Toxidromes: Clinical

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Toxidromes: Clinical

USMLE® Step 2 questions

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USMLE® Step 2 style questions USMLE

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A 65-year-old man is being evaluated for hematuria following urinary catheterization. The patient was hospitalized four days ago with severe chest pain and left lower limb swelling, and he was subsequently diagnosed with venous thromboembolism. The patient was admitted to the floor and initiated on heparin anticoagulation therapy. Today, the nursing staff noted bright red blood following urinary catheterization. The patient’s past medical history includes chronic kidney disease, for which he receives dialysis on Monday, Wednesday, and Friday. The patient’s blood pressure is 120/75 mmHg, heart rate is 100/minute, and respirations are 18/minute. The patient’s serum analysis is demonstrated below. Which of the following is the most appropriate next step in management?

Hemoglobin   9 g/dL 
 Hematocrit  45% 
 Platelet count  190,000/mm3 
 Leukocyte count  8,000/mm3 
 International normalized ratio (INR)  1.6 
 Activated partial thromboplastin time (PTT)   114 seconds 


Accidental and intentional intoxications or drug overdoses produce toxidromes, which are a combination of symptoms and characteristic findings for a particular substance or class of substances.

Sometimes there’s more than one substance that’s used, so there are a combination of findings.

The general goals of management include stabilizing the clinical condition and controlling the symptoms, as well as finding the causing substance and give specific treatment.

Individuals who present only mild toxicity can be observed in the emergency department until they are asymptomatic, while those with significant toxicity should be admitted to an intensive care unit or ICU.

The initial step in evaluating a person who may have a toxidrome is to assess the A, B, C’s - airway, breathing and circulation.

The respiratory rate and oxygen saturation should be assessed and if the oxygen saturation is lower than 92%, high-flow oxygen can be given by face mask.

In individuals with severe respiratory distress, intubation and mechanical ventilation may be needed right away.

Next, an electrocardiogram is done along with continuous cardiac monitoring to assess for cardiac arrhythmias.

If the individual is hypotensive, then 2 liters of IV isotonic crystalloid solution is given, followed by a norepinephrine drip.

Next, if the individual has neurological symptoms- like confusion or delirium, then IV thiamine is given to prevent Wernicke’s encephalopathy. That’s usually caused by vitamin B1 deficiency, which is often due to ethanol abuse and can cause the triad of nystagmus, ataxia, and confusion.

Additionally, if the individual presents with respiratory depression, then an opioid overdose is the most likely cause. In this case, 0.05 milligrams of iv naloxone or 0.1 milligrams of intramuscular naloxone is administered. The dosage is then doubled every 2 minutes until reversal of respiratory depression.



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