Toxicology symposium

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  • 1. Updates in Clinical ToxicologyEmerging Trends inEmergency Medicine 2012-13

2. Introduction Welcome CGD Toxicology 20-40 mins My Background Emergency Medicine 6 months as Toxicology Registrar in 2010 Disclosures None to declare 3. Learning Objectives Aims and Learning Objectives Topics Emerging Therapies in Toxicology Emerging Illicit Drugs Updates in Toxinology Approach Case based approach Interactive session Discussion of emerging topics in Toxicology* There is emerging evidence in the areas discussedbut an absence of Randomised Control Trials (RCTs) 4. Risk Assessment Based Approach toPoisonings 5. Risk Assessment (1) Drug* taken, form, route and dose Defined Daily Dose Threshold for Toxicity (2) Time since the Ingestion (3) Progress and Clinical Features (4) Patient Specific Factors Age Weight Past Medical History Resources CIAP, Toxinz, Handbooks, Poisons 6. Toxicology in Retrieval Common Secondary Transfer 3/50 for me Data from recent months. 7. - High Dose Insulin- Intralipid Emulsion (ILE)- Methylene Blue 8. Case 1 Cassie 17 years old, no medical history From Parkes (rural NSW) Living with her parents and grandma After a fight with her mother at dinner shestormed out stating I hate you all 1 hour latershe tells her mother she has taken Grans pills Mum tearfully calls an Ambulance and she isbrought to the local rural EmergencyDepartment with single weekend coverage 9. Parkes 10. Case 1 - Cassie On arrival in Emergency she states regret at takingthe tablets and wants to go home Risk assessment 2 hours ago she took 2 full blisters (24) of Verapamil The tablets were Slow release (240mg) She also took 7 Panadol (5oomg) Is this a concerning overdose? What do we expect to happen? 11. Progress Cassie initially has normal observations (BP 121/70) Activated Charcoal (50g) is given Routine bloods are taken from the patient On advice from poisons information IV fluids arestarted and she is monitored. A discussion in regards to W.B.I. is undertaken and itis decided against 12. Progress 2 The patient is persuaded to stay in hospital After 4 hours of observation she feels light headedand nauseous. She has had 20ml/kg of fluid Her blood pressure quickly drops to 70/40(confirmed by manual readings) Her heart rate is now 45/min and despite furtherfluids, IV calcium, atropine and glucagon shedevelops evidence of cardiac failure Now Retrieval Rescue 23 is tasked to get patient 13. High Dose Insulin Therapy High-dose insulin euglycemic therapy (HIET) High-dose insulin therapy with IV glucose Emerging as an effective treatment for severebeta-blocker & calcium channel-blocker poisoning Animal data and case reports demonstrate thathigh-dose insulin (1-10 U/kg/hour) is a superiorto standard treatment* in terms of safety andsurvival in both beta-blocker and calcium-channel blocker poisoning**. 14. Kearns et al Free at http://emcrit.org/wp-content/uploads/ccb.pdf 15. Local Case Reports 16. Case 2 John 79 year old Presenting to hospital following a fall on thefront porch of his house He was unable to get up afterwards and has anobvious deformity of his right leg 17. Analgesia John receives Morphine and Paracetamol IV but stillhas persistent pain The local locum places a femoral block usingMarcaine (Bupivicaine) 20mls with a landmarktechnique with aspiration every 5mls infiltrated A few moments later the patient becomesunresponsive and CPR is started The patients rhythm is Asystole 18. Intralipid Emulsion (ILE) Intralipid is emerging as a first line therapy fortreating the cardiotoxic effects of LocalAnaesthetic toxicity and otherrefractory emergencies First described in the 1990s Data emerging for LA and TCA from Human Case Series Animal Data 19. Intralipid Oil and Water Micro Emulsion Derived from Soya Bean pH 8.0 How does it work? (1) Lipid Sink Redistribution** (2) Effects on channels Sodium Channels Calcium Channels (3) Metabolotropic 20. How to give 21. Intralipid Emulsion (ILE) 22. Intralipid Emulsion (ILE) 23. Methylene Blue EAPCCT Abstract 24. Summary Risk assessment is the mainstay of goodmanagement of toxicological emergencies New therapies are emerging and awareness ofthese is useful These new therapies should be used in thecontext of advice from a toxicologist andreserved in the main for refractory cases 25. - Quetiapine- The Synthetic Cannabinoids 26. Case 3 Richard is a 41 year old man History of Schizophrenia managed with Seroquel Treated in the community 27. Case 3 Richard presents to his GP in Warren (NSW)stating he has taken extra tablets to help himsleep but is now worried he has taken too many! An ambulance is called after he reveals he hastaken 40 x 200mg tablets (a total of 8g) today On route he is tachycardic (120) and drowsy butopens his eyes to speech and obeys commands Where is Warren? What is your risk assessment? 28. Warren 29. Risk Assessment (1) Drug* taken, form, route and dose Defined Daily Dose Threshold for Toxicity (2) Time since the Ingestion (3) Progress and Clinical Features (4) Patient Specific Factors Age Weight Past Medical History 30. On arrival at Warren Hospital 31. Quetiapine (Seroquel)Emerging as the number 1 toxicological cause ofICU admission in Australia 32. Adverse Effects Tachycardia (common) Reduced Level of Consciousness (variable) Delirium (masked) Coma (dose dependent) Common in overdoses > 3 grams Respiratory Depression Hypotension ECG changes include prolonged QT Arrhythmias are described but are unusual 33. The ECG of Quetiapine overdose 34. ECG QT interval 35. Case 4 Raymond is a 39 year old He doesnt normally take drugs However he accepted the offer of trying a newdrug at a party After a short time Raymond became agitated andappeared to be disorientated An ambulance was called and he arrives at yourED being held down by police and paramedics 36. K2 Spice Synthetic Drug Potent Cannabinoid Multiple Formulations Reports of Seizures and Psychosis at increasedrates compared to organic Marijuana Risk of seizures Risk assessment should predict a higherlikelihood of adverse outcomes and a longerduration of observation in the ED Treatment is primarily supportive 37. K2 Spice 38. New Drugs 39. New Drugs 40. Summary 41. - Snake antivenom use - what has changed in recent years?- Trends in Red-back spider antivenom use 42. Case 5Jason - 13 years old Playing cricket While retrieving the ball stood on a twig He ran back to the field complaining of pain A few minutes later he collapsed and is taken tohospital by ambulance On the way to hospital he develops epistaxis andbleeding from the gums What is the most likely diagnosis? 43. Australian Snakes *Brown Snake (pictured) A common snake,can be aggressive Causes the most fatalities dueto Coagulopathy *Death Adder *Tiger Snake *(Red Bellied) Black Snake Mulga & Colletts Snake *Taipan - reclusive hunter and therefore hasminimal contact with humans. Bites aretherefore uncommon. This snake having themost potent venom (LD50) of all snakes *Sea Snake 44. Envenomation Summary COAGULOPATHY (VICC, AC) and MAHA LOCAL EFFECTS MYOTOXICITY RENAL FAILURE NEUROTOXICITY 45. Snake Bite - Updates Recent years have seen changes in recommendations: Antivenom Cross over Quantity Indications for antivenom Effectiveness of antivenom Use of the Snake VDK Snake Coagulopathy FFP and antivenom When to Discharge? 46. Antivenom Dosing 47. Antivenom early 2000s 48. Antivenom Effectiveness 49. Discharge 50. Summary PIB PIB removal in a monitored setting VDK Antivenom use FFP 51. Case 5 A young mother presents in distress after beingbitten by a spider in a shoe She has severe leg pain, nausea and has noticedsweating on both legs as well as goose-bumps atthe site of the bite Her confident husband identifies the spider as aRedback and has brought the specimen intohospital (alive) in a glass jar 52. Spider Bite Redback Common presentation Clinical Syndrome Pain + Sweating Piloerection 53. RedbackSpider BiteClinical EffectsLocal andRegionalNB ThereMay be noHistory ofSpider BiteSystemicEffectsLocal PainRadiating PainPiloerectionLocal SweatingNauseaVomitingHeadachesLethargyRemote PainAgitationHypertensionNeurologicalSpider Bite Redback 54. Redback Antivenom Historically there has been a low threshold for use Now Controversial 55. Redback Antivenom 56. IM Antivenom 57. Summary and Future Directions Provisional results of the FFP and RAVE II studyare imminently pending A single vial of antivenom is sufficient for thetreatment of snake envenomation Analgesia is the mainstay of treatment forredback spider bite. 58. Other Emerging Topics(Brief Discussion if Time) New Anticoagulants Decontamination and WBI Naloxone Sulphonyureas 59. Questions and Discussion