The toxicity of cadmium and resulting hazards for human health. In industry, arsenic is primarily used in the production of glass and semiconductors. Her medications include amphetamine, desipramine, intranasal ipratropium, and diphenhydramine as needed. Acute and chronic arsenic toxicity. Crossgrove J, Zheng W. Manganese toxicity upon overexposure. 30. A 66-year-old man presents to his primary care physician with abdominal pain in the setting of progressively worsening constipation. His temperature is 100°F (37.8°C), blood pressure is 114/64 mmHg, pulse is 120/min, respirations are 21/min, and oxygen saturation is 98% on room air. 17. Toxic metals have many industrial purposes and therefore represent occupational hazards for a number of professions. [10] Dimercaprol competes with the thiol groups for binding the metal ion, which is then excreted in the urine. A 65-year-old man arrives to the emergency department (ED) complaining of pain and swelling in his right leg. A-Aldrich Mees line (Nail) R-Raindrop pigmentation Reinsch Test (Gutzeit test used nowadays) Rashes(fading measles rashes) Red velvety mucosa(Postmortem finding) S-Subendocardial hemorrhage(Postmortem finding) E-Excess pigmentation and keratosis (Palms and soles) N-Neuritis Toxicity of lead: a review with recent updates. Rafati-Rahimzadeh M, Rafati-Rahimzadeh M, Kazemi S, Moghadamnia A. Cadmium toxicity and treatment: An update. A mother presents to the family physician with her 16-year-old son. Please enable JavaScript in your browser settings and reload this page to access AMBOSS. Lead Poisoning and Health Fact Sheet. In: Tarabar A. Arsenic is found in Insecticides and Pesticides. USMLE® & other trade marks belong to their respective owners, read full disclaimer USMLE Forums created under Creative Commons 3.0 License. Lead toxicity: a review. Seven days later the patient arrives back to the ED complaining of crushing substernal chest pain. Labs return with the following values: Na 140, K 4, Cl 106, BUN 8, Cr 2. Find quick answers in 1,000+ articles covering all important clinical subjects, Augment your understanding with videos, interactive images, flowcharts, calculators, and illustrations, Ace your next exam with 5,000+ USMLE-style multiple choice questions in our Qbank, Identify knowledge gaps with our complex learning analysis. 1. Chronic exposure to heavy metals generally manifests first as, , contaminated water (esp. Which of the following is the most likely intoxication? Arterial blood gas shows a pH of 7.29 and pCO2 of 28. Upon physical exam, the patient is agitated and grabbing at the air. Which of the following is the most appropriate next step in management? Abdominal X-ray is shown in Figure A. Figure A shows his retina on ophthalmologic exam. Agency for Toxic Substances and Disease Registry, CDC. Arsenic is mainly encountered occupationally in the smelting of zinc and copper ores. (M2.PH.17.4733) 23. On arrival, his temperature is 99°F (37.2°C), blood pressure is 135/82 mmHg, pulse is 88/minute, and oxygen saturation is 99% O2. What is the most likely cause of his symptoms? Pb neurotoxicity: Neuropsychological effects of lead toxicity. The boyfriend also reports that the patient recently received a negative evaluation at work and that she has been stressed. Which of the following can be administered intravenously to treat this patient in addition to intravenous fluids, thiamine, vitamin B12 and folate? A 5-year-old boy is brought to the emergency room lapsing in and out of consciousness. In order to be able to post messages on the USMLE Forums forums, you must first register. Tested Concept, Type in at least one full word to see suggestions list. Dimercaprol, also called British anti-Lewisite (BAL), is a medication used to treat acute poisoning by arsenic, mercury, gold, and lead. She mentions that her son ingested some supplements after confusing them for candy. Childhood Lead Poisoning: Management. He states he was working on his car when his car battery sprayed a chemical on his face and eye. Powerful learning and clinical decision support tools combined into one platform. Which of the following is the most appropriate next step in management? [6] It is also used as an antidote to the chemical weapon Lewisite. Arsenic also leads to an increase in oxidative stress and can lead to multi-system organ failure. What USMLE books you really think are useful. | STEP 2 CK A 55-year-old man presents to the emergency department with a concern of having sprayed a chemical in his eye. Rev Environ Contam Toxicol 110: 75-115, Mückter H, Liebl B, Reichl FX et al. 6. Warniment C, Tsang VK, Galazka VS. Lead poisoning in children. Dimercaprol is most effective when used within 1 or 2 hours after a sudden poisoning. Which of the following may account for these symptoms? Effect of succimer on growth of preschool children with moderate blood lead levels. Washington State Department of Health. On exam, the patient's vitals are: T: 36 deg C, HR: 65 bpm, BP: 100/66, RR: 4, SaO2: 96%. the only liquid which contains lead that i can think of is gasoline... its arsenic. Urine and serum toxicology are pending. Dietary selenium's protective effects against methylmercury toxicity. Upon further questioning, he relates that he has been taking three of his wife's multivitamins each day for the past three weeks to "combat a cold." His temperature is 97.6°F (36.4°C), blood pressure is 104/64 mmHg, pulse is 130/min, respirations are 19/min, and oxygen saturation is 98% on room air. Her parents came home to their daughter like this while she was at home being watched by the babysitter. Although treatment with dimercaprol will increase the excretion of cadmium, there is a concomitant increase in renal cadmium concentration, so that its use in case of cadmium toxicity is to be avoided. [3] Dimercaprol works by binding with heavy metals. Diagnosis of arsenic poisoning is made by determining inorganic and organic levels of arsenic in the blood and urine. Tested Concept, (M1.PH.15.75) Used for aluminum poisoning in renal failure, Used in iron overload with repeat transfusions (thalssemia), Avoid in patients who have penicillin allergy, Used in conjunction with EDTA for lead poisoning, garlic odor, cardiovascular instability, Mees lines, CO binds with much greater affinity than O. Cyanide found in rodenticides "gopher goitter", Initial management: N-acetylcysteine, charcoal, and acetaminophen level, First sign of OD is hyperventilation and respiratory alkalosis, First check an EKG for QRS prolongation, then treat with sodium bicarbonate in TCA overdose, Eliminates amphetamines by acidifying urine which results in a charged amphetamine molecule which is excreted, Removed contaminated clothing if patient was exposed to insectisides, Atropine as an anti-cholinergic and combats the excess Ach, Pralidoxime if given in a timely manner regenerates acetylcholinesterase reversing the condition (timing is critical), Do not give if patient may have TCA OD as it may lead to heart block or asystole, Tertiary amine that can cross the blood brain barrier and reverse anticholinergic effects in the CNS, Toxidrome: hot as a hare, dry as a bone, full as a flask, blind as a bat, red as a beet, and mad as a hatter, Precipitates withdrawal symptoms in chronic opioid users, Use in patients with respiratory depression, Opioid withdrawal will NOT kill a patient it is just unpleasant, May cause seizures in addicted benzodiazepine users, Rarely used with benzodiazepine overdose unless concerned for respiratory depression, Otherwise let the patient "sleep off" the benzodiazepines, Glucagon, insulin, dextrose, calcium, lipid emulsion, and epinephrine are antidote, Visual and GI symptoms classically seen in overdose, Bridge with heparin as warfarin can deplete protein C and S first (anticoagulants) leading to an initial prothrombotic state, Protamine is a highly positively charged peptide which strongly binds to the negatively charged heparin, substance is said to be sweet and individual appears "drunk without the typical smell of alcohol", Fomepizole should be followed by dialysis, Could perhaps use small amount of diluent, Crotaline envenomation (rattlesnake bite), Small parallel bite marks that ooze suggest envenomation, Most deaths due to iron poisoning (ingestion of iron tablets) occur in children between 12 - 24 months of age, Symptoms occur within 30 min to several hours, an apparent recovery may happen from 6 - 12 hours, If not treated early, damage to the stomach, can lead to pyloric stenosis or gastric scarring, Early treatment with deferoxamine can reduce mortality significantly from 45% to 1%, Mechanism of action of iron related damage, iron overdose results in the peroxidation of membrane lipids leading to cell death, uncouples oxidative metabolism => anaerobic metabolism => lactic acidosis, metabolized by ADH to formaldehyde followed by aldehyde dehydrogenase to form, formic acid which is toxic to the optic nerve, early toxicity of formic acid is metabolic acidosis by formic acid itself, formic acid also binds to cytochrome oxidase blocking oxidative phosphorylation, resulting in lactic acidosis which is the latter and leading cause of the metabolic acidosis, methanol acts similarly as ethanol as a CNS depressant, blindness occurs with as little as 30 mL and death at 100 mL ingestion, colorless, odorless, sweet-tasting liquid, toxicity derives from the hepatic oxidation of ethylene glycol to glycolic and oxalic acid, the glycolic acid produced by aldehyde dehydrogenase is converted in oxalic acid, oxalic acid binds calcium and forms calcium oxalate crystals that damage the heart, brain, lungs, kidneys, signs and symptoms develop in stages after ingestion, stronger inebriant than methanol and ethanol causing mild depression of CNS resulting in seizures and coma, within 4 - 12 hours, calcium oxalate crystals deposit in the brain causing CNS toxicity, cerebral edema, meningismus (nuchal rigidity, photophobia, headache without infection or inflammation), hypocalcemia occurs due to binding of calcium by oxalic acid and can cause prolonged QT, arrhythmias, myocardial depression, tachypnea occurs to offset the metabolic acidosis due to the toxic metabolites produced, multiorgan failure (CHF, lung injury, myositis) due to widespread crystal deposition, NOTE: most deaths occur in the second stage, acute anuric renal failure from crystal deposition but full recovery occurs within weeks to months, competitive substrate for ADH and has greater affinity for ADH than methanol and ethylene glycol, inhibits ADH preventing production of toxic metabolites, common in alcoholics who have ran out of alcohol, found in rubbing alcohol, disinfectants, and hand sanitizers, profoundly intoxicated (much more stuporous/ataxic than ethanol), nausea, vomiting, and abdominal pain (from gastritis), osmolar gap without an anion gap acidosis, When behavioral changes are recognized in adolescents screen for substance use, Calcium, epinephrine, insulin, dextrose, and glucagon, Toxicology medications can be broken down into the following categories, Anabolic properties (used by bodybuilders), Agitation, bradycardia, respiratory depression, pinpoint pupils, somnolence, amnesia, and 6-8 hour duration of symptoms, Calcium channel blockers (verapamil and diltiazem), Similar toxidrome with miosis, bradycardia, hypotension, and somnolence, Solvent for phenytoin, diazepam/lorazepam, nitroglycerin, Cardiovascular collapse (bradycardia, hypotension, vasodilation, increased vagal tone), Hyperkalemia, hypocalcemia, hypomagnesemia, toxic appearance, nausea/vomiting, and elevated liver enzymes with stigmata of liver failure, peppery/bitter fish taste when consuming tuna, mahi mahi, herring, and mackerel, GI (vomiting, diarrhea, and abdominal pain), neurologic (perioral paresthesias, pruritus, metallic taste, painful dentition, sensation that teeth are loose, temperature related dysesthesias, and blurry vision), cardiac (bradycardia, heart block, and hypotension).