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Poisoning and Overdose-1
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1. After being fired from his job, a 35-year-old man attempts suicide by drinking from a bottle labeled “insecticide.” Three hours later, emergency medical services (EMS) brings him into the emergency department (ED) and you notice that he is extremely diaphoretic, drooling, and He is awake but confused. His vital signs include a blood pressure (BP) of 170/90 mm Hg, heart rate (HR) of 55 beats per minute, respiratory rate (RR) of 22 breaths per minute, temperature of 98.6°F, and oxygen satu- ration of 95% on room air. Physical examination demonstrates pinpoint pupils and crackles and wheezing on lung examination. What is the treat- ment to reverse this patient’s poisoning?
- N-acetylcysteine (NAC)
- Atropine and pralidoxime (2-PAM)
2. A 19-year-old man is brought to the ED by EMS after he was found lying on the floor at a dance EMS states that the patient seemed uncon- scious at the dance club, but as soon as they transferred him onto the gurney, he became combative. Upon arrival in the ED, his BP is 120/65 mm Hg, HR is 75 beats per minute, temperature is 98.9°F, RR is 12 breaths per minute, and oxygen saturation is 98% on room air. On physical examina- tion, his pupils are midsized, equal, and reactive to light. His skin is warm and dry. Lung, cardiac, and abdominal examinations are unremarkable. As you walk away from the bedside, you hear the monitor alarm signaling zero respirations and the oxygen saturation starts to drop. You perform a sternal rub and the patient sits up in bed and starts yelling at you. As you leave him for the second time, you hear the monitor alarm again signal zero respirations. You administer naloxone, but there is no change in his condition. Which of the following is most likely the substance ingested by this patient?
- g-Hydroxybutyrate (GHB)
- Phencyclidine (PCP)
3. A 43-year-old woman presents to the ED with a 3-week history of intermittent headache, nausea, and She was seen at her private doctor’s office 1 week ago along with her husband and children, who also have similar symptoms. They were diagnosed with a viral syndrome and told to increase their fluid intake. She states that the symptoms began approximately when it started to get cold outside. The symptoms are worse in the morning and improve while she is at work. Her BP is 123/75 mm Hg, HR is 83 beats per minute, temperature is 98.9°F, and oxygen saturation is 98% on room air. Physical examination is unremarkable. You suspect her first diagnosis was incorrect. Which of the following is the most appropri- ate next step to confirm your suspicion?
- Order a mono spot test.
- Perform a nasal pharyngeal swab to test for influenza.
- Consult psychiatry to evaluate for malingering.
- Order a carboxyhemoglobin (COHb) level.
- Order a lead level.
4. An 18-year-old woman is brought to the ED by her The patient is diaphoretic and vomiting. Her mom states that she thinks her daughter tried to commit suicide. The patient admits to ingesting a few handfuls of acetaminophen (Tylenol) approximately 3 hours ago. Her temperature is 99.1°F, BP is 105/70 mm Hg, HR is 92 beats per minute, RR is 17 breaths per minute, and oxygen saturation is 99% on room air. On examination, her head and neck are unremarkable. Cardiovascular and pulmonary examinations are within normal limits. She is mildly tender in her right upper quadrant, but there is no rebound or guarding. Bowel sounds are normoactive. She is alert and oriented and has no focal deficits on neurologic examination. You administer 50 g of activated charcoal. At this point, she appears well and has no complaints. Her serum acetamino- phen (APAP) concentration 4 hours after the reported time of ingestion returns at 350 mg/mL. You plot the level on the nomogram seen below. Which of the following is the most appropriate next step in management?
- Discharge home with instructions to return if symptoms return.
- Observe for 6 hours and, if the patient still has no complaints, discharge her home.
- Repeat the acetaminophen level 4 hours after the patient arrived in the ED. Treat only if this level is above the line.
- Admit to the psychiatry unit and keep on suicide watch while performing serial abdominal examinations.
- Begin NAC and admit to the hospital.
5. A 47-year-old man is brought to the ED by EMS after being found wandering in the street His BP is 150/75 mm Hg, HR is 110 beats per minute, temperature is 100.5°F, RR is 16 breaths per minute, oxygen saturation is 99% on room air, and fingerstick glucose is 98 mg/dL. On examination, the patient is confused with mumbling speech. His pupils are dilated and face is flushed. His mucous membranes and skin are dry. Which of the following toxic syndromes is this patient exhibiting?
- Sympathomimetic syndrome
- Anticholinergic syndrome
- Cholinergic syndrome
- Opioid syndrome
- Ethanol syndrome
6. A 25-year-old man is carried into the ED by two of his friends who state that he is not The patient has a history of heroin abuse. His vital signs are BP 115/70 mm Hg, HR 99 beats per minute, temperature 98.9°F, RR 3 breaths per minute, and oxygen saturation 87% on room air. You notice fresh needle marks and miotic pupils. You begin bag-valve- mask ventilation and his oxygen saturation increases to 99%. Which of the following is the most appropriate next step in management?
- Continue bag-valve-mask ventilation until he breathes on his own.
- Perform endotracheal intubation of the patient.
- Evaluate response to administration of naloxone.
- Put the patient on supplemental oxygen.
- Place a nasogastric tube and administer activated charcoal.
7. A 42-year-old man who is actively seizing is brought to the ED by EMS after a massive ingestion of an unknown The man is known to have a history of acquired immunodeficiency syndrome (AIDS). An intra- venous (IV) line is established and anticonvulsant therapy is administered. After high doses of diazepam, phenobarbital, and phenytoin, it is deter- mined that the seizures are refractory to standard anticonvulsant therapy. Which of the following substances did this patient most likely ingest?
- Tricyclic antidepressant (TCA)
- Isoniazid (INH)
8. A 60-year-old woman with a history of diabetes is brought into the ED by EMS workers who state that the patient was found on a bus in a lethargic and diaphoretic condition. Her fingerstick glucose level at the scene was 35 mg/dL. EMS workers quickly administered dextrose through an IV The patient became alert and responsive, stating that she just took her normal medication. Her blood sugar went up to 110 mg/dL and she remained this way throughout her trip to the ED. However, in the ED you notice that the patient is again diaphoretic and is mumbling her speech. Her fingerstick glucose is now 47 mg/dL. You administer dex- trose and she perks right up. Which of the following diabetes medications commonly causes hypoglycemia for which the patient is likely to require hospital admission?
- Regular insulin
9. A 23-year-old woman presents to the ED complaining of abdomi- nal pain, nausea, and She has a history of depression but is not currently taking any antidepressant medications. Upon further question- ing, the patient states that she ingested a bottle of pills in her medicine cabinet approximately 3 hours ago. Her BP is 115/65 mm Hg, HR is 101 beats per minute, temperature is 100.1°F, RR is 29 breaths per minute, and oxygen saturation is 100% on room air. Physical examination is unremark- able except for mild diffuse abdominal tenderness. Laboratory results reveal a white blood cell (WBC) count of 10,300/mL, hematocrit 46%, platelets 275/mL, aspartate transaminase (AST) 70 U/L, alanine transaminase (ALT) 85 U/L, alkaline phosphatase 75 U/L, sodium 143 mEq/L, potassium 3.7 mEq/L, chloride 98 mEq/L, bicarbonate 8 mEq/L, blood urea nitrogen (BUN) 22 mg/dL, creatinine 0.9 mg/dL, and glucose 85 mg/dL. Arterial blood gas values on room air are pH 7.51, PCO2 11 mm Hg, and PO2 134 mm Hg. Which of the following substances did this patient most likely ingest?
10. A 35-year-old agitated man presents to the ED in police He denies any past medical history and takes no medication. He admits to using some drugs today. His BP is 195/90 mm Hg, HR is 121 beats per minute, temperature is 100.1°F, RR is 18 breaths per minute, and oxygen saturation is 99% on room air. On examination, he is diaphoretic, and has pupils that are 8 mm in diameter, along with 3+ patella reflexes bilater- ally. Electrocardiogram (ECG) reveals sinus tachycardia with a rate of 123. Which of the following toxic syndromes is this patient exhibiting?
- Sedative hypnotic
11. A 31-year-old woman with a known psychiatric history presents to the ED after ingesting an unknown quantity of pills from her medica- tion In the ED, she complains of nausea, abdominal cramping, and feels unsteady on her feet. On physical examination, you observe that she is tachycardic and ataxic. Which of the following substances will best be treated by activated charcoal that could present like this?
- Lye (sodium hydroxide)
12. A 27-year-old man presents to the ED extremely agitated complain- ing of mild chest pain and He states that he was snorting cocaine all afternoon. You place him on a monitor and get his vital signs. His BP is 215/130 mm Hg, HR is 112 beats per minute, temperature is 100.1°F, RR is 17 breaths per minute, and oxygen saturation is 98% on room air. An ECG reveals sinus tachycardia at a rate of 116. Which of the following is the most appropriate medication to administer?
13. A 30-year-old man is brought to the ED by police The patient is agitated, vomiting, and complaining of body aches. He states that he is withdrawing from his medication. His vital signs are BP 160/85 mm Hg, RR 20 breaths per minute, HR 107 beats per minute, and temperature 99.7°F. On examination he is diaphoretic, has rhinorrhea, piloerection, and hyper- active bowel sounds. Which of the following substances is this patient most likely withdrawing from?
14. A 25-year-old man is brought into the ED by two police officers because of suspected drug The patient is extremely agitated and is fighting the police officers. It takes three hospital staff members and the two police offi- cers to keep him on the stretcher. His vital signs are BP 150/80 mm Hg, HR 107 beats per minute, temperature 99.7°F, RR 18 breaths per minute, and oxygen saturation 99% on room air. Physical examination is unre- markable except for cool, diaphoretic skin, persistent vertical and horizon- tal nystagmus, and occasional myoclonic jerks. Which of the following is the most likely diagnosis?
- Cocaine intoxication
- Cocaine withdrawal
- Anticholinergic toxidrome
- PCP intoxication
- Opiate withdrawal
15. An undomiciled 49-year-old man presents to the ED with altered mental His BP is 149/75 mm Hg, HR is 93 beats per minute, temperature is 97.5°F, RR is 18 breaths per minute, and O2 saturation is 99% on room air. Physical examination reveals an unkempt man with the odor of “alcohol” on his breath. His head is atraumatic and pupils are 4 mm, equal, and reactive. The neck is supple. Cardiovascular, pulmonary, and abdominal examinations are unremarkable. There is no extremity edema and his pulses are 2+ and symmetric. Neurologically, he withdraws all four extremities to deep stimuli. ECG is sinus rhythm. Laboratory results reveal:
Sodium 141 mEq/L Arterial blood pH 7.26
Potassium 3.5 mEq/L Lactate 1.7 mEq/L
Chloride 101 mEq/L Ethanol level undetectable
Bicarbonate 14 mEq/L Measured serum osmolarity 352 mOsm/L
BUN 15 mg/dL Calculated serum osmolarity 292 mOsm/kg
Creatinine 0.7 mg/dL Urinalysis: no blood, ketones, or protein
Glucose 89 mg/dL
Which of the following statements best describes the laboratory findings?
- Anion gap metabolic acidosis and osmol gap
- Anion gap metabolic acidosis without osmol gap
- Nonanion gap metabolic acidosis and osmol gap
- Nonanion gap metabolic acidosis without osmol gap
- Metabolic alkalosis with secondary acidosis
16. A 26-year-old woman with a history of depression is brought into the ED. She was found lying on the floor of her apartment next to an unlabeled empty pill Her HR is 117 beats per minute, BP is 95/65 mm Hg, RR is 14 breaths per minute, and oxygen saturation is 97% on 2-L nasal cannula. On examination, the patient appears obtunded, and her pupils are 3 mm and reactive. Her oropharynx is dry and there is no gag reflex to pharyngeal stimulation. Her neck is supple. The heart is tachycardic without murmurs, the lungs are clear to auscultation, and the abdomen is soft. There is normal rectal tone and brown stool that is heme negative. Her skin is cool and moist with no signs of needle tracks. Neurologically, she is unresponsive but withdraws all extremities to deep palpation. Fingerstick blood glucose is 85 mg/dL. Her ECG reveals sinus tachycardia at 119 with a QRS complex of 140 milliseconds and a terminal R wave in lead aVR. Which of the following is the most appropriate next step in management?
- Orotracheal intubation, administer activated charcoal through orogastric tube, and IV naloxone
- Orotracheal intubation, administer activated charcoal through orogastric tube, and IV sodium bicarbonate
- Orotracheal intubation, administer activated charcoal through orogastric tube, and IV NAC
- Orotracheal intubation, administer syrup of ipecac through orogastric tube, and IV sodium bicarbonate
- Induce vomiting prior to intubation to lower the risk of aspiration then admin- ister IV sodium bicarbonate
17. A 37-year-old woman is brought into the ED by her friend who states that the patient swallowed approximately 50 capsules of 325-mg acetamino- phen (APAP) 6 hours ago in an attempted The patient states she feels nauseated and vomits while you take her history. Her BP is 100/75 mm Hg, HR is 97 beats per minute, temperature is 98.9°F, RR is 18 breaths per minute, and oxygen saturation is 99% on room air. Examination is unre- markable except for mild epigastric tenderness. Which of the following is the correct antidote for APAP overdose?
18. A 31-year-old man is brought to the ED by EMS who state that the man was found lying on the floor of his He is rousable in the ED, speaks with slurred speech, and vomits. His BP is 140/85 mm Hg, HR is 94 beats per minute, temperature is 98.8°F, RR is 17 breaths per minute, and oxygen saturation is 99% on room air. You place an IV line, draw blood, and start a liter of normal saline running through the line. Laboratory results reveal serum sodium 139 mEq/L, potassium 3.5 mEq/L, chloride 101 mEq/L, bicarbonate 14 mEq/L, BUN 15 mg/dL, creatinine 1 mg/dL, glu- cose 105 mg/dL, arterial blood pH 7.27, COHb 4%, and lactate 2.8 mEq/L. Urinalysis shows 1+ protein, trace ketones, WBC 4/hpf (high-power field), red blood cell (RBC) 2 to 3/hpf, and multiple envelope-shaped and needle- shaped crystals. Which of the following conditions would best explain his metabolic acidosis?
- Ibuprofen toxicity
- Ethylene glycol poisoning
- Diabetic ketoacidosis (DKA)
- Lactic acidosis
- Isopropyl alcohol poisoning
19. A 35-year-old man who is employed as a forklift operator was found sitting outside a He came stumbling out complaining of dizzi- ness and headaches. Coworkers in an adjoining warehouse also complained of headache and nausea. After collapsing outside, he regained consciousness immediately but appeared confused. In the ED, his BP is 100/54 mm Hg, HR is 103 beats per minute, temperature is 100°F, pulse ox is 91% on room air, and RR is 23 breaths per minute. Physical examination is unremark- able. Laboratory results reveal WBC 10,500/mL, hematocrit 45%, platelets 110/mL, sodium 137 mEq/L, potassium 4 mEq/L, chloride 103 mEq/L, bicarbonate 21 mEq/L, BUN 8 mg/dL, creatinine 0.5 mg/dL, and glucose 89 mg/dL. Arterial blood gas results are pH 7.32, PCO2 32 mm Hg, and PO2 124 mm Hg. Which of the following is the most likely diagnosis?
- Hypoglycemic syncope
- Hydrocarbon poisoning
- Opioid overdose
- CO poisoning
20. A 51-year-old man presents to the ED complaining of nausea and abdominal pain after drinking some “bitter ” He is considered one of the “regulars” who is usually at triage with ethanol intoxication. His tem- perature is 97.9°F, BP is 130/65 mm Hg, HR is 90 beats per minute, RR is 16 breaths per minute, and oxygen saturation is 97% on room air. Physical examination is unremarkable, except for slurred speech and the smell of acetone on the patient’s breath. Laboratory results reveal serum sodium 138 mEq/L, potassium 3.5 mEq/L, chloride 105 mEq/L, bicarbonate 23 mEq/L, BUN 10 mg/dL, creatinine 2.1 mg/dL, glucose 85 mg/dL, arte- rial blood pH 7.37, and lactate 1.4 mEq/L. Urinalysis shows moderate ketones. Which of the following is the most likely diagnosis?
- Ethanol intoxication
- Methanol intoxication
- Isopropyl alcohol intoxication
- Ethylene glycol intoxication