Board Questions

1. Which of the following are recommended first line agents for possible ingestion? 

a) sryrup of ipecac
b) gastric lavage
c) activated charcoal
d) flumazenil

2. Activated charcoal is NOT helpful in which of the following ingestions? 

a) Heavy metals
b) Acetaminophen
c) Salicylates
d) Tricyclic antidepressants 

3. A 3 year old patient with eczema and asthma comes in febrile, tachycardic, hypertensive, and tachypneic. His pupils are dilated and his skin is dry and flushed. He appears agitated and his parents note that he has not been making much urine. What type of ingestion would be most consistent with this clinical presentation? 

a) Hallucinogen
b) Serotonin syndrome
c) Sympathomimetic
d) Anticholinergic

4. Which of the following ingestion:antidote pairings is incorrect?

a) opioid:naloxone
b) serotonin syndrome:dantrolene
c) TCA:sodium bicarbonate
d) Iron:deferoxamine

5. Which of the following electrolyte abnormalities is most associated with increased mortality in the setting of digoxin ingestion?
a) Hyperkalemia
b) Hypokalemia
c) Hypermagnesemia
d) Hypomagnesemia



ANSWERS & EXPLANATIONS

1. C. Syrup of ipecac, gastric lavage, and flumazenil are generally not recommended in cases of ingestion. While flumazenil may be considered for benzodiazepene ingestion, in general, due to the possibility of provoking seizures, its use is not recommended. While activated charcoal may not always be of benefit, it is the first line agent used for decontamination purposes. 

2. A. Activated charcoal is helpful in most ingestions as it provides a large surface area to bind toxins and drugs to limit systemic absorption. Nonetheless, it is not effective with heavy metals such as lithium, corrosives (alkalis or acids), hydrocarbons, or alcohols (acetone, ethanol, ethylene glycol).

3. D The patient has classic signs of anticholinergic toxicity (Dry as a bone, red as a beet, mad as a hatter, hot as hades, blind as a bat), likely precipitated by antihistamine overdose (ie for his eczema). While many of his symptoms are also consistent with sympathomimetic ingestion (ie amphetamines, cocaine, etc), sympatomimetics generally lead to diaphoresis rather than dry skin. Furthermore, an antihistamine such as benadryl is a much more likely agent given the history. 

4. B Dantrolene, a muscle relaxant that functions at the ryanodine receptor and limits intracellular calcium, should NOT be used with serotonin syndrome. The treatment of choice for serotonin syndrome is cyprohepatadine, which has anti-serotonin activity. 

5. A- Hyperkalemia occurs in digoxin toxicity due to inactivation of the Na/K ATPase pump, leading to increased intracellular sodium and increased extracellular potassium. Hyperkalemia correlates with the severity of digoxin toxicity and the mortality rate. The mortality rate is ~35% with a K of 5 and invariably fatal at a K of 6.4. Hypokalemia predisposes to digoxin toxicity. 

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