Toxicology Management in The Emergency Department - Jordan Barnett MD

TOXICOLOGYAn Overview

TOXICOLOGYAn Overview

Jordan B. Barnett, M.D., FACEPJordan B. Barnett, M.D., FACEP

Interim Director, Department of Emergency Interim Director, Department of Emergency MedicineMedicine

Episcopal HospitalEpiscopal Hospital

POISONINGPOISONING

Estimated 4 Million AnnualPediatric

Child AbuseAdult

RecreationalSuicide

HISTORYHISTORY

What Poison?How Much?How?When?Why?What Else Taken?

PHYSICAL EXAMPHYSICAL EXAM

Vital SignsABC’sTemperature

Toxic Syndrome Respiratory Cardiovascular Neurologic

TREATMENTTREATMENT

ABC’s Treat Other Injuries Decontamination Supportive Care Definitive Care

AntidotesElimination

DECONTAMINATION: IPECACDECONTAMINATION: IPECAC

Absorption Reduced By 30% Interferes With Further

Decontamination Interferes With Further Treatment Home UseNO EMERGENCY DEPARTMENT

USE!

DECONTAMINATION:GASTRIC LAVAGEDECONTAMINATION:GASTRIC LAVAGE

250 - 300 cc Aliquots Of Fluid 36 - 40F Tube Advantages

Immediate Recovery Of Gastric ContentsDirect access For Charcoal Instillation

Left Lateral Decubitus With Trendelenburg

Intubation May Be Needed

DECONTAMINATION:GASTRIC LAVAGEDECONTAMINATION:GASTRIC LAVAGE

DisadvantagesNot Complete Gastric Emptying 30% Recovery At 1 HourLabor IntensiveComplications

3% Overall Esophageal Rupture Aspiration Hypoxia

DECONTAMINATION:CHARCOALDECONTAMINATION:CHARCOAL

Not Absorbed From GI Tract Binds Most Substances Prevents Absorption Enhance Excretion

Multiple DoseEnterohepatic Circulation

DECONTAMINATION:CHARCOALDECONTAMINATION:CHARCOAL

CharcoalCharcoalEmesisEmesisLavageLavage

57%57%

38%38%

32%32%

Ampicillin ModelDecreased Absorption

ACTIVATED CHARCOALACTIVATED CHARCOAL

Dose 1g/kgDose 1g/kg Repeat DoseRepeat Dose DisadvantagesDisadvantages

MessyMessy AspirationAspiration

SUBSTANCES NOT BOUND BY CHARCOALSUBSTANCES NOT BOUND BY CHARCOAL

Alcohols And Alcohols And GlycolsGlycols

CorrosivesCorrosives AlkalisAlkalis AcidsAcids

CyanideCyanide Saline CatharticsSaline Cathartics

Heavy MetalsHeavy Metals IronIron LeadLead LithiumLithium MercuryMercury

HydrocarbonsHydrocarbons

CATHARTICSCATHARTICS

Mechanism Types Mixture With Charcoal Disadvantages Use In Children

OTHER MODALITIESOTHER MODALITIES

Whole Bowel Irrigation IndicationsTechnique

Skin Eye

RESPIRATORY COMPLICATIONSRESPIRATORY COMPLICATIONS

Airway Protection Ventilatory Insufficiency Bronchospasm Noncardiogenic Pulmonary Edema Aspiration

CARDIOVASCULAR COMPLICATIONSCARDIOVASCULAR COMPLICATIONS

Tachycardia Bradycardia Hypotension Hypertension

NEUROLOGIC COMPLICATIONSNEUROLOGIC COMPLICATIONS

Coma Seizures Behavioral Abnormalities

DIAGNOSTIC STUDIESDIAGNOSTIC STUDIES

Drug Screens/Levels Acetaminophen ABG Electrolytes Organ Function EKG X-RAY

SERUM OSMOLARITYSERUM OSMOLARITY

Serum Osmolarity= 2 (Na+) + BUN/2.8 + Glucose/18

Osmolar Gap 10 mOsm or less Methanol, Ethylene Glycol, Ethanol Glycerol, Mannitol +ETOH/4.6

ETHANOLETHANOL

C2H5OH

Molecular Weight=________

DEFINITIVE CAREDEFINITIVE CARE

Decontamination Supportive Care Antidotes

Oxygen/Glucose/Narcan/?Flumazenil Elimination

AlkalinizationRepeated Dose Charcoal

Dialysis

DISCHARGEDISCHARGE

Stable In Emergency Department Psychiatric Issues

TOXIDROMETOXIDROME

Toxic Syndromes

TOXIDROMES: CASE 1TOXIDROMES: CASE 1

25 Year Old PA Student Just Back From Spring Break In Mexico. He's Been Having Terrible Diarrhea Since Returning and Has Been Using Pills to Alleviate the Symptoms.

TOXIDROMES: CASE 1TOXIDROMES: CASE 1

Dry Skin And Mucous Membranes Thirst Blurred Vision Fixed Dilated Pupils Flushing Urinary Urgency And Retention Hallucinations

TOXIDROMES: CASE 1TOXIDROMES: CASE 1

AnticholinergicHot As HadesBlind As A BatDry As A BoneRed As A BeetMad As A Hatter

TOXIDROMES: CASE 1TOXIDROMES: CASE 1

Belladonna AlkaloidsAtropine/ScopolamineScopolamine

Synthetic AnticholinergicsDicyclomine

OtherAntihistamines/Phenothiazines/TCA

TOXIDROMES: CASE 2TOXIDROMES: CASE 2

A 50 Year Old Farmer Is Found Unresponsive at His Barn.

TOXIDROMES: CASE 2TOXIDROMES: CASE 2

Sweating Constricted Pupils Lacrimation Excessive Salivation Wheezing Vomiting/Diarrhea Fasiculations

TOXIDROMES: CASE 2TOXIDROMES: CASE 2

Acetylcholinesterase Inhibitors Pesticides

OrganophosphateCarbamates

Mechanism Treatment

AtropinePralidoxime (2-PAM)

TOXIDROMES: CASE 3TOXIDROMES: CASE 3

An 8 Year Old Child Is Brought to the Emergency Department After Being Given a Compazine Suppository for Vomiting.

TOXIDROMES: CASE 3TOXIDROMES: CASE 3

Dysphonia Oculogyric Crises Rigidity Torticollis/Opisthotonos

TOXIDROMES: CASE 3TOXIDROMES: CASE 3

Extrapyramidal EffectsMedications

AntipsychoticAntiemetic

Treatment

TOXIDROMES: CASE 4TOXIDROMES: CASE 4

During a Visit to Grandma in the Nursing Home, You Find That You Can Not Wake Her Up.

TOXIDROMES: CASE 4TOXIDROMES: CASE 4

CNS DepressionPinpoint PupilsSlowed RespirationsHypotension

TOXIDROMES: CASE 4TOXIDROMES: CASE 4

NarcoticNarcoticMedicationsMedications

PrescribedPrescribedIllicit

TreatmentTreatment

TOXIDROMES: CASE 5TOXIDROMES: CASE 5

A Movie Star Presents to Your Hospital.

TOXIDROMES: CASE 5TOXIDROMES: CASE 5

CNS ExcitationSeizuresHypertensionTachycardia

TOXIDROMES: CASE 5TOXIDROMES: CASE 5

SympathomimeticMedication

PrescribedIllicit

Treatment

TOXIDROMES: CASE 6TOXIDROMES: CASE 6

A Family of 6 Presents to Your Office in the Middle of Winter and All Complain of “the Flu”.

TOXIDROMES: CASE 6TOXIDROMES: CASE 6

Headache “Flu” Symptoms Nausea, Vomiting, Dizziness Dyspnea Seizures Death Cyanosis “Chocolate” Blood

TOXIDROMES: CASE 6TOXIDROMES: CASE 6

HemoglobinopathiesCarbon MonoxideMethemoglobinTreatment

TRICYCLIC ANTIDEPRESSANTSTRICYCLIC ANTIDEPRESSANTS

Mortality 2 - 5 PercentLow Therapeutic/Toxic RatioMechanism

Inhibition Of Amine UptakeAnticholinergicAlpha Receptor BlockerSodium Channel Blockade

TCACLINICAL FEATURESTCACLINICAL FEATURES

Anticholinergic SymptomsTachycardiaCNS ToxicityComaHypotensionArrhythmiaSeizures

TCACLINICAL FEATURESTCACLINICAL FEATURES

ECG“right axis deviation of the terminal

40ms of QRS greater than 1200 “Sinus Tach-Wide QRS-Decreased

Inotropy-Increased PRI-BradycardiaWide QRS=Life Threatening Toxicity

TCATREATMENTTCATREATMENT

GI Decontamination Sodium Bicarbonate-Indications

QRS WideningHypotensionVentricular Arrhythmias

Sodium Bicarbonate-Mechanism 1 - 2 mEq/Kg To pH 7.50-7.55

TCATREATMENTTCATREATMENT

PhysostigminePeripheral Anticholinergic SymptomsAgitation/Seizures/Hypotension When

Other Methods FailSide Effects

SeizuresBenzodiazepines/Barbiturates

Hypotension

SALICYLATESSALICYLATES

Gastroenteritis Mixed Respiratory And Metabolic

Acidosis CNS Cardiac Toxicity Pulmonary

ARDS Tinnitus

SALICYLATESTOXIC DOSESALICYLATESTOXIC DOSE

Done Nomogram Acute, Single Ingestion Cannot Use For:

Acute Ingestion With Salicylate Taken Within Last 24 Hours

Chronic Salicylate Poisoning Ingestion Of Enteric Coated Tablets

Treat Patient If Symptomatic

SALICYLATESTREATMENTSALICYLATESTREATMENT

Charcoal IV Fluids Urine Alkalinization

Mechanism “Ion Trapping”Un-ionized Salicylate Reabsorbed By Renal

TubulesAlkaline Urine Favors Ionized Salicylate

Which Cannot Be Reabsorbed Dialysis

SALICYLATESDISPOSITIONSALICYLATESDISPOSITION

Asymptomatic Nomogram After 6 Hours

Patient Asymptomatic Enteric Coated

150 mg/kg Psychiatric Evaluation Follow-up