appears to be brain dead. What overdose must be excluded?
Tie Breaker GF A
Baclofen
LEARN MORE
Suggested resourceshttp://litfl.org/1lIDCrC
TheEND
Additional unused
questions
Team A Q2Name 3 risk factors for
propofol infusion syndrome (PRIS)?
Team A A2>4mg/kg/hr propofol for 48 hours
younger ageacute neurological injurylow carbohydrate intakecatecholamine infusion
corticosteroids infusion
http://lifeinthefastlane.com/education/ccc/propofol-infusion-syndrome/
Tie BreakerWhat agent may controversially be
used as an antidote for valproate overdose and
propofol infusion syndrome (PRIS)?
Tie BreakerCarnitine
http://lifeinthefastlane.com/education/ccc/sodium-valproate-overdose/ http://lifeinthefastlane.com/education/ccc/propofol-infusion-syndrome/
Team D Q3What are the ECG features
of digoxin toxicity?
Team D Q3AV 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 Q3Outline the management
(Resus-RSI-DEAD) of iron overdose?
Team F A3ABCs, fluids
Supportive care + monitoringWBI (if >60mg/kg) or retrieval
Desferrioxamine(if >90uM, HAGMA, shock)
http://lifeinthefastlane.com/education/ccc/iron-overdose/
Tie Breaker 3QWhat is the best specific antidote
to use in severe beta-blocker overdose?
Tie Breaker 3AHigh dose insulin euglycemic
therapy
…not glucagon(e)
http://lifeinthefastlane.com/education/ccc/glucagon-as-an-antidote/
Team H Q3A patient with GHB overdose should regain consciousness
within what period following ingestion?
Team H A36 hours
http://lifeinthefastlane.com/grievous-bodily-harm/
Team CD Q1What are the clinical manifestations
of carbamazepine overdose?
Team CD A1Nystagmus, Ataxia, Delirium
Anticholinergic effectsComa
VT/VF in massive overdoses
http://lifeinthefastlane.com/education/ccc/carbamazepine-toxicity/
Team CD Q3A comatose adult in Australia with miosis, tachycardia, long Qtc
and hypotension has most likely overdosed on what drug?
Team CD A3Quetiapine or olanzepine(clozapine if hypersalivating)