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Toxicologie clinica

curs nr. 3

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DIAGNOSTICUL INTOXICATIILOR ACUTE

ISTORIC:

EXPUNEREA UNDE, CAND, DE CE , CAT ?

MARTORI AI 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

150/min

DISRITMII: SOLVENTI, FENOL, FLUOROACETAT

TULBURARI DE CONDUCERE: DINITROFENOL, As,P, OP, CARBAMATI, Li, CO, CN, H2S,CLORALHIDRAT, ANTIDEP.TRICICLICE, CHINIDIN,FENOTIAZINE, SUCCINILCOLINA, COCAINA,

DIGITALICE, -BLOCANTE, TEOFILINA,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

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

A. CENTRALLOCUS COERULEUS- scade tonus simpatic central

1. agonisti : CLONIDINA

2. receptori opiacei: MORFINA, HEROINA

3. coma profunda: DEPRIMANTE, BARBITURICE,BENZODIAZEPINE, ETANOL

4. hemoragia pontina

B. EFECTE PE REC. PERIFERICI5. blocare: PRAZOSIN, FENOTIAZINE

6. anticolinesterazice: CARBAMATI, OF, FENCICLIDINA

7. stimulare muscarinica: AMANITA MUSCARIA C . EFECTE GANGLIONARE

8. stimulare nicotinica: NICOTINA

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COMPUSI MIOTICI

D. EFECTE LOCALE: PILOCARPINAMIOTICE

DIVERSE: BROMURA

CAI REZISTENTE LA AGRESIUNEA TOXICO-METABOLICA

CONSERVAREA RASPUNSULUI FOTO-MOTOR(DIAGNOSTIC DIFERENTIAL CU COMA STRUCTURALA)

EXCEPTIE: ANTICOLINERGICE, GLUTETIMIDA

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MIDRIAZA MEDICAMENTOASAANTICOLINERGICE:

Atropina Cocaina Pralidoxima

Ciclopentolat Etanol Chinina

Glicopirolat Etoclorovinal Rezerpina

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 FLUORURI

BENZEN 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 orale

CBr4 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, EACindometacin, fenilbutazona

aminoglicozide, cefalosporine

HEMATURIE: cefalosporine, peniciline,

ciclofosfamida

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COMPUSI care genereazaFEBRAAMFOTERICINA B ocazional

ANTIHISTAMINICE ALOPURINOLBARBITURICE CEFALOSPORINE

BLEOMICINA CIMETIDINA

METILDOPA DERIV. COCAINA

PENICILINE HIDRALAZINAFENITOINA IZONIAZIDA

PROCAINAMIDA IODURI

CHINIDINA NITROFURANTOIN

SALICILATI PASSULFONAMIDE RIFAMPICIN

STREPTOMICINA STREPTOKINAZA

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MECANISME TOXICE HIPERTERMIZANTE1. INTERFERENTA CU METABOLISMUL OXIDATIV: SALICILATI,

DINITROFENOL, SDR. INTRERUPERE, H. TIROIDIENI2. CRESTEREA RIGIDITATII MUSCULARE: STRICNINA,

FENCICLIDINA3. HIPERACTIVITATE: AMFETAMINE, LSD, COCAINA,

FENCICLIDINA, MESCALINA, IMAO, GLUTETIMIDA, TRICICLICE4. IMPIEDICAREA TRANSPIRATIEI: ANTICOLINERGICE,

ANTIHISTAMINICE, ADT, FENOTIAZINE5. HIPERTERMIA MALIGNA: RAR ASOCIERE HALOTAN SUSCINILCOLINA

6. 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 NARCOTICE

NARCOTICE MORFINICE MONOXID CARBON

BARBITURICE INSULINA(hipoglicemie)

CLORALHIDRAT GLUTETIMIDA

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TULBURARI DIGESTIVE TOXICE

FIER

MERCUR

LITIU

FOSFOR ARSENIC

CIUPERCI

TEOFILINA VOMA, 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, TRIAMTERENALBASTRU-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

RASPUNSMOTOR

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 pDEZORIENTAT 4 p

CUVINTE INADECVATE 3 p

SUNETE ININTELIGIBILE 2 p

FARA RASPUNS 1 p

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SCALA COME REEDGrad Nivel

constientaRaspuns

verbal

Raspunsdurere

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 METABOLICA

a) INGESTIE b) EXCRETIEPRODUCTIE PIERDERE ALCALINA

Hiatus anionic normal= [Na+]-([HCO3-]+ [Cl-])=12 mEq/l

Hiatus anionic toxic = acumulare de acizi organiciACID 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 + BUN18 2,8

VALOARE > 10 Mosm = anormal

MANITOL ETANOL

GLICEROL CLOROFORM

SORBITOL METANOL

ETILENGLICOL IZONIAZIDA

PARALDEHIDA ACETONA

TRICLORETAN ETER

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Exemple TOXIDROAMEmai frecvent intalnite

TOXIDROM SIMPTOME COMPUSIIMPLICATI

COLINERGICMUSCARINIC

relaxare sfincteriana,colici, hipersecretie

bronsica,bronhospasmbradicardie, hTA,emeza, mioza,lacrimatie, salivatie

acetilcolina,pilocarpina,

Amanitamuscaria,carbamati,organofosforice

COLINERGICNICOTINIC tahicardie, HTA,fasciculatii musculare,

paralizii musc. striata

nicotina,anticolinesterazice, vaduvaneagra

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Exemple TOXIDROAMEmai frecvent intalnite

TOXIDROM SIMPTOME COMPUSIIMPLICATI

ANTICOLI

NERGICtahicardie, piele si mucoaserosii si uscate, sete, disfagie,

midriaza, retentie, delir,halucinatii, insuf.respiratorie

alcaloizi din

belladona,

antihistaminice, antidepresive triciclice

NARCOTIC

(opioid)deprimare centrala, hTA,

deprimarea centruluiresp,hipoventilatie, mioza

morfina,heroina,codeina,pentazocina

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Exemple TOXIDROAMEmai frecvent intalnite

TOXIDROM SIMPTOME COMPUSIIMPLICATI

SINDROMINTRERUPERE

midriaza, diaree,tahicardie,lacrimatie, colici,halucinatii

alcool,barbiturice,benzodiazepine,opiacee,cloralhidrat

SIMPATOMIMETIC agitatie, convulsii,halucinatii,

tremuraturi,tahicardie, HTA,diaforeza,hiperreflexie

cocaina,amfetamine,

teofilina, cofeina

fenciclidina

LSD