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Emergency Toxicology
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Poison Vs. Toxin Poison:
is a substance that cause disturbances to organisms, usually by chemical reaction or other activity on the molecular scale, when a sufficient quantity is absorbed by an organism.
Poisoning: the action of poison in organism body.
Toxin: is a poisonous substance produced within living cells or organisms
Intoxication: The action of toxin in organism body
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Introduction 2.5 million ER visits drug abuse or misuse (51%).
(Drug Abuse Warning Network, US, 2011)
Recreational drug use is common worldwide 6.1 % of the worlds population (aged 15-64 years). (J. Med. Toxicol, 2012)
Asia Pacific region over half of the worlds opioid using population lives in Asia. (WHO, 2002)
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Introduction Toxic overdose can present with various clinical
findings the only clue to a diagnosis.
In patients who have unknown overdoses, a toxidrome can assist in making a diagnosis.
Toxidrome = collections of physical findings that occur with specific class of substances.
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Important! Drug overdose (OD) is often unreliable!
Have a high index of suspicion & assume the possibility of mixed overdose, incl. alcohol intake!
Do proper physical examination to get clues about the types of DO!
Altered mental state (AMS) with a suspicion of DO should have ECG and bed-side capillary glucose done!
Pay attention to emotional/psychiatric state of your pt!
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History D.O.?
What? How much? How long ago? How? Where? Why?
Any suicidal risk? Any previous suicide attempts?
Psychiatric and past medical history?
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Vital Signs are IMPORTANT!
1. Temperature
2. Pulse
3. Blood Pressure
4. Respiratory
5. Rhythm
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Vital Signs TEMPERATURE PULSE RATE/RHYTHM BLOOD PESSURE RESPIRATORY
HYPOTHERMIA (COOLS)
C Carbon monoxide
O Opioid
O Oral Hypoglycaemics, insulin
L Liquor
S Sedative hypnotics
BRADICARDIA (PACED)
P Propanolol (beta blockers)
A Anticholinesterase drugs
C Clonidine, Calcium channel
E Ethanol/alcohol
D Digoxin
HYPOTENSION (CRASH)
C Clonidine (or any
antihypertensive)
R Reserpine
A Antidepressant
S Sedative hypnotics
H Heroin (opiates)
HYPOVENTILATION
Opioids
HYPERTHERMIA (NASA)
N Neuroleptic malignant syndrome,
nicotine
A Antihistamines
S Salicylat, sympathomimetics
A Anticholinergic, antidepressant
TACHYCARDIA (FAST)
F Free base (cocaine)
A Anticholinergic, antihistamine,
amphetamine
S Sympathomimetic (cocaine, PCP)
T Theophylline
HYPERTENSION (CT SCAN)
C Cocaine
T Theophylline
S Sympathomimetic
C Caffeine
A Anticholinergic, amphetamine
N Nicotine
HYPERVENTILATION
Salicylates
CNS stimulant
Cyanide
DISRITMIA
Digoxin
Cyclic antidepressant
Sympathomimetic
Phenothiazine
Chloral hydrate
Anticonvulsant
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A Case 23-years-old male came to Emergency Department
unconscious with history of consuming some unknown
yellow pills, alcoholism, and drug abuse. On presentation, he
was shock, respiratory distress, hypothermia, pinpoint
pupils, hypoglycemia , cyanotic, full rales on both lungs, and
tattoo on his lower left arm. ECG was unremarkable. Lab
result showed type II respiratory failure. Toxicology test were
unavailable.
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Vital Signs TEMPERATURE PULSE RATE/RHYTHM BLOOD PESSURE RESPIRATORY
HYPOTHERMIA (COOLS)
C Carbon monoxide
O Opioid
O Oral Hypoglycaemics, insulin
L Liquor
S Sedative hypnotics
BRADICARDIA (PACED)
P Propanolol (beta blockers)
A Anticholinesterase drugs
C Clonidine, Calcium channel
E Ethanol/alcohol
D Digoxin
HYPOTENSION (CRASH)
C Clonidine (or any
antihypertensive)
R Reserpine
A Antidepressant
S Sedative hypnotics
H Heroin (opioids)
HYPOVENTILATION
Opioids
HYPERTHERMIA (NASA)
N Neuroleptic malignant syndrome,
nicotine
A Antihistamines
S Salicylat, sympathomimetics
A Anticholinergic, antidepressant
TACHYCARDIA (FAST)
F Free base (cocaine)
A Anticholinergic, antihistamine,
amphetamine
S Sympathomimetic (cocaine, PCP)
T Theophylline
HYPERTENSION (CT SCAN)
C Cocaine
T Theophylline
S Sympathomimetic
C Caffeine
A Anticholinergic, amphetamine
N Nicotine
HYPERVENTILATION
Salicylates
CNS stimulant
Cyanide
DISRITMIA
Digoxin
Cyclic antidepressant
Sympathomimetic
Phenothiazine
Chloral hydrate
Anticonvulsant
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Odours Odours Probable poisons
Fruity Mothballs Bitter almonds Silver polish Stove gas* Rotten eggs Garlic Wintergreen
Ethanol Camphor/nophtalene Cyanide Cyanide Carbon monoxide Hydrogen sulphide Arsenic/parathion Methylsalicylate
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Neurologic Examination Level of consciousness
CNS antidepressant Anticholinergics
Antihistamins
Barbiturates
Cyclic antidepressant
Ethanol & other alcohols
Phenotiazines
Sedative-hypnotic agents
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Sympatholytic agents Clonidins
Methyldopa
Opiates
Cellular hypoxia Carbon monoxide
Cyanide
Hydrogen sulphide
Methaemoglobinemia
Neurologic Examination Pupils
Miosis (COPS) C Cholinergics, clonidine
Opiates, organophosphate
Phenothiazines, pilocarpins, pontin bleed
S sedative-hypnoyics
Mydriasis (AAAS) A Antihistamins
A Antidepressants
A Anticholinergics, atropines
S Sympathomimetics cocaine, amphetamines)
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Neurologic Examination Fits (OTIS CAMPBELL)
O Organophosphate
T Tri-cyclic antidepressant
I Insulin, isoniazid
S Sympathomimetic
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C Camphor, cocaine
A Amphetamines
M Methylxanthines
P Phencyclidine
B Beta-blockers
E Ethanol
L Lithium
L Lead
Skin Diaphoretic (SOAP)
S Sympathomimetics
O Organophosphates
A ASA (salicylates)
P Phencyclidine
Blistering
Carbon monoxide
Barbiturates
Poison ivy
Sulphur mustard
Lewisite
Dry
Antocholinergic
Colour
Red
Anticholinergic
Cyanides
Carbon monoxide
Blue
Methaemoglobinemia
Needle tracks
opioids
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Toxidromes (toxicology syndromes) Opioids Cholinergics (SLUDGE)
Coma
Respiratory depressions
Pinpoint pupils
Hypotension
Bradycardia
S Salivation
L Lacrimation
U Urination
D Defecation
G Gastric emptying
E Emesis
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Toxidromes (toxicology syndromes) Anticholinergics
(antihistamines, cyclic antidepressant, homatropine, scopolamine)
Hot: hyperthermia
Red: cutaneous vasodilatation
Dry: decreased salivation
Blind: cycloplegia and mydriasis
Mad: delirium and hallucinations
Tachycardia
Urine retention
Decreased GIT motility
Toxidromes (toxicology syndromes) Salicylates Sympathomimetics
Fever
Tachypnoea
Vomiting
Lethargy
tinnitus
Hypertension
Tachycardia
Hyperpyrexia
Mydriasis
Anxiety or delirium
Toxidromes Sedative-hypnotics Extrapyramidal (TROD)
Unpredictable pupillary changes
Confusion or coma
Respiratory depression
Hypothermia
Vesicle or bullae
Tremor
Rigidity
Opistothonus, oculogyric crisis
Dysphonia, dysphagia
Laboratory Full Blood Count Toxicology Screen
Elevated total white count
Infection
Iron
Theophylline
hydrocarbon
Paracetamol
Salicylates
Cholinesterase
Iron
Lithium
Theophylline
Carbon monoxide
Laboratory Elevated Anion Gap
Anion Gap: Na HCO3 Cl
Normal AG: 8-16 mEq/l
Metabolic acidosis
C: Carbon monoxide, cyanide
A: Alcoholic ketoacidosis
T: Toluene
M: Methanol
U: Uraemia
D: Diabetic ketoacidosis
P: Paraldehyde
I: INH, iron
L: Lactic acidosis
E: Ethylene glycol
S: Salicylates, solvent
X-rays Chest Abdominal
Pulmonary toxic agents
Hydrocarbons
Toxic gases
Paraquat
Non-cardiogenic ALO
Opiates
Phenobarbitone
Salicylates
Carbon monoxide
Toxins radioopaque on X-rays (CHIPES)
C Chloral hydrate
H Heavy metals
I Irons
P Phenothiazines
E Enteric-coated salicylates
S Sustained-release theophyllines
ECG Prolonged PR & QRS Intervals
Cyclic antidepressant
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Treat Patient, Not Poison! At your clinic: Attend to
the ABC of drug overdose patient first before sending the patient to the ED
At ED: Attend to the ABC of drug overdose patient first before seeking for antidotes
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Patient is NEVER just drunk until all other possibilities are excluded
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Critical Care Area Airway management
Resuscitation drugs
Supplemental oxygen
Monitoring ECG, VS, pulse oxymetry
Peripheral IV lines
Labs
Urinary catheter
Control fits
Control dysrhytmias
Unknown Case Coma Cocktail
D40% 40ml if the pt hypoglycemia, followed by D10% over 3-4hours
Naloxon (Nokoba) 0,8 - 2,0 mg iv bolus
Thiamine 100mg iv bolus in alcoholic or malnourished pt
Flumazenil (Anexate) 0,5mg iv bolus
C-spine X-ray if trauma cannot be excluded
Decontamination Procedure
Remove from contaminated area
Remove cloth
Brush off all powder contaminants from skin
Wash all areas with water/soap
Areas to concentrate are head, axille, groin, back
Brush under nail
Irrigate the eyes
All open wounds must be additionally decontaminated with water
Gastric Decontamination Dilution: water
Indications: ingested within 1-3 hours of ingestion
Contraindications:
Corrosive
Petroleum
On-going fits
Non-toxic ingestion
Ingestion of sharp material
Significant haemorrhage
Procedure: large bore NG tube
Activated Charcoal Indication:
poison absorbed by charcoal (if known)
Within 1-3 hours of ingestion
Drugs absorbed by charcoal:
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Activated Charcoal Dosis
1 gm/kg
Dosis dewasa : 25 to 50 gms
Dosis anak : 12.5 to 25 gms
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Enhancement of Elimination Forced alkaline diuresis
Haemoperfusion
Haemodialysis
Specific antidotes
Specific antidotes Toxin Antidotes Dosage
Paracetamol N-acetylcysteine
IV 150mg/kg iv in 200ml D5 x 15 min, then IV
50mg/kg in 500ml D5 x 4 hours, then IV 100mg/kg
in 1000ml D5 x 16 hours
Arsenic, Mercury BAL (Dimercaprol) 5mg/kg body weight IM
Atropine Physostigmine 0,5-2mg IV
Benzodiazepine Flumazenil (anexate) 0,5mg IV bolus
Carbon monoxide Oxygen O2 100%
Cyanide
Amyl nitrite pearls Inhalation of contents of 1-2 pearls
Sodium nitrite (3% sol) Adults: IV 300 mg (10 ml) over 2-5 min
Children: IV 0,2-0,33ml/kg (6-10mg)
Sodium thiosulfate (25% sol)
Adults: 50 ml IV (12,5g) over 10 min; can repeat
half dose x 1 prn
Children: 1,65 ml/kg IV over 10 menit
Ethylene glycol, methanol Ethanol (10%) mixed in D5 Loading dose : 800mg/kg
Maintenance : 1-1,5ml/kg/hour
Ion Desferoxamine 1,5mg/kg/hour IV
Lead EDTA: calsium disodium edetate 1000-1500mg/m2/day IV continuous infusion
Nitrites Methylene blue (1% sol) 1-2mg/kg IV x 5 min
Organophosphate Atropine
2-4mg IV every 5-10 min prn (adults)
0,5 mg/kg IV every 5 min prn (children)
Pralidoxime (2-PAM) 25-50mg/kg IV (up to 1 g)
Opioids Naloxone 0,8 - 2,0 mg iv bolus
Phenothiazine Benztropine (Cogentin) 2mg IV/IM
Diphenhydramine 50mg IV/IM/PO
Isoniazid (INH) Pyridoxine 5 g IV (can be repeated if fits persist)
Digoxin Digibind
Digoxin level unknown: 5-10 vial IV (40g vial):
can repeat
Digoxin level known: # vial digibind =
(serum digoksin) x 5,6L/kg x wt in kg
1000
0,6
Disposition Internal Medicine
High Dependency unit/ICU admission
Psychiatric consultation for suicidal intention case
Further reading: Hack JB, Hoffman RS. General Management of Poisoned Patients. In: Tintinalli JE,
editor. Emergency Medicine; A Comprehensive Study Guide. 6th ed. USA: McGraw-Hill;
2004. p. 1015-21.
Travers J, Manning P, Ibrahim I. Poisoning: General Poisoning. In: Ooi S, Manning P,
editors. Guide to the Essentials in Emergency Medicine. Singapore: McGraw-Hill; 2004.
p. 75-80.
Goldfrank LR, Hoffman RS, Nelson LS, Howland MA, Lewin NA, Flomenbaum NE.
Principles of Managing the Poisoned or Overdosed Patient. In: Goldfrank LR, Hoffman
RS, Nelson LS, Howland MA, Lewin NA, Flomenbaum NE, editors. Goldfranks
Toxicologic Emergencies; 2007. p. 24-28.
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Thank You