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Drug Overdose

All substances are poisons. The right dose differentiates a

poison and a remedy.

(Fallopiusvon Hohenheim-Paracelsus 1493-1541)

Adapted from source

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Drug Overdose

Objectives

Determine a systematic approach

Discuss high profile toxidromes

Discuss some specific overdoses

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20 y male, unresponsive, GCS 3/15

Vodka

QAS assessment

Drug Overdose

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Drug Overdose

Guedel.

RR 14/min, shallow, SpO299% @ 6 l/m,

no cyanosis.

P 110/min, CRT

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Drug Overdose

ECG

Glucose

IV access and bloods

Search clothing

Antidotes -

Toxicology

Secondary survey

mechanism/AMPLE

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Drug Overdose

needle track marks

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Drug Overdose

Mnemonic: COPS

Cholinergic toxicity

Clonidine

Opiates

Organophosphates

Phenothizines

Pilocarpine Pontine haemorrhage

Sedative hypnotics

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Drug Overdose

Mnemonic: CAAAS

Carbon monoxide

Anticholenergic

Antihistamines

Antidepressants

Sympathomimetics

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Drug Overdose

Risk Assessment

Takes into account

Patient

Agent

DoseTime since ingestion

History from patient T/F

Trivial poisonings reassurance, decon, Ix, LOSLee V. et al, Emerg.Med. 2001;13:37-42

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Drug Overdose

Risk Assessment

Eg Valproic acid

400 mg/kg fatalities

~39% unintentional OD more likely to be hospitalised

Warfarin and Insulins ~16% of ADRs overall and 33% in those>50yrs

Budnitz, et al.Annals of Emerg Med. 2005. 45(2).

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Drug Overdose

Gastrointestinal decontamination

Gastric lavage TCA, Ca++, anticholenergics, recent, slow release, not adsorbed

conditions

Activated Charcoal (C*) 10:1 or 1g/kgconditions

Whole Bowel Irrigation Go-Lytely 1-2 l/hr

Cathartics

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Drug Overdose

5 Toxidromes:

Cholenergic

Anti-cholenergic

Sympathomimetic

Opioid

Sedative-hypnotic

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Drug Overdose

Cholenergic

Organophosphates, carbamate insecticides, sarin

Miosis

Bradycardia, bronchospasm, bronchorrhoea, salivation, lacrimation

Vomiting, diarrhoea, urination

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Drug Overdose

Cholenergic

Organophosphates, carbamate insecticides, sarin

Miosis

Bradycardia, bronchospasm, bronchorrhoea, salivation, lacrimation

Vomiting, diarrhoea, urination

Atropine pralidoxime diazepam

dumbells

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Drug Overdose

Anti-cholenergic

Tricyclics, phenothizines, antihistamines

belladonna, scopolamine, datura

Mydriasis

Dry membranes, dry flushed skin, tachycardia, hypertension

Absent bowel sounds, urinary retention

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Drug Overdose

Anti-cholenergic

Tricyclics, phenothizines, antihistamines

belladonna, scopolamine, datura

Mydriasis

Dry membranes, dry flushed skin, tachycardia, hypertension

Absent bowel sounds, urinary retention

Supportive (physostigmine) benzos, nitrites, /

hot, dry, red, blind, mad

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Belladonna atopa

Nightshade family

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Drug Overdose

Sympathomimetic

Amphetamines, cocaine, decongestants

caffeine

Mydriasis

Sweaty, hyperthermia, tachycardia, hypertension

Hyperactive bowel sounds, urinary retention

Agitation seizures, myocardial infarction, rhabdomyolysis

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Drug Overdose

Sympathomimetic

Amphetamines, cocaine, decongestants

caffeine

Mydriasis

Sweaty, hyperthermia, tachycardia, hypertension

Hyperactive bowel sounds, urinary retention

Agitation seizures, myocardial infarction, rhabdomyolysis

Supportive benzos, nitrites, /

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Drug Overdose

Opioid

Heroin, morphine, methadone, fentanyl, oxycodone, imidazoles

Miosis

Analgesic, euphoric, sedative, anxiolytic

Hypothermia, bradycardia, hypotension, pulmonary oedema

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Drug Overdose

Opioid

Heroin, morphine, methadone, fentanyl, oxycodone, imidazoles

Miosis

Analgesic, euphoric, sedative, anxiolytic

Hypothermia, bradycardia, hypotension, pulmonary oedema

Naloxone

addict,

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Drug Overdose

Sedative-hypnotic

Benzodiazepines, barbiturates, GHB

Normal eyes and vital signs

Striated muscle relaxation, sedative, anxiolytic

Supportive C* (Flumazenil)

addict

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Drug Overdose

Paracetamol

Tricyclics

Calcium channel blockers

Iron

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Drug Overdose

ParacetamolHepatic metabolism ~90% is converted to nontoxic

glucuronide and sulfate conjugates

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Drug Overdose

N-acetyl cysteine?

NAC converted to cysteine

converted to glutathione within hepatocytes

NAC acts as a direct substitute for glutathione,

AndN

AC acts as a sulfur donor in the formation of thenontoxic sulfate metabolite of acetaminophen

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Drug Overdose

All patients with serum paracetamol on or above the lower line(150 g/mL) after an acute ingestion.

History (or suspicion) of overdose requires NAC until plasma levelsare known can wait up to 8 hours

Delayed presentation >24 hr post ingestion

if paracetamol measurable or transaminases are elevated

Chronic ingestion

treat for 24 to 36 hr, then reassess levels

Progressive hepatotoxicity requires NAC until INR

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Drug Overdose

CI

IV NAC 150mg/kg over 15 minutes

50-100mg/kg

Anaphylactoid20%

Cost $207.90

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Drug Overdose

BUT

if ingested 200mg/kg or less

STOP

2nd level not required

dont move nomogramreportable

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Drug Overdose

TricyclicsMydriasis

Dry membranes, dry flushed skin, tachycardia, hypertension

Absent bowel sounds, urinary retention

Decontaminate C*

Intubate

Acidosis Seizures Hypotension

QRS >120msec Sodium bicarbonate 2meq/kg

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Drug Overdose

Calcium channel blockersQRS width blocks AV and SA nodes

vasodilatation

bradycardia hypotension

Correct pH gastr ic lavage C*

Ca++ loading

Glucagon

Insulin

Atropine, inotropes

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Drug Overdose

Fe-poisoninggastro-enteritis, vomiting, metabolic acidosis, cardiotoxic

AXR Count tablets

Whole bowel irrigation no C*

20mg/kg do nothing

40 mg/kg vomit, gastr

60 mg/kg toxic 100 mg/kg lethal

desferrioxamine

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Drug Overdose

?

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Drug Overdose

Objectives

Determine a systematic approach

Discuss high profile toxidromes

Discuss some specific overdoses

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Drug Overdose

Management principles

Resuscitation

Ri

sk assessment Supportive care

Decontamination

Antidotes

Enhanced elimination

Ongoing monitoring/supportive/disposition

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Drug Overdose

www.worstpills.org

www.nicd.us

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