Toxicological Emergencies
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Transcript of Toxicological Emergencies
Toxicological EmergenciesToxicological Emergencies
Dr. Shahid Aziz MBBS, MRCP (UK), MCEM (London)Dr. Shahid Aziz MBBS, MRCP (UK), MCEM (London)Assistant professor and consultant emergency medicine, Assistant professor and consultant emergency medicine,
DEMDEMKing Khalid University HospitalKing Khalid University Hospital
ObjectivesObjectives
History and Physical ExaminationHistory and Physical ExaminationToxicology ScreeningToxicology ScreeningThree gaps are important in Three gaps are important in toxicologytoxicologyTreatmentTreatmentICU AdmissionICU Admission
History and Physical Examination
No reliable history in patients with profoundly altered metal status
Focused treatment decisions quite difficult.
Multiple substances
Difficulties
Separating patients who have Separating patients who have suspected poisoning into broad suspected poisoning into broad
categories that are based on vital categories that are based on vital signs, eye findings, mental status, and signs, eye findings, mental status, and muscle tone, that helps to determine muscle tone, that helps to determine drug or toxin class i.e.drug or toxin class i.e.“toxidromes.”
History and Physical Examination
Diagnosing toxicity from vital signs
Bradycardia (PACED)
Propranolol (beta-blockers), poppies (opiates), propoxyphene, physostigmine
Anticholinesterase drugs, antiarrhythmics
Clonidine, calcium channel blockers
Ethanol or other alcohols
Digoxin, digitalis
Tachycardia (FAST)
Free base or other forms of cocaine, freon
Anticholinergics, antihistamines, antipsychotics, amphetamines, alcohol withdrawal
Sympathomimetics (cocaine, caffeine, amphetamines, PCP), solvent abuse, strychnine
Theophylline, TCAs, thyroid hormones
Carbon monoxide
Opioids
Oral hypoglycemics, insulin
Liquor (alcohols)
Sedative-hypnotics
Hypothermia (COOLS)
Neuroleptic malignant syndrome, nicotine
Antihistamines, alcohol withdrawal
Salicylates, sympathomimetics, serotonin syndrome
Anticholinergics, antidepressants, antipsychotics
Hyperthermia (NASA)
Clonidine, calcium channel blockers
Rodenticides (containing arsenic, cyanide)
Antidepressants, aminophylline, antihypertensives
Sedative-hypnotics
Heroin or other opiates
Hypotension (CRASH)
Cocaine
Thyroid supplements
Sympathomimetics
Caffeine
Anticholinergics, amphetamines
Nicotine
Hypertension (CT SCAN)
Rapid respiration (PANT)
PCP(phencyclidine), paraquat, pneumonitis (chemical), phosgene
ASA and other salicylates
Noncardiogenic pulmonary edema, nerve agents
Toxin-induced metabolic acidosis
Slow respiration (SLOW)
Sedative-hypnotics (barbiturates, benzodiazepines)
Liquor (alcohols)
Opioids
Weed (marijuana)
COMA L: Lead, lithiumE: Ethanol, ethylene glycol, ethchlorvynolT: Tricyclic antidepressants, thallium, tolueneH: Heroin, hemlock, hepatic encephalopathy, heavy metals, hydrogen sulfide, hypoglycemicsA: Arsenic, antidepressants, anticonvulsants, antipsychotics, antihistaminesR: Rohypnol (sedative hypnotics), risperidoneG: GHBI: Isoniazid, insulinC: Carbon monoxide, cyanide, clonidine
Agents that cause seizures (OTIS CAMPBELL)
Organophosphates, oral hypoglycemicsTricyclic antidepressantsIsoniazid, insulinSympathomimetics, strychnine, salicylatesCamphor, cocaine, carbon monoxide, cyanide, Amphetamines, anticholinergicsMethylxanthines (theophylline, caffeine), methanolPhencyclidine (PCP), propranololBenzodiazepine withdrawal,bupropion, GHB Ethanol withdrawal, ethylene glycolLithium, lidocaine Lead, lindane
Agents that affect pupil size
Miosis (COPS)
Cholinergics, clonidine, carbamates
Opiates, organophosphates
Phenothiazines (antipsychotics), pilocarpine)
Sedative-hypnotics
Mydriasis (SAW)
Sympathomimetics
Anticholinergics
Withdrawal
Agents that cause skin signs
Diaphoretic skin (SOAP) SympathomimeticsOrganophosphatesAcetylsalicylic acid or other salicylatesPhencyclidineDry Skin Antihistamines, anticholinergicsBullae Barbiturates and other sedative-hypnotics,Bites: Snakes and spidersAcneiform rash BromidesChlorinated aromatic hydrocarbons (dioxin)
Flushed or red appearance Anticholinergics, niacinBoric acidCarbon monoxide (rare)Cyanide (rare)Cyanosis ErgotamineNitratesNitritesAniline dyesPhenazopyridineDapsoneAny agent causing hypoxemia, hypotension, or methemoglobinemia.
Agents causing an elevated anion gap (METAL ACID GAP)
Methanol, metformin, massive overdosesEthylene glycolTolueneAlcoholic ketoacidosisLactic acidosisAcetaminophen (large overdoses)Cyanide, carbon monoxide, colchicineIsoniazid, iron, ibuprofenDiabetic ketoacidosisGeneralized seizure-producing toxinsAcetylsalicylic acid or other salicylatesParaldehyde, phenformin
Drugs causing pneumonitis or pulmonary edema (MOPS)
Meprobamate, methadone
Opioids
Phenobarbital, propoxyphene, paraquat, phosgene
Salicylates
Common toxidromes
Cholinergic (Examples: organophosphates, carbamates, pilocarpine)
(DUMBELLS )Diarrhea, diaphoresisUrinationMiosisBradycardia, bronchosecretionsEmesisLacrimationLethargicSalivation
Monday: Miosis
Tuesday: Tachycardia
Wednesday: Weakness
Thursday: Tremors
Friday: Fasciculations
Saturday: Seizures
Sunday: Somnolent
Nicotinic (recalled by the days of the week)
Anticholinergic (Examples: antihistamines, cyclic antidepressants, atropine, benztropine, phenothiazines, scopolamine)
Hyperthermia (HOT as a hare)
Flushed (RED as a beet)
Dry skin (DRY as a bone)
Dilated pupils (BLIND as a bat)
Delirium, hallucinations (MAD as a hatter)
Tachycardia
Urinary urgency and retention
Mydriasis
Tachycardia
Hypertension
Hyperthermia
Seizures
Sympathomimetic (Examples: cocaine, amphetamines, ephedrine, phencyclidine, pseudoephedrine)
Miosis
Bradycardia
Hypotension
Hypoventilation
Coma
Opioid (Examples: heroin, morphine, codeine, methadone, fentanyl, oxycodone, hydrocodone)
Agents responsive to multiple doses of activated charcoal
Substances adsorbable by activated charcoal (ABCD)
Antimalarials (quinine), aminophylline (theophylline)Barbiturates (phenobarbital)CarbamazepineDapsone
Substances not adsorbable by activated charcoal (PHAILS)
Pesticides, potassiumHydrocarbonsAcids, alkali, alcoholsIron, insecticidesLithiumSolvents
AntidoteIndication (agent)
n-acetylcysteineEthanol/fomepizole (4-MP)Oxygen/hyperbaricsNaloxone/nalmefenePhysostigmineAtropine/pralidoxime (2-PAM)Methylene blueNitritesDeferoxamineDimercaprol (BAL)Succimer (DMSA)Fab fragmentsGlucagonSodium bicarbonateCalcium/insulin/dextroseDextrose, glucagon, octreotide
AcetaminophenMethanol/ethylene glycolCarbon monoxideOpioidsAnticholinergicsOrganophosphatesMethemoglobinemiaCyanideIronArsenicLead, mercuryDigoxin, colchicine, crotalidsBeta-blockersTricyclic antidepressantsCalcium channel antagonistsOral hypoglycemics
Table -- Antidotes and their indications
Toxins accessible to hemodialysis (UNSTABLE)
Uremia
No response to conventional therapy
Salicylates
Theophylline
Alcohols (isopropanol, methanol)
Boric acid, barbiturates
Lithium
Ethylene glycol
Theophylline
Barbiturates
Carbamazepine
Paraquat
Glutethimide
Enhanced elimination by charcoal hemoperfusion
History and Physical Examination
ToxidromeToxidrome Treat
ovital signsvital signsoocular findingsocular findingsomental statusmental statusomuscle tonemuscle tone
determine drugdetermine drug or toxin classor toxin class
Yes
No
Initially, a rapid survey for ABCs & life-threatening natureInitially, a rapid survey for ABCs & life-threatening nature
Then, a more focused examination for Then, a more focused examination for
Physical examinationPhysical examination
A rapid but careful physical A rapid but careful physical examination of the patient is examination of the patient is
performed in stagesperformed in stages..
Signs of traumaSigns of trauma Neurologic findingsNeurologic findings Skin changesSkin changes OdorsOdors EyesEyes
History and Physical Examination
Patients may present with Patients may present with hypotension or hypertensionhypotension or hypertension bradyarrhythmias or tachyarrhythmias. bradyarrhythmias or tachyarrhythmias.
The pathogenesis of hypotension varies and The pathogenesis of hypotension varies and may include may include
Physical examinationPhysical examination
HypovolemiaHypovolemia Myocardial depressionMyocardial depression Cardiac arrhythmiasCardiac arrhythmias Systemic vasodilation. Systemic vasodilation.
History and Physical Examination
Urine Drug ScreensUrine Drug Screens
Detect only natural opiatesDetect only natural opiates
Do not detect synthetic or semisynthetic Do not detect synthetic or semisynthetic productsproducts
o OxycodoneOxycodoneo HydrocodoneHydrocodoneo FenanylFenanylo PropoxyphenePropoxypheneo MeperidineMeperidineo methadone. methadone.
o morphineo codeineo heroin
Laboratories InvestigationLaboratories Investigation
Most hospital laboratories have the capability Most hospital laboratories have the capability to rapidly identify and quantify to rapidly identify and quantify onlyonly a small a small
fraction of the substances commonly fraction of the substances commonly encountered in clinical practice. encountered in clinical practice.
Toxicology ScreeningToxicology Screening
Check acetaminophen levels in all Check acetaminophen levels in all cases of suspected intoxicationcases of suspected intoxication
Supportive serum toxicology assays
AcetaminophenLithiumSalicylateValproic acidCarbamazepineCo-oximetry (carboxyhemoglobin, methemoglobin)
Data from Wu AH, McKay C, Broussard LA, et al. National Academy of Clinical Biochemistry Laboratory Medicine practice guidelines: recommendations for the use of laboratory tests to support poisoned patients who present to the emergency department. Clin Chem 2003;49:357–79.
SkeltonSkelton H.,H., DannDann L.M.,L.M., et al.et al. Drug screening of patients who deliberately harm Drug screening of patients who deliberately harm themselves admitted to the emergency department.themselves admitted to the emergency department. Ther Drug Monit Ther Drug Monit (1998) (1998) 2020 : pp : pp 98-103. 98-103.
DigoxinPhenobarbitalIronEthanolMethanolEthylene glycolTheophylline
GENERAL TREATMENTGENERAL TREATMENT
ABCsABCs.. Protection of the Protection of the cervical spinecervical spine (unless trauma (unless trauma
has been excluded). has been excluded). A rapid assessment of the need A rapid assessment of the need of of endotracheal endotracheal
intubation intubation Attention to any abnormalities of the Attention to any abnormalities of the vital signsvital signs.. Discontinuing the offending Any Any life-threateninglife-threatening abnormalities abnormalities A A 12-lead EKG12-lead EKG is obtained along with continuous is obtained along with continuous
cardiac monitoring.cardiac monitoring. ABG ABG
Initial supportive measuresInitial supportive measures
Endotracheal intubation is indicatedEndotracheal intubation is indicated
when there is concern regarding airway when there is concern regarding airway protection and clinical deterioration protection and clinical deterioration
acute respiratory failure. acute respiratory failure.
the need for high levels of the need for high levels of supplemental oxygensupplemental oxygen
It decreases (but does not eliminate) the risk of aspiration It decreases (but does not eliminate) the risk of aspiration (which is approximately 11% in the comatose patient with drug (which is approximately 11% in the comatose patient with drug
overdose).overdose).
Initial supportive Initial supportive measuresmeasures Rapid IV normal saline solution Rapid IV normal saline solution
infusion is indicated in most instances. infusion is indicated in most instances. Vasopressors may be required for Vasopressors may be required for
refractory hypotension. refractory hypotension. The vasopressor of choice depends on The vasopressor of choice depends on
the type of intoxication the type of intoxication Hypertension-induced (reflex) Hypertension-induced (reflex)
bradycardia generally should not be bradycardia generally should not be treated.treated.
Initial supportive measuresInitial supportive measures
Dexrtrose, flumazenil, naloxone, thiamine. Dexrtrose, flumazenil, naloxone, thiamine.
Coma CocktailComa Cocktail
..
There is no evidence that dextrose should be There is no evidence that dextrose should be withheld until thiamine is administered.withheld until thiamine is administered.
Initial supportive measuresInitial supportive measuresComa CocktailComa Cocktail
Reuler JB, Girard DE, Cooney TG. Wernicke's Reuler JB, Girard DE, Cooney TG. Wernicke's encephalopathy. N Engl J Med 1985; 312:1035encephalopathy. N Engl J Med 1985; 312:1035––10391039
rapidly reverses coma, respiratory rapidly reverses coma, respiratory depression, and hypotension induced by depression, and hypotension induced by opioids. opioids.
An initial dose of 0.2 to 0.4 mg is An initial dose of 0.2 to 0.4 mg is administered IV (or endotracheally). administered IV (or endotracheally).
If there is no response after 2 to 3 min, If there is no response after 2 to 3 min, repeated up to 10 mg as required. repeated up to 10 mg as required.
lack of response to 10 mg of naloxone lack of response to 10 mg of naloxone generally excludes opioid toxicity. generally excludes opioid toxicity.
Initial supportive measuresInitial supportive measuresComa CocktailComa Cocktail
NaloxoneNaloxone
a higher dose may precipitate a higher dose may precipitate large cardiovascular changes in large cardiovascular changes in opioid dependent patients.opioid dependent patients.
Observe forObserve for
acute pulmonary edema opioid withdrawal seizures
Initial supportive measuresInitial supportive measuresComa CocktailComa Cocktail
NaloxoneNaloxone
Its use in undifferentiated ED patients is not Its use in undifferentiated ED patients is not recommended recommended
Withdrawal seizures in mixed overdoses or in Withdrawal seizures in mixed overdoses or in patients with long-term use of benzodiazepines. patients with long-term use of benzodiazepines.
HoffmanHoffman R.S.,R.S., GoldfrankGoldfrank L.R.,L.R., The poisoned patient with The poisoned patient with altered consciousness: controversies in the use of a coma altered consciousness: controversies in the use of a coma cocktail.cocktail. JAMA JAMA (1995) 274 : pp 562 (1995) 274 : pp 562
SpiveySpivey W.H.,W.H., Flumazenil and seizures: analysis of 43 cases. Flumazenil and seizures: analysis of 43 cases. Clin Ther Clin Ther (1991) 14 : pp 292-305. (1991) 14 : pp 292-305.
Initial supportive measuresInitial supportive measuresComa CocktailComa Cocktail
FlumazenilFlumazenil
Case reports have cautioned clinicians Case reports have cautioned clinicians of the risk of precipitating seizures with of the risk of precipitating seizures with flumazenil when there is a suspicion of flumazenil when there is a suspicion of benzodiazepine plus benzodiazepine plus TCATCA overdose overdose
0.2 mg of IV flumazenil over 30 s 0.2 mg of IV flumazenil over 30 s followed by another 0.3-mg dose if followed by another 0.3-mg dose if necessary.necessary.
Doses beyond 3 mg generally do not Doses beyond 3 mg generally do not provide additional benefit. provide additional benefit.
Initial supportive measuresInitial supportive measuresComa CocktailComa Cocktail
Flumazenil
Patients must be able to maintain their Patients must be able to maintain their airways or be intubated. airways or be intubated.
Should not be performed on patients who Should not be performed on patients who have ingested medications that may cause have ingested medications that may cause seizures or abrupt central nervous system seizures or abrupt central nervous system deterioration.deterioration.
GASTRIC LAVAGEGASTRIC LAVAGE DecontaminationDecontamination
There is no clear definition of There is no clear definition of when to end the procedurewhen to end the procedure..
GASTRIC LAVAGEGASTRIC LAVAGE DecontaminationDecontamination
One study using radiographic markers One study using radiographic markers suggested that GL may actually propel suggested that GL may actually propel gastric contents past the pylorus, moving gastric contents past the pylorus, moving the poison into the small intestine, where the poison into the small intestine, where most of the drug will be absorbedmost of the drug will be absorbed
SaettaSaetta J.P.,J.P., MarchMarch S.,S., GauntGaunt M.E.,M.E., et al.et al. Gastric emptying Gastric emptying procedures in the self-poisoned patient: are we forcing procedures in the self-poisoned patient: are we forcing contents beyond the pylorus?.contents beyond the pylorus?. J R Soc Med (1991) J R Soc Med (1991) 8484 : pp : pp 274-276. 274-276.
GASTRIC LAVAGEGASTRIC LAVAGE DecontaminationDecontamination
three clinical trials have failed to three clinical trials have failed to demonstrate improved outcomes when GL is demonstrate improved outcomes when GL is added to AC for the management of added to AC for the management of undifferentiated symptomatic poisoning undifferentiated symptomatic poisoning patients. patients.
GASTRIC LAVAGEGASTRIC LAVAGE DecontaminationDecontamination
KuligKulig K.,K., Bar-OrBar-Or D.,D., CantrillCantrill S.V.,S.V., et al.et al. Management of acutely poisoned Management of acutely poisoned patients without gastric emptying.patients without gastric emptying. Ann Emerg Med Ann Emerg Med (1985) 14 : pp 562-(1985) 14 : pp 562-567. 567. Pond Pond S.M.,S.M., Lewis-DriverLewis-Driver D.J.,D.J., WilliamsWilliams G.M.,G.M., et al.et al. Gastric emptying in Gastric emptying in acute overdose: a prospective randomised trial.acute overdose: a prospective randomised trial. Med J Aust Med J Aust (1995) 163 : (1995) 163 : pp 345-349.pp 345-349.
SaettaSaetta J.P.,J.P., MarchMarch S.,S., GauntGaunt M.E.,M.E., et al.et al. Gastric emptying procedures in Gastric emptying procedures in the self-poisoned patient: are we forcing contents beyond the pylorus?.the self-poisoned patient: are we forcing contents beyond the pylorus?. J J R Soc Med (1991) 84 : pp 274-276R Soc Med (1991) 84 : pp 274-276
GI tract perforationGI tract perforation hypoxiahypoxia aspiration. aspiration. esophageal perforationesophageal perforation Arterial oxygen tension dropped Arterial oxygen tension dropped
17% during GL17% during GL pneumothoraxpneumothorax
Complications associated with GL includeComplications associated with GL include
GASTRIC LAVAGEGASTRIC LAVAGE DecontaminationDecontamination
Based on the available data, the American Academy of Clinical Toxicology does not recommend gastric lavage unless a patient has ingested a potentially life-threatening amount of a poison and the procedure can be undertaken within 60 minutes of ingestion
GASTRIC LAVAGEGASTRIC LAVAGE DecontaminationDecontamination
Current consensus recommendations are that adult overdose patients receive 25 to 100 g
The efficacy of charcoal is time dependent. A recent consensus statement suggests
that charcoal should be administered within 60 minutes of ingestion
ACTIVATEDACTIVATED CHARCOALCHARCOAL DecontaminationDecontamination
LaineLaine K.,K., KivistoKivisto K.T.,K.T., NeuvonenNeuvonen P.J.,P.J., Effect of delayed administration Effect of delayed administration of activated charcoal on the absorption of conventional and slow-of activated charcoal on the absorption of conventional and slow-release verapamil.release verapamil. J Toxicol Clin Toxicol J Toxicol Clin Toxicol (1997) 35: pp 263-268(1997) 35: pp 263-268
CLINICAL EFFICACY OF ACTIVATED CHARCOAL CLINICAL EFFICACY OF ACTIVATED CHARCOAL A study evaluated AC versus supportive care A study evaluated AC versus supportive care
alone in asymptomatic pt.alone in asymptomatic pt. 231 patients were assigned to observation 231 patients were assigned to observation
and 220 were assigned to AC. and 220 were assigned to AC.
No patient in either group deteriorated, No patient in either group deteriorated, suggesting that AC provided no benefit in the suggesting that AC provided no benefit in the management of asymptomatic poisoning management of asymptomatic poisoning patients. patients.
ACTIVATEDACTIVATED CHARCOALCHARCOAL DecontaminationDecontamination
MerigianMerigian K.S.,K.S., WoodardWoodard M.,M., HedgesHedges J.R.,J.R., et al.et al. Prospective evaluation of gastric emptying in the self-Prospective evaluation of gastric emptying in the self-poisoned patient.poisoned patient. Am J Emerg Med (1990) 8 : pp 479-483. Am J Emerg Med (1990) 8 : pp 479-483.
a large study was published comparing AC a large study was published comparing AC with supportive care for symptomatic and with supportive care for symptomatic and asymptomatic overdose patients. asymptomatic overdose patients.
This study is described as a randomized This study is described as a randomized controlled trial (RCT) where 1479 patients controlled trial (RCT) where 1479 patients were assigned on an alternating-day basis to were assigned on an alternating-day basis to either AC or supportive care. either AC or supportive care.
ACTIVATEDACTIVATED CHARCOALCHARCOAL DecontaminationDecontamination
MerigianMerigian K.S.,K.S., BlahoBlaho K.E.,K.E., Single-dose oral activated Single-dose oral activated charcoal in the treatment of the self- poisoned patient: a charcoal in the treatment of the self- poisoned patient: a prospective, randomized, controlled trial.prospective, randomized, controlled trial. Am J Ther (2002) 9 Am J Ther (2002) 9 : pp 301-308. : pp 301-308.
One additional RCT with Preliminary One additional RCT with Preliminary results suggest that the patients who results suggest that the patients who were given AC had a trend toward were given AC had a trend toward longer ED stay and no change in longer ED stay and no change in mortality mortality
ACTIVATEDACTIVATED CHARCOALCHARCOAL DecontaminationDecontamination
CooperCooper G.M.,G.M., Le CouteurLe Couteur D.G.,D.G., RichardsonRichardson D.,D., et al.et al. A A randomised controlled trial of activated charcoal for the randomised controlled trial of activated charcoal for the routine management of oral drug overdose.routine management of oral drug overdose. J Toxicol Clin J Toxicol Clin Toxicol Toxicol (2002) 40 : pp 313-. (2002) 40 : pp 313-.
The major complications of AC are The major complications of AC are
VomitingVomiting intestinal obstructionintestinal obstruction aspiration. aspiration.
ACTIVATEDACTIVATED CHARCOALCHARCOAL DecontaminationDecontamination
Clinical benefits remain unproved Clinical benefits remain unproved
American Academy of Clinical Toxicology and American Academy of Clinical Toxicology and European Association of Poison Centers and European Association of Poison Centers and Toxicologist.Toxicologist. Position paper: single-dose Position paper: single-dose activated charcoal.activated charcoal. J Toxicol Clin Toxicol J Toxicol Clin Toxicol (2005) (2005) 4343 : pp 61-87 : pp 61-87
ACTIVATEDACTIVATED CHARCOALCHARCOAL DecontaminationDecontamination
ComplicationComplication
ACTIVATEDACTIVATED CHARCOALCHARCOAL DecontaminationDecontamination
pneumoniapneumoniabronchiolitis obliteransbronchiolitis obliteransARDSARDSdeath.death.
Alcohols
Hydrocarbons
Organophosphates
Carbamates
Acids
Potassium
Dichloro diphenyl trichloroethane )DDT(
Alkali
Iron
Lithium
Toxins and Drugs Not Adsorbed by Activated Charcoal
ACTIVATEDACTIVATED CHARCOALCHARCOAL DecontaminationDecontamination
Three methodsThree methods (1) dialysis (usually hemodialysis (1) dialysis (usually hemodialysis
rather than peritoneal dialysis)rather than peritoneal dialysis) (2) hemoperfusion(2) hemoperfusion (3) hemofiltration. (3) hemofiltration.
ExtracorporealExtracorporeal Removal of ToxinsRemoval of Toxins
Toxins Characteristics Toxins Characteristics
low molecular weight (< 500 d)low molecular weight (< 500 d) water solublewater soluble low protein binding (< 70 to 80%)low protein binding (< 70 to 80%) small volume of distribution (< 1 L/kg). small volume of distribution (< 1 L/kg).
It can especially be effective in correcting concomitant It can especially be effective in correcting concomitant electrolyte abnormality and metabolic acidosis. electrolyte abnormality and metabolic acidosis.
I,e:I,e: methanol, methanol, ethylene glycol, ethylene glycol, boric acid, boric acid, SalicylatesSalicylates lithium. lithium.
HemodialysisHemodialysis
Hemoperfusion is defined as direct contact of blood Hemoperfusion is defined as direct contact of blood with an adsorbent system with an adsorbent system
drug clearance is not limited by low water solubility, drug clearance is not limited by low water solubility, high molecular weight, or increased protein binding, high molecular weight, or increased protein binding, but on the ability of the adsorbent to bind to the but on the ability of the adsorbent to bind to the drug/toxin. drug/toxin.
toxin needs to be present in the central compartment toxin needs to be present in the central compartment for hemoperfusion to be effective. for hemoperfusion to be effective.
used to enhance elimination of used to enhance elimination of theophylline, theophylline, phenobarbital, phenytoin, carbamazepine, paraquat.phenobarbital, phenytoin, carbamazepine, paraquat.
HemoperfusionHemoperfusion
application of this technique has not been vigorously studied application of this technique has not been vigorously studied in poisoned patientsin poisoned patients
there are increasing numbers of case reports of there are increasing numbers of case reports of extracorporeal intoxicant removal by either the continuous extracorporeal intoxicant removal by either the continuous arteriovenous or venovenous hemofiltration methodsarteriovenous or venovenous hemofiltration methods
Hemofiltration is potentially useful for removal of substances Hemofiltration is potentially useful for removal of substances with a large volume of distribution, slow intercompartmental with a large volume of distribution, slow intercompartmental transfer, or extensive tissue binding. transfer, or extensive tissue binding.
combined digoxin-Fab fragment complexes, or combined digoxin-Fab fragment complexes, or desferoxamine complexes with iron or with aluminum.desferoxamine complexes with iron or with aluminum.
HemofiltrationHemofiltration
Criteria for Admission of the Poisoned Patient to the ICU
•Respiratory depression )PaCO2 > 45 mm Hg(•Emergency intubation •Cardiac arrhythmia •Seizures •SBP < 80 mm Hg •Unresponsiveness to verbal stimuli •Glasgow coma scale score < 12 •Need for emergency dialysis, hemoperfusion, or ECMO •Increasing metabolic acidosis •Pulmonary edema induced by toxins )including inhalation( or drugs
ICU Admission Initial supportive measuresInitial supportive measures
•Hypothermia or hyperthermia including neuroleptic malignant syndrome •Tricyclic or phenothiazine overdose manifesting anticholinergic signs, neurologic abnormalities, QRS duration > 0.12 s, or QT > 0.5 s •Body packers and stuffers •Emergency surgical intervention•Administration of pralidoxime in organophosphate toxicity•Antivenom administration •continuous infusion of naloxone •Hypokalemia secondary to digitalis overdose (or need for digoxin-immune antibody Fab fragments)
Criteria for Admission of the Poisoned Patient to the ICU
ICU Admission Initial supportive measuresInitial supportive measures
In this retrospective study, if a poisoned patient did In this retrospective study, if a poisoned patient did not exhibit any of the eight characteristics, no ICU not exhibit any of the eight characteristics, no ICU interventions (intubation, vasopressors or interventions (intubation, vasopressors or antiarrhythmics, and dialysis or hemoperfusion) antiarrhythmics, and dialysis or hemoperfusion) were required.were required.
(1) PaCO2 > 45 mm Hg, (1) PaCO2 > 45 mm Hg, (2) need for intubation, (2) need for intubation, (3) toxin-induced seizures, (3) toxin-induced seizures, (4) cardiac arrhythmias, (4) cardiac arrhythmias, (5) QRS ≥ 0.12 s, (5) QRS ≥ 0.12 s, (6) sBP < 80 mm Hg, (6) sBP < 80 mm Hg, (7) 2(7) 2ndnd or 3 or 3rdrd degree AV block, degree AV block, (8) unresponsiveness to verbal stimuli. (8) unresponsiveness to verbal stimuli.
ICU Admission Initial supportive measuresInitial supportive measures
• Brett AS, Rothschild N, Gray R, et al. Predicting the clinical course in intentional drug Brett AS, Rothschild N, Gray R, et al. Predicting the clinical course in intentional drug overdose: implications for the use of the intensive care unit. Arch Intern Med 1987; overdose: implications for the use of the intensive care unit. Arch Intern Med 1987; 147:133147:133––137137•Mokhlesi B, Leikin JB, Murray P, et al. Adult toxicology in critical care: part I: general approach to the intoxicated patient. Chest 2003;123(2):577-92.