tox

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What are some of the core toxicology topics that every ED physician/student should study up on? I know that opiate, aspirin, and tricyclic overdoses are pretty common. What about things like pesticides or heavy metals?

According to the 2007 EM model of Clinical Practice of Emergency Medicine, the following topics within Toxicology are considered the baseline expected knowledge of Emergency Physicians / Residents.

Analgesics (acetaminophen, NSAIDs, Opiates, Salicylates), Alcohols (ethanol, ethylene glycol, isopropanol, methanol), Anesthetics, Anticholinergics & cholinergics, anticoagulants, anticonvulsants, antidepressants, antiparkinsonism drugs, antihistamines & antiemetics, antipsychotics, bronchodilators, carbon monoxide, cardiovascular drugs (beta blockers and calcium channel blockers, digoxin, antihypertensives), caustic ingestions (alkali & acids), cocaine, cyanide, hydrogen sulfide, hallucinogens, heavy metals, herbicides, insecticides, rodenticides, household chemicals / cleaners, steroids, hydrocarbons, hypoglycemics / insulin, iron, isoniazid, marine envenomations, methemoglobinemia, mushrooms, neuroleptics, organophosphates, sedative hypnotic drugs, stimulants & sympathomimmetics, strychnine, and lithium.

With that said, as a medical student, start with opiates, cholinergics & anticholinergics, acetaminophen, alcohols, cardiovascular drugs (especially digoxin, calcium channel blockers and beta blockers), iron, cyanide, illicit drugs, methemoglobinemia, insulin, and carbon monoxide. There will always be more that you can know, but knowing these is an exceptional foundation I think.

Cheers,
TL

Originally Posted by reedman

What are some of the core toxicology topics that every ED physician/student should study up on?

Do you mean for a test or do you mean for actual practice. I'll give two very different answers depending on what you are looking for.

Originally Posted by reedman

What are some of the core toxicology topics that every ED physician/student should study up on? I know that opiate, aspirin, and tricyclic overdoses are pretty common. What about things like pesticides or heavy metals?

Doesn't CDEM have some online modules?

As far as I know, there isn't any widely distributed "standard" tox curriculum out there. That being said, if all goes well, we (a hodgepodge of random ppl) might make one available via SAEM in a year. We'll see how it goes.

If not, start with understanding the test characteristics and utility of the standard urine drug screen. Even some senior EM residents that have rotated with us have a poor understanding of it. If you know its test characteristics, I guarantee that you'll make some intern(s) look foolish at some point on your rotations.

Well, I guess I'm mostly interested in real applications, but exam related stuff is great too.

dlung: can you elaborate on "understanding test characteristics"? Anything specific?

I guess I should ask: what are some of the most common toxicology cases?

The standard urine drug screen isn't exactly testing for what it says. You have to understand what the drug screen is testing to determine what sort of validity the test has in your patient. Is that positive on the PCP actually angel dust, or is it dextrometorphan? Is the negative on the opioids because the patient takes an opioid that metabolizes through a different intermediate then what the UDS tests for? Does the positive on cocaine mean that the patient's tachycardia is a result of acute intoxication?

These reasons and more are why the UDS isn't highly valued by emergency physicians for diagnosing altered mental status. On the other hand, becoming familiar with toxidromes is extremely useful. Using absent bowel sounds to diagnose TCA toxicity makes you look like a stud.

Originally Posted by reedman

Well, I guess I'm mostly interested in real applications, but exam related stuff is great too.

Tests tend to focus on testable material. Classic questions are are something like: A patient presents with tachycardia, large pupils, dry mouth, absent bowels sound and then show an ECG. What is the most appropriate treatment?

Real life is never this clean. Many real patients present with multiple drug ingestions. The patient rarely has a single acute ingestion of acetaminophen, at a known time, with no other co-ingestents.

In real life, you have to know the common meds that are prescribed in your area for your population. I see lots of atypical antipsychotics and they can look an awful lot like an opiate, for example. Knowing the commonly prescribed psychiatric meds is a great place to start.

Knowing some of the more common, potentially fatal medication, presentation and treatment is a good idea. Depending on your area, it might be a good idea to know the common venomous creatures.

It is also useful to know the management and presentation and differences in treatment of some of the sub-acute/chronic overdoses, such as acetaminophen, aspirin, digoxin, and lithium. Theophylline is a classic, but less common.

I'm sure I could go on, but there is plenty to know and limited time.

There's some great stuff on this threat! Thank you. In the core 3rd year EM rotation at my school tox wasn't stressed AT ALL on the exam or in lectures, and as a result nobody studied for it or paid it much mind. I think I'll brush up however going into my sub-I. Seems like a cool topic and one that takes quite a bit of art to diagnosis and become comfortable with.