Clinical Toxicology Laboratory

Prepared by: Junabeth B. Cervantes RPh, MSPH

Experiment 1:
Assessment of
Poisoning
Group Number:
Name of Members:
Caser, Mia Jane
Diaz, Alvin
Jacinto, Riza
Magbanua, Czariana Cassidy
Panaga, Fanny Lois
Tadena, Mari-mar
Tanguilan, Heywardley

Part 1: Case Study number 1:

A 26-year-old female medical student with a history of diabetes was brought to the ER
complaining of whiteness in her vision. She exclaimed that she had drank 1 bottle of mineral
water during her afternoon laboratory class. On admission, she had irregular rapid respirations
at 31 beats/min, BP is 170/110 mmHg, and pulse at 114 beats/min. Laboratory values indicated
acidosis and high blood methanol concentration.

I. Vital Signs of the Patient

VITAL SIGNS NORMAL VALUES ACTUAL VALUES

A. Blood pressure 120/80 mmHg 170/110 mmHg

B. Pulse Rate 60 - 100 beats/min 114 beats/min.

C. Heart Rate 60 - 100 beats/min N/A

D. Body Temperature 36℃ - 37 ℃ N/A

E. Breathing 12 - 20 breath/min 31 beats/min

II. Assessment

VARIABLES INFORMATION

A. Substance Swallowed Mineral water contaminated with methanol

B. Amount 1 bottle
Clinical Toxicology Laboratory
Prepared by: Junabeth B. Cervantes RPh, MSPH

C. Time In the afternoon

D. Symptoms Whiteness in her vision

E. Age of the Patient 26 years old

Diabetes
G. Previous Medical History (PMH)
Clinical Toxicology Laboratory
Prepared by: Junabeth B. Cervantes RPh, MSPH
Part 2: Research
a. Provide examples of drugs/toxins that manifest the following conditions:

SIGNS AND SYMPTOMS DRUGS AND TOXINS

A. COMA AND STUPOR COMA

Drugs: propofol, pentobarbital and thiopental
Toxins: carbon monoxide and lead

STUPOR
Drugs: poppy, opium and it's derivatives
(morphine, codeine, heroin) or synthetic
substitutes (meperidine, methadone).
Toxins: carbon monoxide

B. HYPOTHERMIA Drugs: propofol; opiates such as fentanyl and

morphine; midazolam; neuromuscular blocking
agents such as vecuronium and rocuronium;
and other drugs such as phenytoin

Toxins: ethanol, phenothiazines, barbiturates,

antidepressants and organophosphate, induce
hypothermia, and some, such as
amphetamines, methamphetamine, MDMA
(“ecstasy”), cocaine, salicylates, lithium, anti-
cholinergics and monoamine oxidase inhibitors,
induce hyperthermia
C. HYPERTHERMIA Drugs: dantrolene (Dantrium, Revonto,
Ryanodex)

Toxins: Lethal catatonia (which can develop

over weeks), central nervous system lesions or
infections, and tetanus.
D. SEIZURES Drugs: Lamotrigine (Lamictal), Gabapentin
(Neurontin), Levetiracetam (Keppra, Spritam),
Phenytoin (Dilantin), Zonisamide (Zonegran),
Carbamazepine (Tegretol), Oxcarbazepine
(Trileptal), Valproic acid derivatives,
Topiramate (Topamax), Phenobarbital

Toxins: Pesticides like parathion and carbaryl

as well as chemical weapons like sarin and VX
that hyperstimulate cholinergic receptors and
promote excitatory neurotransmission. After
being exposed to excitatory amino acid toxins
like the marine toxin domoic acid, glutamatergic
hyperstimulation can happen.
Clinical Toxicology Laboratory
Prepared by: Junabeth B. Cervantes RPh, MSPH

E. AGITATION, DELIRIUM AND AGITATION

CONFUSION Drugs: The most popular treatments for acute
agitation are haloperidol and lorazepam
because they work well across a broad
spectrum of diagnoses and can be given to
individuals with compromised health.
Significant extrapyramidal symptoms are one of
haloperidol's more uncommon side effects,
along with abrupt death and heart arrhythmia.

Toxins: selective serotonin reuptake inhibitors

(SSRIs), levodopa, mefloquine, efavirenz, etc.

DELIRIUM
Drugs: Haloperidol is the most frequently
prescribed typical antipsychotic, whereas
olanzapine, quetiapine, risperidone, and (most
recently) aripiprazole are the most frequently
used atypical antipsychotics for delirium.
cardiac arrhythmia and sudden death.

Toxins: carbon monoxide poisoning, mushroom

toxins, and organophosphorus insecticides

CONFUSION
Drugs: carbon monoxide poisoning, mushroom
toxins, and organophosphorus insecticides

Toxins:Medicines for bladder control problems

(anticholinergics)
F. HYPOXIA Drugs: Nitric oxide, almitrine, inhaled
prostacyclin, and cyclooxygenase inhibitors are
new medications that enhance arterial
oxygenation and are helpful in treating severe
hypoxemia that is resistant to traditional
treatment and is typically present in patients
with acute respiratory distress syndrome
(ARDS).

Toxins: Histotoxic hypoxia is the outcome of

tissue poisoning, which can be brought on by
substances like cyanide (which works by
blocking cytochrome oxidase) and some
other toxins like hydrogen sulfide (a waste
product used in leather tanning) (ARDS).
G. BRADYCARDIA OR AV BLOCK Drugs: Octreotide, Esmolol, Betaxolol,
Metoprolol, Atenolol, Diltiazem, Timolol,
Digoxin, Bendroflumethiazide and Sotalo
Clinical Toxicology Laboratory
Prepared by: Junabeth B. Cervantes RPh, MSPH
Toxins: sarin (a very deadly chemical weapon),
phosgene, and many others
Common insecticides, specific halogenated
chemical substances, and significant cyanide
concentrations (typically as a combustion result
in fires)

H. TACHYCARDIA Drugs: Anagrelide, Aspirin and Oxycodone,

Chlordiazepoxide and Clidinium Bromide,
Dothiepin, Ephedrine, Epinephrine,
Epoprostenol, Glyceryl Trinitrate and
Moclobemide

Toxins: Organophosphate pesticides and

Aluminum phosphide
I. HYPERTENSION Drugs: Acetaminophen, Venlafaxine,
Bupropion, Desipramine, Corticosteroids,
Mineralocorticoids, Tyrosine kinase inhibitors,
Monoclonal antibodies, Phentermine and
Migraine medicines

Toxins: Hypertension has also been linked to

persistent alcohol use and exposure to metals
like lead, mercury, and arsenic.
J. HYPOTENSION Drugs:Furosemide, Hydrochlorothiazide,
Prazosin, Atenolol, Propranolol, Pramipexole,
Levodopa and Doxepin

Toxins:
Grayanotoxin, Aconitine, Mesaconitine and
Hypaconitine
K. VENTILATORY FAILURE Drugs: nitrofurantoin and sulfa drugs,
amiodarone, bleomycin, cyclophosphamide,
and methotrexate

Toxins: Hydrogencyanide, Carbon monoxide,

Ammonia, Carbon dioxide, Aldehydes, Sulfur
dioxides and Nitrogen dioxid e
L. MIOSIS Fentanyl
Atropine, Lysergic acid diethylaminde
M. MYDRIASIS
Serotonin reuptake inhibitors (citalopram)
N. SWEATING
Vasodilator (nitroglycerin) (nitroglycerin)
O. FLUSHED RED SKIN

P. ANAPHYLACTIC REACTION Non-SteroidaL Anti-inflammatory Drugs, Proton

Pump Inhibitors (PPIs), Antibiotic
Clinical Toxicology Laboratory
Prepared by: Junabeth B. Cervantes RPh, MSPH
b. Guided Questions for learning:
1. Give the significance of getting the patients' vital signs.

 Vital signs can be used to spot or track medical issues. They choose which
therapy protocols to implement, give vital details required to make life-saving
choices, and verify patient comments on therapies received.

2. Give the importance of each of the following in evaluating the cause of poisoning.

a. Patient’s history
 Knowing the patient's background can help determine whether past
poisoning experiences may have contributed to suicide ideation.

b. Analytical protocol
 By using various laboratory procedures like blood tests, urinalysis,
fecalysis, and others, analytical protocols are utilized to identify or confirm
the type of toxicant or toxin that the patient ingested or came into contact
with.

c. Parents and relative information

 The patient's parents or other family members may know something about
what transpired to the patient because the patient is unconscious and cannot
be questioned or examined by medical personnel. Also, they may be
knowledgeable of the patient's allergies or other genetic details that can be
used to treat the patient.

3. Differentiate acute from chronic intoxication, systemic from non-systemic

effects, and reversible from irreversible toxic effects.

 A single, brief exposure constitutes acute toxicity. Effects typically occur quickly
and are reversible.
 Exposure that occurs repeatedly over a long period of time causes chronic
toxicity. Effects can be long-lasting but are frequently gradual and delaying.
 It's not systemic if it doesn't affect the entire body.
 Systemic refers to effects that manifest in tissues that have previously been
exposed to absorption.
 When an effect is reversible, the damaged tissue can go back to its initial
biological state when the exposure has ended.
 Reversibility may be tissue- or excretion-related, dose-dependent, or both.
Examples of irreversible impacts include harm to the central nervous system
(CNS) and the development of a tumor cell.

4. What are the minimum requirements for setting up a clinical unit to treat acute
poisoning
Clinical Toxicology Laboratory
Prepared by: Junabeth B. Cervantes RPh, MSPH

The following minimum standards must be met before a clinical unit may be established to treat
acute poisoning:
 Methods, tools, and locations must be accessible for resuscitation, decontamination,
and the initial management of poisoning patients.
 With a poison information center, there are effective communications.
 Well defined procedures for treating the most typical types of acute poisoning
 Antidotes are available in quantities that correspond to the frequency of the primary
poisoning kinds.
 Facilities for conventional biological analyses and toxicological screening in
laboratories
 Access to patient emergency transportation
 An emergency strategy to handle catastrophes and significant chemical occurrences.
 A CTU service should be situated as a separate unit within an advanced
multifunctional hospital and within or close to the PICC in order to operate at its best.
 It should be well equipped to provide prolonged life support, stabilize vital signs,
correct acid-base, fluid, and electrolyte irregularities, and remove toxins, including
dialysis and hemoperfusion.

5. Differentiate: Intoxication from Poisoning and Overdose.

 When a foreign substance interacts with a live creature, it can injure or damage it,
resulting in intoxication. As an example, acute ethanol ingestion may result in
intoxication, which can immediately result in death.
 Overdosing is defined as "excessive consumption" or "a intentional or accidental dose
of a substance that is in excess of what is typically taken"

REFERENCES:
https://accesspharmacy.mhmedical.com/content.aspx?
sectionid=39910803&bookid=449#:~:text=The%20primary%20goal%20of
%20taking,extent%20and%20time%20of%20exposure.
https://www.meridian.edu/importance-taking-vital-signs-medical-assisting-guide/
https://www.baylor.edu/ehs/index.php?id=92236#:~:text=Acute%20toxicity%20results
%20from%20a,gradual%2C%20and%20may%20be%20irreversible.
https://app.croneri.co.uk/topics/toxicology/indepth#:~:text=A%20reversible%20effect
%20is%20one,are%20examples%20of%20irreversible%20effects.
http://repository.iifphc.org/bitstream/handle/123456789/1014/Guideline%20for
%20Poison%20Control%20Center%20June%202017.pdf?sequence=1&isAllowed=y