Summary clinical toxicology
Normaal
Heart rhythm→60-100 slagen per minuut
Breathing frequency→ 12-20 per minuut
Blood pressure→ SBP 90-120 mmHg, DBP 60-80 mmHg
Pupil diameter→ 2-4 mm in fel licht en 4-8 mm in donker licht
Kalium→ Kalium (3.5-5 mmol/liter)
Natrium→ (135-145 mmol/liter)
Not hemodialysis->when large volume of distribution and large protein binding, lipophilic drug
When proteinbinding is saturable->hemodailysis can
Verschil hypotension, bradycardia→hypotensie verlaagde bloeddruk (bloedvaten), bradycardia verlaagde hartfrequentie
Charcoal->niet bij polaire, kleine ionen absorbeert niet en niet bij chronische overdosis, niet meer maag-darmkanaal
Totale irrigation darmspoeling-> spoeling -><1 uur
Charcoal->als het kan
Darm lavage serious-> 4 later, moet wel kunnen, benzoars etc.
1
,Content
Summary clinical toxicology .............................................................................................................................................. 1
Content.......................................................................................................................................................................... 2
Lecture 1 ........................................................................................................................................................................... 8
Part 1 introduction ........................................................................................................................................................ 8
Case 1 laurel leafs ..................................................................................................................................................... 8
Curare ........................................................................................................................................................................ 8
Hemlock (conine)....................................................................................................................................................... 8
Analytical toxicology ............................................................................................................................................... 10
Part 2 pharmacokinetics and toxicokinetic ................................................................................................................. 11
Case digoxin poisoning ............................................................................................................................................ 11
Case lithium poisoning ............................................................................................................................................ 11
Therapeutic range ................................................................................................................................................... 14
Toxicokinetics........................................................................................................................................................... 15
Drug absorption ...................................................................................................................................................... 15
Drug distribution ..................................................................................................................................................... 17
Drug metabolism ..................................................................................................................................................... 17
Drug elimination ..................................................................................................................................................... 17
Lecture 2 23-09-2025 ...................................................................................................................................................... 19
Part 1 analytical methods in clinical toxicology .......................................................................................................... 19
Case ......................................................................................................................................................................... 19
Color tests/spot tests............................................................................................................................................... 19
Direct UV/VIS spectrophotometry ........................................................................................................................... 19
Infrared spectrophotometry .................................................................................................................................... 20
Atomic absorption/atomic emission spectrophotometry........................................................................................ 20
ICP-MS ..................................................................................................................................................................... 20
Immuno assay ......................................................................................................................................................... 20
Turbidimetric immuno assay ................................................................................................................................... 21
Thin Layer chromatography .................................................................................................................................... 22
................................................................................................................................................................................. 22
Gas chromatography............................................................................................................................................... 22
Liquid chromatography ........................................................................................................................................... 23
Part 2 prevention of absorption and forced elimination ............................................................................................ 25
Case 1 ...................................................................................................................................................................... 25
Case 2 ...................................................................................................................................................................... 25
Prevention of absorption and forced elimination.................................................................................................... 25
2
, Emesis...................................................................................................................................................................... 26
Gastric lavage.......................................................................................................................................................... 26
Activated charcoal................................................................................................................................................... 27
Single dose activated charcoal ................................................................................................................................ 27
Repeated dose activated charcoal .......................................................................................................................... 27
Whole bowel irrigation............................................................................................................................................ 28
Forced elimination................................................................................................................................................... 28
Forced diuresis alkaline ........................................................................................................................................... 29
Forced diuresis acid ................................................................................................................................................. 29
Hemodialysis ........................................................................................................................................................... 29
Hemofiltration ......................................................................................................................................................... 30
Hemodiafiltration .................................................................................................................................................... 30
Hemoperfusion ........................................................................................................................................................ 32
Cytosorb® ................................................................................................................................................................ 32
Case Cytosorb .......................................................................................................................................................... 32
MARS ....................................................................................................................................................................... 33
Indications for dialysis? ........................................................................................................................................... 33
Lipid sink .................................................................................................................................................................. 34
Lecture 3 paracetamol .................................................................................................................................................... 35
Part 1 ........................................................................................................................................................................... 35
Case paracetamol.................................................................................................................................................... 35
Prognostic factors ................................................................................................................................................... 36
Acute poisoning ....................................................................................................................................................... 37
History paracetamol ................................................................................................................................................ 37
Special populations ................................................................................................................................................. 39
Ethanol .................................................................................................................................................................... 39
Dose of N-acetylcystein ........................................................................................................................................... 39
Advantages of SNAP regimen ................................................................................................................................. 39
Chronic paracetamol poisoning .............................................................................................................................. 40
Consequences failure of Liver Function ................................................................................................................... 40
Part 2 paracetamol poisoning II .................................................................................................................................. 41
Early level: (non)sense ............................................................................................................................................. 42
SNAP regimen.......................................................................................................................................................... 43
Massive overdose .................................................................................................................................................... 45
Markers of paracetamol toxicity ............................................................................................................................. 46
Bonus pharmacokinetics ................................................................................................................................................. 49
Bioavailability (F)..................................................................................................................................................... 49
Presystemic and first-pass metabolism ................................................................................................................... 49
3
, Distribution.............................................................................................................................................................. 49
Volume of distribution ............................................................................................................................................. 49
Clearance................................................................................................................................................................. 50
Clearance................................................................................................................................................................. 51
Excretion .................................................................................................................................................................. 51
Lecture 4 25-9-2025 ........................................................................................................................................................ 52
Part 1 Toxidromes and clinical parameters ................................................................................................................. 52
ABCDE...................................................................................................................................................................... 52
Sympathomimetic toxidrome .................................................................................................................................. 53
Anticholinergic toxidrome ....................................................................................................................................... 54
Hallucinogenic toxidrome........................................................................................................................................ 54
Opioid toxidrome..................................................................................................................................................... 55
Sedative hypnotic toxidrome ................................................................................................................................... 55
Cholinergic toxidrome ............................................................................................................................................. 56
Withdrawel syndrome ............................................................................................................................................. 56
Serotonin toxidrome ................................................................................................................................................ 57
Anion gap ................................................................................................................................................................ 60
Osmol gap ............................................................................................................................................................... 61
Hypokalemie/ hyperkalemia ................................................................................................................................... 61
Types of samples ..................................................................................................................................................... 62
Hair analysis ............................................................................................................................................................ 62
Part 2 Acid-base disturbance ...................................................................................................................................... 63
Metabolic acidosis ................................................................................................................................................... 64
Metabolic alkalosis .................................................................................................................................................. 64
Respiratory acidosis ................................................................................................................................................ 64
Respiratory alkalosis................................................................................................................................................ 64
Lecture 5 26-9-2025 ........................................................................................................................................................ 66
Part 1 tramadol ........................................................................................................................................................... 66
Case tramadol ......................................................................................................................................................... 66
Naloxone ................................................................................................................................................................. 69
Part 2 toxic alcohols .................................................................................................................................................... 70
Case ......................................................................................................................................................................... 70
Methanol ................................................................................................................................................................. 70
Antidote ethanol ..................................................................................................................................................... 72
Etylene glycol........................................................................................................................................................... 73
Fomepizole .............................................................................................................................................................. 75
Diethylene glycol ..................................................................................................................................................... 76
Lecture 6 antidotes ......................................................................................................................................................... 76
4
Normaal
Heart rhythm→60-100 slagen per minuut
Breathing frequency→ 12-20 per minuut
Blood pressure→ SBP 90-120 mmHg, DBP 60-80 mmHg
Pupil diameter→ 2-4 mm in fel licht en 4-8 mm in donker licht
Kalium→ Kalium (3.5-5 mmol/liter)
Natrium→ (135-145 mmol/liter)
Not hemodialysis->when large volume of distribution and large protein binding, lipophilic drug
When proteinbinding is saturable->hemodailysis can
Verschil hypotension, bradycardia→hypotensie verlaagde bloeddruk (bloedvaten), bradycardia verlaagde hartfrequentie
Charcoal->niet bij polaire, kleine ionen absorbeert niet en niet bij chronische overdosis, niet meer maag-darmkanaal
Totale irrigation darmspoeling-> spoeling -><1 uur
Charcoal->als het kan
Darm lavage serious-> 4 later, moet wel kunnen, benzoars etc.
1
,Content
Summary clinical toxicology .............................................................................................................................................. 1
Content.......................................................................................................................................................................... 2
Lecture 1 ........................................................................................................................................................................... 8
Part 1 introduction ........................................................................................................................................................ 8
Case 1 laurel leafs ..................................................................................................................................................... 8
Curare ........................................................................................................................................................................ 8
Hemlock (conine)....................................................................................................................................................... 8
Analytical toxicology ............................................................................................................................................... 10
Part 2 pharmacokinetics and toxicokinetic ................................................................................................................. 11
Case digoxin poisoning ............................................................................................................................................ 11
Case lithium poisoning ............................................................................................................................................ 11
Therapeutic range ................................................................................................................................................... 14
Toxicokinetics........................................................................................................................................................... 15
Drug absorption ...................................................................................................................................................... 15
Drug distribution ..................................................................................................................................................... 17
Drug metabolism ..................................................................................................................................................... 17
Drug elimination ..................................................................................................................................................... 17
Lecture 2 23-09-2025 ...................................................................................................................................................... 19
Part 1 analytical methods in clinical toxicology .......................................................................................................... 19
Case ......................................................................................................................................................................... 19
Color tests/spot tests............................................................................................................................................... 19
Direct UV/VIS spectrophotometry ........................................................................................................................... 19
Infrared spectrophotometry .................................................................................................................................... 20
Atomic absorption/atomic emission spectrophotometry........................................................................................ 20
ICP-MS ..................................................................................................................................................................... 20
Immuno assay ......................................................................................................................................................... 20
Turbidimetric immuno assay ................................................................................................................................... 21
Thin Layer chromatography .................................................................................................................................... 22
................................................................................................................................................................................. 22
Gas chromatography............................................................................................................................................... 22
Liquid chromatography ........................................................................................................................................... 23
Part 2 prevention of absorption and forced elimination ............................................................................................ 25
Case 1 ...................................................................................................................................................................... 25
Case 2 ...................................................................................................................................................................... 25
Prevention of absorption and forced elimination.................................................................................................... 25
2
, Emesis...................................................................................................................................................................... 26
Gastric lavage.......................................................................................................................................................... 26
Activated charcoal................................................................................................................................................... 27
Single dose activated charcoal ................................................................................................................................ 27
Repeated dose activated charcoal .......................................................................................................................... 27
Whole bowel irrigation............................................................................................................................................ 28
Forced elimination................................................................................................................................................... 28
Forced diuresis alkaline ........................................................................................................................................... 29
Forced diuresis acid ................................................................................................................................................. 29
Hemodialysis ........................................................................................................................................................... 29
Hemofiltration ......................................................................................................................................................... 30
Hemodiafiltration .................................................................................................................................................... 30
Hemoperfusion ........................................................................................................................................................ 32
Cytosorb® ................................................................................................................................................................ 32
Case Cytosorb .......................................................................................................................................................... 32
MARS ....................................................................................................................................................................... 33
Indications for dialysis? ........................................................................................................................................... 33
Lipid sink .................................................................................................................................................................. 34
Lecture 3 paracetamol .................................................................................................................................................... 35
Part 1 ........................................................................................................................................................................... 35
Case paracetamol.................................................................................................................................................... 35
Prognostic factors ................................................................................................................................................... 36
Acute poisoning ....................................................................................................................................................... 37
History paracetamol ................................................................................................................................................ 37
Special populations ................................................................................................................................................. 39
Ethanol .................................................................................................................................................................... 39
Dose of N-acetylcystein ........................................................................................................................................... 39
Advantages of SNAP regimen ................................................................................................................................. 39
Chronic paracetamol poisoning .............................................................................................................................. 40
Consequences failure of Liver Function ................................................................................................................... 40
Part 2 paracetamol poisoning II .................................................................................................................................. 41
Early level: (non)sense ............................................................................................................................................. 42
SNAP regimen.......................................................................................................................................................... 43
Massive overdose .................................................................................................................................................... 45
Markers of paracetamol toxicity ............................................................................................................................. 46
Bonus pharmacokinetics ................................................................................................................................................. 49
Bioavailability (F)..................................................................................................................................................... 49
Presystemic and first-pass metabolism ................................................................................................................... 49
3
, Distribution.............................................................................................................................................................. 49
Volume of distribution ............................................................................................................................................. 49
Clearance................................................................................................................................................................. 50
Clearance................................................................................................................................................................. 51
Excretion .................................................................................................................................................................. 51
Lecture 4 25-9-2025 ........................................................................................................................................................ 52
Part 1 Toxidromes and clinical parameters ................................................................................................................. 52
ABCDE...................................................................................................................................................................... 52
Sympathomimetic toxidrome .................................................................................................................................. 53
Anticholinergic toxidrome ....................................................................................................................................... 54
Hallucinogenic toxidrome........................................................................................................................................ 54
Opioid toxidrome..................................................................................................................................................... 55
Sedative hypnotic toxidrome ................................................................................................................................... 55
Cholinergic toxidrome ............................................................................................................................................. 56
Withdrawel syndrome ............................................................................................................................................. 56
Serotonin toxidrome ................................................................................................................................................ 57
Anion gap ................................................................................................................................................................ 60
Osmol gap ............................................................................................................................................................... 61
Hypokalemie/ hyperkalemia ................................................................................................................................... 61
Types of samples ..................................................................................................................................................... 62
Hair analysis ............................................................................................................................................................ 62
Part 2 Acid-base disturbance ...................................................................................................................................... 63
Metabolic acidosis ................................................................................................................................................... 64
Metabolic alkalosis .................................................................................................................................................. 64
Respiratory acidosis ................................................................................................................................................ 64
Respiratory alkalosis................................................................................................................................................ 64
Lecture 5 26-9-2025 ........................................................................................................................................................ 66
Part 1 tramadol ........................................................................................................................................................... 66
Case tramadol ......................................................................................................................................................... 66
Naloxone ................................................................................................................................................................. 69
Part 2 toxic alcohols .................................................................................................................................................... 70
Case ......................................................................................................................................................................... 70
Methanol ................................................................................................................................................................. 70
Antidote ethanol ..................................................................................................................................................... 72
Etylene glycol........................................................................................................................................................... 73
Fomepizole .............................................................................................................................................................. 75
Diethylene glycol ..................................................................................................................................................... 76
Lecture 6 antidotes ......................................................................................................................................................... 76
4
