PMH

what environment was patient in?

other people exposed?

odors or smells

suicide note

drug paraphernalia

what type of pills or meds-sustained release or enteric coated/milligram amts or dosage

how many pills or how much liquid?

time of ingestion?

actual pill contained

beware myopia

ABC's

vitals

general appearance: GESTALT

Skin

Pupils

Mucous membranes

heart, lungs

neuro exam: mental status, tone

Pt presents tachycardia, elev BP, restlessness, excessive speech and motor activity, tremor, insomnia, hallucinations, dilated pupils, elevated temp.

What type of toxidrome?

What's treatment?

What do you need to be aware of?

Sympathomimetic/stimulant

tx: Benzos, fluids

be aware of temp and possibilty of rhabdo, and MI "cocaine chest pain")

Pt presents with sedation, confusion, delirium, hallucinations, coma, diplopia, blurred vision, slurred speech, ataxia, nystagmus.

What is toxidrome?

what is treatment?

what should you consider?

Sedative-hypnotic toxidrome

tx: supportive (ABC) consider flumazanil for BZD overdose

Pt presents with decreased mental status, miosis, decreased RR, bradycardia, decreased bowel sounds and hypothermia.

What's the toxidrome?

What's the treatment?

Opiate toxidrome

tx: supportive ABC's and consider Naloxone (Narcan)- just enough to restore protected acute withdrawal reflexes and resp effort without producing emesis and acute withdrawal

How long is methadone half life?

How long is oxycodone half life?

Feelings of anxiety, insomnia, yawning, lacrimation, diaphoresis, rhinorrhea, diffuse myalgias, piloerection, mydriasis, n/v/d and abdominal cramping.

These are all withdrawl signs of what?

benzoylecgonine

wil be positive if used within the past 72 hrs.

Pt presents and they have flushed skin, hyperthermia, hallucinations, psychosis, seizure, blurred vision, dilated pupils, urinary retention.

What toxidrome are you thinking?

What's treatment?

Would you use gastric decontamination?

Benzo benzo benzo!

Gastric decontamination not used due to poss of seizure

IV O2 Monitor

maybe Haloperidol

consider physostigmine to inactive acetylcholinesterase increasing available acetylcholine/however need normal EKG before giving

Pt presents with salivation, lacrimation, urination, diarrhea, GI upset, emesis

OR sweating, seizure, miosis, muscle fasciculation, bradycardia, bronchorrhea, bronchoconstriction

What's the toxidrome?

What's the treatment?

atropine to dry secretions and increase HR

Pralidoxine (2 PAM): reactivates AcheE used for weakness or fasciuclations, definitive antedote for organophosphates

BZD with 2-PAM and atropine for seizures

secretory exocrine glands, smooth and cardiac muscle are controlled by what cholinergic receptor?

skeletal muscle is controlled by what cholinergic receptor

Baclofen

alpha blockers

beta blockers

calcium channel blockers

digoxin

opioids

cholinergics

in terms of VS, what could these cause?

amphetamines

anticholinergics

antipsychotics

caffeeine and theophylline

cocaine

TCA

sudafed

epi

thyroxine

opioid withdrawal

all of these can cause what?

alpha blockers

beta blockers

ethanol

carbon monoxide

general anesthetics

oral hypoglycemics (sulfonylureas)

opioids

phenothiazines

sedative-hypnotics

what can these cause?

amphetamines

anticholinergics

cocaine

antipsychotics

cocaine

TCAs and MAOs

lithium

PCP

ASA

thyroxine

What can these cause?

alpha blockers and beta blockers

calcium channel blockers

ace inhibitors

TCAs

Ethanol

benzo

barbs

nitrites

phenothiazines

what can these cause?

amphetamines, cocaine, sudafed, epi, nicotine, MAO inhibitors and interactions

what can these cause?

What is considered part of general lab work up for overdose?

Chem 7: bicarb is prob most imp/ glucose always check with altered MS

CBC: need and H and H

ETOH level

PT/PTT and LFTs

carbon monoxide

cyanide

methanol ingestion

uremia

gastric emptying: Ipecac

Gastric lavage

single dose activated charcoal

whole bowel irrigation

What are indications for using Ipecac?

What are contraindications?

Indications: very recent, potentially very serious ingestion remote from health care setting; OR someone downs a bottle of pills right in the ED

Contraindications:

aspiration risk: esp with decreased MS or potential for decreased MS or seizure

causes prolonged emesis, limited use of charcoal or po antidotes

risk of abuse in pts with bulimia- long term can cause cardiomyopathy

what are indications for gastric lavage?

potentially serious ingestion presenting within one hour of ingestion

no known antidote

substance does not bind to activated charcoal

Activated charcoal comes in direct contact with, and adsorbs poisons in the gastrointestinal tract, decreasing the extent of absorption of the poison, thereby reducing or preventing systemic toxicity.

aspiration

esp to pts with decreased MS, seizure risk, or risk that ingestion will cause decreased MS

What is often given in conjunction to single dose activated charcoal?

what are complications of giving?

what are contraindications?

Cathartics given (ie. sorbitol, or mag citrate)

complications: cramping and abdominal pain/volume depletion

contraindications: kids <5; renal failure

Pt presents with recent ingestion of lithium or iron

maybe patient is a body packer.

What method do you want to use for toxicity?

Whole Bowel Irrigation

use polyethylene glycol 1-2L/hr PO or via OGT/NGT until rectal effluent clear (usually 4-6 hrs)

What are side effects of whole bowel irrigation?

what are contraindications?

side effects: vomiting, abd pain

contraindications: aspiration risk (decreased MS, seizure risk), bowel perforation or obstruction

What are ways to remove the toxin directly from plasma?

(3)

multi-dose activated charcoal

urinary alkalinization

hemodialysis

1. interrupts "enterohepatic recirculation" of selected drug (GI-portal system-liver absorption-excreted in bile-GI tract) trap toxin in GI tract

2. Diffusion from plasma across intestinal lining into charcoal- AGAIN trap toxin in GI tract

necessitates intact airway- awake and aler or intubated, no seizure risk)

No signs of ileus or obstruction (soft, nontender abdomen with normal bowel sounds)

What is the MOA of urinary alkalinization?

What are indications?

MOA: enhances urinary excretion of acids, traps weak acids in ionized state, prevents resorption of acids from renal tubules

Indications: overdose with WEAK acid

barb, s/a phenobarb

salicylates

chlorpropamide- a sulfonylurea

TCAs

when using urinary alkalinization: what is goal urine pH?

when is using urinary alkalinization contraindicated?

What is procedure?

7.5-8

contraindicated: renal failure, CHF

procedure: 3 amps bicarb in D5NS

WHen can you use hemodialysis?

ISTUMBLES

Isopropyl Alcohol

Salicylates

Theophylline (caffeine)

Uremia

Methanol

Barbiturates, beta-blockers (water soluble, such as atenolol)

Lithium

Ethylene glycol

salicylates with level over 90 mg/dl (acute) or 60 mg/do (chronic)

OR severe symptoms OR inability to alkalinize urine (renal failure or CHF)

aspirin

methyl salicylate- oil of wintergreen

darvon

percodan

pepto bismol

What would be a pt's level who has salicylate toxicity:

no toxicity-mild

moderate

severe

chronic

no toxicity-mild: <150 mg/kg or serum levels < 50 mg/dl

moderate: serum levels from 30-110 mg/dl OR ingestion of 150-300 mg/kg

severe: more than 300 mg/kg or serum levels acutely greater than 110 mg/dl

chronic: 10 to 30 mg/dl

A salicylate toxicity consistent with the following would be considered what stage?

GI irritation, N/V, tinnitus

A salicylate toxicity consistent with the following would be considered what stage?

tinnitus, hyperventilation, sweating, emesis, acid base changes

A salicylate toxicity consistent with the following would be considered what stage?

seizures

hypoglycemia

N/V and Gi complains: gastric perforation, GI hemorrhage

Renal failure

severe cardiotoxicity

coma

pulmonary edema or ARDS

hyperventilation

agitation

hypokalemia

change in MS

acidosis

volume depletion

Assumes:

1. a one time ingestion

2. a specific time

3. non enteric coated preparation

How do you treat salicylate ingestions?

what do you anticipate?

ABCs

activated charcoal 1 gm/kg if within one hour and no change MS

consider whole bowel irrigation: for enteric coated preps

ICU: for severe toxicity

Anticipate HYPOGLYCEMIA!

first liter NSS, thereafter give D5 solution

alkalinize the urine

Hemodialysis for cases not responsive to fluid, AC and urinary alkalinization

Stage 1: first 24 hrs.; few or no sxs; n/v or mild GI complaints

stage 2: evidence of hepatoxicity: days 2 to 3; RUQ pain

elevated LFTs: ALT and AST very very very night

*Most of these pts will recover even without tx

stage 3: liver failure

days 3 to 4

metabolic acidosis/sepsis looking

renal failure

coagulopathy- synthetic liver failure

encephalopathy/cerebral edema

Stage 4: recovery

4 to 14 days

occurs over a one week period

complete resolution of sxs in survivors

Smells

when you smell acetone THINK:

bitter almonds:

rotten eggs

fruits

Arsenic

Burned rope:

when you smell acetone THINK: ETOH, Isoprpanol

bitter almonds: cyanide

rotten eggs: hydrogen sulfide/NAC

fruits: nitrites like amyl and butyl

Arsenic: DMSO, selenium

Burned rope: THC

What are complications of ethanol overdose?

(5)

hypoglycemia

alcholic ketoacidosis

gastritis

pancreatitis

thiamine deficiency: decreased absorption

suspect metabolic derangement, co-ingestion, trauma

"banana bag": MVI, thiamine, Mag, Folate

D5 and 1/2 or just NSS

*No chemical slower the rate of oxidation of ETOH

labs

EKGs

CT scan if new seizures

IV, O2, Monitor, Thiamine, Banana bag

Benzos, benzos benzos

chronic ETOH users develop impressive tolerance to Benzos- dosing may be much higher than that of non-drinkers

These products all share a common ingredient:

cleansing materials

paints

varnishes

moonshine

windshield washer

duplicator fluid

you find a patient with sluggish reactive pupils, blindness present, fixed and dilated pupils

Patient is lethargic, confused, coma and seizures.

There is severe abdominal tenderness and nausea.

There is an increased anion gap.

What could it be?

NaHCO3 for acidosis

2 amps of bicarb in D5W

formaldehyde

formic acid

fomepizole

folic acid

How is ethylene glycol metabolized?

How is it excreted?

metabolized in the liver via alcohol dehydrogenase pathway

excreted renally

What stage of ethylene glycol toxicity would you see the following:

CNS depression- appears intoxicated w/o odor of ETOH

ataxia

nystagmus

opthalmoplegia

papilledema

stupor/coma

What stage of ethylene glycol toxicity would you see the following:

tachycardia

hypertension

pulmonary edema

CHF and circulatory collapse

What stage of ethylene glycol toxicity would you see the following:

costovertebral angle tenderness

acute renal failure from tubular toxicity

hypocalcemia

urinary calcium oxalate crystals

NSS at 250 to 500 to prevent deposition of oxalate crystals in kidneys

bicarb for acidosis of pH less than 7.2

pyridoxine and thiamine replacement

examine urine for crystals or fluroescence

loading dose of 4mp or ETOH depending on availability

consult nephro for early dialysis

Ca Chloride for hypocalcemia

beta blockers

lidocaine

When thinking a patient may have a TCA overdose-

what is very important about management?

EKG is VERY IMP: look for widening of the intervals and terminal r in AVR

charcoal if normal EKG and not horribly sick

intubate

alkalinize with bicarb drip and fluids

What is contraindicated in treatment of TCA overdose?

How do you treat arrythmias?