Transcript Antidotes: An Interactive Patient Case Based Approach to Overdoses

Antidotes:
An Interactive Patient Case Based
Approach to Overdoses
Jeanna M. Marraffa, Pharm.D., DABAT
Assistant Professor, Depts of Emergency Medicine & Medicine, Section of
Clinical Pharmacology
Upstate Medical University, University Hospital
Upstate New York Poison Center
Syracuse NY
Objectives
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Identify the role of GI Decontamination in the
management of an acutely poisoned patient
Identify and discuss specific treatment modalities
for toxin induced bradycardia and hypotension
Identify patients who will benefit from the
administration of hydroxocobalamin
Discuss cases that highlight the role of 20% Fat
Emulsion in the acutely poisoned patient
Disclosures
• No financial disclosures
What is the Poison Center National
Number?
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A. 1-800-222-1222
B. 1-800-777-1222
C. 1-800-999-1222
D. There is no National PCC Number
Case 1:
To GI Decontaminate or Not
Past medical
history
32 year old
male
• Depression
• Anxiety
• Discharged 4
hours prior from
inpatient psych
facility
Presents 2
hours after
intentional
overdose
He is
complaining of
nausea and
tinnitus
90 Aspirin 500
mg missing
• No Vomiting
• AAOx3
• HR 110 bpm
• BP 120/70 mmHg
• RR 26
breaths/min
• Diaphoretic
Initial Thoughts
What about GI
decontamination?
Is this a significant
ingestion?
Initial Stabilization
• ABCs
GI Decontamination
Gastric Lavage
Syrup of Ipecac
Activated Charcoal
• 40 French E-wall Tube
• Left Lateral Decubitus
Position
• Protect airway
• Literature to support it?
• Risks/Benefits
• Not Commonly
employed
• LIFE-Threatening
exposures
• Causes vomiting in
nearly 90% of patients
after single dose
• Literature to support it?
• Very few scenarios
where it should be
employed
• Most frequently
administered method of
GI decon
• Adsorbs drug
• 10 : 1 Charcoal to drug
Ratio
• Some drugs don’t
adsorb to charcoal
Whole Bowel
Irrigation
• PEG solution
• 2 L/hour
• Not an easy task
• 6 – 8 hours to clear GI
tract
• Sustained release
products
• Life-threatening
exposures
What Would you do in terms of GI
decontamination?
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A. Syrup of Ipecac
B. Gastric Lavage
C. Whole Bowel Irrigation
D. Lavage followed by Charcoal
E. None of the above
GI Decontamination: What to do
Depends on Who You Ask
• Clin Tox 2000; 38(5): 465-470
• Telephone survey was conducted of 76 poison
centers in the US and Canada
• Objective: To describe the recommendations
for GI decontamination in an adult male with
normal vital signs presenting 1 hour after
ingesting 500 mg/kg of enteric coated aspirin
Brain
Ion Trapping
Plasma
Urine
pH 6.8
pH 7.4
pH 8.0
HA
HA
HA
H+ + A-
H+ + A-
H+ + A-
Let’s Get Back to the Patient
IV-O2Monitor
Gastric
Lavage
Activated
charcoal 50
grams
Initial Aspirin
level = 90
mg/dL
•Alkalinization
started
•Nephrology
consulted
MDAC 50
grams every 4
hours x 3
doses
Acute
hemodialysis
•Aspirin levels
declined < 20
mg/dL
Case 2:
The Hypotensive/Bradycardic Patient
27 year old female presents to
the ED after overdosing on her
grandmother’s medications
• 9 hours earlier
AAOx3
• Heart rate 30 beats per minute
• Blood pressure 70/30 mmHg
• Respiratory Rate 20 breaths/minute
• 98% saturation on room air
• Fingerstick glucose 300 mg/dL
• Negative Bowel Sounds
Medication List
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Furosemide 20 mg daily
Digoxin 0.25 mg daily
Atenolol 50 mg daily
Diltiazem CD 240 mg daily
Initial Approach to this Patient
ABCs
Airway
•AAOx3
Breathing
•RR 20 breaths/min; 98% saturation
Circulation
•BP 70/30 mmHg; weak peripheral pulses; cool extremities
Dextrose
•Fingerstick glucose 300 mg/dL
Initial Approach to this Patient
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IV-O2-Monitor
Crystalloid Bolus
Atropine 1 mg
Electrocardiogram
Labs:
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Basic Metabolic Profile
APAP/ASA Levels
Beta-HcG
Serum Digoxin
• Treat if Suspicion of Digoxin
How Do You Differentiate the Cause
Based on the Med List
and Toxidrome of the Patient?
Medication List
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Furosemide 20 mg daily
Digoxin 0.25 mg daily
Atenolol 50 mg daily
Diltiazem CD 240 mg daily
Differential Diagnosis
• CCB
• BB
• Digoxin
• Clonidine
• Alert, decreased BS later,
SR DELAY IN ONSET;
Hyperglycemia
• Decreased MS, need
decreased HR, SR DELAY
IN ONSET; ?synergistic
with CCB
• Need AV conduction
abnormality, N/V, PVCs;
BP usually good
• Decreased MS, small
pupils, NO DELAY IN
ONSET
And Things Start Coming Back….
More Info
• Basic Metabolic Profile
– HCO3: 16
– Glucose 320 mg/dL
• Digoxin: Negative
• APAP/ASA: Negative
Now What?
Repeat Vital Signs
AAOx3
Heart
Rate 2530 bpm
Blood
Pressure
65/30
mmHg
Thoughts?
My Working Differential Diagnosis
• CCB HIGH on my differential
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Slow junctional rhythm
Hypotensive/Bradycardic
Hyperglycemia
Negative Bowel Sounds
• BB are there but lower
– Atenolol: water soluble; little intrinsic toxicity
• Digoxin: Off my differential
– No hyperkalemia
– No GI Toxicity
– Negative Level
Treatment of CCB/BB Toxicity
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Alter Absorption
Fluids
Atropine
Calcium
Glucagon
High Dose Insulin-Euglycemia
Cardiac pacing
Vasopressors
Intraaortic balloon pump/Cardiopulmonary bypass
Vasopressin ?
Fatty Acid Emulsion ?
Interventions in the ED:
– 1 dose of Activated Charcoal
– Atropine 2 mg
– IV Normal Saline 3 L
– Calcium Chloride 4 grams IV
– Dopamine 10 mcg/kg/min
– Norepinephrine 2 mcg/kg/min
– Insulin 70 Units/hour (70 Units bolus also)
– External pacers
She Codes
Became
progressively
more
lethargic
Obtunded
• Pulseless; No
Rhythm
What are Reasonable Next Steps in this
Scenario?
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A. Atropine
B. IV Fluids
C. Dobutamine
D. Fatty Acid Emulsion 20%
Sirianni AJ et al. Ann Emerg Med 2008; 51:412415
• 17 yo intentional overdose of bupropion and
lamotrigine
• 10 hrs after ingestion, complete cardiovascular
collapse
• Failed ACLS for 65 minutes
• Return of spontaneous circulation within 1 minute
of intralipid®; sinus rhythm within 15 minutes of
intralipid; prolonged ICU stay; awake and talking on
hospital day 20
Case 3: Isn’t a House Fire Just a
Fire?
911 call to a
house fire
with victims
trapped
inside
Obvious
dermal burns
40 yo male
found
unresponsive
• Soot in nose
and mouth
Vital signs
• Heart rate 110
bpm
• BP 70/palp
mmHg
• RR 12
breaths/min
• 90 % saturation
on room air
Initial Approach to this Patient
ABCs
Airway
•Soot in mouth
Breathing
•RR 12; 90% saturation
Circulation
•BP 70/palp; HR 110; cool extremities
Dextrose
•Fingerstick glucose 120 mg/dL
Lactate from I-Stat
•15 mmol/L
Toxins in the Fire Victim
• The Two Major Ones
–Carbon Monoxide
–Cyanide
Cyanide: Treatment
 Cyanide antidote kit
 Amyl Nitrite pearls: inhaled until IV established;
creates ~ 3% MetHgb
 Sodium Nitrite: creates ~20-30% MetHgb
 Hypotension major limiting factor
 Sodium Thiosulfate, 25% soln: relatively benign, IV
 Nausea, vomiting, pain at injection possible after IV use
AVOID NITRITES in Smoke Inhalation Victims
Goldfrank’s Toxicologic Emergencies; 8th edition. Ch 121
Hydroxocobalamin
Hydroxocobalamin (Vitamin B12a)
Cyanide
Cyanocobalamin (Vitamin B12)
Hydroxocobalamin
• When and How?
– Any smoke-inhalation victim that is
NOT improving despite supportive
care including O2
– Any intentional cyanide exposure
– Smoke-inhalation victim with High
Lactate
– 5 gram dose; can be repeated x1
– Give concurrently with sodium
thiosulfate (avoid physical mixing)
Hydroxocobolamin: Adverse Events
Conclusions
• Majority of patients do well with good
supportive care
• Do NO Harm
• Antidotes can be life-saving in the right
circumstances
• Utilize your Poison Center!
– 1-800-222-1222