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Module 1: Introduction
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Module 2 : Initial Evaluation and Stabilization
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Module 3 - Diagnostic Testing
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Module 4 - Gastrointestinal Decontamination
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Module 5 - Enhanced Elimination and Extracorporeal Therapies
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Module 6 - Antidotes and Specific Treatments
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Module 7 - Disposition and Follow-Up
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Module 8: Case Studies
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Module 9 - Summary and Additional Resources
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Module 10: Approach to the Toxic Patient Feedback
Quizzes
Participants 396
This module will provide an opportunity to apply the knowledge and skills gained throughout this course through analysis of complex patient case scenarios involving poisonings and overdoses.
8.1 Case Studies
Working through challenging real-world examples will reinforce clinical decision-making, differential diagnosis, and evidence-based treatment plan development for toxicology patients.
Case 1: Unknown Ingestion in a Pediatric Patient
Initial presentation: 2 year old female brought to ED by parents after ingesting an unknown medication from grandmother’s purse. Initial vital signs concerning for tachycardia, hypertension, and dilated pupils. Parents unsure of what or how much was ingested.
Develop an initial differential diagnosis based on concerning presenting signs and symptoms. What classes of drugs or toxins could potentially cause this clinical picture?
Recommend initial diagnostic tests and labs that could help identify the substance.
Formulate a treatment plan including airway/breathing/circulation management, GI decontamination if indicated, antidotes, and supportive care.
Provide education to parents on preventative strategies to avoid future accidental pediatric ingestions.
Case 2: Acetaminophen Toxicity
Presentation: 17 year old female presenting with vomiting and abdominal pain hours after intentionally ingesting ~40 acetaminophen 500 mg tablets in a suicide attempt.
Interpret the acetaminophen levels drawn and determine if toxicity threshold has been reached.
Outline acute management including GI decontamination, antidote dosing, lab monitoring, and supportive care.
Discuss criteria for liver transplant referral in acetaminophen-induced acute liver failure.
Review psychiatric support and suicide risk assessment for this adolescent patient.
Case 3: Aspirin Toxicity
Initial presentation: 72 year old male with altered mental status and respiratory distress after being found next to an empty bottle of aspirin tablets. Vital signs show tachypnea, fever, and hypotension.
Develop a differential diagnosis for his presentation and determine likelihood that this is an aspirin overdose.
Outline your initial management priorities including airway stabilization, GI decontamination, aspirin level testing, and addressing metabolic abnormalities.
At what aspirin level would you recommend dialysis?
Discuss instructions for safe discharge and prevention of future aspirin toxicity events.
8.2 Explanations for Case Studies
Case 1:
Initial differential diagnosis could include sympathomimetic drugs, anticholinergic agents, serotonin syndrome, or unknown pediatric ingestion.
Recommended initial diagnostic tests: fingerstick glucose, electrolytes, acetaminophen level, aspirin level, blood gases, EKG, and comprehensive urine drug screen.
Treatment priorities include airway stabilization if needed, IV fluids for hypotension, activated charcoal if ingestion within 1-2 hours, benzodiazepines for hypertension and agitation. Consult poison control for guidance on possible antidotes.
Educate parents on safe medication storage up and away from children’s reach. Use child-proof lids. Keep purses/bags out of reach.
Case 2:
The acetaminophen level is 78 mcg/mL, which exceeds the toxic threshold of 50 mcg/mL at 4 hours post-ingestion.
Start IV acetylcysteine protocol for acetaminophen toxicity. Monitor liver function tests. Hydrate and correct electrolyte abnormalities. Psychiatric evaluation.
Consider liver transplant if ALT >3000 IU/L or if showing signs of hepatic encephalopathy, coagulopathy, or acidosis.
Provide suicide risk assessment, psychiatry referral, consider inpatient psych admission to ensure safety.
Case 3:
Presentation suggests salicylate toxicity. Check aspirin level, electrolytes, glucose, renal function, coagulation studies.
Priorities are airway protection, IV fluids, urinary alkalinization with sodium bicarbonate, and GI decontamination if ingestion within 2-4 hours.
Dialysis is indicated for aspirin level >100 mg/dL, renal dysfunction, pulmonary edema, or CNS symptoms.
Educate on proper aspirin dosing, interacting with provider before combining analgesics, safe storage. Consider temporary or permanent transition to alternative analgesics.