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Question 1
Incorrect
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A 35 year old male is brought into the emergency department by his coworkers after they checked on him and found him crying with empty paracetamol packets beside him. The patient reveals taking approximately 50 paracetamol tablets in an attempt to commit suicide 45 minutes ago.
When should paracetamol levels be taken?Your Answer: At 1 hour post ingestion
Correct Answer: At 4 hours post ingestion
Explanation:Paracetamol levels should be measured 4 hours after ingestion. If the patient arrives at the emergency department more than 4 hours after ingestion, the levels can be taken immediately. However, if the patient has not reached the 4-hour mark yet, the measurement should be postponed until they reach that time.
Further Reading:
Paracetamol poisoning occurs when the liver is unable to metabolize paracetamol properly, leading to the production of a toxic metabolite called N-acetyl-p-benzoquinone imine (NAPQI). Normally, NAPQI is conjugated by glutathione into a non-toxic form. However, during an overdose, the liver’s conjugation systems become overwhelmed, resulting in increased production of NAPQI and depletion of glutathione stores. This leads to the formation of covalent bonds between NAPQI and cell proteins, causing cell death in the liver and kidneys.
Symptoms of paracetamol poisoning may not appear for the first 24 hours or may include abdominal symptoms such as nausea and vomiting. After 24 hours, hepatic necrosis may develop, leading to elevated liver enzymes, right upper quadrant pain, and jaundice. Other complications can include encephalopathy, oliguria, hypoglycemia, renal failure, and lactic acidosis.
The management of paracetamol overdose depends on the timing and amount of ingestion. Activated charcoal may be given if the patient presents within 1 hour of ingesting a significant amount of paracetamol. N-acetylcysteine (NAC) is used to increase hepatic glutathione production and is given to patients who meet specific criteria. Blood tests are taken to assess paracetamol levels, liver function, and other parameters. Referral to a medical or liver unit may be necessary, and psychiatric follow-up should be considered for deliberate overdoses.
In cases of staggered ingestion, all patients should be treated with NAC without delay. Blood tests are also taken, and if certain criteria are met, NAC can be discontinued. Adverse reactions to NAC are common and may include anaphylactoid reactions, rash, hypotension, and nausea. Treatment for adverse reactions involves medications such as chlorpheniramine and salbutamol, and the infusion may be stopped if necessary.
The prognosis for paracetamol poisoning can be poor, especially in cases of severe liver injury. Fulminant liver failure may occur, and liver transplant may be necessary. Poor prognostic indicators include low arterial pH, prolonged prothrombin time, high plasma creatinine, and hepatic encephalopathy.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 2
Incorrect
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A 45-year-old woman presents with painful bilateral gynaecomastia. She began taking a new medication a few months ago.
Which medication is the SINGLE LEAST likely cause for this adverse drug effect?Your Answer: Spironolactone
Correct Answer: Ranitidine
Explanation:Gynaecomastia, a condition characterized by the enlargement of breast tissue in males, can be caused by certain drugs. Some medications that have been associated with gynaecomastia include Cimetidine, Omeprazole, Spironolactone, Digoxin, Furosemide, Finasteride, and certain antipsychotics. Interestingly, Ranitidine, another medication commonly used for gastric issues, does not tend to cause gynaecomastia. In fact, studies have shown that gynaecomastia caused by Cimetidine can be resolved when it is substituted with Ranitidine.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 3
Incorrect
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A 32-year-old man with a known history of diabetes presents with fatigue, frequent urination, and blurred vision. His blood glucose levels are elevated at 250 mg/dL. He currently takes insulin injections and metformin for his diabetes. You organize for a urine sample to be taken and find that his ketone levels are markedly elevated, and he also has biochemical abnormalities evident.
Which of the following biochemical abnormalities is LEAST likely to be present?Your Answer: Hypophosphataemia
Correct Answer: Hypoglycaemia
Explanation:The clinical manifestations of theophylline toxicity are more closely associated with acute poisoning rather than chronic overexposure. The primary clinical features of theophylline toxicity include headache, dizziness, nausea and vomiting, abdominal pain, tachycardia and dysrhythmias, seizures, mild metabolic acidosis, hypokalaemia, hypomagnesaemia, hypophosphataemia, hypo- or hypercalcaemia, and hyperglycaemia. Seizures are more prevalent in cases of acute overdose compared to chronic overexposure. In contrast, chronic theophylline overdose typically presents with minimal gastrointestinal symptoms. Cardiac dysrhythmias are more frequently observed in individuals who have experienced chronic overdose rather than acute overdose.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 4
Incorrect
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You review a 65-year-old man who has presented with visual problems. He has been taking amiodarone for several years.
Which SINGLE statement regarding the effects of amiodarone on the eye is true?Your Answer: Optic disc swelling occurs in over 50% of patients on long-term treatment
Correct Answer: Corneal microdeposits are almost universally present in patients taking amiodarone for longer than six months
Explanation:Corneal microdeposits are found in almost all individuals (over 90%) who have been taking amiodarone for more than six months, particularly at doses higher than 400 mg/day. These deposits generally do not cause any symptoms, although approximately 10% of patients may experience a perception of a ‘bluish halo’ around objects they see.
Amiodarone can also have other effects on the eye, but these are much less common, occurring in only 1-2% of patients. These effects include optic neuropathy, nonarteritic anterior ischemic optic neuropathy (N-AION), optic disc swelling, and visual field defects.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 5
Incorrect
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A 32-year-old man with a known history of diabetes presents with fatigue, frequent urination, and blurred vision. His blood glucose levels are significantly elevated. He currently takes insulin injections and metformin for his diabetes. You organize for a urine sample to be taken and find that his ketone levels are markedly elevated, and he also has electrolyte abnormalities evident.
Which of the following electrolyte abnormalities is most likely to be present?Your Answer: Metabolic alkalosis
Correct Answer: Hypokalaemia
Explanation:The clinical manifestations of theophylline toxicity are more closely associated with acute poisoning rather than chronic overexposure. The primary clinical features of theophylline toxicity include headache, dizziness, nausea and vomiting, abdominal pain, tachycardia and dysrhythmias, seizures, mild metabolic acidosis, hypokalaemia, hypomagnesaemia, hypophosphataemia, hypo- or hypercalcaemia, and hyperglycaemia. Seizures are more prevalent in cases of acute overdose compared to chronic overexposure. In contrast, chronic theophylline overdose typically presents with minimal gastrointestinal symptoms. Cardiac dysrhythmias are more frequently observed in individuals who have experienced chronic overdose rather than acute overdose.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 6
Correct
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A 40-year-old man is brought to the Emergency Department by his wife after overdosing on one of his prescribed medications. He is restless, disoriented, and experiencing visual hallucinations. His heart rate is currently 110 bpm, and his pupils are dilated. It is challenging to gather information from him as he is speaking incoherently. Upon further inquiry, you learn that he has ingested an anticholinergic medication.
What is the antidote for this type of poisoning?Your Answer: Physostigmine
Explanation:Patients who present with an anticholinergic toxidrome can be difficult to manage due to the agitation and disruptive behavior that is typically present. It is important to provide meticulous supportive care to address the behavioral effects of delirium and prevent complications such as dehydration, injury, and pulmonary aspiration. Often, one-to-one nursing is necessary.
The management approach for these patients is as follows:
1. Resuscitate using a standard ABC approach.
2. Administer sedation for behavioral control. Benzodiazepines, such as IV diazepam in 5 mg-10 mg increments, are the first-line therapy. The goal is to achieve a patient who is sleepy but easily roused. It is important to avoid over-sedating the patient as this can increase the risk of aspiration.
3. Prescribe intravenous fluids as patients are typically unable to eat and drink, and may be dehydrated upon presentation.
4. Insert a urinary catheter as urinary retention is often present and needs to be managed.
5. Consider physostigmine as the specific antidote for anticholinergic delirium in carefully selected cases. Physostigmine acts as a reversible acetylcholinesterase inhibitor, temporarily blocking the breakdown of acetylcholine. This enhances its effects at muscarinic and nicotinic receptors, thereby reversing the effects of the anticholinergic agents.Physostigmine is indicated in the following situations:
1. Severe anticholinergic delirium that does not respond to benzodiazepine sedation.
2. Poisoning with a pure anticholinergic agent, such as atropine.The dosage and administration of physostigmine are as follows:
1. Administer in a monitored setting with appropriate staff and resources to manage adverse effects.
2. Perform a 12-lead ECG before administration to rule out bradycardia, AV block, or broadening of the QRS.
3. Administer IV physostigmine 0.5-1 mg as a slow push over 5 minutes. Repeat every 10 minutes up to a maximum of 4 mg.
4. The clinical end-point of therapy is the resolution of delirium.
5. Delirium may reoccur in 1-4 hours as the effects of physostigmine wear off. In such cases, the dose may be cautiously repeated. -
This question is part of the following fields:
- Pharmacology & Poisoning
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Question 7
Correct
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A 68 year old male with dementia is brought into the emergency department by his daughter due to a sudden decline in cognitive function over the past week. The daughter suspects that the patient's medication may have been altered recently. She presents you with the tablets she discovered in the patient's room. Which medication is most likely responsible for the decline in the patient's cognitive abilities?
Your Answer: Oxybutynin
Explanation:Anticholinergic drugs have been found to worsen cognitive impairment in individuals with dementia. Certain commonly prescribed medications are associated with a higher anticholinergic burden, which can lead to increased cognitive decline. Examples of drugs with high anticholinergic potency include tricyclic antidepressants like amitriptyline hydrochloride, paroxetine, first-generation antihistamines such as chlorpheniramine maleate and promethazine hydrochloride, certain antipsychotics like olanzapine, clozapine, and quetiapine, urinary antispasmodics like solifenacin, oxybutynin, and tolterodine, and antimuscarinics like ipratropium, tiotropium, atropine, and cyclopentolate. However, it’s important to note that rivastigmine and memantine are recommended as first-line treatments for Alzheimer’s and DLB, while haloperidol, despite being an antipsychotic, has low anticholinergic potency.
Further Reading:
Dementia is a progressive and irreversible clinical syndrome characterized by cognitive and behavioral symptoms. These symptoms include memory loss, impaired reasoning and communication, personality changes, and reduced ability to carry out daily activities. The decline in cognition affects multiple domains of intellectual functioning and is not solely due to normal aging.
To diagnose dementia, a person must have impairment in at least two cognitive domains that significantly impact their daily activities. This impairment cannot be explained by delirium or other major psychiatric disorders. Early-onset dementia refers to dementia that develops before the age of 65.
The most common cause of dementia is Alzheimer’s disease, accounting for 50-75% of cases. Other causes include vascular dementia, dementia with Lewy bodies, and frontotemporal dementia. Less common causes include Parkinson’s disease dementia, Huntington’s disease, prion disease, and metabolic and endocrine disorders.
There are several risk factors for dementia, including age, mild cognitive impairment, genetic predisposition, excess alcohol intake, head injury, depression, learning difficulties, diabetes, obesity, hypertension, smoking, Parkinson’s disease, low social engagement, low physical activity, low educational attainment, hearing impairment, and air pollution.
Assessment of dementia involves taking a history from the patient and ideally a family member or close friend. The person’s current level of cognition and functional capabilities should be compared to their baseline level. Physical examination, blood tests, and cognitive assessment tools can also aid in the diagnosis.
Differential diagnosis for dementia includes normal age-related memory changes, mild cognitive impairment, depression, delirium, vitamin deficiencies, hypothyroidism, adverse drug effects, normal pressure hydrocephalus, and sensory deficits.
Management of dementia involves a multi-disciplinary approach that includes non-pharmacological and pharmacological measures. Non-pharmacological interventions may include driving assessment, modifiable risk factor management, and non-pharmacological therapies to promote cognition and independence. Drug treatments for dementia should be initiated by specialists and may include acetylcholinesterase inhibitors, memantine, and antipsychotics in certain cases.
In summary, dementia is a progressive and irreversible syndrome characterized by cognitive and behavioral symptoms. It has various causes and risk factors, and its management involves a multi-disciplinary approach.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 8
Correct
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A 28-year-old man is brought in by ambulance. He is unconscious and was discovered next to an empty container of antifreeze by his girlfriend.
What type of acid-base imbalance would you anticipate in a patient with ethylene glycol poisoning?Your Answer: Raised anion gap metabolic acidosis
Explanation:The following list provides a summary of common causes for different acid-base disorders.
Respiratory alkalosis can be caused by hyperventilation, such as during periods of anxiety. It can also be a result of conditions like pulmonary embolism, CNS disorders (such as stroke or encephalitis), altitude, pregnancy, or the early stages of aspirin overdose.
Respiratory acidosis is often associated with chronic obstructive pulmonary disease (COPD) or life-threatening asthma. It can also occur due to pulmonary edema, sedative drug overdose (such as opiates or benzodiazepines), neuromuscular disease, obesity, or other respiratory conditions.
Metabolic alkalosis can be caused by vomiting, potassium depletion (often due to diuretic usage), Cushing’s syndrome, or Conn’s syndrome.
Metabolic acidosis with a raised anion gap can occur due to lactic acidosis (such as in cases of hypoxemia, shock, sepsis, or infarction) or ketoacidosis (such as in diabetes, starvation, or alcohol excess). It can also be a result of renal failure or poisoning (such as in late stages of aspirin overdose, methanol or ethylene glycol ingestion).
Metabolic acidosis with a normal anion gap can be caused by conditions like renal tubular acidosis, diarrhea, ammonium chloride ingestion, or adrenal insufficiency.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 9
Incorrect
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A 30 year old male is brought to the emergency department by his friends after they discovered he had ingested an excessive amount of medication. The patient seems disoriented. The friends inform you that he had consumed 4 bottles (120 tablets) of 500 mg ibuprofen tablets. The initial ibuprofen level is reported as 600 mg/L. What level of ibuprofen toxicity does this indicate?
Your Answer: Severe
Correct Answer: Moderate
Explanation:The classification of severity in salicylate overdose can sometimes be confused by mixing up the ingested dose and the measured plasma salicylate level. To clarify, when using the blood salicylate level, moderate toxicity is indicated by a level of 350-700 mg/L, while severe toxicity is indicated by a level exceeding 700 mg/L.
Further Reading:
Salicylate poisoning, particularly from aspirin overdose, is a common cause of poisoning in the UK. One important concept to understand is that salicylate overdose leads to a combination of respiratory alkalosis and metabolic acidosis. Initially, the overdose stimulates the respiratory center, leading to hyperventilation and respiratory alkalosis. However, as the effects of salicylate on lactic acid production, breakdown into acidic metabolites, and acute renal injury occur, it can result in high anion gap metabolic acidosis.
The clinical features of salicylate poisoning include hyperventilation, tinnitus, lethargy, sweating, pyrexia (fever), nausea/vomiting, hyperglycemia and hypoglycemia, seizures, and coma.
When investigating salicylate poisoning, it is important to measure salicylate levels in the blood. The sample should be taken at least 2 hours after ingestion for symptomatic patients or 4 hours for asymptomatic patients. The measurement should be repeated every 2-3 hours until the levels start to decrease. Other investigations include arterial blood gas analysis, electrolyte levels (U&Es), complete blood count (FBC), coagulation studies (raised INR/PTR), urinary pH, and blood glucose levels.
To manage salicylate poisoning, an ABC approach should be followed to ensure a patent airway and adequate ventilation. Activated charcoal can be administered if the patient presents within 1 hour of ingestion. Oral or intravenous fluids should be given to optimize intravascular volume. Hypokalemia and hypoglycemia should be corrected. Urinary alkalinization with intravenous sodium bicarbonate can enhance the elimination of aspirin in the urine. In severe cases, hemodialysis may be necessary.
Urinary alkalinization involves targeting a urinary pH of 7.5-8.5 and checking it hourly. It is important to monitor for hypokalemia as alkalinization can cause potassium to shift from plasma into cells. Potassium levels should be checked every 1-2 hours.
In cases where the salicylate concentration is high (above 500 mg/L in adults or 350 mg/L in children), sodium bicarbonate can be administered intravenously. Hemodialysis is the treatment of choice for severe poisoning and may be indicated in cases of high salicylate levels, resistant metabolic acidosis, acute kidney injury, pulmonary edema, seizures and coma..
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 10
Correct
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You assess a 42-year-old woman who has a background of schizophrenia. She was initiated on an atypical antipsychotic drug a few months ago and has since experienced significant weight gain.
Which SPECIFIC atypical antipsychotic medication is most likely to be accountable for her weight gain?Your Answer: Clozapine
Explanation:Clozapine is the atypical antipsychotic that is most likely to result in notable weight gain. Additionally, it is linked to the emergence of impaired glucose metabolism and metabolic syndrome.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 11
Correct
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A 22-year-old arrives at the emergency department after ingesting a combination of pills 45 minutes ago following a heated dispute with their partner. The patient reports consuming approximately 30 tablets in total, consisting of four or five different types. These tablets were sourced from their grandparents medication, although the patient is uncertain about their specific names. They mention the possibility of one tablet being called bisoprolol. What is the recommended antidote for beta-blocker toxicity?
Your Answer: Glucagon
Explanation:Glucagon is the preferred initial treatment for beta-blocker poisoning when there are symptoms of slow heart rate and low blood pressure.
Further Reading:
Poisoning in the emergency department is often caused by accidental or intentional overdose of prescribed drugs. Supportive treatment is the primary approach for managing most poisonings. This includes ensuring a clear airway, proper ventilation, maintaining normal fluid levels, temperature, and blood sugar levels, correcting any abnormal blood chemistry, controlling seizures, and assessing and treating any injuries.
In addition to supportive treatment, clinicians may need to consider strategies for decontamination, elimination, and administration of antidotes. Decontamination involves removing poisons from the skin or gastrointestinal tract. This can be done through rinsing the skin or using methods such as activated charcoal, gastric lavage, induced emesis, or whole bowel irrigation. However, induced emesis is no longer commonly used, while gastric lavage and whole bowel irrigation are rarely used.
Elimination methods include urinary alkalinization, hemodialysis, and hemoperfusion. These techniques help remove toxins from the body.
Activated charcoal is a commonly used method for decontamination. It works by binding toxins in the gastrointestinal tract, preventing their absorption. It is most effective if given within one hour of ingestion. However, it is contraindicated in patients with an insecure airway due to the risk of aspiration. Activated charcoal can be used for many drugs, but it is ineffective for certain poisonings, including pesticides (organophosphates), hydrocarbons, strong acids and alkalis, alcohols (ethanol, methanol, ethylene glycol), iron, lithium, and solvents.
Antidotes are specific treatments for poisoning caused by certain drugs or toxins. For example, cyanide poisoning can be treated with dicobalt edetate, hydroxocobalamin, or sodium nitrite and sodium thiosulphate. Benzodiazepine poisoning can be treated with flumazanil, while opiate poisoning can be treated with naloxone. Other examples include protamine for heparin poisoning, vitamin K or fresh frozen plasma for warfarin poisoning, fomepizole or ethanol for methanol poisoning, and methylene blue for methemoglobinemia caused by benzocaine or nitrates.
There are many other antidotes available for different types of poisoning, and resources such as TOXBASE and the National Poisons Information Service (NPIS) can provide valuable advice on managing poisonings.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 12
Incorrect
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A 32 year old male with a previous diagnosis of depression is admitted to the emergency department following an intentional overdose of amitriptyline tablets. When would it be appropriate to start administering sodium bicarbonate?
Your Answer: Heart rate < 60 bpm
Correct Answer: QRS > 100ms on ECG
Explanation:Prolonged QRS duration is associated with an increased risk of seizures and arrhythmia. Therefore, when QRS prolongation is observed, it is recommended to consider initiating treatment with sodium bicarbonate.
Further Reading:
Tricyclic antidepressant (TCA) overdose is a common occurrence in emergency departments, with drugs like amitriptyline and dosulepin being particularly dangerous. TCAs work by inhibiting the reuptake of norepinephrine and serotonin in the central nervous system. In cases of toxicity, TCAs block various receptors, including alpha-adrenergic, histaminic, muscarinic, and serotonin receptors. This can lead to symptoms such as hypotension, altered mental state, signs of anticholinergic toxicity, and serotonin receptor effects.
TCAs primarily cause cardiac toxicity by blocking sodium and potassium channels. This can result in a slowing of the action potential, prolongation of the QRS complex, and bradycardia. However, the blockade of muscarinic receptors also leads to tachycardia in TCA overdose. QT prolongation and Torsades de Pointes can occur due to potassium channel blockade. TCAs can also have a toxic effect on the myocardium, causing decreased cardiac contractility and hypotension.
Early symptoms of TCA overdose are related to their anticholinergic properties and may include dry mouth, pyrexia, dilated pupils, agitation, sinus tachycardia, blurred vision, flushed skin, tremor, and confusion. Severe poisoning can lead to arrhythmias, seizures, metabolic acidosis, and coma. ECG changes commonly seen in TCA overdose include sinus tachycardia, widening of the QRS complex, prolongation of the QT interval, and an R/S ratio >0.7 in lead aVR.
Management of TCA overdose involves ensuring a patent airway, administering activated charcoal if ingestion occurred within 1 hour and the airway is intact, and considering gastric lavage for life-threatening cases within 1 hour of ingestion. Serial ECGs and blood gas analysis are important for monitoring. Intravenous fluids and correction of hypoxia are the first-line therapies. IV sodium bicarbonate is used to treat haemodynamic instability caused by TCA overdose, and benzodiazepines are the treatment of choice for seizure control. Other treatments that may be considered include glucagon, magnesium sulfate, and intravenous lipid emulsion.
There are certain things to avoid in TCA overdose, such as anti-arrhythmics like quinidine and flecainide, as they can prolonged depolarization.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 13
Incorrect
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A 72-year-old woman with a history of hypertension and kidney disease is prescribed spironolactone. Upon reviewing her blood test results, you observe a notable electrolyte imbalance.
Which of the following electrolyte imbalances is most likely to have occurred?Your Answer: Hypernatraemia
Correct Answer: Hyperkalaemia
Explanation:Spironolactone is a medication used to treat conditions such as congestive cardiac failure, hypertension, hepatic cirrhosis with ascites and edema, and Conn’s syndrome. It functions as a competitive aldosterone receptor antagonist, primarily working in the distal convoluted tubule. In this area, it hinders the reabsorption of sodium ions and enhances the reabsorption of potassium ions. Spironolactone is commonly known as a potassium-sparing diuretic.
The main side effect of spironolactone is hyperkalemia, particularly when renal impairment is present. In severe cases, hyperkalemia can be life-threatening. Additionally, there is a notable occurrence of gastrointestinal disturbances, with nausea and vomiting being the most common. Women may experience menstrual disturbances, while men may develop gynecomastia, both of which are attributed to the antiandrogenic effects of spironolactone.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 14
Incorrect
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A young patient has developed a tremor and is experiencing nausea and vomiting as a result of taking a prescribed medication. Additionally, the patient has developed nephrogenic diabetes insipidus.
Which of the following medications is most likely to be the cause of these symptoms?Your Answer: Desmopressin
Correct Answer: Lithium
Explanation:Lithium is a commonly prescribed medication for bipolar disorder, as it helps stabilize mood. The recommended therapeutic range for lithium levels is typically between 0.4 and 0.8 mmol/l, although this range may vary depending on the laboratory. For maintenance therapy and treatment in older individuals, the lower end of the range is usually targeted. Toxic effects of lithium are typically observed when levels exceed 1.5 mmol/l. It is important to monitor lithium levels one week after starting therapy and after any dosage adjustments.
One potential side effect of lithium is the development of nephrogenic diabetes insipidus, a condition that affects the kidneys’ ability to concentrate urine. However, lithium does not cause diabetes mellitus. Another known side effect is hypothyroidism, which is a decrease in thyroid hormone production, but it does not lead to hyperthyroidism, an overactive thyroid.
Signs of lithium toxicity include nausea, vomiting, diarrhea, tremors, ataxia (loss of coordination), confusion, increased muscle tone, clonus (repetitive, involuntary muscle contractions), nephrogenic diabetes insipidus, convulsions, coma, and renal failure. It is crucial to be aware of these symptoms and seek medical attention if they occur.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 15
Incorrect
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A 30-year-old woman is given carbamazepine for her epilepsy during her pregnancy. As a result of this medication, the newborn develops a defect.
What is the most probable defect that will occur as a result of using this drug during pregnancy?Your Answer: Persistent pulmonary hypertension of the newborn
Correct Answer: Haemorrhagic disease of the newborn
Explanation:There is an increased risk of neural tube defects in women with epilepsy who take carbamazepine during pregnancy, ranging from 2 to 10 times higher. Additionally, there is a risk of haemorrhagic disease of the newborn associated with this medication. It is crucial to have discussions about epilepsy treatments with women of childbearing age during the planning stages so that they can start early supplementation of folic acid.
Below is a list outlining the most commonly encountered drugs that have adverse effects during pregnancy:
ACE inhibitors (e.g. ramipril): If given in the second and third trimester, these medications can cause hypoperfusion, renal failure, and the oligohydramnios sequence.
Aminoglycosides (e.g. gentamicin): These drugs can lead to ototoxicity and deafness in the fetus.
Aspirin: High doses of aspirin can cause first-trimester abortions, delayed onset labor, premature closure of the fetal ductus arteriosus, and fetal kernicterus. However, low doses (e.g. 75 mg) do not pose significant risks.
Benzodiazepines (e.g. diazepam): When given late in pregnancy, these medications can result in respiratory depression and a neonatal withdrawal syndrome.
Calcium-channel blockers: If given in the first trimester, these drugs can cause phalangeal abnormalities. If given in the second and third trimesters, they can lead to fetal growth retardation.
Carbamazepine: This medication is associated with haemorrhagic disease of the newborn and neural tube defects.
Chloramphenicol: Use of this drug can cause grey baby syndrome in newborns.
Corticosteroids: If given in the first trimester, corticosteroids may cause orofacial clefts in the fetus.
Danazol: When administered in the first trimester, danazol can cause masculinization of the female fetuses genitals.
Finasteride: Pregnant women should avoid handling finasteride tablets. Crushed or broken tablets can be absorbed through the skin and affect male sex organ development in the fetus.
Haloperidol: If given in the first trimester, haloperidol may cause limb malformations. In the third trimester, there is an increased risk of extrapyramidal symptoms in the neonate.
Heparin: Use of heparin during pregnancy is associated with an acceptable bleeding rate and a low rate of thrombotic recurrence in the mother.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 16
Incorrect
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A child is brought in by their family with noticeable tremors, muscle contractions, muscle spasms, and slow movements. They have a significant history of mental health issues and are currently taking multiple medications.
Which of the following medications is most likely causing these side effects?Your Answer: Olanzapine
Correct Answer: Haloperidol
Explanation:Extrapyramidal side effects refer to drug-induced movements that encompass acute dyskinesias and dystonic reactions, tardive dyskinesia, Parkinsonism, akinesia, akathisia, and neuroleptic malignant syndrome. These side effects occur due to the blockade or depletion of dopamine in the basal ganglia, leading to a lack of dopamine that often resembles idiopathic disorders of the extrapyramidal system.
The primary culprits behind extrapyramidal side effects are the first-generation antipsychotics, which act as potent antagonists of the dopamine D2 receptor. Among these antipsychotics, haloperidol and fluphenazine are the two drugs most commonly associated with extrapyramidal side effects. On the other hand, second-generation antipsychotics like olanzapine have lower rates of adverse effects on the extrapyramidal system compared to their first-generation counterparts.
While less frequently, other medications can also contribute to extrapyramidal symptoms. These include certain antidepressants, lithium, various anticonvulsants, antiemetics, and, in rare cases, oral contraceptive agents.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 17
Incorrect
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A 65-year-old patient arrives at the hospital after an acute digoxin overdose. She is experiencing nausea and complaining of irregular heartbeats.
Which of the following is NOT a reason to administer DigiFab to this patient?Your Answer: 12 mg of digoxin ingested
Correct Answer: Prolonged seizures
Explanation:Digoxin-specific antibody (DigiFab) is an antidote used to counteract digoxin overdose. It is a purified and sterile preparation of digoxin-immune ovine Fab immunoglobulin fragments. These fragments are derived from healthy sheep that have been immunized with a digoxin derivative called digoxin-dicarboxymethoxylamine (DDMA). DDMA is a digoxin analogue that contains the essential cyclopentanoperhydrophenanthrene: lactone ring moiety coupled to keyhole limpet hemocyanin (KLH).
DigiFab has a higher affinity for digoxin compared to the affinity of digoxin for its sodium pump receptor, which is believed to be the receptor responsible for its therapeutic and toxic effects. When administered to a patient who has overdosed on digoxin, DigiFab binds to digoxin molecules, reducing the levels of free digoxin in the body. This shift in equilibrium away from binding to the receptors helps to reduce the cardiotoxic effects of digoxin. The Fab-digoxin complexes are then eliminated from the body through the kidney and reticuloendothelial system.
The indications for using DigiFab in cases of acute and chronic digoxin toxicity are summarized below:
Acute digoxin toxicity:
– Cardiac arrest
– Life-threatening arrhythmia
– Potassium level >5 mmol/l
– Ingestion of >10 mg of digoxin (in adults)
– Ingestion of >4 mg of digoxin (in children)
– Digoxin level >12 ng/mlChronic digoxin toxicity:
– Cardiac arrest
– Life-threatening arrhythmia
– Significant gastrointestinal symptoms
– Symptoms of digoxin toxicity in the presence of renal failure -
This question is part of the following fields:
- Pharmacology & Poisoning
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Question 18
Correct
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You review a 52-year-old woman who has recently been prescribed antibiotics for a urinary tract infection (UTI). She has a history of COPD and is currently taking salbutamol and Seretide inhalers and Phyllocontin Continus. Since starting the antibiotics, she has been experiencing nausea, vomiting, and abdominal pain.
Which SINGLE antibiotic is she most likely to have been prescribed for her UTI?Your Answer: Ciprofloxacin
Explanation:Phyllocontin Continus contains aminophylline, which is a combination of theophylline and ethylenediamine. It is a bronchodilator that is commonly used to manage COPD and asthma.
In this case, the woman is showing symptoms of theophylline toxicity, which may have been triggered by the antibiotic prescribed for her urinary tract infection. Quinolone antibiotics, like ciprofloxacin, can increase the concentration of theophyllines in the blood, leading to toxicity.
There are other medications that can also interact with theophyllines. These include macrolide antibiotics such as clarithromycin, allopurinol, antifungals like ketoconazole, and calcium-channel blockers such as amlodipine. It is important to be aware of these interactions to prevent any potential complications.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 19
Incorrect
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A 30-year-old man is diagnosed with a psychiatric disorder during the 3rd-trimester of his partner's pregnancy and is prescribed medication. As a result of this treatment, the newborn is born with weak muscle tone, difficulties with feeding, hypothyroidism, and an enlarged thyroid gland.
Which of the following medications is the most probable cause of these abnormalities?Your Answer: Fluoxetine
Correct Answer: Lithium
Explanation:Lithium is a medication used to stabilize mood and is approved for the treatment and prevention of mania, bipolar disorder, recurrent depression, and aggressive or self-harming behavior. During pregnancy and the postnatal period, it is important to monitor lithium levels more frequently. If taken during the first trimester, lithium is associated with an increased risk of fetal cardiac malformations, such as Ebstein’s anomaly. If taken during the second and third trimesters, there is a risk of various complications in the newborn, including hypotonia, lethargy, feeding problems, hypothyroidism, goiter, and nephrogenic diabetes insipidus.
Here is a list outlining commonly encountered drugs that have adverse effects during pregnancy:
Drug: ACE inhibitors (e.g. ramipril)
Adverse effects: If taken during the second and third trimesters, ACE inhibitors can cause hypoperfusion, renal failure, and the oligohydramnios sequence.Drug: Aminoglycosides (e.g. gentamicin)
Adverse effects: Aminoglycosides can cause ototoxicity and deafness in the fetus.Drug: Aspirin
Adverse effects: High doses of aspirin can lead to first-trimester abortions, delayed onset labor, premature closure of the fetal ductus arteriosus, and fetal kernicterus. However, low doses (e.g. 75 mg) do not pose a significant risk.Drug: Benzodiazepines (e.g. diazepam)
Adverse effects: When taken late in pregnancy, benzodiazepines can cause respiratory depression and a neonatal withdrawal syndrome.Drug: Calcium-channel blockers
Adverse effects: If taken during the first trimester, calcium-channel blockers can cause phalangeal abnormalities. If taken during the second and third trimesters, they can lead to fetal growth retardation. -
This question is part of the following fields:
- Pharmacology & Poisoning
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Question 20
Correct
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A 30-year-old woman with a history of bipolar disorder presents with a side effect from the mood stabilizer medication that she is currently taking.
Which SINGLE statement regarding the side effects of mood stabilizer drugs is FALSE?Your Answer: Dystonia tends to only appear after long-term treatment
Explanation:Extrapyramidal side effects are most commonly seen with the piperazine phenothiazines (fluphenazine, prochlorperazine, and trifluoperazine) and butyrophenones (benperidol and haloperidol). Among these, haloperidol is the most frequently implicated antipsychotic drug.
Tardive dyskinesia, which involves involuntary rhythmic movements of the tongue, face, and jaw, typically occurs after prolonged treatment or high doses. It is the most severe manifestation of extrapyramidal symptoms, as it may become irreversible even after discontinuing the causative medication, and treatment options are generally ineffective.
Dystonia, characterized by abnormal movements of the face and body, is more commonly observed in children and young adults and tends to appear after only a few doses. Acute dystonia can be managed with intravenous administration of procyclidine (5 mg) or benzatropine (2 mg) as a bolus.
Akathisia refers to an unpleasant sensation of restlessness, while akinesia refers to an inability to initiate movement.
In individuals with renal impairment, there is an increased sensitivity of the brain to antipsychotic drugs, necessitating the use of reduced doses.
Elderly patients with dementia-related psychosis who are treated with haloperidol face an elevated risk of mortality. This is believed to be due to an increased likelihood of cardiovascular events and infections such as pneumonia.
Contraindications for the use of antipsychotic drugs include reduced consciousness or coma, central nervous system depression, and the presence of phaeochromocytoma.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 21
Correct
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A 60-year-old man presents with frequent urination and excessive thirst. He has a history of bipolar affective disorder, which has been effectively managed with lithium for many years.
You schedule blood tests for him, and the results are as follows:
Na: 150 mmol/L (135-147 mmol/L)
K: 3.7 mmol/L (3.5-5.5 mmol/L)
Urea: 9.5 mmol/L (2.0-6.6 mmol/L)
Creatinine: 127 mmol/L (75-125 mmol/L)
What is the SINGLE most likely diagnosis?Your Answer: Nephrogenic diabetes insipidus
Explanation:Diabetes insipidus is a condition where the body is unable to produce concentrated urine. It is characterized by excessive thirst, increased urination, and constant need to drink fluids. There are two main types of diabetes insipidus: cranial (central) and nephrogenic.
Cranial diabetes insipidus occurs when there is a deficiency of vasopressin, also known as antidiuretic hormone. This hormone helps regulate the amount of water reabsorbed by the kidneys. In patients with cranial diabetes insipidus, urine output can be as high as 10-15 liters per day. However, with adequate fluid intake, most patients are able to maintain normal sodium levels. The causes of cranial diabetes insipidus can vary, with 30% of cases being idiopathic (unknown cause) and another 30% being secondary to head injuries. Other causes include neurosurgery, brain tumors, meningitis, granulomatous disease (such as sarcoidosis), and certain medications like naloxone and phenytoin. There is also a very rare inherited form of cranial diabetes insipidus that is associated with diabetes mellitus, optic atrophy, nerve deafness, and bladder atonia.
On the other hand, nephrogenic diabetes insipidus occurs when there is resistance to the action of vasopressin in the kidneys. Similar to cranial diabetes insipidus, urine output is significantly increased in patients with nephrogenic diabetes insipidus. Serum sodium levels can be maintained through excessive fluid intake or may be elevated. The causes of nephrogenic diabetes insipidus include chronic renal disease, metabolic disorders like hypercalcemia and hypokalemia, and certain medications like long-term use of lithium and demeclocycline.
Based on the history of long-term lithium use in this particular case, nephrogenic diabetes insipidus is the most likely diagnosis.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 22
Correct
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A 72-year-old man with a history of COPD complains of a headache, dizziness, and palpitations. He is currently taking modified-release theophylline for his COPD. You suspect theophylline toxicity and schedule a blood test to check his levels.
When should the blood sample be taken after his last oral dose?Your Answer: 4-6 hours
Explanation:In order to achieve satisfactory bronchodilation, most individuals require a plasma theophylline concentration of 10-20 mg/litre (55-110 micromol/litre). However, it is possible for a lower concentration to still be effective. Adverse effects can occur within the range of 10-20 mg/litre, and their frequency and severity increase when concentrations exceed 20 mg/litre.
To measure plasma theophylline concentration, a blood sample should be taken five days after starting oral treatment and at least three days after any dose adjustment. For modified-release preparations, the blood sample should typically be taken 4-6 hours after an oral dose (specific sampling times may vary, so it is advisable to consult local guidelines). If aminophylline is administered intravenously, a blood sample should be taken 4-6 hours after initiating treatment.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 23
Incorrect
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A 25-year-old male arrives at the emergency department with a significant laceration on his right forearm. You suggest that this can be stitched up using local anesthesia. Bupivacaine 0.5% is accessible in the suture room. What is the maximum dosage of Bupivacaine 0.5% that can be administered?
Your Answer: 7 mg/kg
Correct Answer: 2 mg/kg
Explanation:The maximum dose of adrenaline is 2 mg/kg, regardless of its concentration or addition. However, when calculating the volume requirements, the concentration of adrenaline becomes a factor.
Further Reading:
Local anaesthetics, such as lidocaine, bupivacaine, and prilocaine, are commonly used in the emergency department for topical or local infiltration to establish a field block. Lidocaine is often the first choice for field block prior to central line insertion. These anaesthetics work by blocking sodium channels, preventing the propagation of action potentials.
However, local anaesthetics can enter the systemic circulation and cause toxic side effects if administered in high doses. Clinicians must be aware of the signs and symptoms of local anaesthetic systemic toxicity (LAST) and know how to respond. Early signs of LAST include numbness around the mouth or tongue, metallic taste, dizziness, visual and auditory disturbances, disorientation, and drowsiness. If not addressed, LAST can progress to more severe symptoms such as seizures, coma, respiratory depression, and cardiovascular dysfunction.
The management of LAST is largely supportive. Immediate steps include stopping the administration of local anaesthetic, calling for help, providing 100% oxygen and securing the airway, establishing IV access, and controlling seizures with benzodiazepines or other medications. Cardiovascular status should be continuously assessed, and conventional therapies may be used to treat hypotension or arrhythmias. Intravenous lipid emulsion (intralipid) may also be considered as a treatment option.
If the patient goes into cardiac arrest, CPR should be initiated following ALS arrest algorithms, but lidocaine should not be used as an anti-arrhythmic therapy. Prolonged resuscitation may be necessary, and intravenous lipid emulsion should be administered. After the acute episode, the patient should be transferred to a clinical area with appropriate equipment and staff for further monitoring and care.
It is important to report cases of local anaesthetic toxicity to the appropriate authorities, such as the National Patient Safety Agency in the UK or the Irish Medicines Board in the Republic of Ireland. Additionally, regular clinical review should be conducted to exclude pancreatitis, as intravenous lipid emulsion can interfere with amylase or lipase assays.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 24
Correct
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A 3-year-old toddler is brought to the Emergency Department after ingesting a few of his father's ibuprofen tablets 30 minutes ago. The child is currently showing no symptoms and is stable in terms of blood flow. The attending physician recommends giving a dose of activated charcoal.
What is the appropriate dosage of activated charcoal to administer?Your Answer: 1 g/kg
Explanation:Activated charcoal is a commonly utilized substance for decontamination in cases of poisoning. Its main function is to attract and bind molecules of the ingested toxin onto its surface.
Activated charcoal is a chemically inert form of carbon. It is a fine black powder that has no odor or taste. This powder is created by subjecting carbonaceous matter to high heat, a process known as pyrolysis, and then concentrating it with a solution of zinc chloride. Through this process, the activated charcoal develops a complex network of pores, providing it with a large surface area of approximately 3,000 m2/g. This extensive surface area allows it to effectively hinder the absorption of the harmful toxin by up to 50%.
The typical dosage for adults is 50 grams, while children are usually given 1 gram per kilogram of body weight. Activated charcoal can be administered orally or through a nasogastric tube. It is crucial to administer it within one hour of ingestion, and if necessary, a second dose may be repeated after one hour.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 25
Correct
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A 70-year-old woman with a history of chronic heart failure presents to the Emergency Department with an unrelated medical condition. Upon reviewing her medications, you discover that she is taking furosemide as part of her management.
Which ONE of the following drugs should be avoided?Your Answer: Citalopram
Explanation:When furosemide and SSRI drugs are prescribed together, there is a higher chance of developing hyponatraemia, which is a condition characterized by low levels of sodium in the blood. Additionally, there is an increased risk of hypokalaemia, which can potentially lead to a dangerous heart rhythm disorder called torsades de pointes. It is important to note that co-prescribing furosemide with citalopram should be avoided due to these risks. For more information, you can refer to the section on furosemide interactions in the BNF.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 26
Correct
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A 28-year-old woman is given an antibiotic while pregnant. As a result, the newborn has teeth that are permanently stained yellow and experiences numerous dental cavities throughout their childhood.
Which of the following antibiotics is the most probable culprit for these abnormalities?Your Answer: Tetracycline
Explanation:The use of tetracyclines is not recommended during pregnancy as it can have harmful effects on the developing fetus. When taken during the second half of pregnancy, tetracyclines may lead to permanent yellow-grey discoloration of the teeth and enamel hypoplasia. Children affected by this may also be more prone to cavities. Additionally, tetracyclines have been associated with congenital defects, problems with bone growth, and liver toxicity in pregnant women.
Here is a list outlining the commonly encountered drugs that can have adverse effects during pregnancy:
ACE inhibitors (e.g. ramipril): If taken in the second and third trimesters, ACE inhibitors can cause reduced blood flow, kidney failure, and a condition called oligohydramnios.
Aminoglycosides (e.g. gentamicin): Aminoglycosides can cause ototoxicity, leading to hearing loss in the fetus.
Aspirin: High doses of aspirin can result in first trimester abortions, delayed labor, premature closure of the fetal ductus arteriosus, and a condition called fetal kernicterus. However, low doses (e.g. 75 mg) do not pose significant risks.
Benzodiazepines (e.g. diazepam): When taken late in pregnancy, benzodiazepines can cause respiratory depression in the newborn and a withdrawal syndrome.
Calcium-channel blockers: If taken in the first trimester, calcium-channel blockers can cause abnormalities in the fingers and toes. If taken in the second and third trimesters, they can lead to fetal growth retardation.
Carbamazepine: Carbamazepine has been associated with a condition called hemorrhagic disease of the newborn and an increased risk of neural tube defects.
Chloramphenicol: Chloramphenicol can cause a condition known as grey baby syndrome in newborns.
Corticosteroids: If taken in the first trimester, corticosteroids may increase the risk of orofacial clefts in the fetus.
Danazol: When taken in the first trimester, danazol can cause masculinization of the female fetuses genitals.
Finasteride: Pregnant women should avoid handling finasteride tablets as the drug can be absorbed through the skin and affect the development of male sex organs in the fetus.
Haloperidol: If taken during the first trimester, this medication may increase the risk of limb malformations. If taken during the third trimester, it can lead to an increased risk of extrapyramidal symptoms in the newborn.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 27
Correct
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A 40-year-old man is brought to the Emergency Department by his wife after taking an excessive amount of one of his prescribed medications. Upon further inquiry, you uncover that he has overdosed on quetiapine. You consult with your supervisor about the case, and she clarifies that the symptoms of this type of poisoning are caused by the blocking of central and peripheral acetylcholine receptors.
What is one of the clinical effects that arises from the blockade of central acetylcholine receptors?Your Answer: Tremor
Explanation:Anticholinergic drugs work by blocking the effects of acetylcholine, a neurotransmitter, in both the central and peripheral nervous systems. These drugs are commonly used in clinical practice and include antihistamines, typical and atypical antipsychotics, anticonvulsants, antidepressants, antispasmodics, antiemetics, antiparkinsonian agents, antimuscarinics, and certain plants. When someone ingests an anticholinergic drug, they may experience a toxidrome, which is characterized by an agitated delirium and various signs of acetylcholine receptor blockade in the central and peripheral systems.
The central effects of anticholinergic drugs result in an agitated delirium, which is marked by fluctuating mental status, confusion, restlessness, visual hallucinations, picking at objects in the air, mumbling, slurred speech, disruptive behavior, tremor, myoclonus, and in rare cases, coma or seizures. On the other hand, the peripheral effects can vary and may include dilated pupils, sinus tachycardia, dry mouth, hot and flushed skin, increased body temperature, urinary retention, and ileus.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 28
Incorrect
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A 32-year-old woman is given trimethoprim for a urinary tract infection while in her second trimester of pregnancy. As a result of this medication, the baby develops a birth defect.
What is the most probable abnormality that will occur as a result of using this drug during pregnancy?Your Answer: Premature closure of the ductus arteriosus
Correct Answer: Neural tube defect
Explanation:During the first trimester of pregnancy, the use of trimethoprim is linked to an increased risk of neural tube defects because it antagonizes folate. If it is not possible to use an alternative antibiotic, it is recommended that pregnant women taking trimethoprim also take high-dose folic acid. However, the use of trimethoprim in the second and third trimesters of pregnancy is considered safe.
Below is a list outlining the commonly encountered drugs that have adverse effects during pregnancy:
ACE inhibitors (e.g. ramipril): If given in the second and third trimesters, they can cause hypoperfusion, renal failure, and the oligohydramnios sequence.
Aminoglycosides (e.g. gentamicin): They can cause ototoxicity and deafness.
Aspirin: High doses can lead to first-trimester abortions, delayed onset labor, premature closure of the fetal ductus arteriosus, and fetal kernicterus. However, low doses (e.g. 75 mg) do not pose significant risks.
Benzodiazepines (e.g. diazepam): When given late in pregnancy, they can cause respiratory depression and a neonatal withdrawal syndrome.
Calcium-channel blockers: If given in the first trimester, they can cause phalangeal abnormalities. If given in the second and third trimesters, they can lead to fetal growth retardation.
Carbamazepine: It can cause hemorrhagic disease of the newborn and neural tube defects.
Chloramphenicol: It can cause grey baby syndrome.
Corticosteroids: If given in the first trimester, they may cause orofacial clefts.
Danazol: If given in the first trimester, it can cause masculinization of the female fetuses genitals.
Finasteride: Pregnant women should avoid handling finasteride as crushed or broken tablets can be absorbed through the skin and affect male sex organ development.
Haloperidol: If given in the first trimester, it may cause limb malformations. If given in the third trimester, there is an increased risk of extrapyramidal symptoms in the neonate.
Heparin: It can cause maternal bleeding and thrombocytopenia.
Isoniazid: It can lead to maternal liver damage and neuropathy and seizures in the neonate.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 29
Correct
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A 30-year-old woman is diagnosed with depression during the 2nd-trimester of her pregnancy and is started on fluoxetine. As a result of this treatment, the baby develops a complication.
Which of the following complications is the most likely to occur due to the use of this medication during pregnancy?Your Answer: Persistent pulmonary hypertension of the newborn
Explanation:During the third trimester of pregnancy, the use of selective serotonin reuptake inhibitors (SSRIs) has been associated with a discontinuation syndrome and persistent pulmonary hypertension of the newborn. It is important to be aware of the adverse effects of various drugs during pregnancy. For example, ACE inhibitors like ramipril, if given in the second and third trimester, can cause hypoperfusion, renal failure, and the oligohydramnios sequence. Aminoglycosides such as gentamicin can lead to ototoxicity and deafness. High doses of aspirin can result in first-trimester abortions, delayed onset labor, premature closure of the fetal ductus arteriosus, and fetal kernicterus. However, low doses (e.g., 75 mg) do not pose significant risks. Late administration of benzodiazepines like diazepam during pregnancy can cause respiratory depression and a neonatal withdrawal syndrome. Calcium-channel blockers, if given in the first trimester, may cause phalangeal abnormalities, while their use in the second and third trimester can lead to fetal growth retardation. Carbamazepine has been associated with hemorrhagic disease of the newborn and neural tube defects. Chloramphenicol can cause grey baby syndrome. Corticosteroids, if given in the first trimester, may cause orofacial clefts. Danazol, if administered in the first trimester, can result in masculinization of the female fetuses genitals. Pregnant women should avoid handling crushed or broken tablets of finasteride as it can be absorbed through the skin and affect male sex organ development. Haloperidol, if given in the first trimester, may cause limb malformations, while its use in the third trimester increases the risk of extrapyramidal symptoms in the neonate. Heparin can lead to maternal bleeding and thrombocytopenia. Isoniazid can cause maternal liver damage and neuropathy and seizures in the neonate. Isotretinoin carries a high risk of teratogenicity, including multiple congenital malformations, spontaneous abortion, and intellectual disability. The use of lithium in the first trimester increases the risk of fetal cardiac malformations, while its use in the second and third trimesters can result in hypotonia, lethargy, feeding problems, hypothyroidism, goiter, and nephrogenic diabetes insipidus.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 30
Correct
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A 42-year-old woman with a long history of anxiety presents having taken a deliberate overdose of the medication she takes for insomnia. She tells you that the medication she takes for this condition is zolpidem 10 mg. She took the medication about 2 hours ago. She is now hypotensive, with her most recent blood pressure reading being 82/56 mmHg. She weighs 70 kg.
The consultant in charge suggests that you administer a bolus dose of calcium to increase her blood pressure. Which of the following should you administer?Your Answer: 10% calcium chloride 20 mL IV
Explanation:Calcium-channel blocker overdose is a serious condition that can be life-threatening. The most dangerous types of calcium channel blockers in overdose are verapamil and diltiazem. These medications work by binding to the alpha-1 subunit of L-type calcium channels, which prevents the entry of calcium into cells. These channels are important for the functioning of cardiac myocytes, vascular smooth muscle cells, and islet beta-cells.
When managing a patient with calcium-channel blocker overdose, it is crucial to follow the standard ABC approach for resuscitation. If there is a risk of life-threatening toxicity, early intubation and ventilation should be considered. Invasive blood pressure monitoring is also necessary if hypotension and shock are developing.
The specific treatments for calcium-channel blocker overdose primarily focus on supporting the cardiovascular system. These treatments include:
1. Fluid resuscitation: Administer up to 20 mL/kg of crystalloid solution.
2. Calcium administration: This can temporarily increase blood pressure and heart rate. Options include 10% calcium gluconate (60 mL IV) or 10% calcium chloride (20 mL IV) via central venous access. Repeat boluses can be given up to three times, and a calcium infusion may be necessary to maintain serum calcium levels above 2.0 mEq/L.
3. Atropine: Consider administering 0.6 mg every 2 minutes, up to a total of 1.8 mg. However, atropine is often ineffective in these cases.
4. High dose insulin – euglycemic therapy (HIET): The use of HIET in managing cardiovascular toxicity has evolved. It used to be a last-resort measure, but early administration is now increasingly recommended. This involves giving a bolus of short-acting insulin (1 U/kg) and 50 mL of 50% glucose IV (unless there is marked hyperglycemia). Therapy should be continued with a short-acting insulin/dextrose infusion. Glucose levels should be monitored frequently, and potassium should be replaced if levels drop below 2.5 mmol/L.
5. Vasoactive infusions: Catecholamines such as dopamine, adrenaline, and/or noradrenaline can be titrated to achieve the desired inotropic and chronotropic effects.
6. Sodium bicarbonate: Consider using sodium bicarbonate in cases where a severe metabolic acidosis develops.
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This question is part of the following fields:
- Pharmacology & Poisoning
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