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  <head>
    <title>059-02 Toxicokinetics, pattern recognition, antidotal logic, and environmental emergencies</title>
    <ownerName>Integrated Medical Foundations</ownerName>
  </head>
  <body>
    <outline text="Toxicokinetics, patterns, antidotes, environment">
      <outline text="Exposure control first">
        <outline text="Identification often arrives late"/>
        <outline text="Protect rescuers, remove clothing">
          <outline text="Brush off dry powder before irrigation"/>
          <outline text="Prevent secondary exposure"/>
        </outline>
        <outline text="Stabilise airway, ventilation, circulation"/>
        <outline text="Looking well does not exclude toxicity">
          <outline text="Delayed release or accumulating metabolite"/>
          <outline text="Observe to expected kinetics"/>
        </outline>
      </outline>
      <outline text="Toxicokinetics">
        <outline text="Toxicity is dose reaching target over time"/>
        <outline text="Absorption: route, formulation, gastric emptying"/>
        <outline text="Distribution: binding, lipid solubility, volume"/>
        <outline text="Metabolism may create toxic products">
          <outline text="Paracetamol, methanol, ethylene glycol"/>
        </outline>
        <outline text="Saturation, cycling, bezoars prolong toxicity"/>
      </outline>
      <outline text="History and toxidromes">
        <outline text="Seek maximum plausible dose">
          <outline text="Records and scene may beat tablet counts"/>
        </outline>
        <outline text="Low stated intent does not reduce dose"/>
        <outline text="Opioids: depressed ventilation, miosis"/>
        <outline text="Sympathomimetic versus antimuscarinic">
          <outline text="Sweating versus dry skin, retention, ileus"/>
        </outline>
        <outline text="Cholinergic: muscarinic secretions">
          <outline text="Nicotinic fasciculation then weakness"/>
        </outline>
      </outline>
      <outline text="Electrocardiogram and decontamination">
        <outline text="Early electrocardiogram reveals channel effects"/>
        <outline text="Wide QRS predicts seizure and dysrhythmia">
          <outline text="Bicarbonate raises sodium and pH"/>
        </outline>
        <outline text="QT: correct potassium and magnesium"/>
        <outline text="Charcoal benefit depends on timing and airway"/>
        <outline text="Corrosives not neutralised">
          <outline text="Exothermic reaction worsens injury"/>
        </outline>
      </outline>
      <outline text="Paracetamol and salicylate">
        <outline text="Paracetamol silent while glutathione consumed"/>
        <outline text="Nomogram only for single timed ingestion"/>
        <outline text="N-acetylcysteine helps even after injury"/>
        <outline text="Salicylate: mixed alkalosis and acidosis"/>
        <outline text="Serial levels, single fall misleading"/>
        <outline text="Acidaemia drives salicylate into brain"/>
        <outline text="Alkalinisation needs potassium correction"/>
        <outline text="Intubation hazardous">
          <outline text="Preserve pre-intubation minute ventilation"/>
          <outline text="Abnormal adaptation may keep patient alive"/>
        </outline>
      </outline>
      <outline text="Opioid, sedative, serotonergic antidote logic">
        <outline text="Opioid death is ventilatory failure">
          <outline text="Ventilate before or with naloxone"/>
        </outline>
        <outline text="Titrate naloxone to breathing, not alertness"/>
        <outline text="Long-acting opioids outlast naloxone"/>
        <outline text="Flumazenil removes anticonvulsant protection"/>
        <outline text="Serotonin toxicity: rapid, clonus, hyperreflexia"/>
        <outline text="Neuroleptic syndrome: slower, severe rigidity"/>
        <outline text="Muscle heat may need paralysis"/>
      </outline>
      <outline text="Toxic alcohols, digoxin, lithium">
        <outline text="Alcohol dehydrogenase makes toxic metabolites">
          <outline text="Osmolar gap falls as anion gap rises"/>
          <outline text="Fomepizole blocks metabolism"/>
        </outline>
        <outline text="Digoxin: bradyarrhythmias and tachyarrhythmias">
          <outline text="Antibody fragments for life threat"/>
          <outline text="Total level uninterpretable afterwards"/>
        </outline>
        <outline text="Lithium: tremor, ataxia, altered consciousness">
          <outline text="Dialysis decided beyond concentration"/>
          <outline text="Charcoal does not adsorb lithium"/>
        </outline>
      </outline>
      <outline text="Gases, organophosphates, corrosives">
        <outline text="Oximetry reads carboxyhaemoglobin as oxygenated">
          <outline text="Late low level underestimates peak"/>
        </outline>
        <outline text="Atropine to secretions and perfusion"/>
        <outline text="Oximes act before enzyme ageing"/>
        <outline text="Late weakness needs respiratory surveillance"/>
        <outline text="Mild oral findings do not exclude injury"/>
        <outline text="Button battery: rapid necrosis, urgent removal"/>
      </outline>
      <outline text="Envenomation and environment">
        <outline text="Identify by geography, syndrome, progression"/>
        <outline text="Antivenom only for significant envenomation"/>
        <outline text="Heat stroke: cool immediately">
          <outline text="Antipyretics fail, not prostaglandin fever"/>
        </outline>
        <outline text="Hypothermia can mimic death"/>
        <outline text="Smoke: carbon monoxide and cyanide"/>
        <outline text="Drowning: ventilate, not drain water"/>
      </outline>
      <outline text="Consultation and discharge">
        <outline text="Confirm formulation and antidotes with poisons service"/>
        <outline text="Discharge after predicted peak passes"/>
        <outline text="Antidote improvement may be temporary"/>
        <outline text="Psychosocial plan and restricted access"/>
        <outline text="Check household and co-workers"/>
      </outline>
    </outline>
  </body>
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