Transcript toxidromes
Identifying Poisoning Is This Patient Poisoned, And If So, With What? The Dose Makes The Poison “What is there that is not poison? All things are poison and nothing [is] without poison. Solely the dose determines that a thing is not a poison” Philip Theophrastus Bombast von Hohenheim aka PARACELSUS (1493-1541) Goal of Clinical Management To proceed from undifferentiated signs and symptoms in a patient [without a dependable history] to a reasonable diagnosis ....... in order to initiate appropriate therapy. Rapid Organized Efficient Safe Effective Is This Patient Poisoned A 37 year old female with a history of a seizure disorder presents with: Fever (38.5oC) A rash (shown) Only medication, phenytoin 300 mg/day for years No occupational exposures No significant hobbies Is This Patient Poisoned Laboratories 21% Eosinophils An AST of 300 IU/L Diagnosis: Anticonvulsant hypersensitivity syndrome The History The toxin Medications, Hobbies, Occupation The form and route Amount Elapsed time Symptoms Current or resolved symptoms Timing of symptom onset Prior therapy administered Is This Person Poisoned A 28 year old female is brought to the hospital because of “lethargy” No past medical or surgical history No medications No hobbies Full time student Vital signs normal Slight nystagmus Slight lethargy easily arousable Dull expression Flat affect Not bothered by her condition Slightly unsteady gait Basic laboratory studies normal ECG normal CT scan normal Lumbar puncture normal Urine positive for benzodiazepines Flumazenil given Mental status normal Police investigation results How Are Poisoned Patients Different Suicide note Empty bottles Occupational or environmental cluster Psychiatric history Substance abuse / misuse Inconsistencies Cardiac findings in young people Vital signs not consistent with mental status Toxidrome = Toxicologic Syndrome Toxidrome recognition allows rapid clinical diagnosis and targeted therapy. Patient history Vital signs Targeted physical examination Rapid, bedside laboratory testing Metabolic – Glucose – Acid-base ECG Toxicologic Physical Examination Vital signs Including temperature and pulse oximetry Key organ system Mental status Pupils Skin Bowels Bladder Toxidrome History Vital signs Symptoms & Signs Simple labs We Do This Will All Patients Headache Fever Altered mental status Rash = Meningococcal meningitis Opioids CNS depression Miosis Respiratory depression Gastrointestinal Stasis Relative bradycardia Relative hypothermia Sympathomimetic Hypertension, tachycardia, hyperthermia, tachypnea Mydriasis Diaphoresis Psychomotor agitation Anticholinergic Antimuscarinic Hypertension, tachycardia, hyperthermia, tachypnea Mydriasis Psychomotor agitation or somnolence Dry flushed skin Absent bowel sounds Urinary retention Remember Hot as a Hare: warm skin Dry as a bone: dry skin and mouth Blind as a Bat: cycloplegia, mydriasis Red as a Pepper: flushed skin Full as a flask: urinary retention Mad as a Hatter: altered mental status, hallucinations Differentiation Anticholinergic vs Sympathomimetic Pupils? Skin Bowels Bladder Cholinergic Muscarinic Salivation Lacrimation Urination Defecation Bronchorrhea Bradycardia Miosis Nicotinic Muscle weakness Fasciculations Paralysis Hypertension Tachycardia Mydriasis Salicylates Nausea and vomiting Tinnitus Tachypnea and hyperpnea, rarely hyperthermia Diaphoresis Respiratory alkalosis Metabolic acidosis Ketonuria Tricyclic Antidepressant Somnolence, lethargy, or coma Tachycardia and hypotension Seizures Abnormal ECG Anticholinergic findings Hypoglycemia Tachycardia Diaphoresis Tremor Altered mental status Decerebrate posturing Decorticate posturing Fixed and dilated pupils Incidence of Hypoglycemia True incidence probably unknown In 12 months 125 patients were diagnosed at the Harlem Hospital ED Malouf and Brust: Ann Neurol 1985;17:421-430 29/340 (8.5%) consecutive EMS runs for AMS, were identified with hypoglycemia Hoffman: Ann Emerg Med 1992;21:20-24. Hypoglycemia Using the classic findings hypoglycemia Altered mental status Tachycardia Diaphoresis And/or a history of diabetes to predict a response to D50W, 25% of hypoglycemic patients would be missed Hoffman: Ann Emerg Med 1992;21:20-24 Hypoglycemia With A Normal Glucose Poorly controlled diabetics had symptoms at glucose levels significantly higher than well controlled diabetics: 4.3 vs 2.9 mmol/L Boyle: N Engl J Med 1988;318:1487-1492 Tackling Toxidromes Good history Directed physical examination Vital signs, pupils, skin, bowel bladder Simple tests Rapid glucose, ECG, ABG, UA, etc Simple interventions Think about… Ethanol Paracetamol (acetaminophen) About 1 out of 500 suicidal patients has an unexpected, treatable level Ashbourne J. Ann Emerg Med 1989;18:1035 Assessment of other potential exposures Assessment of pregnancy Provide Life-Saving Care Treat the Patient Before the Poison: Airway Breathing Circulation Rare immediate Antidotes Cyanide kit Poisoning Includes Deficiencies Withdrawal syndromes Alcohol Sedatives Opioids Etc Metabolic Thiamine (Wernicke’s encephalopathy)