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Diagnosis
• Make a thorough history
• Identify the poison
• Estimate the time from ingestion
• Estimate the expected severity
• Do a complete physical examination
• Airway - Breathing - Circulation - Disability - Complete evaluation
• Toxidromes
Toxidromes
• Anticholinergic
• Sympathomimetic
• Narcotic
• Sedatives/hypnotics
• Serotoninergic
• Confusion, tremor, fasciculations, extrapyramidal symptoms, hypereflexia, hyperpyrexia, diaphoresis, tachycardia
• Cholinergic
Treatment
• Maintenance of vital functions
• Give antidote
• Prevent absorption
• Drug analysis
• Increase elimination
• Observe in appropriate location
Extracorporeal techniques
• (Potential) lifethreatening intoxication
• Low volume of distribution (< 1 L/kg)
• Low protein binding
• Low endogenous clearance
• Low molecular (HD)
Hemodialysis - Hemoperfusion - Hemofiltration
Examples
• Aspirin (neurotoxic, Acid-base disturbances)
• Lithium (neurotoxic) - often multiple sessions
• Methanol/Ethylene glycol
• Valproic acid (CNS toxicity, NH4 ↑)
• Theophyline (HP)
Hemoperfusion?
• Teicoplanin and vancomycin
• Digoxin
• Theophyline
• Phenobarbital, phenytoin, carbamazepine and valproic acid
Betasorb ®
Reiter K. Blood Purif 2002;20:380-388
Analgesics
• Opioids
• CZS depression, respiratory depression, miosis, acute pulmonary oedema
• Activated charcoal, sodium bicarbonate, naloxone
• Acetaminophen
• Centrilobular liver necrosis
• Activated charcoal, N-acetylcysteine (Rumack-Matthew)
• Salicylates
• Stimulation respiratory centre, uncoupling oxidative phosphorylation
• Activated charcoal, urinary alkalinization, haemodialysis
5-Oxoproline
• High anion gap (SIG) metabolic acidosis
• Basic underlying mechanism is glutathione deficiency
• Usually during prolonged acetaminophen treatment - mostly women
• Clinically often diminished consciousness
Cell membrane
Aminoacid (AA)
Cysteine - Glycine Glutamate - AA
Gluthathione
Gluthathione Cysteine - Glycine γ-glutamyl - AA
γ-glutamyl transpeptidase
5-oxoproline
AA
Renal failure
γ-glutamylcyclotransferase
L-glutamate
FlucloxacillinNetilmycinVigabatrin
5-oxoprolinase
γ-glutamylcyclotransferase
Dipeptidase
γ-glutamyl cysteine
Cysteine
Gluthathionesynthase
Glycine
γ-glutamylcysteine synthase
Negativefeedback
AcetaminophenAlcoholDiet
MalnutritionLiver disease
γ-Glutamyl cycle
= gluthatione stores are reduced and negative feedback falls away
Sedatives
• Activated charcoal
• Supportive Care
• Flumazenil
• Alkaline diuresis/haemodilalysis
• barbiturates
ϒ-Hydroxybutyric acid
• [Peak] 40 minutes after oral ingestion
• T1/2 20-30 minutes
• Coma after 40 - 60 mg/kg
• Coma, myoclonus, hypoventilation and bradycardia
• Supportive therapy
Neuroleptic agents
• Recovery without sequelae is the rule
• Convulsions, hypotension, dysrhythmia
• Activated charcoal, supportive care
Tricyclische AD
• > 1000 mg
• Dysrhythmias, hypotension, seizures, coma, anticholinergic effects
• Activated charcoal, sodium bicarbonate, hypertonic saline
SSRI’s
• CNS depression, seizures, QT/QRS ↑, autonomic dysfunction
• Especially in combination with MAOI’s
• Supportive care