Transcript
ANTIDOTES IN THE! EMERGENCY DEPARTMENT
Chris Nickson FACEM FCICM Intensivist, The Alfred ICU
Financial Conflicts of Interest NO !
http://litfl.org/CONCEPTOS
Objectives!
The role of antidotes in emergencies!
!The problem of antidote stocking!!
Tips, Tricks and Controversies!
THE ROLE OF ANTIDOTES !
Antidotes !correct the effects of
poisoning!
Antidote use is based on !risk-benefit analysis
Antidotes should !generally be!
titrated to effect
Consider transporting the antidote not the patient
ANTIDOTE STOCKING!
Antidote stocking is a!difficult problem
Dart et al (2009) PMID:19406507!
Atropine! Methylene blue!
Calcium! Naloxone!
Cyanide antidotes! Physostigmine!
Digoxin immune Fab! Pyridoxine!
Flumazenil! Sodium bicarbonate!
Glucagon!
Immediately available !
N-Acetylcysteine (NAC)!
Ethanol/!fomepizole!
Antivenoms! Octreotide!
Deferoxime! Potassium iodide!
Dimercaperol! Pralidoxime!
Available <60 minutes !
!!
Hospitals should perform!Vulnerability Assessments
ANTIDOTAL TIPS & TRICKS !
Know the nuances of!naloxone
Glucagon should be!glucaGONE
Flumazenil…!forget about it
Goodbye Cyanide kit…!Hello hydrocobalamin
Refractory seizures…!Think pyridoxine
Physostigmine !is your friend!
Know the key antidotes for cardiotoxic overdoses
resuscitating these patients, such as toxin redistribu-tion, enterohepatic recirculation and haemodialysis.These should ideally be considered in consultationwith a toxicologist. A flowchart representation of theextra-ordinary resuscitative measures in toxic cardiacarrest (or intractable drug-induced hypotension) isillustrated in Figure 1.
Prolonged resuscitation
Survival with completely normal neurological functionfollowing prolonged resuscitation in poisoned patientshas been reported, particularly in previously healthypatients.3,10–12 Continuing cardiac massage and promot-
ing end-organ perfusion until the toxin is clearedor redistributed from the intra-vascular compartmentand high blood flow organs allows the myocardiumto recover from temporary dysfunction related toextremely high myocardial tissue concentrations of therespective toxin.13 This has been reported particularly intricyclic antidepressant poisoning but might also betrue for b-receptor antagonist and calcium channelantagonist toxicity as well. Just as prolonged CPR isrecommended in hypothermic patients, it might be simi-larly warranted in toxic cardiac arrest, potentially for upto 4 h. Younger patients with no pre-existing medicalconditions might have a higher likelihood of survivalto hospital discharge and good neurologic outcome
Toxic cardiac arrest (or shock)
Early aggressive resuscitation:• ABC & ACLS protocols• Large bore intravenous access• Crystalloid fluid bolus/catecholamines• Early ECHO: pump vs vasoplegia• Consult Poisons Centre/Toxicologist
BB/CCB NCBD (or WCT) Antidoted toxin* LA agent
HIE NaHCO3 Antidote ILE
Consider:• Other Inotropes• ECMO• Haemodialysis• IABP• Cardiac pacing• Vasopressin/4-AP• ILE for lipophilic
All patients:• Optimise electrolytes
• ILE for lipophiliccardiac toxin
•• Maintain euglycaemia• Consider prolonged resuscitation• Maintain communication with
Poisons Centre/Toxicologist
Figure 1. Management flowchart. *Toxin with available antidote, e.g. natural toxin, digoxin, organophosphates. 4-AP,4-aminopyridine; BB, b-blocker; CCB, calcium channel blocker; ECMO, extra-corporeal membrane oxygenation; HIE, high-dose insulineuglycaemia; IABP, intra-aortic balloon pump; ILE, intravenous lipid emulsion; LA, local anaesthetic; NCBD, sodium channel blocker;WCT, wide complex tachycardia.
N Gunja and A Graudins
18 © 2011 The AuthorsEMA © 2011 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
Gunja (2011) PMID:21284810 !
HIET! 1U/kg insulin + 50mL D50W!
Digoxin immune Fab! Depends!!
NaHCO3! 1mmol/kg q3-5min!
Intralipid 20%! 1.5 mL/kg IV bolus!
Key cardiotoxic antidotes !
Antidotes are rarely used but can have an important
role
Antidote stocking!is a challenge
Know the nuances! and phone a friend!
http://litfl.org/CONCEPTOS
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