Toxicological Jeopardy
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ToxicologicalToxicological JeopardyJeopardy
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Street Street Drugs And Drugs And SalicylatesSalicylates
Picture Picture ThatThat
ToxicToxic
TidbitsTidbits
Final JeopardyFinal Jeopardy
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Antidotes Antidotes And And
Anecdotes Anecdotes
Name That Name That ToxidromeToxidrome
400400
Toxic TidbitsToxic Tidbits
Acute Lithium toxicity is characterized Acute Lithium toxicity is characterized
by which of the following?by which of the following?
A)A) Seizures, hypotension, arrhythmiasSeizures, hypotension, arrhythmias
B)B) Rotary nystagmus, Agitation, Rotary nystagmus, Agitation, hypertensionhypertension
C)C) GI symptoms, tremor, GI symptoms, tremor, hyprerreflexiahyprerreflexia
D)D) Hypoglycemia, tremor, AMSHypoglycemia, tremor, AMS
Toxic Tidbits $100 (1 of 1)
Toxic TidbitsToxic Tidbits
Overdose of which of the following isOverdose of which of the following is
most likely to result in a metabolic most likely to result in a metabolic
acidosis?acidosis?
A)A) CaptoprilCaptopril
B)B) FurosemideFurosemide
C)C) AcetaminophenAcetaminophen
D)D) MetforminMetformin
Toxic Tidbits $200 (1 of 1)
Alkaline diuresis enhances the Alkaline diuresis enhances the excretionexcretion
of all of the following substancesof all of the following substances
Except?Except?
A)A) PhenobarbitalPhenobarbital
B)B) ChlorpropamideChlorpropamide
C)C) SalicylateSalicylate
D)D) PentobarbitalPentobarbital
Toxic TidbitsToxic Tidbits
Toxic Tidbits $300 (1 of 2)
PentobarbitalPentobarbital
All the other substances except All the other substances except pentobarbital can be enhanced by pentobarbital can be enhanced by urinary alkalinizationurinary alkalinization
Increasing the ionized form of Increasing the ionized form of weak acids increases their water weak acids increases their water solubility, therefore, more solubility, therefore, more eliminated in urine rather than eliminated in urine rather than distributing to tissuesdistributing to tissuesH + + A -HA
Toxic Tidbits $300 (2 of 2)
Toxic TidbitsToxic Tidbits
After an overdose of captopril, which After an overdose of captopril, which ofof
the following electrolyte disturbancesthe following electrolyte disturbances
Is most likely to occur?Is most likely to occur?
A)A) HypokalemiaHypokalemia
B)B) HypocalcemiaHypocalcemia
C)C) HypercalcemiaHypercalcemia
D)D) HyperkalemiaHyperkalemia
Toxic Tidbits $300 (1 of 2)
Angiotensinogen
Angiotensin I
Angiotensin IINE release
Aldosterone
Na+
Resorption
ADH
Blood Pressure
Renin
ACE I
Bradykinin
Inactive Peptide
PG synthesis
Vasodilation
Peripheral Vascular
ResistanceVasoconstriction Na+ Resorption K+ Excretion H2O Resorption
H2O Resorption
X X
Blood Pressure
Substance P
Toxic Tidbits $300 (2 of 2)
Toxic TidbitsToxic Tidbits
Serotonin Syndrome is most likely toSerotonin Syndrome is most likely to
occur with combination of which ofoccur with combination of which of
the following?the following?
A)A) Prozac and AmbienProzac and Ambien
B)B) Lexapro and DemerolLexapro and Demerol
C)C) Linezolid and EtomidateLinezolid and Etomidate
D)D) Lithium and Valproic AcidLithium and Valproic Acid
Toxic Tidbits $400 (1 of 1)
Toxic TidbitsToxic Tidbits
A 3 y/o female presents with a BG level A 3 y/o female presents with a BG level
of 14mg/dl. Labs show an elevated of 14mg/dl. Labs show an elevated
prolactin, GH, insulin and C peptide, prolactin, GH, insulin and C peptide,
UDS (-) What was the child exposed to?UDS (-) What was the child exposed to?
A)A) RosiglitazoneRosiglitazone
B)B) MetforminMetformin
C)C) GlyburideGlyburide
D)D) insulininsulin
Toxic Tidbits $500 (1 of 2)
Sulfonylurea Sulfonylurea MechanismMechanism
Pancreatic cell
Sulfonylurea receptor
sulfonylurea
KATP
Ca
I I
I
I
insulin
K+
Toxic Tidbits $500 (2 of 2)
Toxic TidbitsToxic Tidbits
(+) anion gap, (-) osmol gap, (+)(+) anion gap, (-) osmol gap, (+)
ketones is seen with which of the ketones is seen with which of the
Following?Following?
A)A) Alcoholic KetoacidosisAlcoholic Ketoacidosis
B)B) Ethylene GlycolEthylene Glycol
C)C) IsopropanolIsopropanol
D)D) MethanolMethanol
Toxic Tidbits $750 (1 of 1)
Antidotes And Antidotes And AnecdotesAnecdotes
A 48 year old male develops chest pain, A 48 year old male develops chest pain,
dyspnea and cyanosis shortly after the dyspnea and cyanosis shortly after the
administration of Benzocaine. Which of the administration of Benzocaine. Which of the
following should be administered?following should be administered?
A) NitroglycerinA) Nitroglycerin
B) Methylene BlueB) Methylene Blue
C) PhysiostygmineC) Physiostygmine
D) NarcanD) Narcan
Antidotes And Anecdotes $100 (1 of 2)
Antidotes And Antidotes And AnecdotesAnecdotes MedicationsMedications
– Amyl nitriteAmyl nitrite– BenzocaineBenzocaine– DapsoneDapsone– LidocaineLidocaine– NTGNTG– NitroprussideNitroprusside– PhenacetinPhenacetin– PhenazopyridinePhenazopyridine– PrilocainePrilocaine– QuinonesQuinones– SulfonamidesSulfonamides
Chemical AgentsChemical Agents– Anline dyesAnline dyes– Butyl nitriteButyl nitrite– ChlorobenzeneChlorobenzene– FiresFires– NitratesNitrates– Isobutyl nitriteIsobutyl nitrite– NapthaleneNapthalene– NitrophenolNitrophenol– Nitrous gasesNitrous gases– Silver nitrateSilver nitrate– TrinitrotolueneTrinitrotoluene
Antidotes And Anecdotes $100 (2 of 2)
Antidotes And Antidotes And AnecdotesAnecdotes
A 16 year old male ingested 20 (200mg) A 16 year old male ingested 20 (200mg)
INH tablets prior to ED arrival. He is INH tablets prior to ED arrival. He is
actively seizing, what course of action actively seizing, what course of action
should be taken?should be taken?
A)A) Administer IV valium 5mgAdminister IV valium 5mg
B)B) Administer IV pyridoxine 2 gramsAdminister IV pyridoxine 2 grams
C)C) Administer IV PHB 20mg/kg IVAdminister IV PHB 20mg/kg IV
D)D) Administer IV pyrodoxine 4 gramsAdminister IV pyrodoxine 4 grams
Antidotes And Anecdotes $200 (1 of 2)
MECHANISM OF INH MECHANISM OF INH TOXICITYTOXICITY
GLUTAMIC ACID GABA
GLUTAMIC ACID DECARBOXYLASE
PYRIDOXAL 5` PHOSPHATE
PYRIDOXINE
PYRIDOXINE PHOSPHOKINASE
INH INHIBITSINH INACTIVATES
URINARY ELIMINATION
INH ENHANCES
Antidotes And Anecdotes $200 (2 of 2)
Antidotes And Antidotes And AnecdotesAnecdotes
Which of the following is NOT a Which of the following is NOT a
mechanism by which N-acetylcysteine mechanism by which N-acetylcysteine
works to prevent APAP induced works to prevent APAP induced
hepatotoxicity? hepatotoxicity?
A)A) Precursor for Glutathione synthesisPrecursor for Glutathione synthesis
B)B) A substrate for sulfonationA substrate for sulfonation
C)C) Directly Binds NAPQUIDirectly Binds NAPQUI
D)D) Increase CYP2E1 activityIncrease CYP2E1 activity
Antidotes And Anecdotes $300 (1 of 2)
Antidotes And Anecdotes $300 (2 of 2)
Antidotes And Antidotes And AnecdotesAnecdotes
Which of the following is not a Which of the following is not a
component of the cyanide antidote component of the cyanide antidote kit?kit?
A)A) Amyl nitrateAmyl nitrate
B)B) Amyl nitriteAmyl nitrite
C)C) Sodium nitriteSodium nitrite
D)D) Sodium thiosulfateSodium thiosulfate
Antidotes And Anecdotes $400 (1 of 2)
Antidotes And Anecdotes $400 (2 of 2)
Antidotes And Antidotes And AnecdotesAnecdotes
Side effects of administration of Side effects of administration of
Deferoxamine include which of the Deferoxamine include which of the
Following?Following?
A) HypotensionA) Hypotension
B) ARDSB) ARDS
C) Increased risk or Yersinia InfectionsC) Increased risk or Yersinia Infections
D All of the aboveD All of the above
Antidotes And Anecdotes $500 (1 of 2)
DeferoxamineDeferoxamine Challenge Challenge
Dose Administered
Antidotes And Anecdotes $500 (2 of 2)
Antidotes And Antidotes And AnecdotesAnecdotes
How many vials of Digibind should be How many vials of Digibind should be
given to a 70kg male with acute given to a 70kg male with acute digoxindigoxin
Toxicity and a level of 7ng/mL?Toxicity and a level of 7ng/mL?
A) 4 vialsA) 4 vials
B) 5 vialsB) 5 vials
C) 6 vialsC) 6 vials
D) 10 vialsD) 10 vials
Antidotes And Anecdotes $750 (1 of 2)
Inhibition of Na-K-ATPase
[Nai+]
[Ko+]
hyperkalemia
[Cai++]
skeletal muscleheart
contractility
premature beatsescape rhythmsV-tach, V-fib
firing
baroceptors
vagal tone
bradycardia, AV blocks, asystole
automoticity
rise in Nai+
and Cai++
rise in Nai+
and Cai++
Picture ThatPicture That
Picture That $100 (1 of 4)
Name the toxin
Picture ThatPicture That
Picture That $100 (2 of 4)
Name the toxin
Picture ThatPicture That
Picture That $100 (3 of 4)
Name the toxin
Anticholinergic PlantsAnticholinergic Plants– Atropa belladonnaAtropa belladonna (deadly nightshade) (deadly nightshade) – Cestrum nocturnumCestrum nocturnum (night blooming jessamine) (night blooming jessamine) – Datura suaveolensDatura suaveolens (angel’s trumpet) (angel’s trumpet) – Datura stramoniumDatura stramonium (jimson weed) (jimson weed) – Hyoscyamus nigerHyoscyamus niger (black henbane) (black henbane) – Lantana camaraLantana camara (red sage) (red sage) – Solanum carolinensisSolanum carolinensis (wild tomato) (wild tomato) – Solanum dulcamaraSolanum dulcamara (bittersweet) (bittersweet) – Solanum pseudocapsicumSolanum pseudocapsicum (Jerusalem cherry) (Jerusalem cherry) – Solanum tuberosumSolanum tuberosum (potato) (potato)– Arctium lappaArctium lappa (burdock root) (burdock root)
Jimson Weed(datura stramonium)
Picture That $100 (4 of 4)
Picture ThatPicture That
Name the toxin
Picture That $200 (1 of 5)
Picture ThatPicture That
Name the toxin
Picture That $200 (2 of 5)
Picture ThatPicture That
Name the toxin
Picture That $200 (3 of 5)
Picture ThatPicture That
Name the toxin
Picture That $200 (4 of 5)
Picture ThatPicture That
Name the toxin
Picture That $200 (5 of 5)
Picture That Picture That
Picture That $300 (1 of 3)
Picture ThatPicture That
Ingestion/exposure to the previously Ingestion/exposure to the previously
pictured plant is most likely to pictured plant is most likely to result in?result in?
A)A) HyponatremiaHyponatremia
B)B) Contact DermatitisContact Dermatitis
C)C) ArrhythmiasArrhythmias
D)D) FlatulenceFlatulence
Picture That $300 (2 of 3)
Picture ThatPicture That
Picture That $400 (1 of 2)
Picture ThatPicture That
Picture That $400 (2 of 2)
Which of the following should be Which of the following should be
administered to the patient after an administered to the patient after an
unknown overdose with the previous unknown overdose with the previous
EKG? EKG?
A)A) PhysiostigminePhysiostigmine
B)B) Calcium SaltsCalcium Salts
C)C) GlucagonGlucagon
D)D) Sodium BicarbonateSodium Bicarbonate
Picture ThatPicture That
Picture That $500 (1 of 2)
Picture ThatPicture That
Which toxin is found in the pictured Which toxin is found in the pictured
mushroom?mushroom?
A)A) Ibotenic acidIbotenic acid
B)B) PsilocybinPsilocybin
C)C) GyromitrinGyromitrin
D)D) muscarinemuscarine
Picture That $500 (2 of 2)
Picture ThatPicture That
Picture That $750 (1 of 2)
Picture ThatPicture That
What is the name of the toxin What is the name of the toxin found in found in
the pictured fish?the pictured fish?
A)A) CigutoxinCigutoxin
B)B) Domoic acidDomoic acid
C)C) TetrodotoxinTetrodotoxin
D)D) ScrombroidScrombroid
Picture That $750 (2 of 2)
SalicylatesSalicylates
The minimal toxic dose (mg/kg) of The minimal toxic dose (mg/kg) of
salicylates is?salicylates is?
A)A) 100100
B)B) 5050
C)C) 2525
D)D) 150150
Salicylates $100 (1 of 2)
Salicylates: Toxic DoseSalicylates: Toxic Dose
Therapeutic Range: 10–15 mg/kgTherapeutic Range: 10–15 mg/kg Mild Toxicity:Mild Toxicity: 150 mg/kg150 mg/kg Moderate Toxicity: 150-300 Moderate Toxicity: 150-300
mg/kgmg/kg Severe Toxicity: > 300 mg/kgSevere Toxicity: > 300 mg/kg
Salicylates $100 (2 of 2)
Street DrugsStreet Drugs
An 18 year old female presents to theAn 18 year old female presents to theEmergency Department obtunded. She is Emergency Department obtunded. She is intubated but self extubates shortly after. intubated but self extubates shortly after.
She She is now awake, alert and appropriate. Which is now awake, alert and appropriate. Which
of of the following may be responsible?the following may be responsible?A)A) GHBGHBB)B) Gamma-butyrolactoneGamma-butyrolactoneC)C) 1,4-butanediol1,4-butanediolD)D) All of the above may be responsibleAll of the above may be responsible
Street Drugs $200 (1of 3)
Tissue lactonases
Nonenzymatic hydrolysis
B-oxidation
Trans-4-hydroxycrotonic acid GHB-receptor
GHB dehydrogenaseGABA transaminaseGABA transaminase
Succinic semialdehyde reductase
GABAB
Receptor
Street Drugs $200 (2of 3)
NAD NADH
Alcohol Dehydrogenase
HO
Aldehyde dehydrogenase
NAD
NADH
Trans-4-hydroxycrotonic acid B-oxidation
GHB-receptor GABAB Receptor
Street Drugs $200 (3of 3)
Salicylates Salicylates
As a salicylate poisoned patient becomes As a salicylate poisoned patient becomes
more acidotic, more salicylate will exist in more acidotic, more salicylate will exist in
the ____ form and the volume of the ____ form and the volume of
distribtuion ____.distribtuion ____.
A)A) Ionized, decreasesIonized, decreases
B)B) Unionized, increasesUnionized, increases
C)C) Unionized, decreasesUnionized, decreases
D)D) Ionized, increasesIonized, increases
Salicylates $300 (1 of 3)
Salicylates $300 (2 of 3)
Volume of distribution (VVolume of distribution (Vdd))– Apparent volume the drug is dissolved inApparent volume the drug is dissolved in– Measured in Liters or Liters/KgMeasured in Liters or Liters/Kg
not a real volumenot a real volume
Salicylates $300 (3 of 3)
SalicylatesSalicylates
Hyperthermia, occuring in salicylate Hyperthermia, occuring in salicylate
toxicity, is secondary to?toxicity, is secondary to?
A)A) Inhibition of the krebs cycleInhibition of the krebs cycle
B)B) Uncoupling of oxidative Uncoupling of oxidative phosphorylationphosphorylation
C)C) Stimulation of lipid metabolismStimulation of lipid metabolism
D)D) Increasing capillary permeabilityIncreasing capillary permeability
Salicylates $500 (1 of 1)
Street DrugsStreet Drugs
A patient presents to the Emergency A patient presents to the Emergency Department with agitation, a sense of Department with agitation, a sense of persecution and rotary nystagmus. Exposure persecution and rotary nystagmus. Exposure to which of the following can cause thesesto which of the following can cause thesessymptoms. symptoms. A)A) A preparation containing CamphorA preparation containing CamphorB)B) A preparation containing PseudophedA preparation containing PseudophedC)C) A preparation containing DXMA preparation containing DXMD)D) A preparation containing EthanolA preparation containing Ethanol
Street Drugs $400 (1of 2)
Street Drugs $400 (2of 2)
SalicylatesSalicylates
Which of the following is more likely to Which of the following is more likely to
be seen in acute vs chronic salicylatebe seen in acute vs chronic salicylate
toxicity?toxicity?
A)A) Neurological symptomsNeurological symptoms
B)B) Gastrointestinal SymptomsGastrointestinal Symptoms
C)C) Renal insufficiencyRenal insufficiency
D)D) Elevated LFT’sElevated LFT’s
Salicylates $500 (1 of 2)
ACUTEACUTE CHRONICCHRONIC
INCIDENCEINCIDENCE 85%85% 15%15%
AGEAGE YOUNGYOUNG OLDOLD
INTENTION ODINTENTION OD OFTENOFTEN RARERARE
COINGESTIONCOINGESTION OFTENOFTEN RARERARE
PSYCH. HXPSYCH. HX COMMONCOMMON UNCOMMON UNCOMMON
COMORBIDITYCOMORBIDITY RARERARE COMMONCOMMON
TIME TO DXTIME TO DX EARLYEARLY LATELATE
ABNORMAL PROTIMEABNORMAL PROTIME YESYES YESYES
RENAL FXNRENAL FXN NORMALNORMAL OFTEN ABNORMALOFTEN ABNORMAL
HEPATIC FXNHEPATIC FXN NORMALNORMAL OFTEN ABNORMALOFTEN ABNORMAL
NEUROLOGIC NEUROLOGIC SYMPTOMSSYMPTOMS
OCCASSIONALLYOCCASSIONALLY COMMONCOMMON
PULMONARY PULMONARY SYMPTOMSSYMPTOMS
RARERARE COMMON (50%)COMMON (50%)
GI SYMPTOMSGI SYMPTOMS VERY COMMONVERY COMMON RARERARE
MORBIDITYMORBIDITY 16%16% 30%30%
MORTALITYMORTALITY 2%2% 25%25%
Salicylates $500 (2 of 2)
Street DrugsStreet Drugs
A patient presents to the Emergency A patient presents to the Emergency
Department with profound hyponatremia and Department with profound hyponatremia and
seizures after attending a RAVE party. Whichseizures after attending a RAVE party. Which
of the following is the most likely causeof the following is the most likely cause
A)A) GHBGHB
B)B) CocaineCocaine
C)C) MDMA (Ectascy)MDMA (Ectascy)
D)D) RohypnolRohypnol
Street Drugs $750 (1 of 1)
Name That ToxidromeName That Toxidrome
An increased heart rate, dry flushed An increased heart rate, dry flushed
skin, dilated pupils agitation and urinary skin, dilated pupils agitation and urinary
retention are seen in which of the retention are seen in which of the following?following?
A)A) Cholinergic ToxidromeCholinergic Toxidrome
B)B) Anticholinergic ToxidromeAnticholinergic Toxidrome
C)C) Sympathomimetic ToxidromeSympathomimetic Toxidrome
D)D) Sedative Hypnotic ToxidromeSedative Hypnotic Toxidrome
Name That Toxidrome $100 (1 of 1)
Name That ToxidromeName That Toxidrome
Ingestion of which of the following Ingestion of which of the following is is
most likely to cause dilated pupils?most likely to cause dilated pupils?
A)A) RisperdalRisperdal
B)B) MeperidineMeperidine
C)C) AmytriptyllineAmytriptylline
D)D) LexaproLexapro
Name That Toxidrome $200 (1 of 1)
The most reliable way to differentiate The most reliable way to differentiate
the difference between anticholinergic the difference between anticholinergic
and sympathomimetic toxidrome are:and sympathomimetic toxidrome are:
A) Dilated pupils, agitationA) Dilated pupils, agitation
B) Diaphoresis, urinary retentionB) Diaphoresis, urinary retention
C) Flushed skin, hyperthermiaC) Flushed skin, hyperthermia
D) Visual hallucinations, pressured D) Visual hallucinations, pressured speechspeech
Name That ToxidromeName That Toxidrome
Name That Toxidrome $300 (1 of 1)
Which of the following is capable of Which of the following is capable of
producing a toxdrome similar to the producing a toxdrome similar to the
opioid toxidrome?opioid toxidrome?
A)A) GeodonGeodon
B)B) ClonidineClonidine
C)C) ReglanReglan
D)D) PropofolPropofol
Name That ToxidromeName That Toxidrome
Name That Toxidrome $400 (1 of 1)
Name That ToxidromeName That Toxidrome
The odor described in a patient The odor described in a patient exposedexposed
to Organophosphate insecticides is?to Organophosphate insecticides is? Bitter AlmondsBitter Almonds Burnt RopeBurnt Rope GarlicGarlic SulfurSulfur
Name That Toxidrome $500 (1 of 1)
Name That ToxidromeName That Toxidrome
Exposure to which of the following Exposure to which of the following
is capable of producing muscle is capable of producing muscle
fasiculations, weakness and respiratory fasiculations, weakness and respiratory
distress?distress?
A)A) China-Berry TreeChina-Berry Tree
B)B) GermaniumGermanium
C)C) Nicotine containing plantsNicotine containing plants
D)D) Grayanotoxin containing plantsGrayanotoxin containing plants
Name That Toxidrome $750 (1 of 1)
Final JeopardyFinal Jeopardy
In the course of treatment of a patient with In the course of treatment of a patient with
Ethylene Glycol Toxicity, which of the Ethylene Glycol Toxicity, which of the
following may be used as an adjunct to following may be used as an adjunct to
decrease the production of Oxalic Acid?decrease the production of Oxalic Acid?
A)A) ThiamineThiamine
B)B) Folic AcidFolic Acid
C)C) NiacinNiacin
D)D) MagnseiumMagnseium
(CH2OH)2
CH2OHCHO
Ethylene glycol
Glycoaldehyde
CH2OHCOOH Glycolic Acid
CHOCOOH Glyoxylic Acid
Glycine + Benzoic Acid
Hippuric Acid
Oxalic Acid
Alpha-hydroxy-beta-ketoadipic acid
thiamine
Mg++
B6
ADH
ADH
ADH
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