Download Toxicology Lecture Outlines

Lecture Aids
Toxicology Lecture Outlines
Dr. Giggleman
I) Introduction
A) General statistics and information on poisonings
1) Number of deaths associated with poisonings
2) Most poisonings ……..
3) Rank order of most frequent non-medicinal exposures
4) Rank order of medicinal and drug exposures
5) Bites and stings
B) Definition of terms
1) Toxicology
2) Toxicologist
3) Hazard
4) Risk
5) Toxic substance
6) Poison
7) Drug overdose
8) Antidotes
C) Historical perspectives
D) Diversity of toxicology
1) Occupational toxicology
2) Environmental toxicology
3) Forensic toxicology
4) Clinical toxicology
E) Child proofing the home
1) Most common poisons swallowed by children
2) Child proofing your home
3) Symptoms of poisoning in a child
F) Household poison safety
G) Emergency actions for non specific poisons
H) Reporting problems to the FDA
1) Report problems with foods, drugs, cosmetics, medical devices,
etc.
2) Questions to ask
3) FDA
5600 Fishers Lane (HFC-160)
Rockville, MD 20857
(301) 443-1240
II) Principles of Toxin elimination and preventing absorption
A) General approach to treating poisoned patients
2) If patient is convulsing
B) Decontamination of the GI tract
1) General comments
a) Prevent absorption
b) Gastric emptying
d) Other measures
2) Induce vomiting
a) syrup of Ipecac
1) History
2) Active principles
3) Dosage instructions
4) Dosage guidelines
2) Gastric lavage
3) Prevent absorption
a) Absorbants
b) Activated charcoal
1) History
2) “Activated”
3) Substances not well adsorbed
4) Dosing guidelines
4) Hasten removal of material from the GI tract
a) Cathartics
b) Commonly used cathartics
1) Sorbitol
2) Mannitol
3) Magnesium sulfate
4) Magnesium citrate
c) Mechanism of action
d) Contraindications
III) Specific Poisons
A) Drugs used to treat depression
1) Tricyclic antidepressants
a) General information
b) Mechanism of action
c) Examples
1) Amitriptyline – Elavil
2) Lofepramine
3) Nortriptyline (Pamelor, Aventyl)
4) Desipramine (Norpramin)
d) Clinical presentation
e) Treatment
a) General information
c) Clinical presentation
B) Alcohols, Aldehydes and Ketones
1) Ethanol
a) General information
b) Metabolism
a) General information
c) Treatment
3) Isopropyl alcohol
a) General information
b) Symptoms of ingestion
c) Treatment
4) Ethylene glycol
a) presentation
1) Phase I
2) Phase II
3) Phase III
c) Diagnosis
d) Treatment
5) Formaldehyde
1) Formaldehyde
a) General information
b) Clinical presentation
c) Treatment
6) Acetone
1) General information
2) Clinical presentation
3) Treatment
C) Acids and Alkalis
1) Definition of terms
a) Corrosive
b) Caustic
c) Federal Hazardous Substance Act of 1967
1) Acids
a) Mechanism of action
b) Case management
1) Eye and skin contact
2) Ingestion
c) Boric acid
d) Carbolic acid - phenol
2) Alkalis
a) General information
b) Mechanism of action
c) Management of toxicity
3) Disc batteries
4) Soaps
5) Ammonia
6) Bleach
D) Hydrocarbons
1) Definition
2) Three basic types of hydrocarbons
3) Petroleum distillates
4) Terpenes
5) Examples of petroleum of distillates
a) Kerosene
b) Gasoline
c) Mineral spirits
d) Naphtha
e) Mineral seal oil
f) Diesel oil
g) Fuel oil
6) Characteristics
a) surface tension
b) volatility
c) viscosity
7) Mechanism of Toxicity
a) Statistics
b) Aspiration pneumonitis
c) Systemic toxicity
8) Characteristics of poisoning
a) Pulmonary system
b) GI system
c) CNS
9) Management of poisoning
10) Terpenes
1) General comments
2) Mechanism of action of Turpentine and Pine oil
3) Treatment
3) Camphor
1) General comments
2) Mechanism of action
3) Treatment
E) Toxic gases
1) Carbon monoxide
a) General comments
b) Sources
c) Mechanism of action
d) Diagnosis
e) Clinical grading of CO poisoning
1) Mild
2) Moderate
3) Severe
4) Other
f) Treatment
2) Hydrogen sulfide
a) General comments
b) Sources
c) Mechanism of action
d) Clinical presentation
d) Treatment
3) Cyanide
a) General comments
b) Sources
c) Mechanism of action
d) Clinical presentation
e) Treatment
F) Heavy metals
1) Mechanism of action
2) Chelating Agents
a) General comments
b) Efficacy of a chelating agent
c) Properties of an ideal chelating agent
d) Examples
3) Lead
a) Sources and general comments
b) Clinical features, plumbism
1) Acute intoxication
2) Chronic intoxication
c) Patient management
1) Acute intoxication
2) Chronic intoxication
3) Iron
a) General comments and sources
b) Clinical features
c) Clinical presentation
1) Stage I
2) Stage II
3) Stage III
4) Stage IV
5) Chronic toxicity
d) Treatment
4) Mercury
a) Sources and general comments
b) Elemental mercury – quicksilver
1) General comments
2) Clinical presentations
c) Inorganic mercury
1) General comments
2) Clinical presentations
d) Organic mercury
1) General comments
2) Clinical presentations
e) Diagnosis
f) Treatment
5) Arsenic
a) General comments
b) Mechanism of action
c) Clinical presentation
1) Acute intoxication
2) Chronic intoxication
d) Diagnosis
e) Treatment
6) Natural chelating agents
G) Insecticides and Pesticides
1) Introduction
2) Organophosphate insecticides
a) General comments
b) Mechanism of action
c) Clinical presentation
d) Diagnosis
e) Treatment
f) Examples
a) TEPP – tetraethyl pyrophosphate
b) Parathion
c) Coumaphos
d) Chlorpyrifos
e) Ronnel
f) Diazinon
g) Malathion
h) Vapona
i) Acephate
2) Carbamate insecticides
a) General comments
b) Mechanism of action
c) Clinical presentation
d) Treatment
e) Examples
1) Aldicarb
2) Methiocarb
3) Baygon
4) Sevin, carbaryl
3) Organochlorine insecticides
a) General comments
b) Mechanism of action
c) Clinical presentation
d) Treatment
4) Pyrethrum insecticides
a) General comments
b) Mechanism of action
c) Clinical presentation
d) Treatment
5) Rotenone
a) General comments
b) Mechanism of action
c) Treatment
6) Insect repellants
a) DDET – N,N diethyltoluamide
1) General comments
2) Clinical presentation
3) Treatment
7) Herbicides
a) Chlorphenoxy compounds, 2,4 D
1) General comments
2) Clinical presentation
3) Treatment
b) Paraquat
1) General comments
2) Mechanism of action
3) Clinical presentation
a) acute toxicity
b) systemic effects
4) Treatment
c) Diquat
1) General comments
2) Treatment
H) Poisonous plants
1) Introduction
a) Frequency of plant exposure by type
b) Examples of non-Toxic plants
African violet Begonia
Boston fern Christmas cactus
Coleus Corn plant
Crab apple Daisies
Dandelion Easter Lilly
Hibiscus Jade plant
Magnolia Marigold
Petunia Prayer plant
Snake plant Velvet plant
c) Toxic plants
2) General management of the plant poisoned patient
3) Common Poisonous plants
a) Arum family
1) General comments
2) Signs, symptoms and treatment
b) Christmas plants
1) General comments
American Holly
Jerusalem Cherry
Mistletoe
Poinsettia
2) American Holly
3) Jerusalem cherry
4) Mistletoe
5) Poinsettia
c) Cardiotoxic plants
1) Oleander
2) Azaleas
d) Castor bean
1) General comments
2) Signs, symptoms and treatment
e) Rhubarb
1) General comments
2) Signs, symptoms and treatment
f) Jimsonweed
1) General comments
2) Signs, symptoms and treatment
g) Pokeweed
1) General comments
2) Signs, symptoms and treatment
h) Toxicodendron
1) General comments
2) Signs, symptoms and treatment
i) Mushroom toxicity
1) General comments
2) Categories of mushroom toxicity
a) Protoplasmic poisons
1) Signs and symptoms
a) Stage I
b) Stage II
c) Stage III
2) Treatment
3) Examples
a) Amanita phalloides
b) Neurotoxins
1) General comments
2) Examples
a) Amanita muscarina
b) Inocybe sp.
c) Psilocybe sp.
c) Gastrointestinal irritants
1) General comments
2) Examples
a) Green gill
d) Disulfiram like compounds
1) General comments
2) Examples
a) Inky cap mushroom
e) Diagnosis of human toxicity
I) Toxicity of medicinal substances
1) General comments
2) Salicylate toxicity
a) General comments
b) Mechanism of action
c) Clinical presentation
d) Treatment
3) Acetaminophen toxicity
a) General comments
b) Mechanism of action
c) Clinical presentation
1) Phase I
2) Phase II
3) Phase III
4) Phase IV
d) Treatment
4) Toxicity’s associated with other non-steroidal anti-inflammatory drugs
a) Ibuprofen
1) General comments
2) Mechanism of action
3) Clinical presentation
4) Treatment
5) Toxicity’s associated with vitamins
a) General Comments
b) Vitamin A Toxicity
1) General comments
2) Functions of Vitamin A
3) Toxic doses
4) Clinical features
1) Acute toxicity
2) Chronic toxicity
5) Diagnosis
6) Treatment
c) Vitamin D toxicity
1) General comments
2) Function
3) Toxic doses
4) Clinical features
5) Treatment
d) Vitamin E toxicity
1) General comments
2) Function
3) Toxicity
e) Vitamin K toxicity
1) General comments
2) Function
3) Toxicity
f) Vitamin C toxicity
1) General comments
2) Functions
3) Clinical features
4) Treatments
6) “Antihistamines” (histamine blockers)
a) Functions of histamine
b) Histamine receptors
c) Mechanism of action
d) Examples of H1 receptor blockers
e) Clinical features
f) Examples of H2 receptor blockers
7) Antibiotics
a) General comments
b) Examples
B-lactase antibiotics - penicillin - hypersensitivity
sulfonamides - hypersensitivity
macrolides - erythromycin - gastric irritation
chloramphenicol - aplastic anemia
tetracyclines - photosensitivity, renal tubular necrosis
aminoglycosides - ototoxic
fluroquinolones - disrupt cartilage synthesis
polymyxin B - urtacaria
8) Caffeine
a) General comments and source
b) Toxic dose
c) Clinical features
1) Acute intoxication
2) Chronic toxicity
3) Treatment
J) Drugs of abuse
1) Introduction
2) Marijuana
a) General comments
b) Metabolism and excretion
c) Acute effects
d) Chronic effects
e) Therapeutic effects
f) Treatment
3) Cocaine
a) History
b) Mechanism of action
c) Toxic effects, signs and symptoms
d) Treatment
4) Opiates and narcotics
a) General comments
b) History
c) Clinical features
d) Examples
1) Morphine
2) Heroin
3) Hydromorphone – Dilaudid
4) Meperidine – Demerol
5) Codeine
6) Hydrocodone – Hycodan
7) Propoxyphene
8) Pentazocine – Talwin
9) Butorphanol - Stadol
5) Barbiturates
a) General comments
b) Examples
1) Secobarbital
2) Pentobarbital
3) Secobarbital-Amobarbital combo
c) Uses
d) Clinical presentation
e) Treatment
6) Phencyclidine
a) General comments
b) Clinical presentation
c) Treatment
7) Amphetamines
a) General comments and history
b) Clinical presentation
c) Treatment
8) Designer drugs
a) History
b) Categories of designer drugs
c) Clinical presentation
d) Treatment
9) Sedatives
a) History
b) Mechanism of action
c) Clinical presentation
d) Treatment
10) Benzodiazepines
a) History
b) Examples
1) Alprazolam – Xanax
2) Chloridazepoxide – Librium
3) Diazepam – Valium
4) Flurazepam – Dalmane
5) Midazolam – Versed
6) Triazolam – Halcion
c) Mechanism of action
d) Clinical presentation
e) Treatment
11) Hallucinogens
a) General comments
b) LSD
c) Peyote and Mescaline
d) Psilocybin
e) Morning glory
f) Nutmeg
12) Inhalants
a) Mechanism of action
b) Clinical effects of inhalants
c) Clinical features
d) Examples
1) Benzene
2) Gasoline
3) Ketones
4) Trichloroethane
5) Toluene
6) Carbon tetrachloride
7) Methylene chloride
e) Detection of solvent abuse
f) Treatment
K) Herbal Medicines
1) General Comments
Up to 33% of population has used some form of unconventional therapy in the
prior year
Reasons people choose these therapies is to treat back pain, headaches,
anxiety, cancer and insomnia
People choose alternative medicines because of fear of drug side effects, heard
about them from a friend, dissatisfied with conventional drug therapy, or because
they received more personal attention from alternative practitioners
Dietary supplement business is a more than $13 billion industry with
multivitamins and minerals accounting for 1/2 of the sales
80% of people in developing countries rely on traditional herbal medicines
4 out of 10 Americans used alternative medicine therapies of all types spending
$21 billion out of pocket
500,000 species of plants on this earth today and only about 5000 have been
studied for their medicinal applications
25% of today’s prescription drugs contain compounds isolated from plants
10% of American pharmacies carry herbal remedies
2) Little to no FDA regulation:
alternative medicines are marketed without efficacy tests
companies do not have to prove their product is safe instead the FDA must prove
it is unsafe
no set standards for manufacturing, no quality control
can not claim cures but can tell how supplements affects the body
label claims do not require supportive evidence
FDA approval in not needed for marketing claims
Drugs are standardized, means the active ingredient is known and each dose is
contains the same amount of the ingredient.
Many herbal products the active ingredient is NOT known
Plants are very complicated chemically
Many times there is no known analysis for the constituents of herbs
There is no legal definition of “standardization” for botanicals
FDA MEDWATCH to report adverse reactions from alternative medications:
1-800-332-10883) Herbal medicine - a plant extract that is used in relatively
unrefined form to achieve a therapeutic effect
Herbs have been used since the beginning of time and written reports date back
to the Egyptians
Chinese herbal medicine dates back to 2500 BC
3) Definitions of terms
Infusion
Decoction
Tincture
Syrup
Compress
Poultice
Emmeragogue
Carminative
4) Precautions:
.
5) Herbal teas:
6) Leading Herbal Supplements
a) Aloe
Use
Adverse effects
b) Bilberry (Huckleberry, Blueberry)
Use
Adverse effects
c) Cascara Sagrada (Fletcher’s castoria)
Use
Adverse effects
d) Cheyenne pepper (Capsicum, Capsaicin)
Use
Adverse effects
e) Cranberry fruit
Use
Adverse effects
f) Echinacea
Use
Adverse effects
g) Evening primrose
Use
Adverse effects
h) Feverfew leaf
Use
Adverse effects
i) Garlic
Use
Adverse effects
j) Ginger
Use
Adverse effects
k) Ginkgo Root
Use
Adverse effects
l) Ginseng:
Chinese word meaning “the essence of man”
Use
Adverse effects
m) Goldenseal root
Use
Adverse effects
n) Kava Kava root
Use
Adverse effects
o) Nutmeg:
Use: considered to be a mood elevator, aphrodisiac, and a narcotic with
hallucinogenic effects
the most psychoactive component is Myristicin, which is metabolized into the
hallucinogen 3-methoxy-4,5-methylenedioxyamphetamine (MMDA) a substance
closely related to methylenedioxymethamphetamine (MDMA, “ectasy”)
used to treat malaria, asthma, dysmenorrhea, fever, flu, pneumonia, as an
appetite stimulant, a carminative, aphrodisiac and a stimulant
Ingestion of 5-30 grams produces GI upset, within 3 hours the hallucinogenic
effects appear
Adverse effects: chronic abuse is limited because of the GI disturbances, may be
an abortifacient
Treatment - reduce environmental stimuli and give supportive and symptomatic
care
p) Saw palmetto
Use
Adverse effects
q) St. John’s Wort
Use
Adverse effects
r) Valerian root
Use
Adverse effects
s) Herb / Drug Interactions:
ginkgo biloba / aspirin, NSAID’s, warfarin, heparin
ginseng / MAO inhibitors, avoid with antidepressants
horseradish / levothyroxine, avoid with kelp, may suppress thyroid
ephedra / caffeine or other stimulants
feverfew / anticoagulants / do not take if pregnant
garlic / warfarin, aspirin / may inhibit clotting
Special Caution with the following:
Pennyroyal - liver damage and may cause abortion
Senna - electrolyte loss
Willow bark - Reye’s syndrome
Wormwood - neurological symptoms
Licorice / blood pressure medication
Ginseng / Digitalis
St. John’s Wort / antidepressants
t) “Folk” medicine - folk remedies are unrefined products taken by local
inhabitants as a treatment for a disease process. Derived from local plants,
animals, or minerals.
.
u) Homeopathy - used by 1% of the American population. Developed by Samuel
Hahnemann in the late 18th century. “Like cures like” and efficacy improves with
increasing dilutions. Same basic principle used in desensitization therapy for
allergies.
Homeopathic tinctures are made by adding 1 part of the agent to 20 parts of
alcohol and then diluted to 1:1000, 1:10,000, etc.; 1x means 1:10 dilution, 2x
means 1:100, and so on.
Because of the dilutions, toxicities are rare
v) Nutritional supplements:
Gamma Hydroxybutyrate (GHB) - used to promote body muscle mass gain and
as a weight loss supplement. Can cause confusion, agitation, hallucinations,
bradycardia, coma and seizures. Its sales have been banned.
L-tryptophan - an essential amino acid, precursor for serotonin; supposedly good
to treat insomnia, depression, and PMS. A widespread outbreak of eosinophilla
and myalgia occurred in 1989 and affected 5-10,000 people. All the toxicities
were traced to a single manufacturer . The manufacture of tryptophan containing
products was banned by the FDA
w) Edible flowers
tuberous begonias jasmine
chrysanthemums lavender
clover honeysuckle
daisies lilacs
yellow day lilies marigolds
gladioli tulips
geraniums roses
violets orange blossoms
x) Worthless products
blue green algae (BGA) - spirulina - contains microcystins - similar to red tides cause liver failure and brain damage
Microhydrin - by Royal Body care - supposed to be a high altitude water
consumed by the people of Northern Pakistan - all bogus
L) Cosmetics and Toilet articles
a) General comments
b) Cosmetics
1) Definition
2) Hair products
3) Bath preparations
4) Colognes, perfumes and toilet water
5) Body paints and makeup
6) Nail polish
7) Nail polish remover
8) Tooth pastes
9) Deodorants
10) Depilatories
11) Skin lighteners
M) Tear gas and riot control agents
1) General comments
2) Tear Gas agents
a) Chloracetophenone – CN
b) Chlorbenzylidene – CS
c) Dibenzoxapine – CR
5) Irritants
a) Capsaicin
N) North American venomous snakes
1) Why did God make snakes?
2) Venomous snakes of Texas
a) Rattlesnakes
b) Water moccasins
c) Copperheads
d) Coral snakes
3) Venomous snakes
a) Vipers (Viperidae)
1) General information
2) Crotaline – Rattlesnakes
a) General information
b) Western diamondback rattlesnake
3) Agkistradon sp.
a) Water moccasin
b) Copperhead
b) Elipidae
1) General information
2) Coral snakes
4) Morbidity rates
5) Snakebite statistics
6) Snake venom
a) General information
b) To determine how serious a bite is
c) Signs and symptoms of a pit viper bite
d) Properties of Elapidae venom
e) Signs and symptoms of a coral snake bite
7) Treatment of a Snake Bite
a) Basics
b) Do Nots
c) Antivenom
8) Assorted snakes
O) Poisonous arthropods
1) Black widow spider
a) General information
2) Brown Recluse spider
a) General information
3) Scorpions
a) Centruroides sp.
b) Bark spider