Pharmacology/Toxicology
Case Studies (60 case studies, each includes multiple
Qns followed by a detailed explanation.
+60 Case Studies
+ Each case includes
multiple questions
followed by a detailed
explanation
PHARMACOLOGY/TOXICOLOGY CASE STUDY #1
History: A 14-year-old female is brought to your emergency department by
her parents after she admitted to ingesting a total of ten, 250
milligram amoxicillin tablets four hours ago after an argument at
home that resulted in loss of her phone privileges. Her parents are
concerned that she was trying to kill herself. She denies any co-
ingestion and has no symptoms. There are no other prescription
medications in the home.
PMH:
None. Physical
Examination:
T: 99°F HR: 100 bpm RR: 16 breaths per minute BP: 100/70
mm Hg General: The patient is tearful, but otherwise in no
distress.
, The remainder of the physical exam is completely normal.
QUESTIONS CASE STUDY #4
• What testing, if any, should be obtained?
• Should activated charcoal be administered?
• Are there other treatments that should be considered?
CASE STUDY #1: GENERAL APPROACH TO TOXIC INGESTIONS
• Acetaminophen levels should be obtained in all cases of reported or
suspected poisoning, regardless of history and physical exam.
Acetaminophen is readily available and patients can initially present
without signs or symptoms even with toxic levels. Dose history should not
be used to make management decisions because studies have found no
correlation between the amount of acetaminophen reportedly ingested
and the serum concentration measured. The patient’s four hour
acetaminophen level in this patient was 85 ug/mL. A pregnancy test
should be performed in all females of childbearing age, as women may
attempt suicide due to an unwanted pregnancy.
The role of routine urine drug screening in the evaluation of patients
presenting to the emergency department with psychiatric-related
complaints is controversial. ACEP’s Clinical Policy: Critical Issues in the
Diagnosis and Management of the Adult Psychiatric Patient in the
Emergency Department, published in January 2006, makes a level C
recommendation that routine urine screening for drugs of abuse in alert,
awake, cooperative patients does not affect ED management and need
not be performed as part of the ED assessment. Often, this testing is
requested by the receiving psychiatric facility for admission purposes,
long-term care planning or diagnosis. In these cases, it may be
reasonable to obtain this testing in the emergency department; however
this testing should not delay patient evaluation or transfer. These
recommendations relate to the management of adult psychiatric patients;
pediatric patients are excluded.
• Previously, activated charcoal was not routinely recommended in
treatment of ingestions that occurred greater than one hour prior to
presentation; however newer data regarding acetaminophen ingestions
suggests that the half-life of this drug in the stomach is markedly
increased in overdose settings and that there may be some therapeutic
benefit to its administration past the traditional one hour mark. Other
, circumstances that may warrant charcoal administration past the one
hour mark include massive overdoses, poisoning with sustained release
preparations and ingestion of agents that slow gastrointestinal motility. or
acetaminophen, activated charcoal may offer some benefit when used up
to four hours post ingestion.
• The patient does not require treatment with N-acetylcysteine because her
four hour acetaminophen level falls below the toxicity line on the Rumack-
Matthew nomogram. Based on recommendations from the American
Academy of Clinical Toxicology, this patient does not meet criteria for
gastric lavage as she meets neither of two criteria for this intervention:
ingestion of a potentially life- threatening amount of a poison and
presentation within 60 minutes of ingestion. For similar reasons, this
patient will not benefit from whole bowel irrigation. Home administration of
ipecac syrup is no longer recommended by the American Academy of
Pediatrics and its routine use in the emergency department is
discouraged by the American Academy of Clinical Toxicology.
PHARMACOLOGY/TOXICOLOGY CASE STUDY #2
History: A 40-year-old male presents to your emergency department after
falling into a vat of chromic acid. The patient arrives via EMS with
a dry cough and is actively vomiting. He is complaining of chest
pain and shortness of breath.
PMH: Asthma.
Medications: Albuterol inhaler as needed.
Physical Examination:
T: 98.6°F HR: 115 bpm RR: 29 breaths per minute BP: 176/94
mm Hg General: He is
awake and alert.
HEENT: Normal.
Pulmonary: Diffuse wheezing, poor air exchange.
CV: Tachycardic, regular rhythm without murmur, normal
perfusion. Extremities: Diffuse skin ulcers in exposed areas.
QUESTIONS CASE STUDY #2
• What would be your initial approach to this patient?
2 What complications may be associated with this type of exposure?
, 3. What therapy is indicated?
CASE STUDY #2: CHROMIC ACID EXPOSURE
• Decontamination should accompany stabilization of the airway,
breathing and circulation. The patient should have all clothing removed
and copious aqueous irrigation performed.
• Chromic acid is a strong acid that contains the hexavalent (CrVI 3), or most
hazardous, form of chromium. Acute skin exposure may cause burns and
chronic exposure may result in skin and nasal ulcer formation. These skin
ulcers are round or oval growths with reddish edges and necrotic centers
and are often referred to as “chrome holes” or “chrome sores”. Chromic
acid inhalation may be associated with upper respiratory irritation and
bronchospasm, manifested by cough, chest pain and dyspnea. Pulmonary
congestion visible on radiographs, interstitial pneumonia and delayed,
non-cardiogenic edema have been reported. Systemic effects include
renal failure secondary to acute renal tubular acidosis, hemolysis and liver
damage.
• Initially, the focus should be decontamination, including removal of
contaminated clothing and a deluge, or heavy downpour safety shower.
Fluid and electrolyte balance should be maintained, especially in the case
of large skin and mucosal lesions which can lead to significant fluid
losses. The efficacy of activated charcoal has not been demonstrated.
Ascorbic acid (vitamin C) has been recommended for cases of ingestion
and skin exposure to reduce absorption of chromium by oxidizing it from
the hexavalent to trivalent form, which does not cross cell membranes as
rapidly. This intervention must be performed within two hours of exposure.
Beta agonist therapy is indicated for bronchospasm. Patients should be
observed for the development of renal failure, non-cardiogenic pulmonary
edema and liver failure. Hemodialysis, exchange transfusion and
chelation therapy are ineffective.
The Poison Control Center should be called for advice on antidotes and
for assistance with management of poisoning/exposure to unfamiliar
chemicals.
Prevention of exposure to chromium, particularly respiratory exposure, is
critical as chromium has a demonstrated carcinogenic potential.
PHARMACOLOGY/TOXICOLOGY CASE STUDY #3
History: A 30-year-old white male presents to your emergency department
after ingesting “white powder” from a bag that was given to him
Case Studies (60 case studies, each includes multiple
Qns followed by a detailed explanation.
+60 Case Studies
+ Each case includes
multiple questions
followed by a detailed
explanation
PHARMACOLOGY/TOXICOLOGY CASE STUDY #1
History: A 14-year-old female is brought to your emergency department by
her parents after she admitted to ingesting a total of ten, 250
milligram amoxicillin tablets four hours ago after an argument at
home that resulted in loss of her phone privileges. Her parents are
concerned that she was trying to kill herself. She denies any co-
ingestion and has no symptoms. There are no other prescription
medications in the home.
PMH:
None. Physical
Examination:
T: 99°F HR: 100 bpm RR: 16 breaths per minute BP: 100/70
mm Hg General: The patient is tearful, but otherwise in no
distress.
, The remainder of the physical exam is completely normal.
QUESTIONS CASE STUDY #4
• What testing, if any, should be obtained?
• Should activated charcoal be administered?
• Are there other treatments that should be considered?
CASE STUDY #1: GENERAL APPROACH TO TOXIC INGESTIONS
• Acetaminophen levels should be obtained in all cases of reported or
suspected poisoning, regardless of history and physical exam.
Acetaminophen is readily available and patients can initially present
without signs or symptoms even with toxic levels. Dose history should not
be used to make management decisions because studies have found no
correlation between the amount of acetaminophen reportedly ingested
and the serum concentration measured. The patient’s four hour
acetaminophen level in this patient was 85 ug/mL. A pregnancy test
should be performed in all females of childbearing age, as women may
attempt suicide due to an unwanted pregnancy.
The role of routine urine drug screening in the evaluation of patients
presenting to the emergency department with psychiatric-related
complaints is controversial. ACEP’s Clinical Policy: Critical Issues in the
Diagnosis and Management of the Adult Psychiatric Patient in the
Emergency Department, published in January 2006, makes a level C
recommendation that routine urine screening for drugs of abuse in alert,
awake, cooperative patients does not affect ED management and need
not be performed as part of the ED assessment. Often, this testing is
requested by the receiving psychiatric facility for admission purposes,
long-term care planning or diagnosis. In these cases, it may be
reasonable to obtain this testing in the emergency department; however
this testing should not delay patient evaluation or transfer. These
recommendations relate to the management of adult psychiatric patients;
pediatric patients are excluded.
• Previously, activated charcoal was not routinely recommended in
treatment of ingestions that occurred greater than one hour prior to
presentation; however newer data regarding acetaminophen ingestions
suggests that the half-life of this drug in the stomach is markedly
increased in overdose settings and that there may be some therapeutic
benefit to its administration past the traditional one hour mark. Other
, circumstances that may warrant charcoal administration past the one
hour mark include massive overdoses, poisoning with sustained release
preparations and ingestion of agents that slow gastrointestinal motility. or
acetaminophen, activated charcoal may offer some benefit when used up
to four hours post ingestion.
• The patient does not require treatment with N-acetylcysteine because her
four hour acetaminophen level falls below the toxicity line on the Rumack-
Matthew nomogram. Based on recommendations from the American
Academy of Clinical Toxicology, this patient does not meet criteria for
gastric lavage as she meets neither of two criteria for this intervention:
ingestion of a potentially life- threatening amount of a poison and
presentation within 60 minutes of ingestion. For similar reasons, this
patient will not benefit from whole bowel irrigation. Home administration of
ipecac syrup is no longer recommended by the American Academy of
Pediatrics and its routine use in the emergency department is
discouraged by the American Academy of Clinical Toxicology.
PHARMACOLOGY/TOXICOLOGY CASE STUDY #2
History: A 40-year-old male presents to your emergency department after
falling into a vat of chromic acid. The patient arrives via EMS with
a dry cough and is actively vomiting. He is complaining of chest
pain and shortness of breath.
PMH: Asthma.
Medications: Albuterol inhaler as needed.
Physical Examination:
T: 98.6°F HR: 115 bpm RR: 29 breaths per minute BP: 176/94
mm Hg General: He is
awake and alert.
HEENT: Normal.
Pulmonary: Diffuse wheezing, poor air exchange.
CV: Tachycardic, regular rhythm without murmur, normal
perfusion. Extremities: Diffuse skin ulcers in exposed areas.
QUESTIONS CASE STUDY #2
• What would be your initial approach to this patient?
2 What complications may be associated with this type of exposure?
, 3. What therapy is indicated?
CASE STUDY #2: CHROMIC ACID EXPOSURE
• Decontamination should accompany stabilization of the airway,
breathing and circulation. The patient should have all clothing removed
and copious aqueous irrigation performed.
• Chromic acid is a strong acid that contains the hexavalent (CrVI 3), or most
hazardous, form of chromium. Acute skin exposure may cause burns and
chronic exposure may result in skin and nasal ulcer formation. These skin
ulcers are round or oval growths with reddish edges and necrotic centers
and are often referred to as “chrome holes” or “chrome sores”. Chromic
acid inhalation may be associated with upper respiratory irritation and
bronchospasm, manifested by cough, chest pain and dyspnea. Pulmonary
congestion visible on radiographs, interstitial pneumonia and delayed,
non-cardiogenic edema have been reported. Systemic effects include
renal failure secondary to acute renal tubular acidosis, hemolysis and liver
damage.
• Initially, the focus should be decontamination, including removal of
contaminated clothing and a deluge, or heavy downpour safety shower.
Fluid and electrolyte balance should be maintained, especially in the case
of large skin and mucosal lesions which can lead to significant fluid
losses. The efficacy of activated charcoal has not been demonstrated.
Ascorbic acid (vitamin C) has been recommended for cases of ingestion
and skin exposure to reduce absorption of chromium by oxidizing it from
the hexavalent to trivalent form, which does not cross cell membranes as
rapidly. This intervention must be performed within two hours of exposure.
Beta agonist therapy is indicated for bronchospasm. Patients should be
observed for the development of renal failure, non-cardiogenic pulmonary
edema and liver failure. Hemodialysis, exchange transfusion and
chelation therapy are ineffective.
The Poison Control Center should be called for advice on antidotes and
for assistance with management of poisoning/exposure to unfamiliar
chemicals.
Prevention of exposure to chromium, particularly respiratory exposure, is
critical as chromium has a demonstrated carcinogenic potential.
PHARMACOLOGY/TOXICOLOGY CASE STUDY #3
History: A 30-year-old white male presents to your emergency department
after ingesting “white powder” from a bag that was given to him
