curs 3 diagnostic
TRANSCRIPT
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Toxicologie clinica
curs nr. 3
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DIAGNOSTICUL INTOXICATIILOR ACUTE
•ISTORIC:
–EXPUNEREA –UNDE, CAND, DE CE , CAT ?
–MARTORIAI EVENIMENTULUI;
CONTAINER
–SIMPTOME-dupa ingestie pana laprezentarea la spital; ex: VOMA, DISPNEE,
TUSE, MODIFICARI DE CONSTIENTA,CONVULSII
–CE TERAPIE S-A EFECTUAT
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•EXAMEN FIZIC
–ALTERAREA –STATUSULUI MENTAL -PARAMETRI
–SIMPTOMATOLOGIA RELEVANTA TOXIDROAME
–ALTE SIMPTOME FIZICE
–COME TOXICE – PARTICULARITATI
•DIAGNOSTICUL DE LABORATOR
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Simptome relevante pt. dg. toxicologic
•HIPER TERMIE
•HIPOTERMIA
•HIPOTENSIUNE
•HIPERTENSIUNEA
•BRADICARDIA
•TAHICARDIA
•DELIR, PSIHOZA
•COMA
•CONVULSII
•MIOZA
•MIDRIAZA
•NISTAGMUS
•NEVRITA OPTICA
•HEMORAGIERETINIANA
•OFTALMOPLEGIA
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Simptome relevante pt. dg. toxicologic
•PIELE: CIANOZA, ERITEM, DIAFOREZA,ACNEE, PIELE USCATA
•TULBURARI DE GUST SI MIROS
•RABDOMIOLIZA
•SIMPT. MUSCULARE
•NEUROPATIE PERIFERICA
•HEPATOTOXICITATE•NEFROTOXICITATE
•SIMPT. PULMONARE
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HIPOTENSIUNEA
•ASOCIATA SAU NU CU HIPOPERFUZIE TISULARA
DEPRIMAREA CONSTIENTEI
VASOCONSTRICTIE PERIFERICA
ACIDOZA METABOLICA
OLIGURIE
•MECANISMELE HIPOPERFUZIEI
↓ PRESARCINA: NITRITI, NITRATI
HIPOVOLEMIE: METALE GRELE, COLCHICINA, INTOX ALIMEN
↑ POSTSARCINA
↓ CONTRACTILITATEA: CLONIDINA, BARBITURICE,
ALTE HIPNOTICE, NARCOTICE, ANTIDEPRESIVE TRICICLICE
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60/min
↑↓ FRECVENTA CARDIACA DEBIT CARDIAC↓
10/min
DISRITMII: SOLVENTI, !ENOL, !LUOROACETAT
TULBURARI DE CONDUCERE: DINITRO!ENOL, A", P,OP, CARBAMATI, Li, CO, CN, H#S, CLORALHIDRAT,ANTIDEP$TRICICLICE, CHINIDIN, !ENOTIA%INE,SUCCINILCOLINA, COCAINA, DIGITALICE, &'
BLOCANTE, TEO!ILINA, HIDANTOINA,VERAPAMIL
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ARITMIA CARDIACA DE ORIGINE TOXICA
•ANTID. TRICICLICE•CHININA
•FENOTIAZINE
•CLOROCHIN
•MONOXID CARBON
•CLORALHIDRAT
•CIANURI
•FENOL•COCAINA
•ARSENIC•DIGITALICE
•DINITROFENOL
•CALCIU BLOCANTE
•FLUOROACETAT
• β BLOCANTE
•SUCCINILCOLINA
•CLONIDINA•ETANOL
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COMPUSI CONVULSIVANTI
•Ag CONTRAST iodati
•AC. NALIDIXIC
•ORGANOFOSFORICE
•STRICNINA
•ANTIHISTAMINICE
•ANTIDEPRESIVE
•ANTIPSIHOTICE
•Ag HIPOGLICEMIANTI
•OXIGEN HIPERBAR
•IZONIAZIDA
•COCAINA
•CO, Pb, Li
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NEUROPATII TOXICE
•NEUROPATIE SENZORIALAETIONAMIDA
•PARESTEZIISTREPTOMICIN
ACID NALIDIXIC
•NEUROPATIE MIXTA (S-M)
IZONIAZIDA ETAMBUTOL
–PREDOMINANT MOTOR
SULFAMIDE•NEVRITA OPTICA
METANOL, ARSENIC ORGANIC, ETAMBUTOL,
HIN, Pb, SULFAMIDE
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COMPUSI MIOTICI
•D. EFECTE LOCALE:PILOCARPINA
MIOTICE
•DIVERSE: BROMURA
CAI REZISTENTE LA AGRESIUNEA TOXICO-METABOLICA
CONSERVAREA RASPUNSULUI FOTO-MOTOR (DIAGNOSTICDIFERENTIAL CU COMA STRUCTURALA)
EXCEPTIE: ANTICOLINERGICE, GLUTETIMIDA
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MIDRIAZA MEDICAMENTOASA
ANTICOLINERGICE:Atropina Cocaina Pralidoxima
Ciclopentolat Etanol Chinina
Glicopirolat EtoclorovinalRezerpina
Antihistaminice Eter Succinimide
Aminofilina Glutetimid Efedrina
Bariu (compusi) LSD Adrenalina
Carbamazepina Mescalina FenilefrinaCimetidina Nicotina Antidepresive tricic
Barbiturice (coma)Fenitoina Amfetamine
Fenfluramida
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MIDRIAZA TOXICA
ACONITINA FLUORURIBENZEN FLUOROACETAT
TOXINA BOTULINICA LOBELINA
CAMFOR ALCOOL METILIC
DIOXID CARBON BROMURA de METIL
MONOXID CARBON PSILOCIBINA
CLOROFORM SOLAMINA
CIANURI TALIU
BROMURA de ETIL TOLUEN
ETILENGLICOL
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HEPATOTOXICE(exemple)
INDUSTRIALE MEDICAMENTE(doze terapeutice)
BENZEN NARCOTICE
• HALOTAN
BROMOFORM HIPOGLICEMIANTE oraleCBr4 ANTIMICROBIENE
• HIN, RIFAMPICINA
CCL4 PARACETAMOL
CLOROFORM
ETANOL
HIDRAZINA
TETRACLORETAN
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NEFROTOXICE(exemple) INDUSTRIALE MEDICAMENTE (doze terap)METALE: Pb, Cr, As, Cd, Bi, Fe,
Ag, Mn, Be
PROTEINURIE: penicilina, EDTA,
captopril
SOLVENTI: metanol,
tricloretan, CCl4, metilceluloza
TUB PROXIMAL: salicilati,
aminoglicozide
TETRACLORETAN NECROZA PAPILARA: analgezice
ALTE SUBSTANTE NEFRITA INTERSTITIALA
sulfamide
TOXICE DIN MEDIU:
• Ciuperci, CO
INSUF. RENALA ACUTA
analgezice, aspirina, EAC
indometacin, fenilbutazona
aminoglicozide, cefalosporineHEMATURIE: cefalosporine, peniciline,
ciclofosfamida
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COMPUSI care genereaza FEBRAAMFOTERICINA B ocazional
ANTIHISTAMINICE ALOPURINOL
BARBITURICE CEFALOSPORINE
BLEOMICINA CIMETIDINA
METILDOPA DERIV. COCAINAPENICILINE HIDRALAZINA
FENITOINA IZONIAZIDA
PROCAINAMIDA IODURI
CHINIDINA NITROFURANTOINSALICILATI PAS
SULFONAMIDE RIFAMPICIN
STREPTOMICINA STREPTOKINAZA
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MECANISME TOXICE HIPERTERMIZANTE
1. INTERFERENTA CU METABOLISMUL OXIDATIV: SALICILATI,DINITROFENOL, SDR. INTRERUPERE, H. TIROIDIENI
2. CRESTEREA RIGIDITATII MUSCULARE: STRICNINA,FENCICLIDINA
3. HIPERACTIVITATE: AMFETAMINE, LSD, COCAINA,FENCICLIDINA, MESCALINA, IMAO, GLUTETIMIDA, TRICICLICE
4. IMPIEDICAREA TRANSPIRATIEI: ANTICOLINERGICE,
ANTIHISTAMINICE, ADT, FENOTIAZINE5. HIPERTERMIA MALIGNA: RAR – ASOCIERE HALOTAN –
SUSCINILCOLINA6. SDR. NEUROLEPTIC MALIGN: RAR, TERAPIA CU :
FENOTIAZINE, BUTIROFENONE, Li, TIOXANTENI, INTRERUPEREL-DOPA
-hiperpirexie- hipertonie musculara- instabilitate vegetativa- constienta fluctuanta- fara corelatie cu durata sau doza
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HIPERTERMIA MALIGNA
• DEFECT CONGENITAL– DELANSARE : NARCOTICE (uzual)– DEBUT LENT RAPID– EVOLUTIE DRAMATICA: 39 – 40 C 50 % PREDISPOZITIE /CPK↑
• MEDICAMENTOASA• SDR. NEUROLEPTIC MALIGN• NARCOTICE INHALATORII:
• ENFLURAN, ETER ETILIC, FLUOREXEN,HALOTAN,
• IZOFLURAN, METOXIFLURAN, TRICLORETILEN
• RELAXANTE MUSCULARE (CURARIZANTE)• DECAMETONIU, D-TUBOCURARINA,SUCCINILCOLINA
• CAUZE ASOCIATE• STRESS (EMOTIONAL, FIZIC)
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HIPOTERMIA
•REZISTENTA VASCULARA PERIFERICA CRESCUTA
•INDEX CARDIAC SCAZUT
ETANOL NARCOTICENARCOTICE MORFINICEMONOXID CARBON
BARBITURICE INSULINA(hipoglicemie)
CLORALHIDRAT GLUTETIMIDA
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TULBURARI DIGESTIVE TOXICE
•FIER
•MERCUR
•LITIU
•FOSFOR•ARSENIC
•CIUPERCI
•TEOFILINAVOMA, DIAREE SAU AMBELE
•COLCHICINA HEMORAGIE (Fe)
•FLUORURI OP
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MIROSURI SPECIFICE PTR. UNELE TOXICE
MIROS AGENT POTENTIAL sau circumstanta
ACETONA Alcool etilic, izopropilic, cloroform, cetoacidoza
ACRID (PERE) Cloralhidrat, paraldehida
AMONIACAL Uremie
MIGDALE Cianuri
OUA ALTERATE Hidrogen sulfurat, mercaptani, disulfiram
PESTE Insuficienta hepatica, fosfura de zinc
USTUROI Fosfor, telur, arsen, paration, malation, seleniu,
DMSO, taliuTUTUN Nicotina
PERE Salicilat de metil
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COMPUSI CARE COLOREAZA URINA
CULOARE AGENT POTENTIAL
GALBEN CHINACRINA, VITAMINA B2
GALBEN-ORANGE FLUORESCEINA
ORANGE-ROSU RIFAMPICINA
ROZ FENOTIAZINE, FENITOINA
ROSU DEFEROXAMINA, METILDOPA, FENITOINA
ROSU-PURPURIU FENACETINA
MARON L-DOPA, METRONIDAZOL, NITROFURANTOINA
ALBASTRU ALBASTRU DE METILEN, TRIAMTEREN
ALBASTRU-VERZUI AMITRIPTILINA
VERDE INDOMETACIN
NEGRU FIER, METILDOPA, CHININA
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COMA• PENTRU DIAGNOSTICUL TOXICOLOGIC: NESPECIFIC
• DEBUT RAPID: CIANURI, HIDROGEN SULFURAT,MONOXID CARBON, OPIACEE, BARBITURICE
• NIVEL FLUCTUANT AL CONSTIENTEI: FENCICLIDINA,GLUTETIMIDA
• SUBSTANTE DEPRIMANTE:– ETANOL, METANOL, ISOPROPANOL
– SEDATIV-HIPNOTICE
– BENZODIAZEPINE
– ANTICOLINERGICE (delir)
– ANTICONVULSIVANTE (FENITOIN, ACID VALPROIC)
– ANTIDEPRESIVE (IMAO, TRICICLICE)
– ANTIHISTAMINICE (DIFENHIDRAMINA)
– BARBITURICE
– BROMURI
– OPIACEE
– TRANCHILIZANTE: minore, majore
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SCALA GLASGOW pentru COME (3 – 15 p)
OCHII
DESCHISI SPONTAN 4 p
LA COMANDA VERBALA 3p
LA DURERE 2 p
FARA RASPUNS 1 p
RASPUNS
MOTOR
COMANDA VERBALA RASPUNS 6 p
STIMUL –LOCALIZARE 5 pDUREROS - FLEXIE 4 p
- EXT. DECORTICARE 3 p
- EXT.DECEREBRARE 2 p
- FARA RASPUNS 1 p
RASPUNS
VERBAL
COERENT 5 p
DEZORIENTAT 4 p
CUVINTE INADECVATE 3 p
SUNETE ININTELIGIBILE 2 p
FARA RASPUNS 1 p
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SCALA COME REED
Grad Nivelconstienta RaspunsverbalRaspunsdurere Reflex Respiratie Circulatie
0 stuporos pozitiv pozitiv intact normal normal
I comatos negativ pozitiv intact normal normal
II comatos negativ negativ intact normal normal
III comatos negativ negativ absent normal normal
IV comatos negativ negativ absent cianoza soc
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HIATUS ANIONIC
• ACIDOZA METABOLICAa) INGESTIE b) EXCRETIE
PRODUCTIE PIERDERE ALCALINA
Hiatus anionic normal=[Na+]-([HCO3-]+ [Cl-])=12 mEq/l
Hiatus anionic toxic = acumulare de acizi organici ACID LACTIC (CO, CN-, HIN, Fe) ACID FORMIC
ETANOL PARALDEHIDATOLUEN FIER
METANOL IZONIAZIDAUREMIA ACIDOZA LACTICACETOACIDOZA ETILENGLICOLSALICILATI STRICNINA
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HIATUS ANIONIC
•ACIDOZA LACTICA TOXICA:
COMPUSI HIPOTENSORI
COMPUSI CONVULSIVANTI DEPRIMANTE RESPIRATORII
COMPUSI HEPATOTOXICI
COMPUSI NEFROTOXICI
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HIATUS OSMOLAL
•Hiatus osmolal= osmolalitate masurata-osmolalitate calculata
•Osmol. calculata = 2[Na+] + glucoza +BUN 18 2,8
• VALOARE > 10 Mosm = anormal
MANITOL ETANOL
GLICEROL CLOROFORM
SORBITOL METANOLETILENGLICOL IZONIAZIDA
PARALDEHIDA ACETONA
TRICLORETAN ETER
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ExempleTOXIDROAME mai frecvent intalnite
TOXIDROM SIMPTOME COMPUSI IMPLICATI
COLINERGICMUSCARINIC
relaxare sfincteriana,
colici, hipersecretie
bronsica,bronhospasm bradicardie, hTA,
emeza, mioza,
lacrimatie, salivatie
acetilcolina,
pilocarpina,
Amanitamuscaria,
carbamati,
organofosforiceCOLINERGICNICOTINIC
tahicardie, HTA,fasciculatii musculare,
paralizii musc. striata
nicotina,anticolinesteraz
ice, “vaduva
neagra”
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ExempleTOXIDROAME mai frecvent intalnite
TOXIDROM SIMPTOME COMPUSI IMPLICATI
ANTICOLI
NERGIC
tahicardie, piele si mucoase
rosii si uscate, sete, disfagie,
midriaza, retentie, delir,
halucinatii, insuf.
respiratorie
alcaloizi din
belladona,
antihistamini
ce, antidepre
sive tricicliceNARCOTIC
(opioid) deprimare centrala, hTA,deprimarea centrului
resp,hipoventilatie, mioza
morfina,heroina,
codeina,
pentazocina
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ExempleTOXIDROAME mai frecvent intalnite
TOXIDROM SIMPTOME COMPUSI IMPLICATI
SINDROM
INTRERUPEREmidriaza, diaree,
tahicardie,
lacrimatie, colici,halucinatii
alcool,
barbiturice,
benzodiazepine,opiacee,
cloralhidratSIMPATOMIMETIC agitatie, convulsii,
halucinatii,tremuraturi,
tahicardie, HTA,
diaforeza,
hiperreflexie
cocaina,
amfetamine,teofilina, cofeina
fenciclidina
LSD