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Toxicology, Bioterrorism, and Chemical Warfare Agents
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1.A patient develops status epilepticus from an unknown poisoning. Which of the following i s the most appropriate fi rst IV drug to give?
- Valproic acid
2. A fi refighter who i s trying to extinguish a car fi re has a leak in his protective air He develops cyanide poisoning from the combustion of plastic. Aside from rendering symptomatic, supportive care, which might be administered to combat the cyanide poisoning?
- Ammonium chloride
- Dimercaprol (BAL; British anti-lewisite)
- Sodium thiosulfate
3. A 28-year-old male patient i s transported to the emergency department after a massive exposure to carbon tetrachloride (CCl 4), a solvent used at his Which one of the following best describes a characteristic of poisoning with this toxicant, or i ts cl inical management?
- Causes a s low death due to bone marrow suppression
- Causes widespread ATP depletion by uncoupling oxidative phosphorylation
- Metabolized to free radicals (tri chloro radicals) that are directly cytotoxic to l iver and kidney cells
- N-Acetylcysteine effectively scavenges carbon tetrachloride’s cytotoxic metabolite
- Toxic consequences reduced or prevented by administration of methylene blue
4. A patient who has been on long-term therapy with a drug develops a lupus-like syndrome in response to i t. With which drug i s this response, probably mediated by an autoimmune reaction, most l ikely to occur?
- Organic mercury
- Tricyclic antidepressants (eg, amitriptyline)
5. A patient presents in the emergency department with a drug Among other things, the physician correctly orders IV infusion of sodium bicarbonate to alkalinize the urine, which increases the toxin’s elimination through pH-dependent inhibition of i ts tubular reabsorption, and helps correct the combined metabolic and respiratory acidosis the toxin caused. Which one of the following drugs most l ikely caused the toxicity?
- Aspirin (acetylsalicylic acid)
- Phencyclidine (PCP)
6. A patient has taken a potentially lethal dose of The emergency department team begins administering repeated doses of N– acetylcysteine, which can be a l i fesaving antidote in many such cases. What i s the main mechanism by which this antidote exerts i ts beneficial effects?
- Alkalinizes the urine to facilitate acetaminophen excretion
- Causes metabolic acidosis to counteract metabolic alkalosis caused by a toxic acetaminophen metabolite
- Inhibits P450 enzymes, thereby inhibiting formation of acetaminophen’s toxic metabolite
- Inhibits synthesis of superoxide anion radical and hydrogen peroxide
- Is ri ch in sulfhydryl (–SH) groups that react with and inactivate the toxic acetaminophen metabolite, sparing hepatocytes from attack by the metabolite
7. Your patient developed acute poisoning as a result of inhaling cyanide gas in an industrial In addition to providing symptomatic, supportive care, and other appropriate interventions, administering which one of the following would be most l ikely to be effective as an adjunctive drug, in treating the cyanide poisoning?
- Ammonium chloride
- Dimercaprol (BAL; British anti-Lewisite)
- N-acetylcysteine Pralidoxime
- Sodium thiosulfate
8. A 5-year-old boy consumed a l iquid from a container in the family He presents with central nervous system (CNS) depression, obtunded reflexes, and ventilatory depression. A blood sample indicates profound metabolic acidosis and an anion gap. A check of the urine reveals crystals that are presumed to be oxalate. What i s the most l ikely cause of the poisoning?
- A halogenated hydrocarbon from a can of spray paint
- An insecticide
- Ethylene glycol
- Paint thinner
9. A farm worker in California i s brought emergently, and declared dead on arrival, to a local emergency He had been exposed to an agricultural toxin. A coworker, who was not poisoned but was nearby right after the time of exposure, said, “He just started shaking bad, collapsed, and immediately stopped breathing. I didn’t see anything else happen. He looked perfectly normal one minute, then he was just dead.” What was the most l ikely cause of this man’s death?
- Cholinesterase inhibitor insecticide, sprayed by a crop duster airplane
- Kerosene from a barn heater, ingested
- Long-term and cumulative cutaneous exposure to arsenic, today’s exposure proving rapidly fatal
- Petroleum distillates used to clean grease off farm machinery, inhaled.
- Strychnine, ingested
10. Here i s an excerpt from newspaper article entitled Weed Users Chase High all the Way to the Hospital. Use i t to answer the next two questions, and note that the “weed” referred to does not include marijuana or any other plants that contain tetrahydrocannabinol or an opioid.
“Teenagers seeking a hallucinogenic high from the seeds of a poisonous weed that now i s in bloom are landing in hospitals across the country, police and health officials say… “Lunatic, crazy kids,” says Dodge County, Wis., Sheriff Todd Nehls, whose deputies picked up three hallucinating teenagers in October….
“Poison centers last year recorded 975 incidents involving plants such as [the] weed…” according to the American Association of Poison Control Centers’ annual report.
“[The weed has]… pods that contain seeds that when eaten or brewed in a tea can cause severe hallucinations [delirium] and other reactions, including dry mouth, overheating [fever], agitation, [and] urinary retention… Some cannot urinate and need to have a catheter inserted… [Severe] overdoses can lead to seizures, coma, or death… Most people hospitalized after eating [the] weed have hallucinations that make them so erratic they are a danger to themselves…”
- Belladonna alkaloids
- Bethanechol e. Cocaine
- . Phencyclidine (PCP)
Which drug l i sted above causes s igns and symptoms that are most s imilar to—indeed, vi rtually identical to—those described in the scenario?
11. A mother calls to report that her 6-year-old child appears to have swallowed a large amount of an over-the-counter s leep aid about 5 hours The product contained only one active drug, and knowing your drugs you suspect the poisoning i s due to diphenhydramine. Assuming your reasoned guess about the cause of poisoning was correct, which of the following s igns or symptoms would you expect to find, upon physical exam, to confirm your hunch?
- Fever; clear lungs; absence of bowel sounds; urinary retention, dry, flushed skin; mydriasis and photophobia; bizarre behavior
- Bradycardia and profuse diarrhea
- Miosis with l i ttle/no papillary response to bright l ights; spontaneous micturition; lack of response to painful stimuli
- Hypothermia; bounding pulse; hypertension
- Skeletal muscle weakness or paralysis; profound hypermotility of gut and bladder smooth muscle; bronchospasm
12. A 3-year-old girl ingests 30 tablets of aspirin, 325 mg We’ve gotten her to the emergency department within 30 minutes of the poisoning. Which one of the following drugs would be the most rational and hopefully effective to administer as part of the initial treatment plan for what otherwise could have a fatal outcome?
- Activated charcoal
13.. A 50-year-old man has been consuming large amounts of ethanol on an almost daily basis for many One day, unable to find any ethanol, he ingests a large amount of methanol (wood alcohol) that he had bought for his camp lantern. Which of the following i s the most l ikely consequence of his methanol poisoning?
- Atrioventricular conduction defect (block)
- Delirium tremens
- Metabolic alkalosis
14. A 15-year-old boy attempts suicide with a l iquid that he found in his parents’ His dad used i t to get rid of “varmints” around the yard. The toxin causes intense abdominal pain, skeletal muscle cramps, projectile vomiting, and severe diarrhea that leads to fluid and electrolyte imbalances, hypotension, and difficulty swallowing. On examination he i s found to be volume depleted and i s showing s igns of a reduced level of consciousness. His breath smells “metallic.” Which of the following probably accounts for these symptoms?
15. A 22-year-old i s brought to the emergency department by a They had been at a bar for about an hour, and then the patient suddenly became drowsy but was sti l l conscious. She fell and cut her head, and has l i ttle difficulty feeling the pain from the trauma. Her ventilatory rate
and depth are depressed, but not to a worrisome degree. Her patellar reflexes are blunted and she i s ataxic. She responds s lowly to questions but i s unable to recall anything that happened after arriving at the bar and s ipping her fi rst (and last) adult beverage. Her friend stated that she had only one Cosmopolitan and hadn’t been drinking before they went out. With what was this patient’s drink most l ikely “spiked?”
- A barbiturate
- A benzodiazepine
- An opioid
- Chloral hydrate Cocaine
- Pure (grain) alcohol
`16. Let’s assume the profoundly CNS-depressed patient in the previous question indeed was overdosed with a Which drug i s most l ikely to be effective, indeed would be a preferred pharmacologic antidote, i f that were the case?
17. Recent occupational health studies in several heavily populated urban areas have revealed an astonishingly large number of homes that have lead-based paint and children l iving in However, a number of environmental poisons that could lead to acute or chronic poisoning have also been found there. Which s igns and symptoms would be consistent with chronic exposure to toxic levels of inorganic lead?
- Anorexia and weight loss; weakness, especially of extensor muscles (eg, wrist drop); recurrent abdominal pain
- Gingivitis, discolored gums, loosened teeth, or stomatitis; tremor of the extremities; swollen parotid or other salivary glands
- Hallucinations, insomnia, headache, generalized CNS i rri tability
- Hyperventilation in response to metabolic acidosis; hypotension; abdominal pain, diarrhea, brown or bloody vomitus; pallor or cyanosis Severe, watery diarrhea; garlicky or metallic breath; encephalopathy, hypovolemia and hypotension
18. Lab tests conducted by the local health department are positive for chronic lead exposure in a Lead levels are s ignificantly elevated, but symptoms fortunately are mild and not at all imminently l i fe-threatening. What i s the most appropriate antidote for reducing the child’s body load of lead?
- Ca-Na 2-EDTA
- N-Acetylcysteine Penicillamine
- . Succimer
19. Not long ago, several patients (and a rather shady health care “provider” who i s now incarcerated) seeking “relief” from facial wrinkles nearly died because they received injections of botulinum toxin that was improperly obtained and inadequately Which i s a correct characteristic, finding, or mechanism associated with this toxin?
- Complete failure of all cholinergic neurotransmission
- Favorable response to administration of pralidoxime
- Impairment of parasympathetic, but not sympathetic, nervous system activation
- Massive overstimulation of all structures having muscarinic cholinergic receptors
- Selective paralysis of skeletal muscle
20. A terrorist drops a vial of “nerve gas” into a crowded subway at rush The patients are brought to the nearest emergency centers and are given atropine. Which effect of the nerve gas will persist after giving the atropine?
- Excessive lacrimal, mucus, sweat, and salivary secretions
- GI hypermotility, fluid and electrolyte loss from profuse diarrhea
- Skeletal muscle hyperfunction or paralysis
21. A neighbor calls you for advice and She knows you are not a veterinary student, but s ince you’re going to be a physician soon she figures you know everything. Her pet puppy, Pookie, a Pekingese, has eaten a large amount of rodent (rat and mouse) poison. She’s panicked and pleads to know i f the precious pooch i s poisoned. The rodenticide indeed contains a powerful poison intended to ki l l rats and mice, but i t can do the same to any other animals that have ingested i t too, including humans. What i s the most l ikely toxic ingredient in these rodenticides, and probably will cause poor Pookie pronounced problems?
- Amphetamine-cocaine combination
- Vecuronium (or a s imilar neuromuscular blocker)