Transcript Emergency Management of the Acutely Poisoned Patient

THE SPIRAL CURRICULUM
General Principles in the
Emergency Management of the
Acutely Poisoned Patient
(one more time)
Allan R. Dionisio MD
What are the 6 principles in the
approach to the poisoned patient?
General Approach
Emergency stabilization
Clinical evaluation
Decontamination
Elimination of absorbed substance
Administration of antidotes
Supportive therapy and observation
When should you not give oxygen to a
poisoned patient?
What is the IV fluid of choice in treating
poisoned patients?
Emergency Stabilization
Maintain adequate airway
Provide adequate oxygenation/ventilation
Exceptions: watusi. paraquat
Maintain adequate circulation
Starting fluids: NSS in adults, 0.3 NaCl in
children
If a previously well patient has seizures, and
he has no history of epilepsy, what
medication can be given as a therapeutic
trial apart from the usual anticonvulsants?
Emergency Stabilization
Treat convulsions
Diazepam 5mg IV
Do NOT mix with D5 containing solutions—the
diazepam will crystalize
Aspirate until you get blood, then inject the
diazepam, then push with plain NSS
Seizures of unknown origin--pyridoxine 80120mg/kg
What is appropriate dose of naloxone in
patients presenting with what appears to be
a metabolic coma in the ER?
Emergency Stabilization
Treat coma
D50-50
the single most common cause of decreased
sensorium
Hypoglycemia is LIFE-THREATENING!
Naloxone 2mg IV (pedia 0.1 mg/kg)
Textbooks will tell you to give 0.2mg IV—good for
pure agonists but NOT EFFECTIVE for mixed
agonist/antagonists
Thiamine 100mg IV
To treat or prevent Wenicke’s encephalopathy
Emergency Stabilization
Correct metabolic abnormalities
Electrolytes
Acid-base abnormalities
General Approach
Emergency stabilization
Clinical evaluation
Decontamination
Elimination of absorbed substance
Administration of antidotes
Supportive therapy and observation
Clinical Evaluation
Time of exposure
Most ingestions beyond 2 hours are not worth
decontaminating
Clinical effectiveness of gut decontamination
appears to be insignificant beyond 1 hour postingestion
Exceptions:
meds that slow down gut motility- ex. Loperamide
Slow release meds—ex. Verapamil SR
Enteric coated preparations—ex. Enteric coated
aspirin
Clinical Evaluation
Mode of exposure—tells you what to
decontaminate
Intake of other substances
always keep co-ingestants in the back of your
mind
Look for incongruences between ssx and hx
Circumstances prior to poisoning
Get MULTIPLE testimonies
Clinical Evaluation
Current medications AND past medical
history of patient and family
Most suicidals get anything within reach
Most children get anything within reach
Any home remedies taken
Milk makes lipophilic toxicants get absorbed
faster (ex. Benzodiazepines)
Egg yolk enhances watusi/firecraker absorption
Aspiration pneumonia is frequent in
kerosene/hydrocarbon ingestions given
household emetics
What toxicant can smell this
way?
Bitter almonds
Fruity odor
Oil of wintergreen
Rotten eggs
Garlic
Mothballs
Clinical Evaluation--Odors
Bitter almonds--cyanide
Fruity odor--DKA, isopropyl alcohol
Oil of wintergreen--methylsalicylate
Rotten eggs--sulfur dioxide, hydrogen sulfide,
Garlic--arsenic, zinc phosphide, watusi
Mothballs--camphor
Clinical Evaluation--Colors
Red skin—
Gray gums—
Green urine—
Blue skin and lips—
Cherry red lips—
Clinical Evaluation--Colors
Red skin—rifampicin, anticholinergics
Gray gums—lead, mercury
Green urine--formaldehyde
Blue skin and lips—methemoglobin
Cherry red lips—carbon monoxide
LEAD
OTHER TOXIC EFFECTS:
 Abdominal colic
 Gingival
lines

Pay attention to autonomic ssx
3 toxicants that can cause hypertension
Clinical Evaluation--HPN
C
T
S
C
A
N
cocaine
theophylline
sympathomimetics
caffeine
anticholinergics
nicotine
3 toxicants where hypotension is the
prominent effect
Clinical Evaluation--Low BP
C
R
A
S
H
clonidine
reserpine and other antihypertensives
antidepressants
sedative-hypnotics
heroin and other opiates
3 toxicants that present primarily as
bradycardia
Clinical Evaluation--Bradycardia
P
A
C
E
D
propranolol and other beta blockers
anticholinesterases
clonidine, calcium channel blockers
ethanol
digitalis
3 toxicants that can cause mydriasis
Clinical Evaluation--Mydriasis
A antihistamines
A antidepressants
S sympathomimetics
I isoniazid
A anticholinergics
3 toxicants that present as miosis
Clinical Evaluation--Miosis
C
O
P
S
cholinergics, clonidine
opiates, organophosphates
phenothiazines, pilocarpine
sedative-hypnotics
Toxidrome
Hot as a hare
Dry as a bone
Red as a beet
Blind as a bat
Mad as a hatter
Toxidrome
D diarrhea, diaphoresis
U urinary incontinence
M miosis, muscle fasciculations
B bradycardia, bronchoconstriction
E emesis
L lacrimation
S salivation
Toxidrome
Seizures
Coma
Acidosis
Toxidrome
Mixed metabolic acidosis and respiratory
alkalosis in an unknown poisoning
Tinnitus
Tachycardia
Lab exams
5-10ml heparinized blood
5-10 ml clotted blood
100 ml urine
Gastric aspirate
General Approach
Emergency stabilization
Clinical evaluation
Decontamination
Elimination of absorbed substance
Administration of antidotes
Supportive therapy and observation
Elimination of Poison:
External Decontamination
Dermal: discard clothing; bathe with
alkaline soap
Eye: irrigate with free flowing water for 30
minutes
Avoid neutralizing solutions in caustic
exposures.
Protect yourself!
Correct dose of activated charcoal and
sodium sulfate
Elimination of Poison:
Gastric Decontamination
Insert NGT; Trendelenburg position
Lavage with NSS
Activated charcoal
Adults: 100g in 200ml water
Children: 1g/kg as a slurry
Sodium sulfate
Adults: 15g in 100ml water
Children: 250mg/kg as 10% solution in water
2 toxicants where activated charcoal is not
effective
Elimination of Poison:
Gastric Decontamination
Contraindications to NGT/lavage
Caustics, kerosene less than 1ml/kg, frank
convulsions
Charcoal
Not effective for: alcohol, cyanide, iron,
lithium, petroleum distillates
Contraindicated in: watusi, caustics
2 contraindications for giving sodium
sulfate
Elimination of Poison:
Gastric Decontamination
Sodium sulfate is contraindicated in:
caustics,
ileus,
electrolyte imbalance,
patients with heart failure
patients with kidney failure
Alternative is sorbitol 1-2g/kg
General Approach
Emergency stabilization
Clinical evaluation
Decontamination
Elimination of absorbed substance
Administration of antidotes
Supportive therapy and observation
Elimination of Poison:
Multiple Dose Activated Charcoal
Adults: 50g in 150ml water retained in
stomach q6h PO or per NGT x 48h
Children: 0.5g/kg as a slurry q6h PO or per
NGT x 48h
Give sodium sulfate every morning to
evacuate the charcoal.
3 toxicants where multiple dose charcoal is
effective
Elimination of Poison:
Multiple Dose Activated Charcoal
Salicylates
Methamphetamine and ecstasy
Diazepam and other benzodiazepines
Phenobarbital
Digoxin
Elimination of Poison:
Multiple Dose Activated Charcoal
Carbamazepine
Dapsone
Phenobarbital
Quinine
theophylline
Elimination of Poison:
Multiple Dose Activated Charcoal
Amitriptyline
Dextropropoxyphene
Digitoxin and digoxin
Disopyramide
Nadolol
Phenylbutazone
Phenytoin
Piroxicam
sotalol
When do you alkalinize and when do you
acidify the urine?
Elimination of Poison:
urine pH manipulation
Alkalinize for weak acids:
Salicylates, barbiturates, INH
Acidify for weak bases:
Amphetamines, phenytoin, theophylline
How do you alkalinize and how do you
acidify the urine?
Elimination of Poison:
urine pH manipulation
To alkalinize--Sodium bicarbonate
1mEq/kg/dose until urine pH > 7.5
To acidify--Ascorbic acid 1g (pedia
20mg/kg) IV q6h until urine pH< 5.5
2 pharamacokinetic parameters that say
dialysis is possible
Elimination of Poison:
Dialysis
Low volume of distribution
Low protein binding
Toxin is dialysable
Benefit outweighs risks of dialysis
3 dialysable toxicants
Elimination of Poison:
Dialysis
Barbiturates
Ethylene glycol
INH
Lithium
Ethanol, methanol, isopropanol
Salicylates
General Approach
Emergency stabilization
Clinical evaluation
Decontamination
Elimination of absorbed substance
Administration of antidotes
Supportive therapy and observation
Antidotes: Pyridoxine (Vit B6)
Specific antidote for INH poisoning
Give IV bolus dose equal to amount of INH
ingested
If dose of INH is not known, give 120mg/kg
of pyridoxine and repeat as necessary to
control seizures
As much as 52g has been given safely
Antidotes: Pyridoxine
Maintain on 10mg/kg/d in 3dd x 6wks
If Vit B1/B6 combination, do not give more
than 1g of Vit B1 at any one bolus; repeat
every 5 minutes until total required B6 is
given
What is atropine the antidote for?
What are the atropinization parameters?
Antidotes: Atropine
Physiologic antidote for cholinesterase
inibitors
1-2mg (pedia 0.01mg/kg) IV q15min until
HR > 100
Pupils > 4mm
Dry oral mucosa
Hypoactive bowel sounds
Antidotes: Atropine
Once fully atropinized, gradually increase
intervals--speed of downloading the dose
depends on whether carbamate or
organophosphate
WOF: hyperpyrexia, tachyarrhythmias,
hallucinations, flushing. Stop atropine and
hydrate patient until symptoms wear off.
What is the antidote for opiate overdose?
What is the appropriate dose?
Antidotes: Naloxone
Specific antidote for opiate poisoning
2mg IV initially. Repeat q5min until awake
or until max of 10mg total given
Once awake, give 2/3 of the wake up dose
as a drip every hour
Antidote for benzodiazepine overdose
Antidotes: Flumazenil
Specific antidote for benzodiazepine
overdose
Anexate 0.5mg/5ml
0.1mg in 4ml D5W IV over 15 seconds
q1min; max of 2mg
Maintain on 0.1-0.2mg/hour as IV drip
General Approach
Emergency stabilization
Clinical evaluation
Decontamination
Elimination of absorbed substance
Administration of antidotes
Supportive therapy and observation
80% of poisoned patients survive
with aggressive supportive
therapy alone.
Your management is NOT
COMPLETE unless you address
the PSYCHOSOCIAL factors
leading to the poisoning.
For suicidals:
Counseling
Co-mgt with Psych
Patients who attempt suicide
deserve compassion, not ridicule
or condemnation.
For accidental poisoning
TOXICOVIGILANCE
(home, workplace, community)
Thank you for listening.