TOXICOLOGY An Overview Jordan B. Barnett, M.D., FACEP Jordan B. Barnett, M.D., FACEP Interim Director, Department of Interim Director, Department of Emergency Medicine Emergency Medicine Episcopal Hospital Episcopal Hospital
Dec 18, 2014
TOXICOLOGYAn Overview
TOXICOLOGYAn Overview
Jordan B. Barnett, M.D., FACEPJordan B. Barnett, M.D., FACEP
Interim Director, Department of Emergency Interim Director, Department of Emergency MedicineMedicine
Episcopal HospitalEpiscopal Hospital
POISONINGPOISONING
Estimated 4 Million AnnualPediatric
Child AbuseAdult
RecreationalSuicide
HISTORYHISTORY
What Poison?How Much?How?When?Why?What Else Taken?
PHYSICAL EXAMPHYSICAL EXAM
Vital SignsABC’sTemperature
Toxic Syndrome Respiratory Cardiovascular Neurologic
TREATMENTTREATMENT
ABC’s Treat Other Injuries Decontamination Supportive Care Definitive Care
AntidotesElimination
DECONTAMINATION: IPECACDECONTAMINATION: IPECAC
Absorption Reduced By 30% Interferes With Further
Decontamination Interferes With Further Treatment Home UseNO EMERGENCY DEPARTMENT
USE!
DECONTAMINATION:GASTRIC LAVAGEDECONTAMINATION:GASTRIC LAVAGE
250 - 300 cc Aliquots Of Fluid 36 - 40F Tube Advantages
Immediate Recovery Of Gastric ContentsDirect access For Charcoal Instillation
Left Lateral Decubitus With Trendelenburg
Intubation May Be Needed
DECONTAMINATION:GASTRIC LAVAGEDECONTAMINATION:GASTRIC LAVAGE
DisadvantagesNot Complete Gastric Emptying 30% Recovery At 1 HourLabor IntensiveComplications
3% Overall Esophageal Rupture Aspiration Hypoxia
DECONTAMINATION:CHARCOALDECONTAMINATION:CHARCOAL
Not Absorbed From GI Tract Binds Most Substances Prevents Absorption Enhance Excretion
Multiple DoseEnterohepatic Circulation
DECONTAMINATION:CHARCOALDECONTAMINATION:CHARCOAL
CharcoalCharcoalEmesisEmesisLavageLavage
57%57%
38%38%
32%32%
Ampicillin ModelDecreased Absorption
ACTIVATED CHARCOALACTIVATED CHARCOAL
Dose 1g/kgDose 1g/kg Repeat DoseRepeat Dose DisadvantagesDisadvantages
MessyMessy AspirationAspiration
SUBSTANCES NOT BOUND BY CHARCOALSUBSTANCES NOT BOUND BY CHARCOAL
Alcohols And Alcohols And GlycolsGlycols
CorrosivesCorrosives AlkalisAlkalis AcidsAcids
CyanideCyanide Saline CatharticsSaline Cathartics
Heavy MetalsHeavy Metals IronIron LeadLead LithiumLithium MercuryMercury
HydrocarbonsHydrocarbons
CATHARTICSCATHARTICS
Mechanism Types Mixture With Charcoal Disadvantages Use In Children
OTHER MODALITIESOTHER MODALITIES
Whole Bowel Irrigation IndicationsTechnique
Skin Eye
RESPIRATORY COMPLICATIONSRESPIRATORY COMPLICATIONS
Airway Protection Ventilatory Insufficiency Bronchospasm Noncardiogenic Pulmonary Edema Aspiration
CARDIOVASCULAR COMPLICATIONSCARDIOVASCULAR COMPLICATIONS
Tachycardia Bradycardia Hypotension Hypertension
NEUROLOGIC COMPLICATIONSNEUROLOGIC COMPLICATIONS
Coma Seizures Behavioral Abnormalities
DIAGNOSTIC STUDIESDIAGNOSTIC STUDIES
Drug Screens/Levels Acetaminophen ABG Electrolytes Organ Function EKG X-RAY
SERUM OSMOLARITYSERUM OSMOLARITY
Serum Osmolarity= 2 (Na+) + BUN/2.8 + Glucose/18
Osmolar Gap 10 mOsm or less Methanol, Ethylene Glycol, Ethanol Glycerol, Mannitol +ETOH/4.6
ETHANOLETHANOL
C2H5OH
Molecular Weight=________
DEFINITIVE CAREDEFINITIVE CARE
Decontamination Supportive Care Antidotes
Oxygen/Glucose/Narcan/?Flumazenil Elimination
AlkalinizationRepeated Dose Charcoal
Dialysis
DISCHARGEDISCHARGE
Stable In Emergency Department Psychiatric Issues
TOXIDROMETOXIDROME
Toxic Syndromes
TOXIDROMES: CASE 1TOXIDROMES: CASE 1
25 Year Old PA Student Just Back From Spring Break In Mexico. He's Been Having Terrible Diarrhea Since Returning and Has Been Using Pills to Alleviate the Symptoms.
TOXIDROMES: CASE 1TOXIDROMES: CASE 1
Dry Skin And Mucous Membranes Thirst Blurred Vision Fixed Dilated Pupils Flushing Urinary Urgency And Retention Hallucinations
TOXIDROMES: CASE 1TOXIDROMES: CASE 1
AnticholinergicHot As HadesBlind As A BatDry As A BoneRed As A BeetMad As A Hatter
TOXIDROMES: CASE 1TOXIDROMES: CASE 1
Belladonna AlkaloidsAtropine/ScopolamineScopolamine
Synthetic AnticholinergicsDicyclomine
OtherAntihistamines/Phenothiazines/TCA
TOXIDROMES: CASE 2TOXIDROMES: CASE 2
A 50 Year Old Farmer Is Found Unresponsive at His Barn.
TOXIDROMES: CASE 2TOXIDROMES: CASE 2
Sweating Constricted Pupils Lacrimation Excessive Salivation Wheezing Vomiting/Diarrhea Fasiculations
TOXIDROMES: CASE 2TOXIDROMES: CASE 2
Acetylcholinesterase Inhibitors Pesticides
OrganophosphateCarbamates
Mechanism Treatment
AtropinePralidoxime (2-PAM)
TOXIDROMES: CASE 3TOXIDROMES: CASE 3
An 8 Year Old Child Is Brought to the Emergency Department After Being Given a Compazine Suppository for Vomiting.
TOXIDROMES: CASE 3TOXIDROMES: CASE 3
Dysphonia Oculogyric Crises Rigidity Torticollis/Opisthotonos
TOXIDROMES: CASE 3TOXIDROMES: CASE 3
Extrapyramidal EffectsMedications
AntipsychoticAntiemetic
Treatment
TOXIDROMES: CASE 4TOXIDROMES: CASE 4
During a Visit to Grandma in the Nursing Home, You Find That You Can Not Wake Her Up.
TOXIDROMES: CASE 4TOXIDROMES: CASE 4
CNS DepressionPinpoint PupilsSlowed RespirationsHypotension
TOXIDROMES: CASE 4TOXIDROMES: CASE 4
NarcoticNarcoticMedicationsMedications
PrescribedPrescribedIllicit
TreatmentTreatment
TOXIDROMES: CASE 5TOXIDROMES: CASE 5
A Movie Star Presents to Your Hospital.
TOXIDROMES: CASE 5TOXIDROMES: CASE 5
CNS ExcitationSeizuresHypertensionTachycardia
TOXIDROMES: CASE 5TOXIDROMES: CASE 5
SympathomimeticMedication
PrescribedIllicit
Treatment
TOXIDROMES: CASE 6TOXIDROMES: CASE 6
A Family of 6 Presents to Your Office in the Middle of Winter and All Complain of “the Flu”.
TOXIDROMES: CASE 6TOXIDROMES: CASE 6
Headache “Flu” Symptoms Nausea, Vomiting, Dizziness Dyspnea Seizures Death Cyanosis “Chocolate” Blood
TOXIDROMES: CASE 6TOXIDROMES: CASE 6
HemoglobinopathiesCarbon MonoxideMethemoglobinTreatment
TRICYCLIC ANTIDEPRESSANTSTRICYCLIC ANTIDEPRESSANTS
Mortality 2 - 5 PercentLow Therapeutic/Toxic RatioMechanism
Inhibition Of Amine UptakeAnticholinergicAlpha Receptor BlockerSodium Channel Blockade
TCACLINICAL FEATURESTCACLINICAL FEATURES
Anticholinergic SymptomsTachycardiaCNS ToxicityComaHypotensionArrhythmiaSeizures
TCACLINICAL FEATURESTCACLINICAL FEATURES
ECG“right axis deviation of the terminal
40ms of QRS greater than 1200 “Sinus Tach-Wide QRS-Decreased
Inotropy-Increased PRI-BradycardiaWide QRS=Life Threatening Toxicity
TCATREATMENTTCATREATMENT
GI Decontamination Sodium Bicarbonate-Indications
QRS WideningHypotensionVentricular Arrhythmias
Sodium Bicarbonate-Mechanism 1 - 2 mEq/Kg To pH 7.50-7.55
TCATREATMENTTCATREATMENT
PhysostigminePeripheral Anticholinergic SymptomsAgitation/Seizures/Hypotension When
Other Methods FailSide Effects
SeizuresBenzodiazepines/Barbiturates
Hypotension
SALICYLATESSALICYLATES
Gastroenteritis Mixed Respiratory And Metabolic
Acidosis CNS Cardiac Toxicity Pulmonary
ARDS Tinnitus
SALICYLATESTOXIC DOSESALICYLATESTOXIC DOSE
Done Nomogram Acute, Single Ingestion Cannot Use For:
Acute Ingestion With Salicylate Taken Within Last 24 Hours
Chronic Salicylate Poisoning Ingestion Of Enteric Coated Tablets
Treat Patient If Symptomatic
SALICYLATESTREATMENTSALICYLATESTREATMENT
Charcoal IV Fluids Urine Alkalinization
Mechanism “Ion Trapping”Un-ionized Salicylate Reabsorbed By Renal
TubulesAlkaline Urine Favors Ionized Salicylate
Which Cannot Be Reabsorbed Dialysis
SALICYLATESDISPOSITIONSALICYLATESDISPOSITION
Asymptomatic Nomogram After 6 Hours
Patient Asymptomatic Enteric Coated
150 mg/kg Psychiatric Evaluation Follow-up