Transcript Approach to poison victim

GENERAL MANAGEMENT OF
POISONING
Dr. T.S.Srinath Kumar
Dept of Emergency & Critical care Medicine
Vinayaka Mission University
Salem
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Introduction
Patients with poisoning presenting in ER pose a
great challenge to the attending physician especially
in our country.
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What is it that is not a poison?
“All things are poison & nothing is without
a poison. It is the dose that makes a
thing not a poison”
Paracelsus(1493-1541)
father of toxicology
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Objectives
First & foremost is to be familiar with the
initial management and stabilization
Second the ability to recognize and
manage the poison & overdoses by
their clinical features
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Management Steps
ABC’s
Immediate consideration of “Coma
Cocktail” ???? –
Gather information
Decontaminate
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Management
Prevention of re-exposure
Treat associated conditions/injuries
Enhanced Elimination Support
Antidotes
Disposition of the patient
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Airway
Patent?,
Ability to protect aspiration?
If not intubate with cuffed tube
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??Indications
Obstructed airway
Inadequate ventilation
Tachypnoeic >35/min
bradypnoeic < 8/min
Shock
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Breathing
Always 0XYGEN by NRB Mask
Intubation/ventilation
Circulation
Large bore IV’s
IV fluids
– Inotropes
– Early in Beta blockers, Calcium
Channel Blockers & Barbiturates
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Hypotension
Clonidine, CCB
Reserpine (anti hypertensive)
Antidepressants
Sedative hypnotics
Heroin (opiates)
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Bradycardia
Propanolol (β-blockers),
phenylpropanolamine (-agonists)
Anticholinesterase drugs
Clonidine,
Ethanol / alcohols
Digoxin, Darvon (opiates)
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Tachycardia
Free base (cocaine/stimulants)
Anticholinergics, antihistamines
Sympathomimetics
Theophylline (methylxanthines)
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Investigations
3 Gs in ER
– RFT
– Toxic screening
– Basics
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History
Circumstances of discovery
Mental illness / suicide attempts
Reason for overdose
Recreational
Self harm
Depression
Additional injuries
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What is this ?????
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Be in doubt
Suspect overdose / poisoning in any
patient with
altered level of consciousness
unexplained signs & symptoms
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Assessment of severity
Vital signs
Physical examination
Eyes-Pupillary size
Neurological
Skin
Odors
Toxidromes
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“Coma Cocktail” ??????
No NEED!!!
– D25W – unless CBG not available
– Thiamine – alcoholics only
– naloxone – 2 to10mg
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GI Decontamination
Ipecac
– No role for Ipecac in management of
overdoses in the ED setting
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Gastric Lavage
Removes stomach contents through a
large bore tube until the return is clear
Contraindicated with corrosives and
hydrocarbons
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Stomach wash
About 150 – 200ml of water to be used
for each lavage
In pediatrics 10 to 15 ml/kg of warm
saline
Lavage to be done until clear fluid is
seen
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Activated charcoal
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GI Decontamination
Charcoal (1g/kg)
First line decontamination method
MDAC- very useful
First dose: 1 g / kg body weight
Subsequent doses: 0.5 g / kg body
weight at 4th hourly
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Doesn’t adsorb
C- Caustics, Corrosives
H- Heavy metals
A- Alcohol
R- Rapid onset - cyanide
C-Chlorine
O- others ( Iron)
A- aliphatic hydrocarbon
L- lithium
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Whole Bowel Irrigation
Heavy metals & Sustained-release meds
PEGLEC
500 – 2000 ml/hr
25cc/kg/hr peds
4-6 hours duration
Decontamination
Skin
Remove contaminated clothing / wash skin
completely with soap water followed by
repeat body wash Q4th hrly
Eyes
Hair
Decontamination
Pay special attention to
Around ears
Arm pits
Eyelids
Groin
Inside nose
Behind knees
Inside mouth
Between toes
Neck creases
ACT093©
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Enhanced Elimination
Urinary alkalinization
Salicylates
1-2 meq/Kg bolus then 3 amps
sodabicarb in 1000cc D5W
150 – 250 cc/hr
Urine pH >7.5
Watch for Hypokalemia and correct
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Enhanced Elimination
Haemodialysis
Charcoal Haemoperfusion
Dialyzable poisons
Alcohols
Aminophyline
Barbiturates
Camphor
Carbon monoxide
Ethylene glycol
Heavy metals
INH
Paraldehyde
Salicylates
Snake bite
antibiotics
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Haemoperfusion
Diazepam
Digoxin
OPC
Dapsone
Chloral hydrate
Paraquat
Phenols
Phenylbutazone
Quinidine/qunine
Salicylates
TCA
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Monitoring
Clinical observation
Pulse oximetry
ECG monitoring
Minimum 6 hours if cardio-active drug
>24 hours if delayed release preparation
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Supportive care
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Supportive care
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Radiographic Examination
limited usefulness for visualizing toxins
a. iron, lead
b. foreign bodies- body packers
diagnosis of toxin-induced pathology
a. non-cardiogenic pulmonary edema
(salicylates, opioids)
b. chemical pneumonitis (hydrocarbons)
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Iron Pills on X-ray
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Body Packer
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Treat associated conditions
Trauma
Chronic illness
Environmental
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Disposition of Patient
ICU Admission
Unstable patient
Potentially lethal overdose
Cardio toxic overdose
Hospital Admission
Moderately symptomatic patient with
low fatality potential
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Scenario 1
H/o ingestion of unknown substance an
hour before at his residence
Vomited once and gastric lavage was
done at a local hospital
On arrival to the ER, the patient was
hemodynamically stable and level of
consciousness fully intact
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Pupils bilaterally constricted & pinpoint
BP: 120/70 mmHg
Tongue Moist
HR: 78 beats / min
SpO2: 97% with O2 at 6 L/min via NRB
No secretions
What to do now?
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administer
Inj. Atropine 5 amp IV stat
Patient became restless, irritable and
agitated
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Pupil Size – not a dose titrating criteria
Atropinisation based on secretions
Over atropinisation is not indicated
Judiciously use Glycopyrrolate
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Scenario 2
H/o ingestion of 4 crushed oleander seeds
along with cola drink 2 hours prior
O/E, patient fully conscious, sweating +, cold
extremities +
BP: 80/60 mmHg
HR: 38/min
SpO2 97% on room air
RR: 16/min
What to do now?
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A, B, C checked and secured
Gastric lavage
Charcoal administration
Inotropic support - Dopamine and
adrenaline
Initial Potassium levels – 5.5 mEq/L
ECG
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ECG
What to do now?
Transvenous Pacing
Pacing with no capture!!
What Next?
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Recheck Potassium levels
K+ 7.4
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Hyperkalemic correction with
• calcium gluconate 10%
• 25% dextrose + insulin drip
• Sodium bicarbonate therapy
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Patient went into asystole!!
Why?
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Pitfalls…
Pacing not capturing – think of
Hyperkalemia
Never give calcium gluconate for correction
of Hyperkalemia in the treatment of
oleander/digitalis poisoning
ABG, ECG, K+ is a must in treatment of
oleander poisoning
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Scenario 3
H/o consumption of All-Out – mosquito killer,
about 10 mL, 1 hour prior at her residence
she was conscious and comfortable
BP:110/80 mmHg,
HR: 106/min,
RR: 16/min,
SpO2 – 94% on RA
Decontamination and supportive care
given. Physician ordered for observation in
ICU.
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Just before shifting from ER to ICU, the
patient suddenly collapsed and had cool
extremities with a heart rate of 160/min
and BP not recordable!
What went wrong?
Connected to ECG monitor
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ECG monitor showed
What should be done now?
Torsades de pointes
Defibrillation
Magnesium sulphate
Over drive pacing
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Pitfalls…
ECG must in all poisoning
ECG - Failure to measure QT interval, QRS
complex
Electrolyte correction
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Scenario 4
A 5-year-old boy was brought to the ER with alleged
H/o convulsions – 1 episode for 2 mins
Regained consciousness spontaneously within 5
mins. No H/o trauma, fever or previous H/o seizures
patient was conscious.
BP: 90/60 mmHg,
HR: 110/min,
RR: 20/min,
SpO2 – 96% on room air
Treatment with lorazepam & Phenytoin was
begun
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Despite the treatment , the boy developed GTCS for a
minute and went on recurrent convulsions, 5-8 episodes
over the next one hour
Neurologist consultation taken and CT brain normal
History reviewed and revealed that the grandmother
had applied pain balm to the boy for body ache over
the last 2 days
Cause of convulsions?
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Think of differential diagnoses
Suspect poisoning….
? Camphor poisoning ..Pain balm..
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MISDIAGNOSIS IS A
POTENTIAL MEDICOLEGAL
PITFALL
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What needs to be done?
Anticipate problems
Reassess frequently
Take home message
Never with hold intubation if the patient in
distress
MDAC (RT and Rectal) decreases the need of
atropine and ICU stay
Metaclopromide decreases the transit time in
GUT
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Remember
Supportive care is the most important
measure in serious overdoses
When in doubt – observe in the ED
When faced with an unfamiliar or serious
toxic exposure call a Poison Centre or
consult with a toxicologist
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Identify poison
center / number
www.emergencymedicineindia.com
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