Clinical Series

Chapter 145 , Rosen 7th edition

TOX JEOPERDY TOX JEOPERDY

GeneralGeneral ToxidromToxidromee

DecontaminationDecontamination OdorOdor

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100 100 100 100 100

200 200 200 200 200

300 300 300 300 300

500 500 500 500

True of FalseTrue of False Hypoglycemia must always be considered

in a patient with altered mental status or seizures

Empiric administration of hypertonic glucose solution should be given in every AMS pt

Naloxone can be given to patients with respiratory depression

Flumazenil is indicated in an undifferentiated overdose patient with decreased LOC

Thiamine should be administered when dextrose is given to nutritionally compromised patients altered mental status

True of FalseTrue of False Hypoglycemia must always be considered

in a patient with altered mental status or seizures

Empiric administration of hypertonic glucose solution should be given in every AMS pt

Naloxone can be given to patients with respiratory depression

Flumazenil is indicated in an undifferentiated overdose patient with decreased LOC

Thiamine should be administered when dextrose is given to nutritionally compromised patients altered mental status

OBTAINING AN OVERDOSE HISTORYOBTAINING AN OVERDOSE HISTORY

  ▪    Obtain all prescription bottles and other containers when possible. Perform a pill

count. Be sure that the bottles contain the medications listed. Identify any unknown tablets.

▪    Contact the prescribing physician(s) or the pharmacy as listed on the bottles to determine previous overdoses or other medications that the patient may have available. Identify underlying medical and psychiatric disorders and medication allergies. Review past medical records.

▪    Talk to the patient's family and friends in the emergency department. If necessary, call the patient's home to ask questions of others. The persons providing the important elements of the history should be identified in the chart.

  ▪    Search the patient's belongings for drugs or drug paraphernalia. A single pill

hidden in a pocket, for example, may provide the most important clue to the diagnosis.

▪    Have family members (or the police) search the patient's home, including the medicine cabinet, clothes drawers, closets, and garage: such searches may also provide clues that make the diagnosis. This has the added benefit of involving the family in the patient's care.

  ▪    Always look for track marks on the patient. Consider body packing or body

stuffing.

In the pupillary examination In the pupillary examination of the poisoned patient :of the poisoned patient :Fentanyl, propoxyphene and

pentazocine are opioid agonist which are strongly suggested by Miosis.

Dilated pupils are seen in cholinergic overdose.

Mydriasis is a hallmark sign to differentiate between sympathomemtics and anticholinergics overdose.

in anticholinergic toxidrome, dilated pupils support the diagnosis.

In the pupillary examination In the pupillary examination of the poisoned patient :of the poisoned patient :Fentanyl, propoxyphene and

pentazocine are opioid agonist which are strongly suggested by Miosis.

Dilated pupils are seen in cholinergic overdose.

Mydriasis is a hallmark sign to differentiate between sympathomemtics and anticholinergics overdose.

In anticholinergic toxidrome, dilated pupils support the diagnosis.

ALL ARE TOXINS CAUSING ALL ARE TOXINS CAUSING DELIRIUM EXCEPT DELIRIUM EXCEPT SalicylatesSeleniumSolventsSteroidsSympathomimetics

ALL ARE TOXINS CAUSING ALL ARE TOXINS CAUSING DELIRIUM EXCEPT DELIRIUM EXCEPT SalicylatesSeleniumSolventsSteroidsSympathomimetics

Toxins and Odor Toxins and Odor Wintergreen

Toxins and Odor Toxins and Odor

Toxins and Odor Toxins and Odor

Toxins and Odor Toxins and Odor

Toxins and Odor Toxins and Odor

Toxins and Odor Toxins and Odor

Toxins and Odor Toxins and Odor

Rotten eggs ,4

Toxins and Odor Toxins and Odor

Rotten eggsDisulfiram hydrogen sulfideN-acetylcysteinedimercaptosuccinic acid (DMSA)

Toxins and Odor Toxins and Odor

Shoe polishBitter almondsFruityPearsCarrots

Toxins and Odor Toxins and Odor

Shoe polish: NitrobenzeneNitrobenzeneBitter almonds : Cyanide: CyanideFruity : Ethanol, acetone, isopropyl Ethanol, acetone, isopropyl

alcohol, chlorinated hydrocarbons (e.g., alcohol, chlorinated hydrocarbons (e.g., chloroform)chloroform)

Pears : Chloral hydrate, paraldehyde: Chloral hydrate, paraldehydeCarrots : Water hemlock (cicutoxin)Water hemlock (cicutoxin)

ToxidromesToxidromesanticholinergic syndrome

At least 5 signs or symptoms3 causes

ToxidromesToxidromesanticholinergic syndrome

Common signs

Delirium with mumbling speech, tachycardia, dry flushed skin, dilated pupils, myoclonus, slightly elevated temperature, urinary retention, decreased bowel sounds. Seizures and dysrhythmias may occur in severe cases.

Common causes

Antihistamines, antiparkinsonians, atropine, scopolamine, amantadine, antipsychotics, antidepressants, antispasmodics, mydriatics, muscle relaxants, many plants (e.g., jimson weed, Amanita muscaria)

ToxidromesToxidromessympathomimetic syndrome

◦At least 5 signs or symptoms ◦At least 5 causes

ToxidromesToxidromessympathomimetic syndrome

Common signs

Delusions, paranoia, tachycardia (or bradycardia with pure alpha-agonists), hypertension,

hyperpyrexia, diaphoresis, piloerection, mydriasis, hyper-reflexia. Seizures, hypotension, and dysrhythmias may occur in severe cases.

Common causes

Cocaine, amphetamine, methamphetamine and its derivatives, over-the-counter decongestants

(phenylpropanolamine, ephedrine, pseudoephedrine). In caffeine and theophylline

overdoses, similar findings, except for the organic psychiatric signs, result from catecholamine

release.

ToxidromesToxidromescholinergic syndrome

◦At lease 7 signs or symptoms◦At least 5 causes

ToxidromesToxidromescholinergic syndrome

Common signs

Confusion, central nervous system depression, weakness, salivation, lacrimation, urinary/fecal incontinence, gastrointestinal cramping, emesis, diaphoresis, muscle fasciculations, pulmonary edema, miosis, bradycardia/tachycardia, seizures

Common causes

Organophosphate and carbamate insecticides, physostigmine, edrophonium, some mushrooms

ToxidromesToxidromesSerotonin syndrome

◦At least 7 signs or symptoms ◦At least 5 medications

ToxidromesToxidromesSerotonin syndrome

Common signs

altered mental status, fever, agitation, tremor, myoclonus, hyper-reflexia, ataxia, incoordination, diaphoresis, shivering, and sometimes diarrhea

Common causes

Fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), and citalopram (Celexa) are commonly used SSRIs. venlafaxine (Effexor), nefazodone (Serzone), and mirtazapine (Remeron).

About Gastric About Gastric decontaminationdecontaminationTrue / False ?True / False ?It has great affect on clinical outcome

and thus should be done routinely in undifferentiated poisoned patient.

Children with accidental ingestion has a fatality rate of 2.5% and gastric Decontamination is reduce it to about 0.5 %

Decontamination with activated charcoal (AC) has been proven to improve outcome in specific poisoning

NGT is mandatory in all oral ingestion poisoned patient

About Gastric About Gastric decontaminationdecontaminationTrue / False True / False It RARELY affect on clinical outcome and

should be done NOT routinely in undifferentiated poisoned patient.

Children with accidental ingestion rarely consume enough drug to cause symptoms, and the fatality rate for those cases is less than 0.0025%

Decontamination with activated charcoal (AC) has NOT been proven to improve outcome in specific poisoning

If a nasogastric tube is required, it should be used selectively and with caution, if at all

About AC ?About AC ?50 g of an oral slurry of AC is

sufficientIn uncooperative patients, AC

should be given after Intubation.Sorbitol is not recommended Agents adsorb to charcol, once

given, has lesser toxicity and improved outcome compared to when AC is not given.

About AC ?About AC ?50 g of an oral slurry of AC is

sufficientIn uncooperative patients, AC

should be given after Intubation.Sorbitol is not recommendedAgents adsorb to charcol, once

given, does not equate to lesser toxicity and improved outcome.

All of the following agents All of the following agents doesn’t bind to Charcol / doesn’t bind to Charcol / EXCEPT?EXCEPT?LithiumIronEthanolBromideHydrocarbons

All of the following agents All of the following agents doesn’t bind to Charcol / doesn’t bind to Charcol / EXCEPT?EXCEPT?LithiumIronEthanolBromideHydrocarbons

About Whole-bowel irrigation About Whole-bowel irrigation usageusagesevere, recent ingestion of

lithium or metalsin patients with ingestion of

sustained-release formulations of highly toxic drugs

Should be encouraged to be done routinely

in the evacuation of drug packets from body packers

About Whole-bowel irrigation About Whole-bowel irrigation usageusagesevere, recent ingestion of

lithium or metalsin patients with ingestion of

sustained-release formulations of highly toxic drugs

should be considered only after consultation with a toxicologist

in the evacuation of drug packets from body packers

In Gastric lavage / all are In Gastric lavage / all are true EXCEPT?true EXCEPT?indicated and should be

considered only when a patient is seen < 2 hours

Is indicated with ingestion of a highly toxic substance like CCB

Is not indicated in undifferentiated poisoned patient

large (30-F or greater) orogastric tube is used

In Gastric lavage / all are In Gastric lavage / all are true EXCEPT?true EXCEPT?indicated and should be

considered only when a patient is seen < 1 hours

Is indicated with ingestion of a highly toxic substance like CCB

Is not indicated in undifferentiated poisoned patient

large (30-F or greater) orogastric tube is used

What is the antidote and its What is the antidote and its dose for ? dose for ? mercury

What is the antidote and its What is the antidote and its dose for ? dose for ? Mercury :

◦BAL, British anti-Lewisite◦3–5 mg/kg IM only◦Also for Arsenic and lead

What is the antidote and its What is the antidote and its dose for ? dose for ? Lead

What is the antidote and its What is the antidote and its dose for ? dose for ? Lead

DMSA dimercaptosu

ccinic acid(succimer)

Reported useful for arsenic and lead as well; one 100-mg capsule per 10-kg body weight tid for 1 wk, then bid, with chelation breaks

EDTAEthylenediam

inetetra- acetic acid

75 mg/kg/day by continuous infusion; watch for nephrotoxicity, best done in hospital

What is the antidote and its What is the antidote and its dose for ? dose for ? Organophosphates and

carbamates

What is the antidote and its What is the antidote and its dose for ? dose for ? Organophosphates and

carbamatesAtropine

Test dose, 1–2 mg IV in adults, 0.03 mg/kg in children; titrate to drying of pulmonary secretions

Protopam

Loading dose, 1–2 g IV in adults, 25–50 mg/kg in children; adult maintenance, 500 mg/hr or 1–2 g q4–6h

What is the antidote and its What is the antidote and its dose for ? dose for ? Methemoglobin-forming agents

What is the antidote and its What is the antidote and its dose for ? dose for ? Methemoglobin-forming agents

Methylene blue

1–2 mg/kg IV, one 10-mL dose of 10% solution (100 mg) is typical for an adult without anemia

What is the antidote and its What is the antidote and its dose for ? dose for ? Black widow spider bite

What is the antidote and its What is the antidote and its dose for ? dose for ? Black widow spider bite

Latrodectus antivenin

One vial by slow IV infusion is usually curative; may cause

anaphylaxis

A toxicology screen rarely results in identification of the ingested agent.

Give Reasons? 3

1. the laboratory does not attempt to screen for many substances

2. the urine screen is often performed soon after the ingestion, when the drug concentration is too low for a positive result and Some present briefly

3. drugs found on screening may not be those responsible for the initial symptoms, especially if the drugs are not quantified. Some lasts for days and weeks.

In Tox. Screen / True or In Tox. Screen / True or False False urine examination may helpful in a

persistent, unexplained metabolic acidosis

Normal ABG results R/O methanol poisoning.

urine examination is mandatory for unresponsive for a prolonged period of time

Radiography has little role in the evaluation of chloral hydrate ingestion.

In Tox. Screen / True or In Tox. Screen / True or False False urine examination may helpful in a

persistent, unexplained metabolic acidosis

Normal ABG results R/O methanol poisoning.

urine examination is mandatory for unresponsive for a prolonged period of time

Radiography has little role in the evaluation of chloral hydrate ingestion.

Following are Radiopaque Following are Radiopaque Drugs Except: Drugs Except: Ironlead HydrochlorothiazidePotassium calcium

Following are Radiopaque Following are Radiopaque Drugs Except: Drugs Except: Ironleadphenothiazines Potassium calcium

What is the antidote of What is the antidote of Valproic acid ? What is the Valproic acid ? What is the dose of it ?dose of it ?

What is the antidote of What is the antidote of Valproic acid ? What is the Valproic acid ? What is the dose of it ?dose of it ?Valproic acidCarnitine100 mg/kg IV or PO loading dose

with 25 mg/kg q6h