Term
40 WM found lying unconscious in the floor surrounded by pills and open bottles
Family member “threw him in the car” and presented by POV
Family is extremely distraught and uncooperative
What’s your initial approach? Temp: 97.5, HR: 52, RR: 6, BP: 100/60
HEENT: pinpoint pupils
Lungs: faint crackles
CV: RRR
ABD: soft, non tender, decreased BS
Neuro: comatose
Ext: extensive scars in the AC
Dx and Tx? |
|
Definition
What’s your initial approach?
A –Airway assessment
B –Support Ventilation if needed
C –Circulatory assessment and support
C –“coma cocktail”
–Narcan
–Thiamine
Opioid Toxidrome
Support ABCs
Narcan (Naloxone)
2mg IV bolus for true bradypnea
0.25mg IV for mild to moderate Sx
–D50 |
|
|
Term
*Coma, *Respiratory depression,
*Miosis (pinpoint), Hypotension,
Bradycardia, Hypothermia,
pulmonary edema, Decreased bowel sounds,
Hyporeflexia, Needle marks. *-triad |
|
Definition
Opioid Toxidrome
Support ABCs
Narcan (Naloxone)
2mg IV bolus for true bradypnea
0.25mg IV for mild to moderate Sx |
|
|
Term
Rocking back and forth, anxious, agitated complaining of chest pain
Temp 101, HR 140, RR 22, BP 200/100
Skin: Diaphoretic
Lungs: Clear
Heart: Tachy but RRR
ABD: S/NT/ND
Neuro: Non-focal |
|
Definition
Sympathomimetic Toxidrome
Treatment?
ABCs as usual
Benzos, Benzos, Benzos
–Ativan 1 to 2 mg IV as needed |
|
|
Term
Paranoid
Tachycardic
Hypertension
Hyperpyrexia
Diaphoresis
Mydriasis (dilated)
Piloerection |
|
Definition
Sympathomimetic Toxidrome
Treatment?
ABCs as usual
Benzos, Benzos, Benzos
–Ativan 1 to 2 mg IV as needed |
|
|
Term
| Thrashing in the bed, anxious, agitated and moaning Temp 101, HR 140, RR 22, BP 140/60 Skin: very dry Lungs: Clear Heart: Tachy but RRR ABD: S/NT/ND Neuro: Non-focal |
|
Definition
| Anticholinergic Toxidrome Mainly Supportive –Consider early elective intubation Benzos for agitation Standard ACLS drugs for dysrhythmias Watch for Rhabdomyolysis BEWARE Physostigmine |
|
|
Term
Mad as Hatter = Delirium
Dry as a Bone = Dry skin/Urinary retention
Red as Beet = Flushed skin
Hot as Hell = Elevated Temp
Blind as a Bat = Visual Changes
Mydriasis with loss of accommodation |
|
Definition
Anticholinergic Toxidrome
Mainly Supportive
–Consider early elective intubation
Benzos for agitation
Standard ACLS drugs for dysrythmias
Watch for Rhabdomyolysis
BEWARE Physostigmine |
|
|
Term
Confused, coughing, and vomiting profusely
Temp 99, HR 120, RR 30, BP 120/80
Skin: profuse diaphoresis
Lungs: Frank rales bilat
Heart: Tachy but RRR
ABD: S/NT/ marked increased bowel sounds
Neuro: Non-focal |
|
Definition
Cholinergic Toxidrome
Treatment
Early Intubation for Severe Poisonings
–Succinylcholine lasts longer !!
DECON DECON DECON
–Case reports of staff members requiring intubation after exposure Cholinergic Toxidrome
Treatment
Atropine 2 to 5 mg every 5 minutes
–Dose based on symptoms
–May require HUNDREDS of milligrams
2-PAM (Pralidoxime)
–2 gm bolus followed by 1gm/hour infusion |
|
|
Term
S = Salivation L = Lacrimation U = Urination D = Defecation G = GI Cramps E = Emesis
What is the toxidrome and how do you manage? |
|
Definition
| Cholinergic Toxidrome Treatment Early Intubation for Severe Poisonings –Succinylcholine lasts longer !! DECON DECON DECON –Case reports of staff members requiring intubation after exposure Cholinergic Toxidrome Treatment Atropine 2 to 5 mg every 5 minutes –Dose based on symptoms –May require HUNDREDS of milligrams 2-PAM (Pralidoxime) –2 gm bolus followed by 1gm/hour infusion |
|
|
Term
|
Definition
S = Salivation
L = Lacrimation
U = Urination
D = Defecation
G = GI Cramps
E = Emesis
Cholinergic Toxidrome |
|
|
Term
Tox Workup
Urine Drug Screen |
|
Definition
The most ordered test on all Tox patients
–AND
The most worthless !!! As a rule
The drugs that appear in the tox screen are rarely the drugs in the acute OD |
|
|
Term
Tox Workup
Serum Alcohol Level |
|
Definition
Can be useful if patient is “acting funny”
–Especially in pediatrics
Also useful for medio-legal aspect of care
–A physician has never been sued successfully for restraining an intoxicated patient in order to
provide appropriate care!!!
–They HAVE been sued for failure to do so!!! |
|
|
Term
|
Definition
Crystals
Rhabdomyolysis
–Poor man’s myoglobin
Pregnancy! |
|
|
Term
|
Definition
As a rule...worthless
Unless you suspect pulmonary edema or aspiration |
|
|
Term
Tox Workup
Abdominal X-RAY (KUB) |
|
Definition
Once again...mostly worthless
You can see heavy metal ingestions
–Iron, Lithium, MVI, etc. |
|
|
Term
Tox Workup
Specific Drug Levels? |
|
Definition
You can’t order every drug level known to mankind
Tailor based on both ingestion history
–AND
Available medications in the house |
|
|
Term
Tox Workup
There are 2 drug levels that are likely worth ordering in EVERY potential
overdose... |
|
Definition
ASA
Tylenol –The Silent Killer |
|
|
Term
|
Definition
| Many stimulants can produce Rhabdomyolysis |
|
|
Term
| Definition of Rhabdomyolysis? |
|
Definition
| rapid breakdown (lysis) of skeletal muscle (rhabdomyo) due to injury to muscle tissue. The muscle damage may be caused by physical (e.g., crush injury), chemical, or biological factors. The destruction of the muscle leads to the release of the breakdown products of damaged muscle cells into the bloodstream; some of these, such as myoglobin (a protein), are harmful to the kidney and may lead to acute kidney failure. Treatment is with intravenous fluids, and dialysis or hemofiltration if necessary. |
|
|
Term
Tox Workup
Electrocardiogram |
|
Definition
Useful for positive predictive value
–If its abnormal = bad
Not necessarily looking for abnormal rhythm
Widened QRS, Prolonged QT, “scooped” ST segments |
|
|
Term
Tox Workup
Arterial Blood Gas |
|
Definition
Can be useful with certain ingestions
Routine ordering of an ABG is not useful
BUT...most admitting docs want it |
|
|
Term
Tox Workup
Basic Metabolic Panel (Chem-7) |
|
Definition
Biggest Bang for the Buck!!!
–Order on ALL possible ingestions
NEVER EVER ignore unexplained metabolic acidosis
–Calculate Anion Gap with EVERY acidosis
–(Na + K) –(Cl + HCO3) = 10 to 12 normally |
|
|
Term
| What do you get on a Chem 7?? |
|
Definition
Na+ | Cl | BUN /
------------------- glucose
K+ |HCO3| Cr \ |
|
|
Term
| Calculate Anion Gap with EVERY acidosis |
|
Definition
| (Na + K) –(Cl + HCO3) = 10 to 12 normally |
|
|
Term
|
Definition
M –Methanol
U –Uremia
D –DKA
P –Paraldehyde
I –INH or Iron
L –Lactic Acidosis
E –Ethylene Glycol
S –Salicylates |
|
|
Term
18 WF presents after “taking a bunch of pills” a “couple” of hours ago “I just don’t want to live anymore” No History of psychiatric disease previously NO Past Med Hx, Past Surg Hx, meds or allergies. Foolish Fanny Upon further prodding she took “Wal-Mart Pain Reliever” How many –“All of them” Her only complaint is nausea and, of course, depressive symptoms Poor eye contact and depressed affect. Foolish Fanny Vital Signs are normal Physical Exam is NORMAL What’s next? What tests are we going to order? Is there any treatment that we can start BEFORE labs come back that may improve outcome?
ECG: normal in every respect UA: negative UPT: Positive Chem 7: Normal ASA: < 5 Acetaminophen: 250 ug/ml What now?
|
|
Definition
| Workup: UA / UPT Chem 7 ECG ASA and tylenol levels. Treatment Is there any treatment that we can start BEFORE labs come back that may improve outcome? GI Decontamination! Treatment? Activated Charcoal 50g PO. ECG: normal in every respect UA: negative UPT: Positive Chem 7: Normal ASA: < 5 Acetaminophen: 250 ug/ml What now? N-Acetylcysteine (NAC) 140 mg/kg IV NAC now approved –intractable vomiting, pregnancy or hepatic failure 17 doses at 4 hour intervals |
|
|
Term
Adsorbs many chemicals
Inert compound...cheap...usually safe
Typical dose = 1g/kg (50g PO)
High Affinity for ASA and anticonvulsants
Does NOT bind heavy metals or alcohols |
|
Definition
|
|
Term
Rarely used in today’s ED...unless...
Truly Toxic ingestion who presents within 1 hour |
|
Definition
Gastric Lavage
“Stomach Pump”
Rarely used in today’s ED...unless...
Truly Toxic ingestion who presents within 1 hour
Elective intubation prior to Lavage is now standard practice |
|
|
Term
RARELY used...unless
Toxic drug poorly bound by AC or certain sustained release preparations
Also for “body packers” |
|
Definition
Whole Bowel Irrigation (WBI)
NG or OG tube instillation of PEG lavage fluid in serial fashion
RARELY used...unless
Toxic drug poorly bound by AC or certain sustained release preparations
Also for “body packers” |
|
|
Term
With certain drugs, able to nearly completely clear the drug from the system
Invasive and expensive
Toxic Alcohols, ASA, and Heavy Metals |
|
Definition
Dialysis
With certain drugs, able to nearly completely clear the drug from the system
Invasive and expensive
Toxic Alcohols, ASA, and Heavy Metals |
|
|
Term
Acetaminophen Toxicity
Most absorption when?
Peak Levels when?
Toxic dose is what? |
|
Definition
Acetaminophen Toxicity
Most absorption within 2 hours
Peak Levels within 4 hours
Toxic dose 140 mg/kg |
|
|
Term
Acetaminophen Toxicity
Mechanism of Toxicity: |
|
Definition
APAP oxidated by Cyto p450 => NAPQI
NAPQI + GSH (glutathione) => non-toxic conjugates
When NAPQI exceeds GSH, then NAPQI exerts its hepatic toxicity |
|
|
Term
Acetaminophen Toxicity
Four Stages of Clinical Symptoms |
|
Definition
Pre-Injury: minimal sx within first 24 hours
–Nausea, anorexia, etc
Onset of Liver injury: RUQ pain, vomiting, usually occurs after 24 hours
Maximal Liver Injury: Fulminate Hepatic Failure, usually 3-4 days
Recovery: Hepatic enzymes return to normal within 5-7 days |
|
|
Term
Acetaminophen Toxicity
ACUTE Ingestion: procedure |
|
Definition
Follow nomogram...
Toxic level of APAP >140 at 4 hours
Start N-Acetylcysteine (NAC) for toxic levels
AST is screening tool for hepatic injury |
|
|
Term
Acetaminophen Toxicity
N-Acetylcysteine (NAC): method of action |
|
Definition
NAC acts as GSH substitute and precursor
NAC may also improve survival in patients with hepatic / multi organ failure
8 hour time window (up to 16 hours) |
|
|
Term
Temp: 98.6, HR 110, RR 22, BP 150/60 HEENT: no odor of alcohol CV: tachy but regular Lungs: clear ABD: obese but soft/NT Neuro: appears uncoordinated and intoxicated but NON-focal. Workup? Interim treatment? ECG: sinus tach ASA < 5 Tylenol < 2 ETOH 0.0 Chem-7: Na 136, K 5.0, Cl 99, HCO3 8, BUN 50, Cr 4.0, GLU 90 –AG = 34 Measured Serum Osmols: 363. UA = Fluorescent crystals.
Workup? Dx? Tx? |
|
Definition
| Workup? UA ECG Chem-7 Serum Osmolarity ASA and Acetaminophen Levels ETOH level. Interim treatment? AC? Lavage? WBI? IV fluids and Zofran. Ethylene Glycol "Slightly Sweet", component of Antifreeze –“Potato Schnapps” etc Toxic metabolites of oxalic acid and glycolic acid Severe Metabolic Acidosis (glycolic). Ethylene Glycol Patients appear intoxicated but WITHOUT the smell of alcohol "Double Gap” Acidosis –AG plus OG = Sick sick sick Ca+ Oxalate crystals in urine => fluorescence with Wood's Lamp. Ethylene Glycol Management NO AC, NO emesis, NO Lavage Aggressive BICARB Ethanol or 4MP (Class C) used to block ADH Hemodialysis is cornerstone (indications controversial) |
|
|
Term
|
Definition
Measured OSM –Calculated OSM = Osm Gap
Highly osmotic active substances like the toxic alcohols produce an “osmol gap”
Osmol Gap + Anion Gap = “Double Gap” acidosis = TRUE emergency and threat to life. Calculated Osmolality = (2 x (Na + K)) + (BUN / 2.8) + (glucose / 18) |
|
|
Term
Elderly aunt brings in her 5 year old niece after the child allegedly ingested “Clorox”
Auntie gave her a glass of milk mixed with castor oil
Child threw up 3 or 4 times. Dx? Treatment?? |
|
Definition
Caustic Ingestions
Treatment??
Consider gentle oral fluids or milk in small amounts for dilution
Emesis and AC have NO ROLE
Steroids controversial
NO ABX. Caustic Ingestions
Laryngeal edema can occur over minutes, therefore rapid intubation may be needed
BE ready for surgical cricothyrotomy
BNTI contraindicated. Caustic Ingestions
CXR useful to Dx mediastinal or abd free air
Endoscopy indicated for Sx patients and presence of oral burns
Late endoscopy is hazardous secondary to wound "softening" |
|
|
Term
Caustic Ingestions
Alkali v. acid?
How are caustic burns graded? |
|
Definition
Caustic Ingestions
Alkali > acid
–Liquefaction vs coagulation necrosis
Caustic burns graded as partial or full thickness (just like thermal) |
|
|
Term
| Caustic Ingestions How can you tell if they have GI Burns? |
|
Definition
| Oral Burns!! –Positive Predictive = POOR –Negative Predictive = GOOD NEITHER CAN PREDICT SEVERITY Dysphagia & Drooling are 100% Sensitive and 90% specific |
|
|
Term
| Temp 102, HR 100, RR 28, BP 160/90 HEENT: normal Lungs: rales CV: tachy but RR Abd: S/NT/ND Neuro: Confused but non-focal. DDx? Workup? Interim Treatment? cl H, co2 L, agap H, cr H, ca2+ L, salicylate H, abg hgb L, abg pco2 L, abg po2 h, abg hco3 L, total co2 L, abg be l, abg 02 cnt l, a-a do2 h, co-ox cohgb l. |
|
Definition
ASA Management: 3 pronged approach to prevent further absorption, correct acid-base, increase excretion
MDAC
Consider WBI for large enteric coated ASA ingestions.
Aggressive IV fluid hydration.
Frequent accu-checks
Repleat K+.
Urine alkalinization (bolus followed by drip) for ASA > 35.
Dialysis for ASA > 100, severe acidosis, rising levels, or other “serious” signs. |
|
|
Term
ASA
Toxic Dose is what?
Lethal Dose is what?
Peak Levels when? |
|
Definition
ASA
Toxic Dose is 250 mg/kg
Lethal Dose is 500 mg/kg
Peak Levels in 2-4 hours |
|
|
Term
|
Definition
ASA
Toxic Effects:
Stimulates respiratory center => hyperventilation => Resp. ALKALOSIS
Uncouples oxidative phosphorylation => increased metabolic rate => Metabolic
ACIDOSIS
Renal failure and hypokalemia
Pulmonary edema and Cerebral Edema
Tinnitus and Hyperthermia |
|
|
Term
|
Definition
ASA
Diagnostics: obtain 4 to 6 hour ASA level
If initial level undetectable => nontoxic ingestion
If initial level is in nontoxic range => repeat in 2 hours |
|
|
Term
| When do you dialysize pt w/ASA OD? |
|
Definition
Dialysis for:
ASA > 100,
severe acidosis,
rising levels,
or other “serious” signs |
|
|
Term
| What OD's do you dialysize? |
|
Definition
| Toxic Alcohols, ASA, and Heavy Metals |
|
|
