Question 1

A 43-year-old woman is brought to the emergency room after a suicide attempt. An empty bottle of bupropion was found at her side. Upon arrival at the emergency department, she has a seizure that lasts approximately 2 minutes. Her mental status never returns to normal, and she has a second seizure 5 minutes later. Her blood glucose level is checked and is normal.

Please choose the single most appropriate answer to the question

1. Phenytoin 20 mg/kg IV
   
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2. Lorazepam 2 mg IV
   
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   Key Concept/Objective: To know the acute treatment of a drug-induced seizure

   
   

   Treatment of seizures includes taking immediate steps to protect the airway and provide oxygen while administering anticonvulsant drugs. The blood glucose level should be determined and dextrose administered if needed. Initial anticonvulsant therapy consists of diazepam (5 to 10 mg IV), lorazepam (1 to 2 mg IV), or midazolam (3 to 5 mg IV or, if IV access is not immediately available, 5 to 10 mg IM). Repeated doses are given if the initial therapy is ineffective. Because it is often ineffective, phenytoin is not a first-line anticonvulsant agent for drug- or toxin-induced seizures. If convulsions persist, phenobarbital should be administered at a dosage of 15 to 20 mg/kg (1 to 1.5 g) IV over 20 to 30 minutes. In fact, phenobarbital has been shown to be more effective at preventing sympathomimetic-induced seizures than diazepam. Propofol, with both g-aminobutyric acid GABA agonist and N-methyl-D-aspartate antagonist properties, has been effective in controlling seizures refractory to benzodiazepines and barbiturates in both drug overdose­induced status epilepticus and refractory withdrawal syndromes (ethanol,g-hydroxybutyrate).
   
   

   
   
   
3. Phenobarbital 15 mg/kg IV
   
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4. Propofol 2 mg/kg IV
   
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Question 2

A 66-year-old man is brought to the emergency department by his wife. She reports that he accidentally took an extra dose of each of his medications about 3 hours ago. His medications are aspirin, metoprolol, and fluvastatin. Physical examination reveals a somnolent man with a heart rate of 33 bpm and a blood pressure of 75/30 mm Hg. He is treated with intravenous fluids (IV), activated charcoal, and a cathartic agent.

Please choose the single most appropriate answer to the question

1. Dopamine
   
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2. Isoproterenol
   
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3. Glucagon
   
   This is correct.
   
   

   Key Concept/Objective: To understand the treatment of the cardiovascular effects of beta-blocker toxicity

   
   

   Treatment of overdose with a beta blocker includes aggressive gut decontamination. In cases of a large or recent ingestion, gastric lavage and the administration of activated charcoal and a cathartic agent should be initiated. Hypotension and bradycardia are unlikely to respond to beta-adrenergic­mediated agents such as dopamine and isoproterenol; instead, the patient should receive high dosages of glucagon (5 to 10 mg IV followed by 5 to 10 mg/hr). Glucagon is a potent inotropic agent that does not require beta-adrenergic receptors to activate cells. When glucagon fails, an epinephrine drip may be more beneficial in increasing heart rate and contractility than isoproterenol or dopamine. If pharmacologic therapy is unsuccessful, transvenous or external pacing should be used to maintain heart rate.
   
   

   
   
   
4. Digoxin
   
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Question 3

You are asked to evaluate a 55-year-old man with G6PD deficiency who developed acute onset of shortness of breath after receiving topical benzocaine prior to an endoscopy. Physical examination reveals a mildly cyanotic man who is tachypneic and tachycardic. Pulse oximetry reveals an oxygen saturation of 82%.

Please choose the single most appropriate answer to the question

1. Methemoglobin level
   
   This is correct.
   
   

   Key Concept/Objective: To know the presentation and diagnosis of methemoglobinemia

   
   

   Methemoglobin is an oxidized form of hemoglobin that is incapable of carrying and delivering oxygen normally. A number of oxidant drugs and chemicals can convert hemoglobin to its oxidized form, causing methemoglobinemia. Benzocaine-containing sprays used for topical anesthesia before certain procedures (e.g., endoscopy, intubation, and nasogastric lavage) are a common cause of methemoglobinemia. Persons with glucose-6-phosphate dehydrogenase (G6PD) deficiency and congenital methemoglobin reductase deficiency are more likely than persons without these conditions to accumulate methemoglobin after exposure to an oxidant. Although pulse oximetry is abnormal, the reported drop in oxygen saturation does not correlate with the actual reduction in oxyhemoglobin saturation, and specific testing for methemoglobinemia should be performed. Mild methemoglobinemia (methemoglobin levels < 15 to 20%) usually resolves spontaneously and requires no treatment. Patients who have more severe intoxication should be given the antidote methylene blue (1 to 2 mg/kg IV [0.1 to 0.2 mL/kg of a 1% solution] over several minutes).
   
   

   
   
   
2. Carboxyhemoglobin level
   
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3. Acetaminophen level
   
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4. Venous oxygen saturation
   
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Question 4

A 72-year-old woman with rheumatoid arthritis is brought to the emergency department by her daughter. The patient's daughter reports that her mother has been having more joint pain for the last 2 days, and this morning, she took an extra dose of oxycodone. She then became confused, prompting her daughter to bring her to the emergency department. Physical examination reveals an elderly woman who is somnolent and difficult to arouse. Her heart rate and blood pressure are stable, but she is only breathing 8 times per minute. Her pupils are 1 mm in diameter and symmetric.

Please choose the single most appropriate answer to the question

1. Intravenous flumazenil
   
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2. Intravenous fomepizole
   
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3. Transvenous cardiac pacemaker
   
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4. Intravenous naloxone
   
   This is correct.
   
   

   Key Concept/Objective: To understand the management of patients with suspected opioid overdose

   
   

   If signs of recent opioid use (e.g., suspicious-looking pill bottles or IV drug paraphernalia) are in evidence or if the patient has clinical manifestations of excessive opioid effect (e.g., miosis or respiratory depression), the administration of naloxone may have both therapeutic and diagnostic value. Naloxone is a specific opioid antagonist with no intrinsic opioid-agonist effects. Initially, a dose of 0.2 to 0.4 mg IV should be administered; if there is no response, repeated doses of up to 4 to 5 mg should be given. Failure to respond to naloxone suggests that (1) the diagnosis is incorrect; (2) other, nonopioid drugs may have been ingested; (3) a hypoxic insult may have occurred before the victim was found and resuscitated; or (4) an inadequate dose of naloxone was given. Flumazenil is a short-acting benzodiazepine receptor antagonist that can rapidly reverse coma caused by diazepam and other benzodiazepines. Additionally, flumazenil has been found to reverse zolpidem and nonbenzodiazepine hypnotic drugs that act at benzodiazepine receptors (zolpidem and other analogues, e.g., zolpiclone are actually called imidazopyridines) induced sedation and (in cases of massive overdose) respiratory depression. Despite these effects, it has not found a place in the routine management of unconscious patients with drug overdose, because it has the potential to cause seizures in patients who have been consuming large quantities of benzodiazepines on a long-term basis or who have ingested an acute overdose of benzodiazepines and a tricyclic antidepressant or another potentially proconvulsant drug.