1.0 Principles of Toxicology

1.1 Pharmacology/Toxicology

• 1.1.1 Pharmacokinetics/Toxicokinetics
  • 1.1.1.1 Bioavailability and Absorption
  • 1.1.1.2 Distribution
  • 1.1.1.3 Metabolism
  • 1.1.1.4 Elimination
  • 1.1.1.5 Clearance
  • 1.1.1.6 Models (eg, compartmental, physiologic)
• 1.1.2 Pharmacodynamics/Toxicodynamics
  • 1.1.2.1 Dose/Concentration Relationship to Effect
  • 1.1.2.2 Structure-Activity Relationship
  • 1.1.2.3 Receptor Agonism/Antagonism
  • 1.1.2.4 Receptor Regulation
• 1.1.3 Adverse Effects
  • 1.1.3.1 Mechanistic (predictable)
  • 1.1.3.2 Idiosyncratic
• 1.1.4 Interactions
  • 1.1.4.1 Xenobiotic-Environment
  • 1.1.4.2 Xenobiotic-Food
  • 1.1.4.3 Xenobiotic-Xenobiotic (eg, drug-drug)
• 1.1.5 Proteomics
• 1.1.6 Tolerance and Withdrawal
  • 1.1.6.1 Behavioral Tolerance
  • 1.1.6.2 Biologic Tolerance
• 1.1.7 Immunologic Response
• 1.1.8 Pharmacogenomics Toxicogenomics(eg, xenobiotic response, gene expression profiling)

1.2 Molecular Components and Mechanisms

• 1.2.1 Glycolysis and Oxidative Phosphorylation
• 1.2.2 Other Metabolic Pathways (eg, amino acids and urea cycle)
• 1.2.3 Membranes
• 1.2.4 Enzymes and Transport Proteins (eg, methemoglobin, G6PD)
• 1.2.5 Channels and Pumps
• 1.2.6 Signal Transduction
  • 1.2.6.1 Receptor Isoforms and Subtypes
  • 1.2.6.2 Regulation and Messengers
  • 1.2.6.3 Neurotransmitters

1.3 Cytotoxic Mechanisms

(eg, apoptosis, microtubular dysfunction)

1.4 Mutagenesis and Carcinogenesis

• 1.4.1 Mutagenesis
  • 1.4.1.1 Chromosome Aberrations (structural, numeric)
  • 1.4.1.2 Gene Mutation (oncogenes, tumor suppressor genes)
• 1.4.2 Development of Neoplasia
  • 1.4.2.1 Initiation (eg, genotoxic mechanisms)
  • 1.4.2.2 Procarcinogens and Conversion to Carcinogens (eg,
  • 1.4.2.3 Progression (eg, growth, invasiveness)
  • 1.4.2.4 Promotion (eg, nongenotoxic mechanisms biotransformation)
• 1.4.3 Inhibition of Carcinogenesis-Modulating Factors
  • 1.4.3.1 Endogenous Factors (eg, age, sex, immune status, hormones)
  • 1.4.3.2 Exogenous Factors (eg, diet, radiation)
• 1.4.4 Interactive Carcinogenesis
  • 1.4.4.1 Xenobiotic: Gene Interactions
  • 1.4.4.2 Xenobiotic: Physical Interactions
  • 1.4.4.3 Xenobiotic: Radiation Interactions
  • 1.4.4.4 Xenobiotic: Viral Interactions

1.5 Adverse Reproductive and Developmental Outcomes

• 1.5.1 Conception Impairment, Mutagenesis, and Teratogenesis
  • 1.5.1.1 Chromosomal and Gene Abnormalities
  • 1.5.1.2 Effects on Gametogenesis and Gametes
  • 1.5.1.3 Effects on Gonads
  • 1.5.1.4 Spontaneous Abortion and Perinatal Death
• 1.5.2 Factors Determining Fetal or Infant Exposure to Agents
  • 1.5.2.1 Breast Milk Transfer
  • 1.5.2.2 Placental Transfer
  • 1.5.2.3 Xenobiotic Disposition (eg, maternal xenobiotic disposition, feta pharmacokinetics)
• 1.5.3 Offspring Effects
  • 1.5.3.1 Cancer
  • 1.5.3.2 Congenital Anomalies and Malformations
  • 1.5.3.3 Development of Infant/Child
  • 1.5.3.4 Genetic Mutations

2.0 Toxins and Toxicants

2.1 Drugs

• 2.1.1 Analgesics, Anti-inflammatory Drugs
  • 2.1.1.1 Acetaminophen
  • 2.1.1.2 Nonsteroidal Anti-inflammatory Drugs
  • 2.1.1.3 Opioids
  • 2.1.1.4 Salicylates
  • 2.1.1.5 Others (eg, antigout drugs, gold)
    • 2.1.1.5.1 Colchicine
• 2.1.2 Antimicrobials
  • 2.1.2.1 Antibiotics
  • 2.1.2.2 Antifungals
  • 2.1.2.3 Antimycobacterials
  • 2.1.2.4 Antiparasitics
  • 2.1.2.5 Antiprotozoals
  • 2.1.2.6 Antiretrovirals
  • 2.1.2.7 Antiseptics
  • 2.1.2.8 Antivirals
• 2.1.3 Chemotherapeutic Drugs
  • 2.1.3.1 Alkylators
  • 2.1.3.2 Antimetabolites
  • 2.1.3.3 Hormones
  • 2.1.3.4 Natural Drugs, (eg, vinca alkaloids, antibiotics)
  • 2.1.3.5 Miscellaneous (eg, platinum, hydroxyurea)
• 2.1.4 Diagnostic Drugs (eg, radionuclides)
• 2.1.5 Drugs That Affect Cholesterol and Lipids
• 2.1.6 Drugs That Affect the Cardiovascular System
  • 2.1.6.1 Antidysrhythmics
    • 2.1.6.1.1 Calcium channel blockers
    • 2.1.6.1.2 Cardiac glycosides
    • 2.1.6.1.3 Potassium channel blockers
    • 2.1.6.1.4 Sodium channel blockers
  • 2.1.6.2 Antihypertensives
    • 2.1.6.2.1 Angiotensin system modulators
    • 2.1.6.2.2 Adrenergic (and mixed , ) antagonists
    • 2.1.6.2.3 Centrally acting receptor agonists Clonidine
    • 2.1.6.2.4 Diuretics
    • 2.1.6.2.5 Vasodilators (eg, nitrates, nitrites)
  • 2.1.6.3 Inotropes
• 2.1.7 Drugs That Affect the Endocrine System
  • 2.1.7.1 Antidiabetic Drugs
    • 2.1.7.1.1 Insulin
    • 2.1.7.1.2 Oral hypoglycemics
    • 2.1.7.1.3 Others (eg, metformin, glitazones)
  • 2.1.7.2 Bone Active Drugs (eg, calcitonin, bisphosphonates)
  • 2.1.7.3 Electrolytes and Minerals
  • 2.1.7.4 Glucocorticoids
  • 2.1.7.5 Sex Hormones, Growth Hormones, and Anabolic Steroids
  • 2.1.7.6 Thyroid Drugs
  • 2.1.7.7 Vasopressin and Somatostatin Analogues
• 2.1.8 Drugs That Affect the Gastrointestinal System
  • 2.1.8.1 Antidiarrheals
  • 2.1.8.2 Antiemetics
  • 2.1.8.3 Drugs Used for Biliary and Pancreatic Diseases (eg, bile salts,pancreatic enzymes)
  • 2.1.8.4 Drugs Used for Inflammatory Bowel Disease
  • 2.1.8.5 Drugs Used to Treat Acid-Peptic Diseases
  • 2.1.8.6 Laxatives
  • 2.1.8.7 Promotilic
• 2.1.9 Drugs That Affect the Hematologic System
  • 2.1.9.1 Anticoagulants
  • 2.1.9.2 Antifibrinolytics
  • 2.1.9.3 Antiplatelet Drugs
  • 2.1.9.4 Blood-Stimulating Drugs (eg, erythropoietin)
  • 2.1.9.5 Drugs Used to Treat Bleeding (eg, clotting factors, antiplasmin drugs
  • 2.1.9.6 Iron
  • 2.1.9.7 Thrombolytics
• 2.1.10 Drugs That Affect the Immune System(eg, interferon, cyclophosphamide)
• 2.1.11 Drugs That Affect the Nervous System
  • 2.1.11.1 Anesthetics
    • 2.1.11.1.1 Inhalational and sedative anesthetics (eg, nitrous oxide, propofol)
    • 2.1.11.1.2 Local anesthetics
  • 2.1.11.2 Anticonvulsants
  • 2.1.11.3 Antiparkinsonism Drugs
  • 2.1.11.4 Drugs That Affect Autonomic Homeostasis
    • 2.1.11.4.1 Anticholinergics
    • 2.1.11.4.2 Antihistamines
    • 2.1.11.4.3 Antiserotonergics
    • 2.1.11.4.4 Cholinergics (eg, nicotine)
    • 2.1.11.4.5 Ergot and derivatives
    • 2.1.11.4.6 Methylxanthines
    • 2.1.11.4.7 Serotonin agonists and other proserotonergics (eg, dextromethorphan)
    • 2.1.11.4.8 Sympathomimetics (eg, amphetamines, cocaine)
  • 2.1.11.5 Ethanol
  • 2.1.11.6 Muscle Relaxants
  • 2.1.11.7 Neuromuscular Blockers
  • 2.1.11.8 Psychoactive Drugs and Hallucinogens (eg, marijuana, lysergic acid diethylamide [LSD])
  • 2.1.11.9 Psychotropics
    • 2.1.11.9.1 Anxiolytics and sedative-hypnotics
    • 2.1.11.9.2 Antidepressants
      • 2.1.11.9.2.1 Tricyclic Antidepressants
      • 2.1.11.9.2.2 Monoamine Oxidase Inhibitors
      • 2.1.11.9.2.3 Serotonin Reuptake Inhibitors
      • 2.1.11.9.2.4 Other Antidepressants (bupropion, mirtazapine, mianserin, venlafaxine
    • 2.1.11.9.3 Antipsychotics
    • 2.1.11.9.4 Mood stabilizers
• 2.1.12 Pharmaceutical Additives (eg, excipients)
• 2.1.13 Veterinary Products
• 2.1.14 Vitamins
• 2.1.15 Complementary Herbal & Traditional Medicines
• 2.1.16 Pharmacognosy

2.2 Industrial, Household, and Environmental Toxicants

• 2.2.1 Airborne Solids
  • 2.2.1.1 Asbestos
  • 2.2.1.2 Coal Dust
  • 2.2.1.3 Organic Dust
  • 2.2.1.4 Silica
  • 2.2.1.5 Other Minerals (eg, man-made mineral fibers)
• 2.2.2 Cleansers and Caustics
  • 2.2.2.1 Acids
  • 2.2.2.2 Alkali
  • 2.2.2.3 Bleach
  • 2.2.2.4 Detergents and Soaps
  • 2.2.2.5 Disinfectants and Topical Anti-infectives
  • 2.2.2.6 Swimming Pool Products
• 2.2.3 Food Additives (eg, monosodium glutamate, sulfites)
• 2.2.4 Household Products
  • 2.2.4.1 Aquarium Products
  • 2.2.4.2 Art Products
  • 2.2.4.3 Batteries
  • 2.2.4.4 Cosmetics
  • 2.2.4.5 Dental Products
  • 2.2.4.6 Hair Products
  • 2.2.4.7 Personal Hygiene Products
• 2.2.5 Hydrocarbons/Solvents/Fuels
  • 2.2.5.1 Aldehydes
  • 2.2.5.2 Alcohols and Glycols
    • 2.2.5.2.1 Diethylene glycol
    • 2.2.5.2.2 Ethylene glycol
    • 2.2.5.2.3 Glycol ethers
    • 2.2.5.2.4 Isopropanol
    • 2.2.5.2.5 Methanol
  • 2.2.5.3 Aliphatic Hydrocarbons
    • 2.2.5.3.1 Hexane and congeners
    • 2.2.5.3.2 Mixtures (eg, gasoline, kerosene)
  • 2.2.5.4 Aromatic Hydrocarbons
    • 2.2.5.4.1 Benzene
    • 2.2.5.4.2 Polycyclic aromatic hydrocarbons
    • 2.2.5.4.3 Toluene
  • 2.2.5.5 Halogenated Hydrocarbons
    • 2.2.5.5.1 Carbon tetrachloride
    • 2.2.5.5.2 Chloroform
    • 2.2.5.5.3 Methylene chloride
    • 2.2.5.5.4 Perchloroethylene
    • 2.2.5.5.5 Trichloroethylene
    • 2.2.5.5.6 Vinyl chloride
  • 2.2.5.6 Hydrazines
  • 2.2.5.7 Ketones
  • 2.2.5.8 Peroxides
  • 2.2.5.9 Terpenes
• 2.2.6 Metals/Metalloids
  • 2.2.6.1 Arsenic (including arsine)
  • 2.2.6.2 Barium
  • 2.2.6.3 Beryllium
  • 2.2.6.4 Cadmium
  • 2.2.6.13 Cesium
  • 2.2.6.5 Chromium
  • 2.2.6.6 Cobalt
  • 2.2.6.7 Copper
  • 2.2.6.8 Lead
  • 2.2.6.9 Manganese
  • 2.2.6.10 Mercury
  • 2.2.6.11 Nickel
  • 2.2.6.12 Thallium
  • 2.2.6.13 Cesium
• 2.2.7 Pesticides
  • 2.2.7.1 Fumigants and Sterilants
  • 2.2.7.2 Fungicides
  • 2.2.7.3 Herbicides
    • 2.2.7.3.1 Paraquat
    • 2.2.7.3.2 Chlorphenoxy Herbicides
    • 2.2.7.3.2 Propanil
    • 2.2.7.3.2 Glyphosate
  • 2.2.7.4 Insecticides and Repellents
    • 2.2.7.4.1 Carbamates
    • 2.2.7.4.2 DEET
    • 2.2.7.4.3 Moth balls
    • 2.2.7.4.4 Organochlorines
    • 2.2.7.4.5 Organophosphates
    • 2.2.7.4.6 Pyrethrins and pyrethroids
    • 2.2.7.4.7 Neonictinoids
    • 2.2.7.4.8 Avermectins
    • 2.2.7.4.9 N-phenylpyrazole
  • 2.2.7.5 Rodenticides
    • 2.2.7.5.1 Anticoagulant
    • 2.2.7.5.2 Nonanticoagulant
  • 2.2.7.6 Other (eg, molluscides)
• 2.2.8 Pollutants
  • 2.2.8.1 Air Pollutants (eg, respirable particulates)
  • 2.2.8.2 Persistent Organic Pollutants (eg, polychlorinated biphenyls, dibenzodioxins)
  • 2.2.8.3 Water Pollutants (eg, trihalomethanes)
• 2.2.9 Toxic Gases
  • 2.2.9.1 Cellular Asphyxiant Gases
    • 2.2.9.1.1 Carbon monoxide
    • 2.2.9.1.2 Cyanide
    • 2.2.9.1.3 Hydrogen sulfide
  • 2.2.9.2 Irritant Gases
    • 2.2.9.2.1 Chlorine
    • 2.2.9.2.2 Nitrogen oxides
    • 2.2.9.2.3 Ozone
    • 2.2.9.2.4 Phosgene
    • 2.2.9.2.5 Sulfur oxides
    • 2.2.9.2.6 Arsene
  • 2.2.9.3 Radon
  • 2.2.9.4 Simple Asphyxiants (eg, methane, nitrogen)
  • 2.2.9.5 Smoke Inhalation
• 2.2.10 Miscellaneous Toxicants
  • 2.2.10.1 Acrolein
  • 2.2.10.2 Acrylamides
  • 2.2.10.3 Acrylates
  • 2.2.10.4 Amines
  • 2.2.10.5 Aniline Compounds
  • 2.2.10.6 Azides
  • 2.2.10.7 Bromide Compounds
  • 2.2.10.8 Butadienes
  • 2.2.10.9 Carbon Disulfide
  • 2.2.10.10 Chlorates
  • 2.2.10.11 Coal Tar Products
  • 2.2.10.12 Diamines
  • 2.2.10.13 Dibromochloropropane (DBCP)
  • 2.2.10.14 Dimethylacetamide (DMAC)
  • 2.2.10.15 Dimethylformamide (DMF)
  • 2.2.10.16 Dinitrobenzene
  • 2.2.10.17 Dinitrotoluene (DNT)
  • 2.2.10.18 Epichlorohydrin
  • 2.2.10.19 Ethylene Dibromide (EDB)
  • 2.2.10.20 Ethylenediamine (EDA)
  • 2.2.10.21 Fluoride Compounds
  • 2.2.10.22 Fuels
  • 2.2.10.23 Hexachloro-1,3-Butadiene (HCBD)
  • 2.2.10.24 Isocyanates (eg, toluene diisocyante)
  • 2.2.10.25 Maleic Anhydride
  • 2.2.10.26 Mercaptans
  • 2.2.10.27 Methylene Diamine (MDA)
  • 2.2.10.28 Nitriles
  • 2.2.10.29 O-Phenylenediamine (OPD)
  • 2.2.10.30 Phosphorus/phosphides
  • 2.2.10.31 Phthalates
  • 2.2.10.32 Polymers
  • 2.2.10.33 Resins
  • 2.2.10.34 Styrene
  • 2.2.10.35 Trimellitic Anhydride
  • 2.2.10.36 Triorthocresylphosphate (TOCP)
  • 2.2.10.37 Xylidine
• 2.2.11 Syndromes Attributed to the Environment, Not Specified Elsewhere
  • 2.2.11.1 Event-Specific Syndromes (eg, Gulf War syndrome, World Trade Center cough)
  • 2.2.11.2 Mold
  • 2.2.11.3 Multiple Chemical Sensitivity Syndrome
  • 2.2.11.4 Tight Building Syndrome

2.3 Natural Products

• 2.3.1 Food Poisoning
  • 2.3.1.1 Bacterial
  • 2.3.1.2 Marine
• 2.3.2 Fungi
  • 2.3.2.1 Mushrooms
  • 2.3.2.2 Other Fungal Toxins (eg, aflatoxins, trichothecene mycotoxins)
• 2.3.3 Herbal and Dietary Supplements
• 2.3.4 Plants
  • 2.3.4.1 Cardiovascular Toxic Plants (eg, Aconitum napellus,Nerium oleander)
  • 2.3.4.2 Cutaneous/Mucus Membrane Toxic Plants (eg, Toxicodendron sp,Dieffenbachiasp)
  • 2.3.4.3 Gastrointestinal Toxic Plants (eg, Phytolacca Americana,Solanumsp)
  • 2.3.4.4 Hepatotoxic Plants (eg, Bilghia sapida,Symphatumsp)
  • 2.3.4.5 Multisystem Toxic Plants (eg, Prunussp,Ricinus communis)
  • 2.3.4.6 Neurotoxic Plants (eg, Daturasp,Nicotiana tabacum)
  • 2.3.4.7 Hallucinogenic Plants
• 2.3.5 Toxic Envenomations
  • 2.3.5.1 Arthropods
    • 2.3.5.1.1 Spiders
    • 2.3.5.1.2 Other Venomous Arthropods
  • 2.3.5.2 Marine Creatures
  • 2.3.5.3 Reptiles and Snakes
    • 2.3.5.3.1 South East Asian Snakes
    • 2.3.5.3.2 Australian Venomous Snakes
  • 2.3.5.4 Amphibians

2.4 Warfare, Terrorism, and Riot Control Agents

• 2.4.1 Biological
  • 2.4.1.1 Bacteria (eg, anthrax, plague)
  • 2.4.1.2 Toxins (eg, botulinum, staphylococcus B)
  • 2.4.1.3 Viruses (eg, smallpox)
• 2.4.2 Chemical
  • 2.4.2.1 Acetylcholinesterase Inhibitors (eg, sarin, soman, VX)
  • 2.4.2.2 Blister Agents (eg, mustard)
  • 2.4.2.3 Incapacitating Agents (eg, calmatives, BZ [3-quinuclidinyl benzilate])
  • 2.4.2.4 Tear Gases (eg, pepper spray)
• 2.4.3 Nuclear/Radiological

3.0 Therapeutics

3.1 ABCs Resuscitation

• 3.1.1 Hypotension

• 3.1.2 Coma

• 3.1.3 Seizures

3.2 Initial Management

• 3.2.1 Assessment Skills

  • 3.2.1.1 Differential Diagnosis

  • 3.2.1.2 Signs and Symptoms

  • 3.2.1.3 Toxidromes

• 3.2.2 Decontamination Strategies

  • 3.2.2.1 Dermal

  • 3.2.2.2 Gastrointestinal

    • 3.2.2.2.1 Emesis
    • 3.2.2.2.2 Gastric lavage
    • 3.2.2.2.3 Activated charcoal
    • 3.2.2.2.4 Whole bowel irrigation (lavage)
  • 3.2.2.3 Ocular

• 3.2.3 Enhance Elimination Techniques

  • 3.2.3.1 Extracorporeal Removal
  • 3.2.3.2 Gastrointestinal Dialysis
  • 3.2.3.3 Urinary Approaches

3.3 Pharmacological Basis of Antidote Use

• 3.3.1 Antagonize Effects of Poison
  • 3.3.1.1 Enzyme Inhibitors (eg, physostigmine)
  • 3.3.1.2 Enzyme Reactivators (eg, pralidoxime)
  • 3.3.1.3 Physiological Antagonists (eg, calcium, glucagon)
  • 3.3.1.4 Receptor Antagonists (eg, atropine, flumazenil, naloxone)
  • 3.3.1.5 Reducing Agent (eg, methylene blue, N-acetylcysteine)
• 3.3.2 Dispositional Agents
  • 3.3.2.1 Alcohol Dehydrogenase Antagonists
  • 3.3.2.2 Antivenoms/Antibodies
  • 3.3.2.3 Chelators
  • 3.3.2.4 Cyanide Antidotes
  • 3.3.2.5 Enzyme/Cofactor Replacement (eg, folinic acid, pyridoxine)
  • 3.3.2.6 Oxygen/Hyperbaric Oxygen
• 3.3.3 Other Antidotes

3.4 Supportive and Other Care

• 3.4.1 Adjunctive Therapy (eg, granulocyte colony-stimulating factor)
• 3.4.2 Anticonvulsants
• 3.4.3 Antidysrhythmics
• 3.4.4 Control of Agitation
• 3.4.5 Control of Temperature
• 3.4.6 Correct Electrolyte and Acid-Base Disturbances
• 3.4.7 Critical Care Procedures (eg, arterial catheter and central line placement-
• 3.4.8 Fluid Resuscitation
• 3.4.9 Patient Monitoring
• 3.4.10 Pressor Agents and Control of Blood Pressure
• 3.4.11 Protect Airway/Ventilation/Manage Airway Injury
• 3.4.12 Psychiatric Issues
• 3.4.13 Social Issues
• 3.4.14 Transplantation
• 3.4.15 Rhabdomyolysis
• 3.4.16 Management of Anaphylaxis

3.5 Drug & Alcohol Syndromes

• 3.5.1 Alcohol
• 3.5.2 Opioid
• 3.5.3 Sedative-Hypnotic
• 3.5.4 Stimulant and Nicotine
• 3.5.5 Mixed Pattern

4.0 Assessment and Population Health

4.1 Criteria for Causal Inference

• 4.1.1 Biological Plausibility
• 4.1.2 Consistency
• 4.1.3 Dose-Response Relationship (biological gradient)
• 4.1.4 Specificity (of exposure or outcome)
• 4.1.5 Strength of Association
• 4.1.6 Temporal Relationship

4.2 Information

• 4.2.1 Consultation Resources (eg, databases, National Library of Medicine)
• 4.2.2 Surveys &Surveillance (eg, poison center data, National Report on Human Exposures

4.3 Monitoring

• 4.3.1 Biological Monitoring and Biomarkers (eg, population norms, indicators of excessive exposure)
• 4.3.2 Environmental Sampling/Exposure Monitoring

4.4 Occupational Assessment and Prevention

• 4.4.1 Medical Surveillance
• 4.4.2 Personal Protective Equipment
• 4.4.3 Preemployment Screening
• 4.4.4 Workplace Safety Engineering

4.5 Principles of Epidemiology and Statistics

• 4.5.1 Statistical Concepts (eg, interpretation of Pvalue, power calculation)
• 4.5.2 Study Design
  • 4.5.2.1 Basic Types (eg, case series, randomized controlled trial)
  • 4.5.2.2 Basics of Validity/Generalizability (eg, bias, confounding, randomisation
  • 4.5.2.3 Measurements (eg, sensitivity, predictive value, limits of detection)
  • 4.5.2.4 Measures of Association (eg, odds ratios)

4.6 Regional Poison Centers

• 4.6.1 Administration/Organization
• 4.6.2 Consultation at a Distance
• 4.6.3 Education
• 4.6.4 Prevention
• 4.6.5 Surveillance/Interaction With Other Professional Health Organizations
• 4.6.6 Triage

4.7 Response to Hazardous Materials (Hazmat) Incidents, Including Terrorism

• 4.7.1 Chemical Weapons Convention and Other Treaties
• 4.7.2 Decontamination (eg, patients and responders)
• 4.7.3 Incident Command System, Site Safety, and Control Zones
• 4.7.4 Incident Response Planning and Emergency Preparedness
• 4.7.5 National Pharmaceutical Stockpile: Deployment
• 4.7.6 National Response Team: Federal Agency Coordination
• 4.7.7 Regulatory and Legal Background (eg, Hazardous Waste Operations

4.8 Risk

• 4.8.1 Risk Assessment
  • 4.8.1.1 Carcinogenicity Testing
  • 4.8.1.2 Extrapolation From High to Low Dose
  • 4.8.1.3 Extrapolation of Animal Studies to Humans
  • 4.8.1.4 Human Epidemiological Studies in Risk Assessment
  • 4.8.1.5 Interpretation of Key Terms (eg, recommended exposure limit [REL])
  • 4.8.1.6 No Observed and Lowest Observed Adverse Effect Levels (NOAEL, LOAEL)
  • 4.8.1.7 Role of Risk Assessment in Formulating Regulations
  • 4.8.1.8 Target Risks (eg, 10 or 10 )
  • 4.8.1.9 “Uncertainty Factors” (reasons for them, approximate values)
• 4.8.2 Risk Perception and Risk Communication

4.9 Role of Federal and International Agencies in Toxicology

• 4.9.1 Agency for Toxic Substances and Disease Registry (ATSDR)
• 4.9.2 Centers for Disease Control and Prevention (CDC)
• 4.9.3 Consumer Product Safety Commission (CPSC)
• 4.9.4 Environmental Protection Agency (EPA)
• 4.9.5 Food and Drug Administration (FDA)
• 4.9.6 Health Resources and Services Administration (HRSA)
• 4.9.7 National Institute of Occupational Safety and Health (NIOSH)
• 4.9.8 Occupational Safety and Health Administration (OSHA)
• 4.9.9 World Health Organization (WHO)

4.10 Toxic Outbreaks of Historical Significance

5.0 Analytical and Forensic Toxicology

5.1 Assay Methods and Interpretation

• 5.1.1 Clinical Drug Testing
  • 5.1.1.1 Confirmatory Tests
    • 5.1.1.1.1 Atomic Absorption
    • 5.1.1.1.2 Gas Chromatography/Mass Spectrometry (GC/MS)
    • 5.1.1.1.3 High-Pressure Liquid Chromatography (HPLC)
  • 5.1.1.2 Screening Tests
    • 5.1.1.2.1 Gas Chromatography (GC)
    • 5.1.1.2.2 Immunoassays (eg, enzyme-multiplied immunoassay technique EMIT
    • 5.1.1.2.3 Colorimetric Tests (eg, color tests, thin layer chromatography)
  • 5.1.1.3 Serum/Blood Drug Levels and Interpretation
  • 5.1.1.4 Urine Drug Testing
    • 5.1.1.4.1 Interpretive Challenges (eg, benzodiazepines, opioids)
    • 5.1.1.4.2 Adulteration Techniques
    • 5.1.1.4.3 Analytical Limitations and Interferences
• 5.1.2 Hair Analysis
• 5.1.3 Laboratory Issues
  • 5.1.3.1 Point of Care Testing
  • 5.1.3.2 Quality Assurance/Quality Control
• 5.1.4 Special Toxicology Testing
  • 5.1.4.1 Heavy Metal Screens
  • 5.1.4.2 Cholinesterase Determinations
• 5.1.5 Therapeutic Drug Monitoring

5.2 Laboratory and Other Diagnostic Assessments

• 5.2.1 Anion Gap
• 5.2.2 Blood Gases and Co-oximetry
• 5.2.3 Electrolytes
• 5.2.4 Hematologic and Coagulation Abnormalities
• 5.2.5 Liver Function Tests
• 5.2.6 Osmolality
• 5.2.7 Renal Manifestations (eg, urine color, crystals)
• 5.2.8 Other Supportive Testing
  • 5.2.8.1 Diagnostic Imaging
  • 5.2.8.2 Electroencephalography
  • 5.2.8.3 Electrocardiography
  • 5.2.8.4 Electromyography/Nerve Conduction Studies

5.3 Forensics

• 5.3.1 Chain of Custody
• 5.3.2 Clandestine Laboratories
• 5.3.3 Definition and Scheduling of Controlled Substances
• 5.3.4 Interpretation of Postmortem Drug Levels
• 5.3.5 Necrokinetics
• 5.3.6 Selection of Postmortem Specimens
• 5.3.7 Special Issues
  • 5.3.7.1 Meconium
  • 5.3.7.2 Vitreous Humor

5.4 Legal Ethanol

• 5.4.1 Alcohol and the Law
• 5.4.2 Alcohol-Induced Psychomotor Impairment
• 5.4.3 Blood and Urine Alcohol Analysis
• 5.4.4 Breath Alcohol Analysis
• 5.4.5 Collection and Storage of Alcohol Specimens
• 5.4.6 Disposition of Alcohol
• 5.4.7 Saliva and Other Media

5.5 Medical Legal Issues (eg, role of expert witness)

5.6 Workplace Drug Test Interpretation

• 5.6.1 Cutoffs
• 5.6.2 Guidelines for Federal Workplace Drug Testing Programs
• 5.6.3 Role of Medical Review Officer (MRO)

6.0 POISONS CENTRE OPERATIONS

6.1 Guidelines for training poisons centre staff