Intro to Emergency Toxicology Author: Cheryl Hunchak MD, CCFP(EM), MPH, Lecturer, University of...
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Transcript of Intro to Emergency Toxicology Author: Cheryl Hunchak MD, CCFP(EM), MPH, Lecturer, University of...
Intro to Emergency Toxicology
Author: Cheryl Hunchak MD, CCFP(EM), MPH, Lecturer, University of Toronto
Date Created: March 2011
Global Health Emergency Medicine Teachi ng Modules by GHEM is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported License.
Lecture Outline
Bedside approach to the patient with suspected overdose/intoxication
Universal antidotes Principles of decontamination Toxidrome recognition and management Cases
Learning Objectives
Develop a structured bedside approach to the intoxicated patient in the ED
Apply universal antidotes when appropriate Feel comfortable choosing appropriate
decontamination strategies Feel confident recognizing and managing
patients with classic toxidromes
What constitutes a poisoning?
Whenever an exposure to a substance adversely affects the function of any system within the body
Major Routes of Poisonings
Inhalation
Ingestion
Injection
Cutaneous exposures
Case 1
An 18 year old woman is brought to the ED by her parents. She has been unresponsive for 8 hrs and has the following vital signs: HR 105 RR 10 BP 90/60 Temp 34.5
How should you proceed?
Bedside Approach to Suspected Intoxication
ABC Oxygen, monitors, IV access Full set of vitals including O2 sat Gather history and collateral information Check glucose* Disability : GCS, pupils Detailed physical exam Drugs: Consider universal antidotes Decontamination Draw Labs Specific antidotes and care
“ABCDDDDD”
What history would you like to know?
History
Often difficult to obtain COLLATERAL very important
Family, friends Careful body search re bottles, powders, etc Patient’s occupation, hobbies Prior psychiatric history Prescription medications
History
Drug(s) or substance taken/exposed to Number of tablets, dosage per tablet Estimated time since ingestion Type of preparation (sustained release?) Chance of caustic ingestion? Co-ingestions (alcohol, etc)
The plot thickens…
The patients’ parents tell you that she has been very stressed at school. They found an empty pill bottle in the house but do not know what was inside. They found her unconscious in her room 8 hours ago. There were no other substances/exposures noted.
Physical Exam….after the ABCs
Completely undress the patient
Carefully search belongings
General observation Odours, powders, track marks Agitation, confusion, obtundation
Detailed Physical Exam
Neuro GCS, extremity tone, tremors, fasiculations Detailed exam if possible
Eyes Pupil size and reactivity Nystagmus, excessive lacrimation
Skin Cyanosis, flushing, diaphoresis, dryness Signs of injury/trauma
Physical Exam
CVS Rate, rhythm, peripheral pulses
Lungs Bronchorrhea, bronchoconstriction
GI Bowel sounds Bladder size Rigidity/tenderness
Drugs:Universal Antidotes
Thiamine 100 mg IV/IM/PO
Oxygen Nasal / face mask
Naloxone 0.4 mg IV/IM/ETT
Glucose 1 ampule IV D50W
“TONG”
Universal Antidotes
Thiamine: administer if appear malnourished or known alcohol/drug abuse
Glucose: administer if no immediate access to glucometer or confirmed hypoglycemia
Order in which glucose & thiamine given no longer felt to be important
Naloxone
Competitive opioid antagonist
0.4 mg IV/IM/ETT titrated to effect
T ½ = 30 mins
Consider for patients with RR < 12
Naloxone
Can safely give 6-10 mg over <10 minCan precipitate acute withdrawal in chronic opiate usersAcute opiate withdrawal is not life threatening BUT can cause aspiration Observe patients for 2-3 hrsMay require re-dosing or infusion
What universal antidotes would you consider giving this patient?
Case 1
An 18 year old woman is brought to the ED by her parents. She has been unresponsive for 8 hrs and has the following vital signs: HR 105 RR 10 BP 90/60 Temp 34.5
How should you proceed?
What labs would you consider drawing for this patient?
What next?
Decontamination Principles
Activated charcoal Orogastric lavage Whole bowel irrigation Urine alkalinization Syrup of Ipecac
Activated Charcoal
Adsorbs substances from the gut Establishes concentration gradient that
favours movement into the intestinal lumen, enhancing excretion by defecation
Can intercept entero-hepatic circulation
What makes charcoal “activated”?
Charcoal prepared from vegetable matter ‘‘Activated’’ by heating at high temperature
in stream of oxidizing gas (steam, CO2, air) or with activating agent (phosphoric acid, zinc chloride)
Creates complex internal pore structure which increases surface area from 2–4 m2/g to >1500 m2/g
Activated Charcoal
Most effective within 1 hr ingestion 1 g/kg OR 10:1 charcoal : dose ingested
Administer whichever is larger Given in slurry of water, coke, juice PO/NG
Activated Charcoal
Indications: Ingestion within 1 hr Airway protected
Contraindications: Known/suspected GI perforation/obstruction GCS <8 or declining rapidly (risk of aspiration) Known ingestion of substance that charcoal
does NOT adsorb
Multi-dose Activated Charcoal
Repeated use of activated charcoal to enhance elimination ingested toxins
Ideal for toxins with long t ½, small volume of distribution, reduced gut motility, bezoar formation
Theophylline, phenobarbitol, quinine, carbamazepine
Improves clearance rates comparable to hemodialysis
Orogastric Lavage
Intubate patient Place in left lateral decubitus position Head tilted 20 degrees downward Insert 40F orogastric tube (24F peds) Ideal length measured from chin to xiphoid Instill 200 cc body-temp fluids repeatedly
until fluid clear
Orogastric Lavage Indications
Life-threatening ingestions Pills able to fit through orogastric tube holes Ingestion within 1 hr
Contraindications Non-life threatening ingestions Pills known to be too big for holes of tube Caustic ingestions No ability to intubate patient Ingestions where lung toxicity>>GI toxicity
Whole Bowel Irrigation
Instillation of large volumes of polyethylene glycol in osmotically balanced electrolyte solutions
Promotes rapid, mechanical elimination of ingested toxins
Whole Bowel Irrigation
Intubate patient Infuse polyethylene glycol through NG tube
at: 2L/hr adults 1 L/hr children > 6 years 0.5 L/hr children < 6 years
Infuse until rectal fluid clear
Whole Bowel Irrigation
Indications Ingestion of sustained release drugs Ingestion of substances that charcoal cannot
adsorb (HAILL) Drugs ingested by body packers/stuffers
Contraindications Known or suspected bowel obstruction Inability to intubate patient Ingested toxin known to cause diarrhea
Syrup of Ipecac
Induces short-lived vomiting Peripherally and centrally acting
90% patients vomit within 20 mins Typical vomiting < 5X and < 2 hrs 30 mL PO (adults) 15 mL PO (peds 1-12 years)
Syrup of Ipecac
Indications Very recent ingestion (<1hr) Toxin known not to cause decreased LOC Toxin known not to fit through OG tube
Contraindications Ingestion > 1 hr ago Toxin known to cause decreased LOC/seizure Caustics, hydrocarbons, TCAs
Urinary Alkalinization
Infusion of sodium bicarbonate to raise urinary pH to enhance clearance of toxins excreted by kidneys
1-2 mEq/kg NaHCO3 IV push 3 ampules of NaHCO3 in 850 cc of D5W at
1.5X maintenance fluid rate
Urinary Alkalinization
Target urinary pH 7.5-8.5
Monitor electrolytes q2-4hrs (re hypokalemia)
For ASA, phenobarbitol, INH, quinolone OD
What decontamination strategy would you choose for this patient?
a) Orogastric lavageb) Syrup of Ipecacc) Urinary decontaminationd) Activated charcoale) None of the above
What decontamination strategy would you choose for this patient?
a) Orogastric lavageb) Syrup of Ipecacc) Urinary decontaminationd) Activated charcoale) None of the above
Next issue:
What toxin did your patient take?
Common Toxidromes
Sedative-hypnotic
Anticholinergic
Cholinergic
Sympathomimetic
Opioid
Sedative-Hypnotic Toxidrome
CNS depression Slurred speech Ataxia
Coma/stupor Respiratory depression apnea Hypotension Hypothermia
Common Sedative-Hypnotics
Benzodiazepines Diazepam, lorazepam, etc
Barbituates Phenobarbitol
Case closed….
The patient’s sister shows up to the hospital very worried. The patient had admitted yesterday that she felt suicidal and today the sister could not find her bottle of phenobarbitol tablets that she takes for her seizure disorder.
Management priorities??
Sedative-hypnotic OD management
Airway management IV fluids ++ (warm)Warming as neededPressors as needed
Case 2
34 yo male found at home by wife Combative, agitated, confused Vitals: HR 108, BP 146/92, T 38.6, RR 20 Pupils round, 5mm bilat Skin dry, flushed Distended bladder palpable below umbilicus
Anticholinergic Toxidrome
Blind as a bat (mydriasis) Mad as a hatter (confused, decr. LOC) Red as a beet (flushed, vasodilation) Dry as a bone (dry skin/membranes) Hot as a hare (hyperthermia) Stuffed as a pipe (urinary/bowel retention)
Seizures, rhabdomyolysis, dysrhythmias Tachycardia is early, sensitive sign
Common Anticholinergics
Atropine, scopolamine Antidepressants (TCAs, SSRIs) Antihistamines Antipsychotics Antiparkinsonians Antispasmodics Amanita mushroom species
Anticholinergic Management
IV fluids Cooling (fluids, mist, fans) Sedation
Diazepam IV Prevents trauma, hyperthermia, rhabdomyolysis
Physostigmine 0.5 – 2 mg slow IV over 5 min **Not for TCA overdoses
Physostigmine
Reversible acetylcholinesterase inhibitor Crosses blood-brain barrier Reverses anticholinergic effects Shorter t ½ than most anticholinergic drugs
Physostigmine
Major side effects: Profound bradycardias, dysrhythmias Seizures
Indications Severe agitation and delirium not responsive to
benzodiazepines
Contraindications TCA overdose or Na channel blockade Asthma or known cardiac conduction abnormalities
TCA Overdose
IV fluids NaHCO3 IF:
QRS > 100 msecs R axis deviation terminal 40 msecs QRS Hypotension refractory to IV fluids Ventricular dysrhythmias
NaHCO3 1-2 mEq/kg IV push then infusion: Mix 3 amps of NaHCO3 into 850 cc D5W Run at 1.5X maintenance Monitor serum lytes, pH (max 7.55) Expect hypokalemia!
TCA Overdose
Case 3
15 yo girl from rural area brought to ED by family on bus
Found behind barn 6 hours prior Decreased LOC, drooling, tears streaming Covered in vomit and urine, feces HR 101, RR 16, BP 90/60, T 36.5
Cholinergic Toxidrome
SalivationLacrimationUrinationDefecationGI painEmesis
Muscarinic Effects
Cholinergic Toxidrome
Bradycardia Bronchorrhea Bronchospasm
Muscle fasiculations, miosis Seizures, resp failure, paralysis
“The Killer Bees”
Common Cholinergics
Organophosphate insecticides Diazinon, acephate, malathion, parathion
Carbamate insecticides
Systemic absorption by inhalation, ingestion, transdermal and transcorneal exposure
Organophosphate Poisoning
Bind irreversibly to acetylcholinesterase Allows accumulation of Ach at NMJ Cholinergic crisis causes central and
peripheral toxidrome Must give antidotes before permanent
binding of organophosphates to acetylcholinesterase (“ageing”)
Cholinergic Management
Decontamination and staff protection! 1:9 bleach : water
Airway management Atropine sulphate 2 mg IV/IM
Every 5-20 mins until tracheobronchial secretions dry up
Treats muscarinic symptoms Pralidoxime 2 g IV/IM infused over 5 min
Treats nicotinic symptoms Continue for 48 hrs if used
Fatal Pesticide Poisonings
258,000 deaths from pesticide self-poisonings worldwide each year
Accounts for 30% suicides worldwide Suicides in developing countries >>
developed countries likely explained by very high case fatality rates in developing countries
Case 4
26 yo male found on street by police No family present Eyes bloodshot, agitated, sweaty Uncooperative HR 126, BP 178/104, RR 20, T 38.5
Sympathomimetic Toxidrome
Mydriasis Diaphoresis Tachycardia Hypertension Hyperthermia
Seizures, rhabdomyolysis, MI, SAH
Common Sympathomimetics
Cocaine Amphetamines Khat (cathinone and cathine)
Sympathomimetic Management
IV fluids Cooling (fans, mist, fluids) Sedation: benzodiazepines Seizures: benzodiazepines, phenobarbitol HTN: benzodiazepines, nitroprusside Chest pain: ASA, nitroglycerin Avoid beta-blockers! Monitor for rhabdomyolysis
Case 5
42 yo female Found at home by daughter unresponsive
in bed HR 90, RR 6, GCS 6, T 36.3, BP 92/60 Pupils pinpoint
Opioid Toxidrome
Respiratory depression
CNS depression/coma
Miosis
Opioid Management
Naloxone IV/IM/SC/ETT/IN
Airway management
Take Home Points
Approach to Tox Patient at Bedside
ABC Oxygen, monitors, IV access Full set of vitals including O2 sat Gather history and collateral information Check glucose (if possible) Disability : GCS, pupils Detailed physical exam Drugs: Consider universal antidotes Decontamination Draw Labs Specific antidotes and supportive care
“ABCDDDDD”
4 Universal Antidotes
Thiamine Oxygen Naloxone Glucose
“TONG”
5 Decontamination Options
Activated charcoal Syrup of Ipecac Orogastric Lavage Whole Bowel Irrigation Urinary alkalinization
5 Decontamination Options
Activated charcoal Syrup of Ipecac Orogastric Lavage Whole Bowel Irrigation Urinary alkalinization
5 substances charcoal cannot adsorb
Hydrocarbons Alcohols Iron Lithium Lead
“HAILL”
5 Toxidromes
Sedative-Hypnotic Anticholinergic Cholinergic Sympathomimetic Opioid
Quiz Question 1
Which of the following is NOT considered a universal antidote? A) Dextrose B) Atropine C) Naloxone D) Thiamine E) Oxygen
Quiz Question 2
Why is it crucial to observe opiate-intoxicated patients who have been given naloxone for 2-3 hours in the ED? A) Naloxone can induce tachycardia B) Naloxone has a high incidence of anaphylaxis C) Naloxone can cause depressed level of
consciousness D) The half-life of naloxone is shorter than that of
the opiates it is reversing E) Naloxone can precipitate urinary retention
Quiz Question 3
A 50 kg female ingested 30 tablets of 500 mg of acetaminophen 45 minutes ago. What is the appropriate dose of activated charcoal that should be given? A) 50 g B) 100g C) 150g D) Charcoal is contraindicated E) Charcoal will not be effective
Quiz Question 4
Which drug overdoses are not likely to be improved by the use of urinary alkalinization as a decontamination strategy? A) Salicylates B) Phenobarbitol C) Isoniazid (INH) D) Quinolone E) Carbamates
Quiz Question 5
Which of the following symptoms are muscarinic manifestations of organophosphate overdose? A) Lacrimation B) Vomiting C) Miosis D) Muscle fasciculations E) All of the above
General References
Gunnell D, Eddleston M, Phillips MR, Konradsen F. The global distribution of fatal pesticide self-poisoning: Systematic review. BMC Public Health 2007; 7:357.
Tintinalli’s Emergency Medicine. 7th Ed. Tintinalli JE et al. 2011. McGraw-Hill Companies, Inc.
American Academy of Clinical Toxicology Position Statement and Practice Guidelines on the Use of Multi-Dose Activated Charcoal in the Treatment of Acute Poisoning. Clinical Toxicology.1999;37(6): 731–751.