MCQ Quiz: Clinical Toxicology Emergencies

Clinical toxicology emergencies are high-stakes, time-sensitive situations where pharmacists play a crucial role as medication experts on the interprofessional team. The ability to rapidly assess a poisoned patient, recognize key toxidromes, and recommend appropriate decontamination, enhanced elimination, or antidote therapy can be the difference between life and death. The Patient Care VII curriculum prepares PharmD students for these challenges, covering the principles of assessment, treatment, and case-based application for common poisonings. This quiz will test your knowledge on the management of these critical emergencies.

1. In the initial management of any poisoned patient, what is the first priority?

• a) Administering an antidote
• b) Obtaining a comprehensive toxicology screen
• c) Assessing and stabilizing the Airway, Breathing, and Circulation (ABCs)
• d) Performing gastric lavage Answer: c) Assessing and stabilizing the Airway, Breathing, and Circulation (ABCs)

2. A patient presents with agitation, tachycardia, hypertension, mydriasis, and diaphoresis. This constellation of symptoms is best described as which toxidrome?

• a) Opioid
• b) Cholinergic
• c) Anticholinergic
• d) Sympathomimetic Answer: d) Sympathomimetic

3. What is the primary role of N-acetylcysteine (NAC) in the treatment of an acetaminophen overdose?

• a) It directly binds to acetaminophen to prevent absorption.
• b) It acts as a precursor to glutathione, which detoxifies the reactive metabolite NAPQI.
• c) It enhances the renal elimination of acetaminophen.
• d) It reverses the CNS depression caused by acetaminophen. Answer: b) It acts as a precursor to glutathione, which detoxifies the reactive metabolite NAPQI.

4. A patient who overdosed on a tricyclic antidepressant (TCA) shows a widened QRS complex on their EKG. What is the indicated treatment for this cardiotoxicity?

• a) Naloxone
• b) Flumazenil
• c) Sodium bicarbonate
• d) Calcium gluconate Answer: c) Sodium bicarbonate

5. The administration of flumazenil for a benzodiazepine overdose is relatively contraindicated in a patient with a history of what condition, due to the risk of precipitating it?

• a) Hypertension
• b) Seizure disorder
• c) Asthma
• d) Diabetes Answer: b) Seizure disorder

6. Which of the following substances is NOT well-adsorbed by activated charcoal?

• a) Phenobarbital
• b) Theophylline
• c) Iron
• d) Aspirin Answer: c) Iron

7. A farm worker presents with symptoms of salivation, lacrimation, urination, defecation, GI distress, and emesis (SLUDGE). This is a classic cholinergic toxidrome caused by exposure to:

• a) Antihistamines
• b) Organophosphate insecticides
• c) Amphetamines
• d) Opioids Answer: b) Organophosphate insecticides

8. The treatment for organophosphate poisoning involves atropine for muscarinic symptoms and which other agent to regenerate acetylcholinesterase?

• a) Pralidoxime
• b) Physostigmine
• c) Fomepizole
• d) N-acetylcysteine Answer: a) Pralidoxime

9. Whole bowel irrigation is a decontamination method considered for toxic ingestions of:

• a) Any liquid medication
• b) Sustained-release medications or substances not bound by charcoal, like iron tablets.
• c) A single tablet of a non-toxic vitamin
• d) Any substance ingested more than 6 hours prior Answer: b) Sustained-release medications or substances not bound by charcoal, like iron tablets.

10. Fomepizole is the antidote for ethylene glycol and methanol poisoning. It works by inhibiting which enzyme?

• a) Aldehyde dehydrogenase
• b) Alcohol dehydrogenase
• c) Catalase
• d) Monoamine oxidase Answer: b) Alcohol dehydrogenase

11. The classic opioid toxidrome consists of CNS depression, respiratory depression, and:

• a) Mydriasis (dilated pupils)
• b) Diaphoresis (sweating)
• c) Miosis (pinpoint pupils)
• d) Tachycardia Answer: c) Miosis (pinpoint pupils)

12. When counseling a caregiver on naloxone use for an opioid overdose, a key instruction is to call 911 because:

• a) The patient may need additional doses as naloxone’s duration may be shorter than the opioid’s.
• b) It is a legal requirement to report all overdoses.
• c) The naloxone may cause an allergic reaction.
• d) The caregiver may need medical attention. Answer: a) The patient may need additional doses as naloxone’s duration may be shorter than the opioid’s.

13. A patient who overdosed on a long-acting calcium channel blocker may be treated with high-dose insulin euglycemia therapy in addition to:

• a) Beta-blockers
• b) Intravenous calcium
• c) N-acetylcysteine
• d) Flumazenil Answer: b) Intravenous calcium

14. An elevated anion gap metabolic acidosis is a hallmark of poisoning with:

• a) Digoxin
• b) Methanol, Ethylene Glycol, and Salicylates
• c) Benzodiazepines
• d) Opioids Answer: b) Methanol, Ethylene Glycol, and Salicylates

15. What is the primary treatment for the cardiovascular toxicity associated with a sympathomimetic overdose (e.g., cocaine)?

• a) Beta-blockers
• b) Benzodiazepines and supportive care
• c) Calcium channel blockers
• d) Naloxone Answer: b) Benzodiazepines and supportive care

16. The Rumack-Matthew nomogram is a tool used in the assessment and management of an acute overdose of which substance?

• a) Aspirin
• b) Iron
• c) Acetaminophen
• d) Lithium Answer: c) Acetaminophen

17. Urinary alkalinization with sodium bicarbonate is a treatment strategy used to enhance the elimination of which weak acid?

• a) Amphetamine
• b) Digoxin
• c) Salicylates (aspirin)
• d) Lithium Answer: c) Salicylates (aspirin)

18. A patient presents with hyperthermia, flushed skin, dry mucous membranes, mydriasis, and delirium (“mad as a hatter, dry as a bone…”). This is the classic toxidrome for:

• a) Cholinergics
• b) Opioids
• c) Anticholinergics
• d) Sedative-hypnotics Answer: c) Anticholinergics

19. What is the specific antidote for digoxin toxicity?

• a) Glucagon
• b) Deferoxamine
• c) Digoxin immune Fab (DigiFab)
• d) Protamine sulfate Answer: c) Digoxin immune Fab (DigiFab)

20. Hemodialysis is an effective method of enhanced elimination for toxins that:

• a) Are large molecules with high protein binding.
• b) Have a large volume of distribution.
• c) Are small, water-soluble, and have low protein binding.
• d) Are highly lipophilic. Answer: c) Are small, water-soluble, and have low protein binding.

21. A patient with a severe beta-blocker overdose may be treated with which agent to bypass the beta-receptor and increase intracellular cAMP?

• a) Naloxone
• b) Glucagon
• c) Flumazenil
• d) Atropine Answer: b) Glucagon

22. In the assessment of a toxicology emergency, an “osmolal gap” is highly suggestive of poisoning with:

• a) Acetaminophen
• b) A toxic alcohol like methanol or ethylene glycol
• c) An opioid
• d) A benzodiazepine Answer: b) A toxic alcohol like methanol or ethylene glycol

23. Why is it critically important to get an acetaminophen level on all patients presenting with an intentional overdose?

• a) It is the most common substance of abuse.
• b) The early symptoms of overdose are often non-specific, but untreated toxicity can be fatal.
• c) It is required by law in all 50 states.
• d) It can be reversed with activated charcoal at any time point. Answer: b) The early symptoms of overdose are often non-specific, but untreated toxicity can be fatal.

24. The mnemonic DUMBBELS (Diarrhea, Urination, Miosis, Bronchospasm, Bradycardia, Emesis, Lacrimation, Salivation) helps in identifying which toxidrome?

• a) Sympathomimetic
• b) Anticholinergic
• c) Cholinergic
• d) Sedative-hypnotic Answer: c) Cholinergic

25. A patient who has ingested a large amount of sustained-release diltiazem would be a candidate for which decontamination method?

• a) Gastric lavage only
• b) Hemodialysis
• c) Whole bowel irrigation
• d) Urinary alkalinization Answer: c) Whole bowel irrigation

26. The antidote for iron poisoning, which works by chelating iron, is:

• a) Deferoxamine
• b) Dimercaprol
• c) Penicillamine
• d) Edetate calcium disodium (EDTA) Answer: a) Deferoxamine

27. Physostigmine is an antidote for severe anticholinergic toxicity but must be used with caution due to the risk of causing:

• a) Hypertension and tachycardia
• b) Seizures and bradycardia
• c) Respiratory depression
• d) Liver failure Answer: b) Seizures and bradycardia

28. The primary role of the pharmacist in a clinical toxicology emergency in the hospital setting is to:

• a) Perform the physical assessment of the patient.
• b) Act as a drug information expert, recommending antidotes, calculating doses, and advising on kinetics.
• c) Intubate the patient.
• d) Call the patient’s family. Answer: b) Act as a drug information expert, recommending antidotes, calculating doses, and advising on kinetics.

29. What laboratory finding is characteristic of a severe salicylate overdose?

• a) A mixed respiratory alkalosis and metabolic acidosis
• b) Respiratory acidosis only
• c) A normal anion gap
• d) Hypoglycemia Answer: a) A mixed respiratory alkalosis and metabolic acidosis

30. Intravenous lipid emulsion (ILE) therapy is a treatment modality for overdoses of which type of substance?

• a) Water-soluble drugs
• b) Highly lipophilic drugs, like local anesthetics or some calcium channel blockers
• c) Heavy metals
• d) Alcohols Answer: b) Highly lipophilic drugs, like local anesthetics or some calcium channel blockers

31. In managing a cocaine overdose, why are beta-blockers typically avoided?

• a) They can cause unopposed alpha-adrenergic stimulation, worsening hypertension.
• b) They are ineffective.
• c) They cause severe bradycardia.
• d) They are too expensive. Answer: a) They can cause unopposed alpha-adrenergic stimulation, worsening hypertension.

32. The toxic metabolite of ethylene glycol (antifreeze) that causes severe metabolic acidosis and renal failure is:

• a) Formic acid
• b) Glycolic acid and oxalic acid
• c) Acetone
• d) Isopropanol Answer: b) Glycolic acid and oxalic acid

33. What is the role of the Poison Control Center (1-800-222-1222) in managing toxicology emergencies?

• a) To provide expert consultation to both the public and healthcare professionals 24/7.
• b) To dispatch ambulances to the scene.
• c) To sell antidotes directly to patients.
• d) To file police reports for all poisonings. Answer: a) To provide expert consultation to both the public and healthcare professionals 24/7.

34. A key part of the “assessment” of a poisoned patient is determining the time of ingestion because:

• a) It helps determine if decontamination methods will be effective.
• b) It is necessary for using certain nomograms, like the one for acetaminophen.
• c) It helps predict the peak clinical effects of the substance.
• d) All of the above. Answer: d) All of the above.

35. Protamine sulfate is the specific antidote for an overdose of which medication?

• a) Warfarin
• b) Heparin
• c) Dabigatran
• d) Rivaroxaban Answer: b) Heparin

36. A patient who overdosed on an unknown substance has a normal heart rate, normal blood pressure, normal respiratory rate, but is comatose. This presentation is most consistent with an isolated overdose of a:

• a) Sympathomimetic
• b) Opioid
• c) Sedative-hypnotic like a benzodiazepine
• d) Cholinergic agent Answer: c) Sedative-hypnotic like a benzodiazepine

37. Serotonin syndrome is a toxicological emergency that can result from an overdose or interaction involving SSRIs. Its classic triad of symptoms includes altered mental status, autonomic hyperactivity, and:

• a) Respiratory depression
• b) Neuromuscular abnormalities like clonus or hyperreflexia
• c) Severe bradycardia
• d) Miosis Answer: b) Neuromuscular abnormalities like clonus or hyperreflexia

38. The treatment for serotonin syndrome is primarily:

• a) Administration of dopamine
• b) Discontinuation of serotonergic agents and supportive care with benzodiazepines.
• c) Administration of another SSRI.
• d) Hemodialysis. Answer: b) Discontinuation of serotonergic agents and supportive care with benzodiazepines.

39. Which of the following EKG abnormalities is most concerning in a toxicology patient?

• a) A normal sinus rhythm
• b) A QRS duration > 100 milliseconds
• c) A heart rate of 75 bpm
• d) A PR interval of 150 milliseconds Answer: b) A QRS duration > 100 milliseconds

40. Why is syrup of ipecac no longer recommended for routine home use to induce vomiting after a poisoning?

• a) It is not effective at removing poisons.
• b) It can delay the administration of more effective treatments like activated charcoal.
• c) It has significant toxicity of its own.
• d) Both B and C. Answer: d) Both B and C.

41. The toxic metabolite of methanol that causes optic nerve damage and blindness is:

• a) Formic acid
• b) Oxalic acid
• c) Acetic acid
• d) Lactic acid Answer: a) Formic acid

42. Which vital sign is the most critical to monitor in a patient with an opioid overdose?

• a) Temperature
• b) Blood pressure
• c) Heart rate
• d) Respiratory rate Answer: d) Respiratory rate

43. A patient is found with a “body packer” emergency (ingested packets of illicit drugs). Which treatment is indicated to facilitate removal of the packets?

• a) Activated charcoal
• b) Gastric lavage
• c) Whole bowel irrigation
• d) Hemodialysis Answer: c) Whole bowel irrigation

44. The toxic dose of acetaminophen is generally considered to be:

• a) 1 gram in a single ingestion
• b) 4 grams in 24 hours for an adult
• c) Greater than 7.5 to 10 grams in a single ingestion for an adult
• d) Any dose taken with alcohol Answer: c) Greater than 7.5 to 10 grams in a single ingestion for an adult

45. After a toxicology emergency is resolved, what is a crucial role for the pharmacist upon patient discharge?

• a) To report the patient to their employer.
• b) To provide poison prevention counseling.
• c) To refuse to fill any future prescriptions for the patient.
• d) To do nothing, as their role is finished. Answer: b) To provide poison prevention counseling.

46. Idarucizumab (Praxbind) is a specific reversal agent for which anticoagulant?

• a) Warfarin
• b) Heparin
• c) Dabigatran
• d) Apixaban Answer: c) Dabigatran

47. A “toxin screen” or “toxicology screen” is often ordered in the ER. It is important to know that these screens:

• a) Test for every possible drug and toxin.
• b) Are often limited immunoassays that only test for common classes of drugs and can have false positives/negatives.
• c) Are always 100% accurate and reliable.
• d) Provide quantitative levels for all substances detected. Answer: b) Are often limited immunoassays that only test for common classes of drugs and can have false positives/negatives.

48. In the event of a cyanide poisoning, what is a component of the antidote kit?

• a) Methylene blue
• b) Hydroxocobalamin or Sodium thiosulfate/sodium nitrite
• c) Fomepizole
• d) Pralidoxime Answer: b) Hydroxocobalamin or Sodium thiosulfate/sodium nitrite

49. Why is a careful medication history, including OTCs and supplements, essential in assessing a toxicology emergency?

• a) To identify the potential toxin(s).
• b) To identify potential drug interactions that could have contributed to the toxicity.
• c) To identify co-ingestants.
• d) All of the above. Answer: d) All of the above.

50. The ultimate goal of the “Clinical Toxicology Emergencies” unit in the Patient Care curriculum is to prepare pharmacists to:

• a) Act as first responders at the scene of an accident.
• b) Function as competent and essential members of the interprofessional team managing a poisoned patient.
• c) Perform gastric lavage and intubations.
• d) Make all treatment decisions without consulting a physician. Answer: b) Function as competent an