Toxicology Transition to critical care
ToxicologyTransition to critical care
The CallAmbulance is transporting a 16 year old girl found unresponsive at home. Moans to light pain stimuli.
Color pink. HR 60 RR12 BP 110 / 50 spo2 93% on room air.
Parents saw her last night at 2400 when she came home after going out with friends
ETA – 10 min
"All substances are poisons; there is none that is not a poison. The right dose differentiates a poison from a remedy." Paracelsus (1493–1541)
Toxic exposures are a common cause of ED visits
2008 – ED saw 2,000 people / day from poisoning
Estimated annual poisonings or drug overdoses = 4.5 million
2/3 of toxic exposures reported involve children
ENO
Management
Provide continuous respiratory and hemodynamic support
Patient safety
Evaluate the potential for toxicosis
Intervene to reduce toxin absorption and promote its excretion
Provide substance-specific therapy, including antidote administration
What Questions do you need to ask?
Discuss with neighbor and determine at least 4 important questions
Poison Control
Initial
Follow - up
LAB?
Toxidrome
A constellation of signs and symptoms that suggest a type of toxin
Ways to remember a toxidrome
Toxidrome handoutGoogle toxidrome and find a toolWord cluesSymptom Clues
Google toxidrome to find one you like
Toxidrome Clues Anticholinergic: Blind as a bat, mad as a hatter, red as a
beet and dry as a bone
Cholinergic: DUMBELS- defication, urination, miosis, bronchospasm, emesis, lacrimation, sedation
Alcohol: hypothermia
Barbiturates: barb blisters
Pulmonary edema: aspirated hydrocarbon, ethyl glycol, ASA,
Gum discoloration: lead arsenic, Vitamin A
Sympathomimetic
Illegal street drug
CocaineAmphetaminesMeth
LSDOver the counter cold agentsAlbuterol, dopamine, tricyclic antidepressants MOA
inhibitors
Pharmacologic agents to reduce temperature will be ineffective
Cholinergic
PesticidesOrganophosphorus warfare – Sarin Soman Tuban
PilocarpineBethenecholSome mushrooms
Control hypoxiaAtropinePralidoxime (2PAM) soon after exposureBenzo - seizures
Anti Cholinergics
AtropineScopolamineAtroventAntiparkinson drugs Plants – Jimson weed, nightshade, leaves of potato plant
Physostigmine – is the cholinergic agent Give slow IV push
Treatment
Treatment
GI decontaminationCharcoal or binding agentsWhole Bowel irrigationLavage
Dermal DecontaminationEnhance EliminationAntidotes
LavageTo lavage or not – That is the question
Syrup of ipecac
Yes or No?
Activated Charcoal
GI decontamination is the preferred treatment
Prevents entry into enterohepatic circulation
Effective alone or in combination with other therapy
Thoughts on administration?
Charcoal
Complications
Absolute contraindication
Repeated dose therapy
Charcoal doesn’t work PotassiumAcidsAlkalineEthanolCyanideFeLeadLithium
Whole Bowel Irrigation
When not bound to charcoalFor sustained release or enteric
coated Toxic substances such as balloons etc
Give PEG solution (goLytely or clolyte solution)
Dermal or optic decontaminationProcedure – lets practice
Enhance Elimination
Alkalinization – goal of urine pH 7.5 – 8
Hemodialysis
CAVH – hemofiltration
Cathartics - Mag Citrate or Sorbitol– electrolyte imbalance, GI discomfort, cramping
AntidotesSee hand out
Specific situations
Toxicology Cases