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/

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



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

/

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)




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



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

/

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




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




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




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)




Round TwoSEMI-FINAL

1

Team AB Q1What overdose does a high osmolar gap,

hypocalcaemia and renal failure suggest?

Team AB A1Ethylene glycol




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




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




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




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




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




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



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/

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

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



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)




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)

Health & Medicine

WICM 2014 Toxicology Quiz