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Toxicology Questions & Case Studies

by Pravin Shukle, MD
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    00:01 Let's look at a couple of questions in toxicology.

    00:04 A 23-year-old female is brought to the emergency room by friends after an evening at a night club.

    00:11 She has been drinking heavily. Her blood pressure is 185/120. Her heart rate is 155.

    00:18 Her temperature is 38.5 degree Celcius or 100 degrees Fahrenheit. This was measured in tympanum.

    00:26 She is hyperactive, euphoric, hypersexual, and easily distracted. She is clearly hallucinating.

    00:33 Blood work is normal. And urinalysis is positve for amphetamines.

    00:38 What is the most likely culprit drug? Is it ecstasy? Is it soap? Is it STP? Or is it angel dust? Right. So, MDMA or ecstasy, is often positive for amphetamines in the urine.

    00:56 And it causes this very typical kind of a picture. Hyperactive, hypersexual, high temperature, high blood pressure, high heart rate.

    01:07 Here is a great question. A 34-year-old male is brought to emergency room by police after beating his wife.

    01:14 The police have him handcuffed to the bed. He is hyperactive, delirious, and violent.

    01:20 Urinalysis is negative for drugs, and the blood work is normal.

    01:23 The blood pressure is 235/130, and the heart rate is 150. The skin is warm and dry to the touch.

    01:30 Now, before you react negatively to my characteristics of this patient, let me just tell you that this is one of my patients, and this happen in real life.

    01:40 So, what do you think the most culprit drug is? Is it ecstasy? Is it soap? Is it STP? Or is it angel dust? Yes. So if you picked soap, you're right. This is a scary drug.

    01:58 Here's another real patient of mine. A 55-year-old homeless male is brought into the emergency department by police.

    02:05 He was dishevelled. He had very poor hygiene. He was literally found on the freeway shouting at a lamppost.

    02:12 Blood pressure was 170/74. Heart rate was 120. He has vertical nystagmus.

    02:18 I should also mention that he thought I was the queen which was also interesting.

    02:22 So, what do you think the most likely culprit drug is? Is it ecstasy, soap, STP or angel dust? And the answer is angel dust.

    02:34 Here is a great question. This is a real patient that was brought into my emergency department when I was working in a hospital in Ottawa. A 23-year-old male is brought to the ER by the police.

    02:46 He is tachycardic, sweating profusely, and agitated. His blood pressure was 155/70, and a heart rate of 145.

    02:55 His temperature was normal. Blood work shows traces of opioids. What is the most likely diagnosis? Is it an opioid withdrawal syndrome? Did he ingest soap? Did he ingest ecstasy? Or is he having a myocardial infarction? Right, opioid withdrawal syndrome. So, opioid withdrawal syndrome is very typical with young patients, especially patients who are sweating profusely but their blood work is either negative or positive for a trace of opioid.

    03:31 That's because the opioid has taken the system for a long time.

    03:36 Once again, this is a real patient. It's heartbreaking. A 10-year-old boy is brought to the emergency room with burn marks on his face. He is confused. He has an increased anion gap metabolic acidosis, a headache, and an elevated creatinine level. Pick the most likely scenario.

    03:55 So, I want you to pay real attention to this question.

    03:59 Okay. The first scenario is that he has never huffed solvents before, but he drank some hairspray.

    04:05 The second choice is that he has probably huffed solvents before, and he drank at least one can of hairspray.

    04:14 The third choice is that he use crack cocaine. And the fourth choice is that he used a designer drug like ecstasy.

    04:22 Now, let's think about this. You chose B, and you're right. Let's look at each of the choices individually.

    04:29 The first choice was he has never huffed solvents before and he drank some hairspray.

    04:35 And the second choice is that he probably huffed solvents before, and he drank at least one can of hairspray.

    04:40 Now, these two choices are very similar with one small difference.

    04:44 When you're doing your exams, remember that if you have two choices that are very similar with one small difference, the answer is probably one of those two. So, pay close attention.

    04:55 He has burn marks on his face. So, the question is, is he a huffer? And the answer is probably yes.

    05:02 He is the right age group, because typically huffers are very young, 10 years or older, 12 years old.

    05:10 He comes in with an anion gap metabolic acidosis. So, we know that he is not hyped from huffing because huffing generally doesn't cause an AG metabolic acidosis, okay.

    05:22 What we have here is a kid who has taken some hairspray. We sometimes call this Alberto V05 syndrome, but it can be any kind of hairpsray. What happens with these patients is they come in and they have a history of other types of abuse.

    05:37 Lower income patients generally use hairspray as a means of getting drunk because they can't afford alcohol.

    05:44 Remember a can of hairspray costs about 2 dollars, and to get the same high from alcohol would cost you 20, 30 dollars.

    05:53 Is it likely that he used crack cocaine? Actually, it's possible but it doesn't fit this picture because crack cocaine doesn't give you an increased AGMA.

    06:04 Now, what about this designer drug like ecstasy? He is not coming in hyperthermic and it's really unlikely with young kids to come in with ecstasy poisoning at this age group.

    06:15 Ecstasy tends to be a drug that is abused by the 20 something crowd, when they go to a party like a rave.

    06:23 This is a real patient of mine. A 32-year-old mother of three was brought in by her husband. She is comatose.

    06:30 An empty bottle of acetaminophen tablet was found in her hand. It had contained 24 tablets of 325 mg each.

    06:40 Her husband last saw her six hours ago, when he asked her for a divorce.

    06:45 Plasma acetaminophen levels will be available in the next 2 to 3 hours. Choose the most appropriate action.

    06:54 Would you A, not administer acetylcysteine because the plasma acetaminophen levels are unlikely to be above the treatment line on the nomogram? Or would you B, administer acetylcysteine once the plasma levels confirm the presence of acetaminophen at toxic levels? Or would you C, administer an appropriate dose of acetylcysteine before the plasma acetaminophen levels are back in 3 hours? Or D, will you administer benzodiazepines in order to prevent seizure activity? This is a clinical judgement question. You don't know and it's going to take time to get an answer.

    07:35 This person has already passed that four hour window where we sometimes can wait and see.

    07:40 You want to get this person treated now. So, make an assumption that they are toxic, give them the medication, especially because she is comatose, you're very very worried about her hepatic function and her renal function because of toxicity from acetaminophen. So, treat first, ask questions later when time is off the essence.

    07:59 So, this is what we did for this poor woman. We gave her the requisite dose of Mucomyst, it ended up being that her plasma acetaminophen levels were sky high, and it seems that she may have taken more than 24 tablets.

    08:12 We ended up saving her liver, unfortunately, not her marriage, but she is well and alive today.

    08:19 Thank you very much. I hope you enjoyed this lecture.

    08:21 If you have any questions, please email us, and we will try to answer them for you.


    About the Lecture

    The lecture Toxicology Questions & Case Studies by Pravin Shukle, MD is from the course Toxicology. It contains the following chapters:

    • Case Study 1: Toxicology
    • Case Study 2: Toxicology
    • Case Study 3: Toxicology
    • Case Study 4: Toxicology
    • Case Study 5: Toxicology
    • Case Study 6: Toxicology

    Author of lecture Toxicology Questions & Case Studies

     Pravin Shukle, MD

    Pravin Shukle, MD


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