Toxicology July TOXICOLOGY

							                                      TOXICOLOGY

   Emergency medicine residents on the Toxicology rotation should focus on:

      1. Learning the pertinent aspects of the history and physical exam relative to acute
         poisoning with particular emphasis on clinical recognition of major toxic syndromes
         (toxidromes).
      2. Learning the general aspects of clinical management of poisoning, including
         resuscitation, stabilization and decontamination, enhancement of elimination of toxins
         and administration of antidotes where appropriate.
      3. Learn the presenting signs, symptoms, laboratory findings, pathophysiology and
         treatment of common therapeutic drug poisonings, drugs of abuse, natural toxins,
         and general household poisons as delineated in RCPS Core curriculum.
      4. Learn to recognize, diagnose, assess and emergently manage acute and chronic
         complications of substance abuse.
      5. Learn the use of adjunctive services, including the toxicology laboratory and the
         poison centre in the management of acute poisonings.

Medical Expert:

      1. Understand the unique aspects of resuscitation and stabilization of the poisoned
         patient
      2. Understand the principles of gastrointestinal decontamination. Specifically,
         understand the risks, benefits, indications and contraindications of:
             1. ipecac induced emesis
             2. cathartics
             3. gastric lavage
             4. whole bowel irrigation
             5. administration of activated charcoal
      3. Discuss the indications, contraindications, dosages, and side effects of the currently
         available antidotes.
      4. Demonstrate clinical recognition of toxidromes associated with drug overdose and
         drug withdrawal.
      5. Define toxidromes for patients with opioid, sympathomimetic, anticholinergic, and
         cholinergic agent poisoning.
      6. Create a differential diagnosis for drugs causing abnormal vital signs. Specifically:
             1. tachycardia and bradycardia
             2. tachypnea, bradypnea, and hyperpnea
             3. hypertension and hypotension
             4. hypothermia and hyperthermia
      7. Create a differential diagnosis of drugs that cause cardiac dysrhythmias and
         myocardial dysfunction.
      8. Create a differential diagnosis of drugs that cause agitation, coma, seizures, delirium,
         psychosis and ocular abnormalities. .
       9. Demonstrate knowledge of the principles of methods to enhance elimination of
           toxins, such as multiple doses of charcoal, alkalinization of the urine, hemodialysis
           and hemoperfusion and the toxic agents that can be removed by these methods.
       10. Demonstrate knowledge of the diagnostic laboratory including methods and
           limitations of testing.
       11. Understand the evaluation of anion-gap and non-anion-gap metabolic acidosis, with
           specific reference to poisoned patients.
       12. Develop a thorough understanding of the pathophysiology, evaluation, management
           and disposition of patients intoxicated with the following (not inclusive):

      acetaminophen                cocaine cyanide            hydrocarbons                 opioids
      amphetamines                  digoxin                    hydrogen sulfide             oral hypoglycemic
      antidepressants              ethanol                    hypo- and                     agents
      barbiturates                 ethylene glycol             hyperthermia                 phencyclidine
      benzodiazepines              food poisoning             iron                         phenytoin and other
      beta-blockers                hallucinogens              isoniazid                     anticonvulsants
      botulism                     heavy metals               isopropanol                  plants
      calcium channel              herbal medicines           lithium                      rodenticides
       blockers                     household                  MAO inhibitors               salicylates/NSAID’s
      carbamates                    poisons                    methanol                     sedative-hypnotics
      carbon monoxide                                          methemoglobin                theophylline/caffeine
      caustics                                                  inducers                     toxic gases
      clonidine                                                mushrooms                    venomous bites and
                                                                neuroleptics                  stings




Communicator
       1. Provide management advice to Health Care professionals requesting Toxicology
          consultation
       2. Develop the ability to write cogent and concise consultations

Collaborator
       1. Understand the vital role of the Toxicology laboratory in the management of the
          poisoned patient
       2. Understand the role of the Poison Centre and Poison Information specialists in the
          management of the poisoned patient.
       3. Participate with the attending physicians to assist in the care of the poisoned patient
          by providing appropriate and expert management advice.

Manager

       1. Understand the structure and function of a regional Poison Control Center.
       2. Consider the cost of health care services when making diagnostic and treatment
          decisions.
Health Advocate
        1. Understand the principles of poison prevention, especially in the Pediatric age group.
        2. Consider the social determinants resulting in poisonings and overdose.

Scholar
        1. Demonstrate ability to critically evaluate the literature as it pertains to toxicology.
        2. Demonstrate inquisitiveness around clinical cases.
        3. Demonstrate ability to apply the principles of evidence-based medicine.


Professional
        1.   Adhere to the code of ethics of the CMA and the institution.
        2.   Treat patients and colleagues with respect.
        3.   Demonstrate ability to self-evaluate, including insight into strengths and weaknesses
        4.   Demonstrate commitment to life-long learning
        5.   Demonstrate willingness to accept responsibility for one’s actions and for patient
             care.



Evaluation
Resident performance is reviewed at the end of the rotation by the attending Toxicologists.

An ITER (In Training Evaluation Report) will be completed at the conclusion of the training period.

The ITER should be reviewed and signed by the resident and returned to the office of the
Residency Program Director and Rotation Evaluation Form.