Tutorial 12

Clinical toxicology

(Spring 2023)
 Tutorial Outline
• General steps for the initial clinical encounter with a poisoned patient
1) Clinical Stabilization of the patient
2) Clinical Evaluation (history, physical, laboratory, radiology)
3) Prevention of further Toxin Absorption
4) Enhancement of Toxin Elimination
5) Administration of an Antidote
6) Supportive care and Clinical Follow-up
General steps for the initial clinical encounter for a poisoned patient:

1) Clinical stabilization of the patient

2) Clinical Evaluation

3) Prevention of further toxin absorption

4) Enhancement of toxin elimination

5)Administration of an antidote

6) Supportive care and clinical follow up

General steps for the initial clinical encounter for a poisoned patient:
A) Assess vital signs

1) Clinical stabilization of the patient B) Assess effectiveness of respiration &

circulation

C) Control Seizures (if drug caused seizures)

2) Clinical Evaluation

3) Prevention of further toxin absorption

4) Enhancement of toxin elimination

5)Administration of an antidote

6) Supportive care and clinical follow up

1) Which of the following is false regarding clinical toxicology?
a) It is concerned with the toxic effect of agents whose intent is to treat, ameliorate,
modify, or prevent disease states.

b) All poisoned patients must show significant symptoms in their presentation.

c) One of the roles of the clinical toxicologist is to identify, diagnose & treat any condition
resulting from environmental, therapeutic, or illicit exposure to chemicals.

d) The initial treatment of a seriously poisoned patient must be done in a hospital

emergency room only.

e) A & B

f) B & D

g) C & D
2)……………………………is an example of a toxicant that shows
little initial symptoms when taken orally although it can
lead to death.

a) Benzodiazepine

b) Camphor

c) Cyanide

d) Cocaine
General steps for the initial clinical encounter for a poisoned patient:
In order to know:
1) Clinical stabilization of the patient A)Medical History  Substance exposed
 Time & extent of exposure

Determine:
 Toxic syndromes
2) Clinical evaluation B)Physical examination  Characteristic odors of
certain poisons

C)Laboratory evaluation  Anion gap & Osmol Gap

3) Prevention of further toxin absorption  Chest radiograph

D)Radiographic examination  Abdominal
radiograph
4) Enhancement of toxin elimination  CT of brain

5)Administration of an antidote

6) Supportive care and clinical follow up

3) All of the following is true regarding clinical evaluation of
poisoned patients except:
a) Upon estimating the level of exposure of a poisoned patient to a bottle of liquid, the clinical
toxicologist must assume the patient took the whole bottle.

b) In case of self-intentional poisoning of the patient, the medical history can be better taken
from one of his family members.

c) Upon physical examination of the poisoned patient, the toxic syndromes recognized will guide
the clinical toxicologist about the category of poison taken and thus its way of treatment.

d) There is a wide range of laboratory assays that rapidly determines the type of poison
exposed to the patient.

e) A & D

f) B&D
4)………………………is calculated by the difference between the
serum cation concentration and serum anion concentration
and its high value indicates……………………..
a) Osmol gap / metabolic acidosis

b) Anion gap / low blood pH

c) Anion gap/ metabolic acidosis

d) Osmol gap/ presence of osmotically active substance in plasma

e) A & D

f) B & C
 5) Match the following toxic agents with the suitable way of
its radiographic detection in human body in case of their
exposure:
Toxic agents Radiographic examination
Carbon monoxide (CO) B A. Chest radiograph
Ferrous salts C
B. CT of brain
Plastic storage vesicles filled with heroin. C
C. Abdominal radiograph
Opioid agonists A
6)Complete the following:
a) Ingestion of overdose of salicylates can lead to
non-cardiac pulmonary edema
………………………………………….and chest radiograph
that can be detected by ………………………….

b) Upon examination of a poisoned patient, mydriasis and decreased bowel

sounds were observed indicating that the poisoned agent can
anticholinergic agent
be……………………………..and support of respiration
its treatment guide can be …………………………………&
administration of physostigmine
……………………………………………..
General steps for the initial clinical encounter for a poisoned patient:
1) Clinical stabilization of the patient

2) Clinical evaluation  Removal of patient

A) Inhalation route from toxin environment
If a person  Adequate ventilation &
oxygenation of patient
was
exposed to  Removal of clothes
3) Prevention of further absorption B) Topical route containing toxic agent
toxic agent
 Washing skin with water
through: & soap

 Induction of emesis
4) Enhancement of toxin elimination C)Oral route  Gastric lavage
 Oral administration of
activated charcoal
5)Administration of an antidote

6) Supportive care and clinical follow up

7) In the following poisonous cases, determine which
method that is not suitable to be used to prevent further
absorption of poison and state the reason for your answer:

a) A person exposed to formaldehyde that made him faint.

Induction of emesis by syrup ipecac as it is contraindicated to induce emesis in case
of unconsciousness.
b) A person ingested liquid hydrocarbon.
Induction of emesis by syrup ipecac or gastric lavage as liquid hydrocarbon has high
aspiration potential.
c) A person drank a high dose of ethanol.
Oral administration of activated charcoal as ethanol is a polar compound that is
less well bound to activated charcoal.
8) Oral administration of activated charcoal is the ideal solution
to prevent the absorption of poison in the following cases
except:
a) A 5-months old child who drank a bottle of cough syrup.

b) A person who has a blockage in the intestinal tract due to inflammatory bowel disease.

c) A person who ingested many tablets of NSAIDS.

d) A person who was exposed to high amount of lithium.

e) A & B

f) B & D

g) C & D
General steps for the initial clinical encounter for a poisoned patient:
1) Clinical stabilization of the patient

2) Clinical evaluation

3) Prevention of further absorption

A) Alkalization of urine

B) Hemodialysis
4) Enhancement of toxin elimination
C) Hemoperfusion

D) Administration of oral activated charcoal

5) Administration of an antidote serially

6) Supportive care and clinical follow up

9) Which of the following is true about increasing toxin elimination
out of the poisoned patient?
a) Alkalization of urine is done by IV infusion of sterile sodium bicarbonate added to sterile
water with 5% dextrose but requires adequate urine flow and close monitoring of urine pH.

b) Hemodialysis (HD) is done by pumping blood through dialysis membrane to allow chemicals
such as digoxin permeable to the membrane to pass through and reach equilibrium.

c) In hemoperfusion, the patient's blood is pumped through a perfusion cartridge, where it is in

direct contact with adsorptive material but the removal of toxic agent is affected by the
degree of its protein binding.

d) The multiple-dose activated charcoal (MDAC) leads to the adsorption of drugs such as opioids
passing from blood to GIT and its excretion in stool.

e) A & B

f) B & D
 10) Match the following drug toxicity cases with the
suitable way of drug elimination outside the body:
Toxicity cases: Drug elimination method
 A person poisoned with a drug that is 20% plasma
A. Hemodialysis
protein bound C
B. Alkalization of urine
 A person that had an overdose of theophylline D

 A person that ingested a high dose of phenobarbital A C. MDAC

D. Hemoperfusion
11) Acidification of urine to eliminate weak bases is not a
frequently used method because it can cause:
a) Acute renal failure

b) Electrolyte imbalance

c) Liver damage

d) A & B

e) A & C

f) B & C
12) To guarantee the effectiveness of elimination of drug by
MDAC, the charcoal must be administered after the initial dose
each …………….hours and administration of charcoal by ……………….
is considered as an alternative to MDAC.

a) 4-6 / orogastric tube

b) 1-3 / nasogastric tube

c) 2-4 / nasogastric tube

d) 6-8 / orogastric tube

General steps for the initial clinical encounter for a poisoned patient:
1) Clinical stabilization of the patient

2) Clinical evaluation

3) Prevention of further absorption

4) Enhancement of toxin elimination

A) Chelation
MOA of
5) Administration of an antidote antidote
through: B) Pharmacological antagonism

6) Supportive care and clinical follow up C) Chemical reactions

13) Complete the following toxic cases with the suitable
antidote for detoxication:
Atropine
a) Toxicity due to organophosphate insecticides is antagonized by …………………
Sodium nitrite
b) Cyanide (CN) toxicity can be detoxified by ………………………
14) A 4-year-old girl swallowed about 20 tablets of iron-containing chewable
multivitamins for children. Her mother discovered this after 4 hours, she
found an empty bottle of the multivitamins near her child. She decided to
give her child crushed activated charcoal, this decision came from a previous
experience when her child swallowed paracetamol tablets a few months ago
and after calling the poison control center, they advised her to give her child
the crushed charcoal. However, in this current situation, the child started
vomiting and diarrhea. So the mother decided to go the emergency
department.
Why wasn’t the activated charcoal effective in detoxication of this poisoned child?
As iron salts doesn’t bind well on activated charcoal.

What is the method that can be used to detect the toxicity in this case?
Abdominal radiograph (as orally ingested iron salts can be visualized by abdominal radiographs).
What is the detoxication method that can be used in this case?
Giving the child the BAL (as BAL is an antidote for heavy metals such as iron)
General steps for the initial clinical encounter for a poisoned patient:
1) Clinical stabilization of the patient

2) Clinical evaluation

3) Prevention of further absorption

4) Enhancement of toxin elimination

5) Administration of an antidote A) Poisons with delayed toxicity

Very B) Poisons with multiple phase of

6) Supportive care and clinical important toxicity
follow up measure in
C) Persons with intentional self-
case of:
poisoning
15) A 53-year old man was presented to the emergency department by his
wife. He had symptoms of confusion, agitation and dyspnea. His wife revealed
that she was outside home and when she returned, she found out that her
husband took a whole bottle of (300 mg) aspirin pills. After taking the medical
history from her, it was found that he has a history of depression. Laboratory
analysis revealed metabolic acidosis.

a) What other diagnostic tests that could be done in this case since he has dyspnea?
Chest radiograph could be done to diagnose if he has non-cardiac pulmonary edema due to
salicylate (aspirin) poisoning or not.
b) What is the detoxication method that can be done in this case?
Alkalization of his urine should be done to enhance the elimination of aspirin.

c) What other treatment measure that should be taken into consideration in this case?
Since he took the aspirin tablets intentionally, so a formal psychiatric evaluation of the patient
should be performed before discharge from hospital.
Thank you