1 Poisonings/ Overdose. 2 Introduction Poisoning- Exposure to substance that is toxic in any amount...

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Poisonings/Poisonings/OverdoseOverdose

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IntroductionPoisoning- Exposure to substance that is toxic in any amount

• approx 775 fatalities annually• 0.03% of total exposures• ages 20 - 49 years = 56%• >6 years = 2.1%

•Exposures by Age:• < 6 years old 52.7%• < 3 years old 39.6%

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Management Location

• Managed on site 75.2%

• Treated, released at ER 12.3%

• Admitted to critical care 2.7%

• Refused referral 2.0%

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Therapy

• No therapy 11.9%

• Observation only 12.7%

• Decontamination only 59.6%

• Activated charcoal 6.8%

• Ipecac 1.2%

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Most Common Substances

• Cleaning substances 10.2%

• Analgesics 9.6%

• Cosmetics 9.4%

• Plants 5.5%

• Foreign bodies 4.6%

• Cough, cold 4.5%

• Bites, stings 4.1%

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Most Common Substances

• Insecticides, pesticides, rodenticides 3.9%

• Sedative, hypnotics, antipsychotics 3.2%• Antidepressants 3.0%• Hydrocarbons 3.0%• Alcohols 2.5%

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Largest Number of Deaths

• Analgesics 264

• Antidepressants 152

• Stimulants, street drugs 118

• Cardiovascular medication 118

• Sedatives, hypnotics 89

• Alcohols 56

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Indicators

• Sudden onset of CNS signs:• Seizures• Coma• Decreased LOC• Bizarre behavior

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Indicators

• Sudden onset of:• Abdominal pain• Nausea• Vomiting

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Indicators

• Sudden onset of unexplained illness• Bizarre, incomplete, evasive history• Trauma • (>50% of adult trauma alcohol, drug-related)• Pediatric patient with arrhythmias

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History

• What?• How much?• How long?• Multiple substances?• Treatment attempted? How? Whose

advice?• Psychiatric history?• History of suicide?

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General Management

• Support ABC’s• Secure airway, intubate as needed• Ensure adequate oxygenation, ventilation• Maintain adequate circulation

• Monitor ECG• Obtain vascular access• Manage hypotension initially with volume• Use vasopressors cautiously

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General Management

• Keep patient calm • Maintain normal body temperature• Evaluate nature/toxicity of poison

• Check container, package insert, poison center information

• Treat the patient, not the poison

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General Management

• Rule out • Trauma

• Neurological disease

• Metabolic disease

• Base general management on route of poison entry

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Poison Entry

• Ingestion

• Slow movement from injection site throughout body

• Remove from skin surfaceRemove from skin surface

• Remove from exposure; Support Remove from exposure; Support oxygenation, ventilationoxygenation, ventilation

• Prevent absorption from GI tractPrevent absorption from GI tract

• InhalationInhalation

• AbsorptionAbsorption

• InjectionInjection

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Ingested Poison Management

Ipecac

• RARELY used anymore

• If used, has to have been initiated within few minutes after ingestion

• Vomiting in 20-30 minutes

• Only removes about 32% of contaminate

• Many contraindications

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Ipecac

• Dose• 15 cc if 12 months to 12 years old• 30 cc if >12 years old

• Follow with 2-3 glasses of water

• Keep patient ambulatory if possible

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Ipecac

• If no vomiting after 20 minutes, repeat

• When emesis occurs, keep head down

• Collect, save vomitus for analysis

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Ipecac • Contraindications

• Comatose or no gag reflex• Seizing or has seized• Caustic (acid or alkali) ingestion• Low viscosity hydrocarbon ingestion• Late term pregnancy• Severe hypertension, cardiovascular insufficiency, possible AMI• Ingestion of:

• Strychnine• Phenothiazines (Thorazine, Stellazine, Compazine)• Tricyclic antidepressants• Iodides• Silver Nitrate

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Lavage

• Commonly used in ED’s

• Removes about 31% of substance

• Helps get activated charcoal in patient, especially if patient is unconscious

• Not helpful for sustained release tablets

• Will not remove large tablets

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Activated Charcoal

• Adsorbs compounds, prevents movement from GI tract

• Very effective at adsorbing substances

• Binds about 62% of toxin

• Dose• 5 - 10X estimated weight of ingested chemical

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Activated Charcoal

• Inactivates Ipecac

• Do not give until vomiting stops

• Do not give with • Cyanide• Methanol• Tylenol (+)

• Containers must be kept airtight

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Inhaled Poison Management

Objective: Move to fresh air; optimize ventilation and protect yourself and other personnel from exposure

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Absorbed Poison Management

Objective: Remove poison from skin

Liquid: Wash with copious amounts of water

Powder: Brush off as much as possible, then wash with copious amounts of water

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Absorbed Poison Management

Dilute / Irrigate / Wash

• Use soap, shampoo for hydrocarbons

• No need for chemical neutralization - heat produced by reaction could be harmful

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Eye Irrigation

• Wash for 15 minutes

• Use only water or balanced salt solutions

• Remove contact lenses

• Wash from medial to lateral

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Drug AbuseDrug Abuse

•Definition: Self administration of drug or Definition: Self administration of drug or drugs in manner not in accord with drugs in manner not in accord with accepted medical or social patternsaccepted medical or social patterns

•Psychological Dependency (Habituation)Psychological Dependency (Habituation)•Drug necessary to maintain user’s sense of well-Drug necessary to maintain user’s sense of well-beingbeing

•Physical DependencyPhysical Dependency•Physical symptoms if intake reducedPhysical symptoms if intake reduced

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Drug AbuseDrug Abuse• Compulsive Drug UseCompulsive Drug Use

• Preoccupation with obtaining drugPreoccupation with obtaining drug• Rituals of preparing, using drug as important as drug effectsRituals of preparing, using drug as important as drug effects

• ToleranceTolerance• Increasing doses needed to obtain drug effectIncreasing doses needed to obtain drug effect

• AddictionAddiction• IncludesIncludes

• Psychological dependencePsychological dependence• Physical dependencePhysical dependence• Compulsive useCompulsive use• ToleranceTolerance

• Plus, complete absorption with obtaining, using drug to exclusion Plus, complete absorption with obtaining, using drug to exclusion of all elseof all else

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Drug AbuseDrug Abuse

• Suspect drug-related problem in patients with:Suspect drug-related problem in patients with:• Altered LOCAltered LOC

• Bizarre behaviorBizarre behavior

• SeizuresSeizures

• Ask Ask EVERYEVERY patient about recreational drugs. patient about recreational drugs.• Be non-judgmental.Be non-judgmental.• Keep drug box/cabinet secured.Keep drug box/cabinet secured.• Use discretion.Use discretion.

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NarcoticsNarcotics

• OpiumOpium

• Opium derivativesOpium derivatives

• Synthetic opium substitutesSynthetic opium substitutes

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NarcoticsNarcotics

• ExamplesExamples• OpiumOpium

• MorphineMorphine

• HeroinHeroin

• CodeineCodeine

• DilaudidDilaudid

• Oxycodone (Percodan)Oxycodone (Percodan)

• Meperidine (Demerol)Meperidine (Demerol)

• Propoxyphene (Darvon)Propoxyphene (Darvon)

• TalwinTalwin

• FentanylFentanyl

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NarcoticsNarcotics

• EffectsEffects• AnalgesiaAnalgesia• CNS depressionCNS depression

• EuphoriaEuphoria

• DrowsinessDrowsiness

• ApathyApathy

• Antidiarrheal actionAntidiarrheal action• Antitussitive actionAntitussitive action

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NarcoticsNarcotics

• OverdoseOverdose• Mild to ModerateMild to Moderate

• LethargyLethargy

• Pinpoint pupilsPinpoint pupils

• BradycardiaBradycardia

• HypotensionHypotension

• Decreased bowel Decreased bowel soundssounds

• Flaccid musclesFlaccid muscles

• SevereSevere• Respiratory depressionRespiratory depression

• ComaComa

• AspirationAspiration

• Seizures with certain Seizures with certain compounds compounds (meperidine, (meperidine, propoxyphene, propoxyphene, tramadol)tramadol)

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NarcoticsNarcotics• OverdoseOverdose

• ManagementManagement• Support oxygenation/ventilationSupport oxygenation/ventilation• Vascular accessVascular access• D50W 50ccD50W 50cc• Narcan 0.4 to 2.0 mgNarcan 0.4 to 2.0 mg

• Improve respirationsImprove respirations• Do Do NOTNOT awaken completely awaken completely• Restrain before givingRestrain before giving

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NarcoticsNarcotics

• Associated DangersAssociated Dangers• Skin abscessesSkin abscesses

• PhlebitisPhlebitis

• SepsisSepsis

• HepatitisHepatitis

• HIVHIV

• EndocarditisEndocarditis

• Adulterant toxicityAdulterant toxicity

• ““Cotton fever”Cotton fever”

• MalnutritionMalnutrition

• TetanusTetanus

• MalariaMalaria

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NarcoticsNarcotics• Withdrawal:Withdrawal:

• Lasts 7 to 10 daysLasts 7 to 10 daysNOTNOT life threatening life threatening

• InsomniaInsomnia• RestlessnessRestlessness• IrritabilityIrritability• AnorexiaAnorexia• TremorsTremors• Back, extremity painBack, extremity pain

• Watery eyesWatery eyes• YawningYawning• RhinorrheaRhinorrhea• SneezingSneezing• DiarrheaDiarrhea• DiaphoresisDiaphoresis

Resembles Severe Influenza

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Sedative-HypnoticsSedative-Hypnotics

• Categories Categories • BarbituratesBarbiturates• BenzodiazepineBenzodiazepine• Barbiturate-like non-barbituratesBarbiturate-like non-barbiturates• Chloral hydrateChloral hydrate

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• Mechanism of Action Mechanism of Action • Most overdoses of sedative-hypnotics are from Most overdoses of sedative-hypnotics are from

benzodiazepines, barbituratesbenzodiazepines, barbiturates• Both enhance effects of gamma-aminobutyric Both enhance effects of gamma-aminobutyric

acid (GABA)acid (GABA)• GABA enhancement results in down-regulation GABA enhancement results in down-regulation

of CNS activityof CNS activity

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Sedative-Hypnotics Sedative-Hypnotics

• Use more then a week leads to tolerance to Use more then a week leads to tolerance to effects on sleep patternseffects on sleep patterns

• Withdrawal after long term results in Withdrawal after long term results in “rebound” increase in frequency of “rebound” increase in frequency of occurrence, duration of REM sleep.occurrence, duration of REM sleep.

• In high doses, sedative-hypnotics depress In high doses, sedative-hypnotics depress CNS to point of Stage III or general CNS to point of Stage III or general anesthesiaanesthesia

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• ToleranceTolerance• Happens with all sedative-hypnoticsHappens with all sedative-hypnotics• Appears very quickly even during short-term Appears very quickly even during short-term

use.use.• Discontinuation will bring receptor response Discontinuation will bring receptor response

back to normal after drug has been back to normal after drug has been metabolizedmetabolized

• Withdrawal symptoms may take up to a week Withdrawal symptoms may take up to a week to see in some patientsto see in some patients

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Chloral hydrateChloral hydrate

• ““Micky Finn” when mixed with alcoholMicky Finn” when mixed with alcohol

• Rapidly absorbed, acts quicklyRapidly absorbed, acts quickly

• Drowsiness, sleepDrowsiness, sleep

• Alcohol, chloral hydrate compete for Alcohol, chloral hydrate compete for metabolism by same enzymemetabolism by same enzyme

• Prolonged action for both when mixedProlonged action for both when mixed

• Not commonly abusedNot commonly abused

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BarbituratesBarbiturates

• Introduced in 1903Introduced in 1903

• Replaced older sedative-hypnoticsReplaced older sedative-hypnotics

• Quickly became major health problemQuickly became major health problem

• In 1950’s-60’s barbiturates were implicated In 1950’s-60’s barbiturates were implicated in overdoses; were responsible for majority in overdoses; were responsible for majority of drug-related suicidesof drug-related suicides

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• Short-actingShort-acting• AmytalAmytal• PentathiolPentathiol

• Intermediate-actingIntermediate-acting• NembutalNembutal• SeconalSeconal• TuinalTuinal

• Long-actingLong-acting• PhenobarbitalPhenobarbital

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Barbiturates Barbiturates

• Initial overdose presentation Initial overdose presentation • Slurred speechSlurred speech• AtaxiaAtaxia• Lethargy Lethargy • NystagmusNystagmus• Headache Headache • ConfusionConfusion

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• As overdose progressesAs overdose progresses• Depth of coma increasesDepth of coma increases

• Patient anesthetized with loss of neurologic functionPatient anesthetized with loss of neurologic function• EEG may mimic brain deathEEG may mimic brain death

• Respiratory depression occursRespiratory depression occurs• Peripheral vasodilation occursPeripheral vasodilation occurs

• Hypotension, shockHypotension, shock• HypothermiaHypothermia

• Blisters (bullae) form on skinBlisters (bullae) form on skin

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• Early deathsEarly deaths• Respiratory arrestRespiratory arrest• Cardiovascular collapseCardiovascular collapse

• Delayed deathsDelayed deaths• Acute renal failureAcute renal failure• PneumoniaPneumonia• Pulmonary edemaPulmonary edema• Cerebral edema Cerebral edema

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• Overdose managementOverdose management• Secure airwaySecure airway• Support oxygenation/ventilationSupport oxygenation/ventilation• IV with LR or NSIV with LR or NS• Prevent heat loss secondary to vasodilationPrevent heat loss secondary to vasodilation• Bicarbonate to alkalinize urine (long-acting Bicarbonate to alkalinize urine (long-acting

only)only)

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• Withdrawal signs/symptomsWithdrawal signs/symptoms• ApprehensivenessApprehensiveness• AnxietyAnxiety• TremulousnessTremulousness• DiarrheaDiarrhea• NauseaNausea• VomitingVomiting• SeizuresSeizures

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Barbiturate-like, non-barbituratesBarbiturate-like, non-barbiturates

• ExamplesExamples• Doriden (glutethimide)Doriden (glutethimide)• Quaalude (methaqualone)Quaalude (methaqualone)• Placidyl (ethchlorvynol)Placidyl (ethchlorvynol)• NoludarNoludar

• Overdose produces sudden, prolonged apneaOverdose produces sudden, prolonged apnea• Highly addictiveHighly addictive• Withdrawal resembles barbiturate withdrawalWithdrawal resembles barbiturate withdrawal• Only Placidyl, Doriden remain available in U.S.Only Placidyl, Doriden remain available in U.S.

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Placidyl (ethchlorvynol)Placidyl (ethchlorvynol)• ““Pickles”, “jelly beans”, “Mr. Green Jeans”Pickles”, “jelly beans”, “Mr. Green Jeans”• Produces vinyl-like odor on breathProduces vinyl-like odor on breath• Concentrates in CNS, slow hepatic metabolismConcentrates in CNS, slow hepatic metabolism• Half-life >100 hrsHalf-life >100 hrs• Prolonged deep coma (100 to 300 hrs), hypothermia, Prolonged deep coma (100 to 300 hrs), hypothermia,

respiratory depression, hypotension, bradycardiarespiratory depression, hypotension, bradycardia• EEG is flatlineEEG is flatline• Keep patient on life support for a few days; they wake Keep patient on life support for a few days; they wake

up, are okup, are ok

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Doriden (gluthethimide)Doriden (gluthethimide)

• Abused in combination with codeineAbused in combination with codeine• ““sets”, “hits”, “loads”, “fours and doors”sets”, “hits”, “loads”, “fours and doors”• Prolonged coma (average 48 hours)Prolonged coma (average 48 hours)• Hypotension, shock commonHypotension, shock common• Anticholinergic signs: dilated pupils, tachycardia, Anticholinergic signs: dilated pupils, tachycardia,

dry mouth, ileus, urinary retention, hyperthermiadry mouth, ileus, urinary retention, hyperthermia

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BenzodiazepinesBenzodiazepines

• Developed due to overdoses, deaths related Developed due to overdoses, deaths related to barbiturates, barbiturate-like non-to barbiturates, barbiturate-like non-barbituratesbarbiturates

• Relatively few deathsRelatively few deaths

• In 1993, prescription rate for barbiturates In 1993, prescription rate for barbiturates dropped to one-sixth that of benzosdropped to one-sixth that of benzos

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• ExamplesExamples• Valium (diazepam)Valium (diazepam)• Ativan (lorazepam)Ativan (lorazepam)• Versed (midazolam)Versed (midazolam)• Librium (chlorodiazepoxide)Librium (chlorodiazepoxide)• Tranxene (chlorazepate dipotassium)Tranxene (chlorazepate dipotassium)• Dalmane (flurazepam)Dalmane (flurazepam)• Halcion (triaxolam)Halcion (triaxolam)• Restoril (temazepam)Restoril (temazepam)

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Benzodiazepines Benzodiazepines

• Adverse EffectsAdverse Effects• WeaknessWeakness• HeadacheHeadache• Blurred visionBlurred vision• VertigoVertigo• NauseaNausea• DiarrheaDiarrhea• Chest painChest pain

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• OverdosesOverdoses• Relatively safe taken by themselves, even in Relatively safe taken by themselves, even in

overdoseoverdose• Can be lethal with other CNS depressants especially Can be lethal with other CNS depressants especially

alcohol alcohol • Look like other CNS depressant overdosesLook like other CNS depressant overdoses• Antidote is Romazicon ( flumazenil )Antidote is Romazicon ( flumazenil )

• Only recommended in known, controlled Only recommended in known, controlled situationssituations

• Can lead to seizures that cannot be controlledCan lead to seizures that cannot be controlled

• Produce withdrawal syndrome similar to Produce withdrawal syndrome similar to barbiturate withdrawalbarbiturate withdrawal

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Benzodiazepine-like, non-benzosBenzodiazepine-like, non-benzos

• BuSpar (buspirone)BuSpar (buspirone)• Used for generalized anxiety disorderUsed for generalized anxiety disorder• Less sedating than diazepamLess sedating than diazepam• Less potentiation by other CNS depressantsLess potentiation by other CNS depressants

• Ambien, Stilnox (zolpidem)Ambien, Stilnox (zolpidem)• Used for short-term insomnia treatmentUsed for short-term insomnia treatment• Toxic effects similar to benzosToxic effects similar to benzos

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NeurolepticsNeuroleptics• Antipsychotics, major tranquilizersAntipsychotics, major tranquilizers• Used in treatment of schizophrenia, other Used in treatment of schizophrenia, other

psychosespsychoses• ExamplesExamples

• HaldolHaldol• MellarilMellaril• ThorazineThorazine• StellazineStellazine• CompazineCompazine

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NeurolepticsNeuroleptics

• Extrapyramidal muscle contractions Extrapyramidal muscle contractions (dystonias)(dystonias)• Bizarre, acute, involuntary movements, Bizarre, acute, involuntary movements,

spasms of skeletal musclesspasms of skeletal muscles• Reversible with BenadrylReversible with Benadryl

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• Acute Overdose PresentationAcute Overdose Presentation• CNS depressionCNS depression• HypotensionHypotension• Anticholinergic symptoms: flushing, dry Anticholinergic symptoms: flushing, dry

mouth, hyperthermia, tachycardia, urinary mouth, hyperthermia, tachycardia, urinary retentionretention

• Ventricular arrhythmias, including TorsadesVentricular arrhythmias, including Torsades• SeizuresSeizures

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• Acute Overdose ManagementAcute Overdose Management• ABCsABCs• Fluid, vasopressors for hypotensionFluid, vasopressors for hypotension• Lidocaine, phenytoin for ventricular Lidocaine, phenytoin for ventricular

arrhythmiaarrhythmia• Magnesium, isoproterenol for TorsadesMagnesium, isoproterenol for Torsades• Benzodiazepines, phenobarbital for seizuresBenzodiazepines, phenobarbital for seizures

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• Neuroleptic malignant syndromeNeuroleptic malignant syndrome• Life-threatening reactionLife-threatening reaction• Signs, symptomsSigns, symptoms

• HyperthermiaHyperthermia

• Muscular rigidityMuscular rigidity

• Altered LOCAltered LOC

• Tachycardia, hypotensionTachycardia, hypotension

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• Neuroleptic malignant syndromeNeuroleptic malignant syndrome• ManagementManagement

• ABCsABCs

• OxygenOxygen

• Assist ventilation, as neededAssist ventilation, as needed

• BenzodiazepinesBenzodiazepines

• Rapid coolingRapid cooling

• Volume for hypotensionVolume for hypotension

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StimulantsStimulants

• ExamplesExamples• CocaineCocaine• AmphetaminesAmphetamines

• Benzedrine (bennies)Benzedrine (bennies)• Dexedrine (dexies, copilots)Dexedrine (dexies, copilots)• Methamphetamine (ice, black beauties)Methamphetamine (ice, black beauties)

• EphedrineEphedrine• CaffeineCaffeine• RitalinRitalin

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• Produce Produce • euphoriaeuphoria• hyperactivityhyperactivity• alertnessalertness• sense of enhanced energysense of enhanced energy• anorexiaanorexia

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StimulantsStimulants• Overdose signs/symptomsOverdose signs/symptoms

• Euphoria, restlessness, agitation, anxietyEuphoria, restlessness, agitation, anxiety• Paranoia, irritability, delirium, psychosisParanoia, irritability, delirium, psychosis• Muscle tremors, rigidityMuscle tremors, rigidity• Seizures, comaSeizures, coma• Nausea, vomiting, chills, sweating, headacheNausea, vomiting, chills, sweating, headache• Elevated body temperatureElevated body temperature• Tachycardia, hypertensionTachycardia, hypertension• Ventricular arrhythmiasVentricular arrhythmias

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StimulantsStimulants• Overdose complicationsOverdose complications

• Hyperthermia, heat stroke Hyperthermia, heat stroke • Hypertensive crisisHypertensive crisis• CVACVA• Acute MIAcute MI• Intestinal infarctionsIntestinal infarctions• RhabdomyolysisRhabdomyolysis• Acute renal failureAcute renal failure

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• Chronic effectsChronic effects• Weight lossWeight loss• CardiomyopathyCardiomyopathy• ParanoiaParanoia• PsychosisPsychosis• Stereotypic behavior: picking at skin Stereotypic behavior: picking at skin

(“cocaine bugs”) (“cocaine bugs”)

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• Overdose managementOverdose management• Oxygen, monitor, IVOxygen, monitor, IV• Activated charcoal for decontamination in first hourActivated charcoal for decontamination in first hour• Valium for sedationValium for sedation• Hypertension controlHypertension control

• NiprideNipride

• PhentolaminePhentolamine

• Avoid beta-blockers, including labetolol (Why?)Avoid beta-blockers, including labetolol (Why?)

• Body temperature reductionBody temperature reduction

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• WithdrawalWithdrawal• DrowsinessDrowsiness• Profound depression (“cocaine blues”)Profound depression (“cocaine blues”)• Increased appetiteIncreased appetite• Abdominal cramps, diarrhea, nauseaAbdominal cramps, diarrhea, nausea• HeadacheHeadache

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HallucinogensHallucinogens

• ExamplesExamples• Indole hallucinogensIndole hallucinogens

• LSD (acid)LSD (acid)

• Morning-glory Morning-glory seedsseeds

• PsilocybinPsilocybin

• DMTDMT

• Amphetamine-like Amphetamine-like hallucinogenshallucinogens

• PeyotePeyote

• MescalineMescaline

• DOMDOM

• MDAMDA

• MDMA (ecstasy)MDMA (ecstasy)

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• Produce altered/enhanced sensationProduce altered/enhanced sensation

• Effects highly variable depending on Effects highly variable depending on patientpatient

• Increased dose does not intensify effectIncreased dose does not intensify effect

• Toxic overdose virtually impossibleToxic overdose virtually impossible

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HallucinogensHallucinogens• Some patients may experience “bad trips”Some patients may experience “bad trips”• Depends on surroundings, emotional stateDepends on surroundings, emotional state• Signs and symptomsSigns and symptoms

• Paranoia, fearfulness, combativenessParanoia, fearfulness, combativeness

• Anxiety, excitementAnxiety, excitement

• Nausea, vomitingNausea, vomiting

• Tachycardia, tachypneaTachycardia, tachypnea

• TearfulnessTearfulness

• Bizarre ReasoningBizarre Reasoning

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• Moderate IntoxicationModerate Intoxication• TachycardiaTachycardia

• MydriasisMydriasis

• DiaphoresisDiaphoresis

• Short attention spanShort attention span

• TremorTremor

• HypertensionHypertension

• HyperreflexiaHyperreflexia

• FeverFever

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• Life-threatening toxicity (rare)Life-threatening toxicity (rare)• SeizuresSeizures

• Severe hyperthermiaSevere hyperthermia

• Hypertension, arrhythmiasHypertension, arrhythmias

• Obtunded, agitated, or thrashing aboutObtunded, agitated, or thrashing about

• Diaphoretic, hyperreflexicDiaphoretic, hyperreflexic

• Untreated hyperthermia can lead to hypotension, Untreated hyperthermia can lead to hypotension, coagulopathy, rhabdomyolysis and multiple organ coagulopathy, rhabdomyolysis and multiple organ failurefailure

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• Management of “bad trip”Management of “bad trip”• Rule out other causes of hallucinationsRule out other causes of hallucinations

• HypoglycemiaHypoglycemia

• Alcohol, drug withdrawalAlcohol, drug withdrawal

• InfectionInfection

• Quiet, supportive environmentQuiet, supportive environment• Benzodiazepines, haldol for agitation, Benzodiazepines, haldol for agitation,

anxietyanxiety

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Phencyclidine (PCP)Phencyclidine (PCP)

• Street namesStreet names• Angel dustAngel dust• Peace PillPeace Pill• Hog Hog • KrystalKrystal• Animal tranquilizerAnimal tranquilizer

• Used as veterinary anestheticUsed as veterinary anesthetic

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• ActionsActions• Dissociative anesthesiaDissociative anesthesia• Generalized loss of pain perceptionGeneralized loss of pain perception• Little or no depression of airway reflexes or Little or no depression of airway reflexes or

ventilationventilation• CNS-stimulant, anticholinergic, opiate, and CNS-stimulant, anticholinergic, opiate, and

alpha-adrenergic effectsalpha-adrenergic effects

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• Low DosesLow Doses

• Lethargy, euphoria, hallucinationsLethargy, euphoria, hallucinations

• Slurred speechSlurred speech

• Blank stareBlank stare

• Insensitivity to painInsensitivity to pain

• Midposition to dilated pupilsMidposition to dilated pupils

• Vertical and horizontal nystagmusVertical and horizontal nystagmus

• Occasionally bizarre or violent behaviorOccasionally bizarre or violent behavior

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• High DosesHigh Doses• DiaphoresisDiaphoresis

• SalivationSalivation

• HypertensionHypertension

• TachycardiaTachycardia

• HyperthermiaHyperthermia

• Localized dystonic reactionsLocalized dystonic reactions

• Wide-eyed comaWide-eyed coma

• RigidityRigidity


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• TreatmentTreatment• Maintain airwayMaintain airway• Assist ventilations, as neededAssist ventilations, as needed• Treat coma, seizures, hypertension, Treat coma, seizures, hypertension,

hypothermia as neededhypothermia as needed• Quiet environmentQuiet environment• Sedation if needed to control agitationSedation if needed to control agitation

• HaldolHaldol• BenzodiazepinesBenzodiazepines

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InhalantsInhalants

• ExamplesExamples• Hydrocarbons (solvents, paints, aerosols)Hydrocarbons (solvents, paints, aerosols)• Gases (freon, halon fire extinguishing agent)Gases (freon, halon fire extinguishing agent)• Metallic paints (“huffing”)Metallic paints (“huffing”)

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InhalantsInhalants

• EffectsEffects• Dysrhythmias including VFDysrhythmias including VF

• CNS depressionCNS depression


• Respiratory irritationRespiratory irritation

• Epinephrine may increase risk of dysrhythmiasEpinephrine may increase risk of dysrhythmias

• TreatmentTreatment• OxygenOxygen

• Treat symptomaticallyTreat symptomatically

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““Date rape” drugsDate rape” drugs

• Flunitrazepam (Rhohypnol)Flunitrazepam (Rhohypnol)

• Gamma hydroxybutyrateGamma hydroxybutyrate

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Flunitrazepam (Rhohypnol)Flunitrazepam (Rhohypnol)

• Street namesStreet names• RophiesRophies• RoofiesRoofies• R2R2• RoofenolRoofenol

• RocheRoche• Roachies Roachies • La rochaLa rocha• RopeRope• RibRib

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• BenzodiazepineBenzodiazepine• Similar to Valium but 10x more potentSimilar to Valium but 10x more potent• Produced, sold legally in Europe, South Produced, sold legally in Europe, South

AmericaAmerica• UsesUses

• Short-term treatment of insomniaShort-term treatment of insomnia• Sedative hypnoticSedative hypnotic• Preanesthetic medicationPreanesthetic medication

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• EffectsEffects• Disinhibition and amnesiaDisinhibition and amnesia• Onset within 30 minutes, peak within 2 Onset within 30 minutes, peak within 2

hours, may persist 8 hours or morehours, may persist 8 hours or more• Frequently abused with alcohol or other Frequently abused with alcohol or other

drugsdrugs• Enhances high produced by heroinEnhances high produced by heroin

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• Adverse EffectsAdverse Effects• DrowsinessDrowsiness• DizzinessDizziness• ConfusionConfusion• Decreased BPDecreased BP• Memory impairmentMemory impairment• GI disturbancesGI disturbances• Excitability, aggressive behaviorExcitability, aggressive behavior

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• Management of overdoseManagement of overdose• Lethal overdose very unlikelyLethal overdose very unlikely• Oxygenate, ventilateOxygenate, ventilate• Intubate if necessary to control airwayIntubate if necessary to control airway• Vascular accessVascular access• ECGECG• Fluid for hypotensionFluid for hypotension• Dextrostick (rule out hypoglycemia)Dextrostick (rule out hypoglycemia)• Treat trauma resulting from assaultTreat trauma resulting from assault

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• WithdrawalWithdrawal• HeadacheHeadache

• Anxiety, tensionAnxiety, tension

• Numbness, tingling of Numbness, tingling of extremitiesextremities

• Restlessness, Restlessness, confusionconfusion

• Loss of identityLoss of identity

• HallucinationsHallucinations

• DeliriumDelirium

• Seizures (up to a Seizures (up to a week after cessation)week after cessation)

• ShockShock

• Cardiovascular Cardiovascular collapsecollapse

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• Management of withdrawalManagement of withdrawal• Oxygen/ventilationOxygen/ventilation• Intubate if necessaryIntubate if necessary• EKGEKG• Vascular accessVascular access• Fluid for hypotensionFluid for hypotension• DextrostickDextrostick• Diazepam for seizuresDiazepam for seizures

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Gamma hydroxybutyrateGamma hydroxybutyrate

• Street namesStreet names• Cherry methCherry meth• Liquid XLiquid X• Liquid ecstacyLiquid ecstacy

• Originally developed as anestheticOriginally developed as anesthetic

• Banned in 1991 because of side effectsBanned in 1991 because of side effects

• Promoted as aphrodisiacPromoted as aphrodisiac

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Gamma hydroxybutyrateGamma hydroxybutyrate

• EffectsEffects• Odorless, nearly tastelessOdorless, nearly tasteless• TremorsTremors• SeizuresSeizures• DeathDeath

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QUESTIONSQUESTIONS

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1 Poisonings/ Overdose. 2 Introduction Poisoning- Exposure to substance that is toxic in any amount...

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