Table of Contents

1.0 Principles of Toxicology


1.1 Pharmacology/Toxicology





  • 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)
  • 1.1.9 organ toxicity
  • 1.1.9.1 renal toxicity

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


1.4.2 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

  • 1.4.4 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



  • 2.1.2 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



  • 2.1.8 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


  • 2.1.12 Pharmaceutical Additives (eg, excipients)
  • 2.1.13 Veterinary Products



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)


  • 2.2.3 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




  • 2.2.8 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)


  • 2.2.10 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



  • 2.3.2 Fungi
    • 2.3.2.1 Mushrooms
    • 2.3.2.2 Other Fungal Toxins (eg, aflatoxins, trichothecene mycotoxins)




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


3.2 Initial Management


3.3 Pharmacological Basis of Antidote Use



  • 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

3.4 Supportive and Other Care


3.5 Drug & Alcohol Syndromes



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



4.3 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