Toxicology for primary care
58
Poisoning AKA: Stupid sailor/marine tricks. Tina F. Edwards, MD FAAEM LCDR MC USN
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Common toxidromes that may be encountered by primary care doctors, particularly military doctors.
Transcript of Toxicology for primary care
Poisoning
AKA: Stupid sailor/marine tricks.Tina F. Edwards, MD FAAEM
LCDR MC USN
Toxicology, in a nutshell
OSupportive careOSeizure, coma, death
Conclusion
OQuestions? OJust Kidding!
OverviewO Basics of the poisoned patientO AnticholinergicsO CholinergicsO SedativesO SympathomimeticsO Carbon MonoxideO Toxic Alcohols
What is a poison?O Too much of anything can be a bad
thing.
Why primary care? O Jus’ gonna send this patient to ED!O RecognizeStabilizeO YOU might be the ED
BasicsO Stable or unstable?
O Abnormal Vital signsO Respiratory distressO Altered Mental Status
BasicsO Nature of the syndrome?
O Mental statusO Agitated vs. SedatedO PupilsO SkinO VitalsO Mucous membranesO Odors
BasicsO Emetics. Don’t. O Charcoal, maybe.O Aggressive supportive care:
O IV, monitors, fluidsO If it’s fast, slow it.O If it’s slow, speed it up.O If it’s low, raise itO If it’s high, lower it.
Common Causes of Seizures
O BupropionO Tricyclic Antidepressants*O TramadolO Isoniazid*O Cocaine, amphetaminesO AntihistaminesO Venlafaxine (Effexor)
WorkupO EKGO Finger stick blood
sugarO ChemistryO Blood GasO CBCO Tylenol, Aspirin, EtOHO UAO CXR,KUB
TreatmentsO Got Activated Charcoal?
O 1 hour +/-O CautionsO Ineffective
O AlcoholsO MetalsO Caustic agents
TreatmentsO DecontaminationO Naloxone
(Narcan)O BenzodiazepinesO DialysisO AntidotesO Sodium Bicarb
So there you are minding your own
business…When...
19 yr old AD Female
O Oriented x 1O AgitatedO 140, 156/92, 20,
101.2, 98%O Dry skin, MM’sO Hypoactive BS
Anticholinergic Toxidrome
O BenadrylO Cough syrupO TCA’sO ScopolamineO DM
Anticholinergic Toxidrome
O Flushed, dry skin, dry mucous membranes
O MydriasisO DeliriumO Hyper: -thermia, -tensionO TachycardiaO Urinary retentionO Hypoactive BS
Anticholinergic Treatment
O Aggressive supportive careO Physostigmine Why?
O Can’t use if any QRS wideningO Contraindicated in asthmaO Requires continuous cardiac
monitoringO Usually won’t outlast the
anticholinergic
24 yr old AD maleO C/O frequent diarrhea,
vomitingO Fatigued, mildly confusedO Acrid garlic smellO 112/62, 52, 18, 98.2,
95%O Productive coughO TearingO Frequent spittingO Muscle twitches
Cholinergic Toxidrome
O MuscarinicO NicotinicO Central
O CausesO InsecticidesO PilocarpineO CarbacholO Betel nutsO Indian
TobaccoO NicotineO Black widow
Cholinergic ToxidromeO Nicotinic
O TachycardiaO HypertensionO Fasciculation'sO WeaknessParalys
is
Cholinergic ToxidromeO Central
O AgitationO Psychosis/
confusionO Seizure/coma/
death
Cholinergic PoisoningO Muscarinic
O DiarrheaO UrinationO MiosisO BradycardiaO BronchorrheaO EmesisO Lacrimation,
salivation
Cholinergic treatmentO Protect yourself!O Stabilize, then decontaminateO Atropine until dryO Pralidoxime currently recommendedO Aggressive supportive care
17 yr old boyO Brought in by momO C/C “not himself”O Sedated, barely
responsiveO Disheveled O 90/58, 52, 10, 97.2,
94%O CracklesO Decreased BSO Hypotonic reflexes
Opioid ToxidromeO Classic Triad
O ComaO Respiratory
DepressionO Pinpoint pupils
Opioid ToxidromeO Causes
O All the usual, plus LomotilO Dextromethorphan
O But wait!
O Random fact:O Not all opioids cause miosis
O Meperidine (Demerol)O Propoxyphene (Darvon)
Opioid TreatmentO NaloxoneO Aggressive supportive care
19 year old AD maleO Brought in by
roommate, “Seized”O Moans, doesn’t open
eyesO 88/52, 101, 10, 95.8,
93%O PERRL, but slowed O Nystagmus
Sedative Hypnotic Toxidrome
O BarbituatesO BenzodiazapinesO GHBO Zolpidem
(Ambien)O Zaleplon (Sonata)
O Confusion/comaO Respiratory
depressionO HypotensionO HypothermiaO Pupillary changes O Vesicles or bullaeO Seizures
Sedative-hypnotic treatment
O Aggressive supportive careO Airway managementO Multiple-dose activated charcoalO Phenobarbital may require dialysis
A note about flumazenilO Why?
O Can precipitate seizuresO Absolutely contraindicated in QRS
wideningO Doesn’t reverse Hypoventilation
What to do?
23 yr old AD maleO Brought in by
command, “not acting right”
O AnxiousO 180/110, 142, 18,
103.2, 100%O Flushed, sweatingO A+O x 3
Sympathomimetic Toxidrome
O CocaineO MethamphetamineO Other CNS StimulantsO Withdrawal from sedative hypnotics
Sympathomimetic Toxidrome
O HypertensionO TachycardiaO HyperpyrexiaO MydriasisO Anxiety or
delirium
Sympathomimetic treatment
O Aggressive supportive careO BenzodiazepinesO Active cooling if needed
What to do?
34 yr old AD maleO Losing balance,
headache, chest pain, vomiting
O 100/72, 120, 32, 98.7, 99%
O A+O x 2O Accessory muscle
use
EKG
Carbon Monoxide Poisoning
O Signs/Sx highly variable, non-specificO HeadacheO DizzinessO Nausea/Vomiting/DiarrheaO ConfusionO SyncopeO SOBO Chest painO Cerebellar ataxia
Mechanism CO Poisoning
O Running engine, closed spaceO MechanicsO Suicide attemptO GeneratorsO Gas heatersO Camp stoves/Charcoal grills
CO Poisoning Treatment
O Oxygen, more is betterO Aggressive supportive careO Mild to moderate acidosis is helpful
O Moves curve to right
23 yr old ADO Sent “I want to
die” textO A+O x 1O 102/62, 110, 12,
97.3, 97%O Covered in vomitO Slurred speechO Ataxic gait
Toxic AlcoholsO Ethanol!O Ethylene GlycolO MethanolO Isopropanol/
AcetoneO Other glycols
Toxic AlcoholsO Ethylene glycol – Ca oxalate
monohydrate crystalsO Methanol – Formic acidO Isopropanol – Acetone
Toxic AlcoholsO All – Airway compromiseO Ethylene Glycol
O DysrhythmiasO NephrotoxicityO MeningoencephalitisO Cerebral/pulmonary edema
Toxic AlcoholsO Methanol
O Visual symptoms, “snowfields”O ComaO Respiratory and circulatory failureO Parkinson-like syndrome
Toxic AlcoholsO Isopropanol
O KetonemiaO CNS Depression (2 x EtOH)O GI effectsO Increased Cr w/nl BUN suggests
Toxic AlcoholsO Other glycolsO Effects
O Neurologic toxicity
O Renal failureO HepatitisO PancreatitisO HemolysisO ARDS
Toxic AlcoholsO Diethylene glycol
O Renal failure epidemicsO Propylene glycol
O “safer” antifreezeO Iatrogenic, IV Benzos
Toxic AlcoholO Aggressive supportive care! O FomepizoleO Plain ol’ ethanolO Look for acidosis, ketones, other
clues
Are you ready?
24 year old maleO Found down
outside barracksO 90/54, 48, 8,
92%, 96.2O Non responsiveO PERRL
18 year old AD femaleO Witnessed
seizureO 160/102, 120, 22,
102.4, 99%O Flushed, DryO Pupils dilated,
reactiveO Absent bowel
sounds
22 year old AD maleO Working outsideO VomitingO 190/120, 130, 24,
104.2, 95%O DiaphoreticO Rigid, shakingO Smells of stoolO Pupils pinpoint,
reactive
SourcesO Harwood-Nuss, Clinical Practice of Emergency Medicine,
5th Edition, Lippincott Williams & Wilkins, Philadelphia, PA, 2010
O Hamilton, Sanders, Strange, Trott. Emergency Medicine, An Approach to Clinical Problem Solving, 2nd Edition. Saunders. Philadelphia, PA. 2003.
O http://www.mrcophth.com/plants.htmlO http://memorize.com/toxidromes-and-antidotes/erichfO http://emedicine.medscape.com/article/812411-clinicalO Thundiyil JG, et. al, Evolving epidemiology of drug-
induced seizures reported to a Poison Control Center System. J Med Toxicol, 2007, Mar, 3(1):15-9.
Questions
