Toxicology Fellowship Questions_2017Question 1

A 29 year old female presents with confusion and drowsiness. She has some superficial cuts to her upper limbs. Her family are concerned that she has taken on overdose but are unsure as to the medications she has access to. She in resus with full non-invasive monitoring and 2x IVC in situ.

P 130BP 70/50Sats 95%RR 30Tep 37.3GCS 9

Mild metabolic acidosis and normal potassium levels on VBG.

Her ECG is shown

a) List the abnormal features on this ECG (5 marks)

b) List 5 drugs that she has potentially taken in overdose of based on the clinical information provided. (5 marks)

c) Outline your immediate management and disposition of this patient (8 marks)

The patient has a tonic clonic seizure that has lasted longer than 5 mins

d) Outline your pharmacological management in this setting (2 marks)

Question 2

A 17 year old female (40kg) states that she has ingested 7 x 200mg ferrous sulphate tablets (elemental iron equivalent = 60mg per tablet).

She is distressed and vomiting

a) What would be the risk assessment based on her stated ingestion, including any calculations? (2 marks)

A CXR is performed

b) What is your revised risk assessment, including any calculations (2 marks)

c) What is the specific antidote for iron toxicity (1 mark)

d) List 3 clinical and 1 laboratory parameter that would warrant treatment with this antidote (4 marks)

e) List 3 adverse effects of desferrioxamine treatment (3 marks)

Question 3

A 12 kg 2 year old has ingested 2 of her grandmother’s pills 2 hours ago. They are unsure which 2 but know that grandma was metformin 500mg x3, diltiazem 180mg x2 SR and aspirin 100mg x1. All of these pills had been in a little cup, and the child has found on the floor with the pills, of which 3 were missing.

Grandma safely flushed the remaining pills down the toilet as they had been on the floor, so it is now unclear which agents the child ingested. The child appears well and is aymptomatic.

a) Complete the table below detailing the risk assessment of ingestion of each agent at the dose stated, plus the investigations warranted for that specific ingestion at the given dose. (6 marks)

Drug Ingested Risk Assessment Proposed InvestigationsMetformin total dose 1500mgDiltiazem total dose 360mgAspirin total dose 100mg

b) Outline the appropriate decontamination for this child. (1 mark)

After 10 hours of observation on the short stay unit the child becomes hypotensive and drowsy. They are moved to resus and have 2x IVC inserted with full non invasive monitoring applied.The Paediatric ICU consultant inserts a femoral central line and arterial line while you arrange the rest of the therapy prior to TF to ICU.

c) Outline your stepwise management plan (4 marks)

Question 4A 23 year old man presents to a rural emergency department with pain in his hands. He was helping his father to clean some antique glass bottles with a hydrofluoric acid containing solution. The burn has been irrigated with water for 30mins thus far.

a) List 6 important questions in the history that will contribute to your risk assessment (6 marks)

b) Aside from irrigation and analgesia, what 2 immediate treatments you could institute in the rural setting for the localised burn seen on this patients hand (2 marks)

c) What indicates successful treatment of the burn (1 mark)

The patient to be kept in the short stay unit overnight to observe for systemic toxicity and await transfer to a tertiary centre for plastic surgical assessment. You do not have access to blood tests other than the bedside iStat tests shown.

pH 7.31pCO2 43HCO3 26Na 132K 4.5Cr 100Cl 102Ionised Ca 1.23Lact 2.1

d) What will you tell your registrar handover regarding the observation for systemic toxicity, assuming the burn on the hand is the isolated injury. (6 marks)

Question 5A 17 year old female presents 16 hours post ingestion of significant quantities of aspirin. She isn’t sure exactly how many but states “a whole packet”. She feels dizzy. Her VBG is shown below

a) List the abnormal features of her VBG, show your calculations (4 marks)

b) List the options, if any, for decontamination of aspirin (1 mark)

c) List the options, if any, for enhanced elimination of aspirin (2 marks)

d) List 3 life threatening complications of salicylate toxicity (3 marks)

After initially agreeing to stay voluntarily, the patient attempts to leave the department prior to commencement of treatment

e) What criteria must be demonstrated in order to complete a mental health section to detain her against her will in the emergency department

Question 6

A 56kg 34 year old female with borderline PD presents after an intentional paracetamol overdose. She estimates that she took 18 tablets 7.5 hrs ago and another 8 tablets 3 hours ago. She has not taken any other medication in the last few weeks. She has a single superficial laceration to her left thigh.

The paracetamol nomogram is shown below

a) What is the risk assessment for this overdose in this patient (2 marks)

b) What investigations are ESSENTIAL in this case (3 marks)

c) Outline how you will proceed with management in this case (4 marks)

d) How will you proceed with antidote management from here (1 mark)

Question 7

A 71 year old man presents to ED with vomiting. He has recently inherited a fruit farm and has been spraying the crops with a pesticide for the first time. He is currently in the triage area.

P 50BP 80/70Sats 90%RR 32Temp 37.2

a) What is the likely poisoning and subsequent toxidrome (2 marks)

b) List the 2 receptor types potentially affected by this poisoning (2 marks)

Receptor 1______________Receptor 2______________

b) In the table below, list 8 additional clinical signs that you will seek when assessing the patient. The signs must be grouped according to the receptor type involved (8 marks)

Receptor 1 = Receptor 2 =

The patient is moved to the resus bay as they have becomes more bradycardic and extremely agitated and compative. They have 2 IV lines inserted and an IV fluid bolus running (NaCl 0.9% 1L). The registrar is contacting the Poisons Information to identify the exact chemical.

c) Outline your management plan (6 marks)

d) What are the 3 useful endpoints of treatment with the antidote (3 marks)

Question 8

A nurse who works in your tertiary emergency department is BIBA after intentionally ingesting a “cup” full of antifreeze solution. She appears intoxicated and is trying to leave. She has full monitoring, IV access and is in a resus bay. She has so far assaulted 2 members of staff and is trying to pull out her IV lines.

P 120BP 100/70Sats 98%RR 22Temp 37.2GCS 12

VBGpH 7.04PCO2 24HCO3 12Lact 2.3Na 138K 6.0Cl 98Gluc 7.0

ETOH level = 0.0Measured Osm = 310Urea = 7.0 Creatinine = 120CCa = 2.02Mg = 0.42

a) List the acid base and osmolar abnormalities, including any calculations that you will perform with the results (6 marks)

b) List the steps in your management plan (9 marks)

Question 9

A 61 year old female with a history of depression presents with vomiting and diarrhoea. She looks clinically dehydrated. She has a history of AF, IHD and HTN. She is taking warfarin, digoxin, ramipril, panadol osteo,

diltiazem. She tells you that she wants to be dead but refuses to speak otherwise. IV line and monitoring in situ. She has recently moved from interstate and has no medical notes at your hospital

P 120BP 80/60Sats 96%RR 16Temp 36.7

Point of Care INR 2.1Panadol level undetectable

Na 132K 6.1Ur 12Cr 140CCa 2.2

Her ECG is shown below

a) List the abnormality on the ECG and what is it pathognomic of (2 marks)

As you are assessing the patient they become unresponsive and you see the following on the monitor

b) What are the essential next steps in the management of this patient (6 marks)

The patients daughter arrives at hospital just after you have achieved ROSC and the patient is due to go to ICU. She has an advanced care directive that states that the patient does not want active treatment ot ICU care for any conditions as she has a diagnosis of MND.

c) Outline your response from here ( 5 marks)