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I have no financial disclosures or commercial endorsements
to disclose
Four ED cases encountered
over the past year
› Differential Diagnosis
› Epidemiology
› Pathophysiology
› Emergency Management
Not a “traditional” toxicology
lecture
Emergency care relevant to
IM & pediatric office practices
59 yo F with a “nosebleed that won’t stop”. Pressure & anterior
nasal packing fail despite clear bleeding site at Kisselbock’s
After 3 hrs at home & 2 hrs of ED failed bleeding control she is
tachycardic, hypotensive then has a syncopal event
Vitals: HR 130s & irregular, BP 74/42, Sat 92% ra
Differential diagnosis?
In 1900s bis-hydroxycoumarin discovered after cows eat spoiled
sweet clover & die of massive hemorrhage
Warfarin derivatives used therapeutically as anticoagulants,
commercially as rodenticides
~3000 accidental exposures annually
› 79% in <6yo children
In adults complications usually from incorrect dosing or diet /
medication misadventures
1%-8% toxicity risk for each year of therapy
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Bleeding risk elevates as INR increases; 50% bleeding episodes occur w/ INR <4.0
Inhibits synthesis of vitamin Kdependent coag factors II, VII, IX, X
› No effect on established thrombus
› Prevent progression / secondary
thromboembolic complications
Metabolized by hepatic CP-450
isoenzymes to inactive metabolites
Abn metabolism alters physiology
› Advanced age, hepatic dysfunction,
diet, numerous meds
½ life 20-60 hrs, effect duration 2–5
days, peak concentration 4 hrs
Reversal & stabilization
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Stable vs unstable?
Acute vs chronic?
Why anticoagulated?
Why reversal?
Exam: includes skin, neurological, rectal
Rads: If AMS or trauma obtain CT / US of affected area
Labs:
› Type / cross, CBC, coags, LFTs, +/- tox screen
› PT / INR (anticoagulant effect)
› Vitamin K dependent factors
If critical need for anticoagulation (i.e. mechanical heart
valve), heparin temporizes while warfarin reversed
INR
BLEEDING PRESENT
RECOMMENDATION
>Therapeutic - <5
No
Lower warfarin dose, or omit
dose & resume at low dose;
no reduction if minimally
elevated
>5-9
No
Omit 1-2 doses, serial PT/INR,
resume warfarin at lower
dose; or omit dose & give 12.5mg vitamin K po
>9
No
Hold warfarin, give 2.5-5 mg
vitamin K po, serial PT/INR,
administer more po vitamin K
prn; If prosthetic heart valves,
FFP > vitamin K
Any
Serious or Life-threatening
Hold warfarin. Vitamin K 10mg
IV. FFP. Consider PCC, rfVIIa
Ansell J. Pharmacology and management of the vitamin K antagonists: Chest 2008
Fat soluble vitamin
required for protein
modification, blood
coagulation, & metabolic pathways
Plant source (soy & green vegetables)
Overcomes competitive blocks
Clinical effect delayed for hours while liver synthesizes
clotting factors & plasma factors II, VII, IX, X restored
IM, IV & PO equivalent, SQ not recommended
FFP contains plasma + coag factors
› Free of RBCs, WBCs, PLTs
› ABO compatible w/o rH considerations
In a 70 kg Patient:
› 1 Unit (250cc) FFP increases factors 2.5%
› 4 Units (1000cc) FFP increase factors 10%
› 10% increase of factor levels required for
clinically significant change in coag
status, so usual dose is 4 units
Prothromin Complex Concentrate (PCC)
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No thawing
Factors II, IX & X, minimal factor VII; new products include factor VII
Some contain protein C & S, antithrombin II or heparin
4-factor products reverse coagulopathy within 30 mins
Must add FFP for F VII if 3-factor products (Prothrombinex-HT®)
Vitamin K1 to sustain reversal
Recombinant Factor VIIa (rFVIIa / Novo7®)
› No thawing
› Less volume, ARDS, transfusion reactions & infection transmission
› Vitamin K1 to sustaining reversal
Despite apparent advantages, no proven mortality benefit for
rFVIIa or PCC > FFP
Initial INR 6 / hemoglobin 7
required 2.5mg po vitamin K,
4 units FFP, 1 unit PRBC
Hemorrhage controlled with
bilateral RhinoRockets®
Admitted for 23 hr obs,
warfarin held x 2 dosages
Determined pt accidentally
doubling warfarin dosage
due to pharmacy error
21 mo F presents because “she wouldn’t wake up from her
nap”. Parents earlier noted child playing with grandma’s pill
bottles; Grandma counted pills & thinks “1 or 2” missing
Child floppy, minimally responsive, dilated pupils
ABCs – airway patent, hypoventilation, thready pulse
› IO, O2, monitor
› HR 68, BP 92 palp, Sat 85% ra, T 96 pr
Differential Diagnosis?
6,000,000 potentially toxic ingestions yearly
› Most common age group: 1-5 yo
Predominately accidental (toddlers), intentional (teens)
MCC fatal poisonings:
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Iron
TCAs
Cardiovascular medications
Hypoglycemics
Hydrocarbons
MEDICATION / DRUG
POTENTIALLY LETHAL DOSE (10KG)
Codeine
3 60mg tablets
Desipramine
2 75mg tablets
Hydrocarbons
1 teaspoon (if aspirated)
Imipramine
1 250mg tablet
Iron
2 adult strength tablets
Lindane
2 teaspoons
Theophylline
1 500mg tablet
Verapamil
1 240mg tablet
Metoprolol
2 50mg tablets
Sulfonylureas
2 5mg tablets
AMS differential diagnosis
In non-diabetics, hypoglycemia
usually asymptomatic until
glucose <40 mg/dL
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Weakness
Diaphoresis
Tachycardia
Tachypnea
Transient neurologic deficit
Pallor / Cyanosis
Seizure / Tremor / Jitteriness
Coma
Hypothermia
Miscellaneous
› Sepsis
› Malnutrition
› Renal / Liver Failure
Hyperinsulinemia
› Beckwith-Weidman
› β Cell Hyperplasia
(Nesidioblastosis)
Toxicity:
› ETOH, Salicylates,
Methadone,
Hypoglycemics
HPA Axis Abnormality
Inborn Errors of
Metabolism:
Carnitine Deficiency
Fructosemia
Galactosemia
Glycogen-Storage
Disease Type I
› Maple Syrup Urine
Disease
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1st generation sulfonylureas (i.e.
tolbutamide), very potent, ½ life 3549 hrs
2nd generation sulfonylureas
(glipizide, glyburide, glimepiride)
less potent, shorter ½ lives
Non-sulfonylureas: biguanides, aglucosidase inhibitors
› High dosages do not significantly
decrease serum glucose
› “Anti-hyperglycemics” not
“hypoglycemics”
Sulfonamide derivatives w/o
antibacterial activity
Bind to K+ receptors sensitive to
β cell membrane ATP resulting in
Ca++ influx, K+ efflux, membrane
depolarization & insulin release
Decrease serum glucagon,
potentiate insulin action in extrapancreatic tissues
Effective if functional β cells
ABC, IV, O2, Monitor
IV / IO dextrose / glucose
PO / IV glucagon
› NPO if AMS
IV octreotide or diazoxide
Other than for glipizide (enterohepatic circulation)
activated charcoal not beneficial >1 hr post ingestion
No role for hemodialysis
Dextrose (D-glucose)
› Rapid serum glucose elevation
› Monosaccharide absorbed from GIT then distributed to
tissues
Glucagon
› Polypeptide hormone from beef or pork pancreas Islets of
Langerhans alpha cells
› ½ life 3-6 min
› Gluconeogenesis & lipolysis by inhibiting glycogen
synthesis & enhancing glucose formation from proteins &
fat stores
› Glycogenolysis by increasing liver hydrolysis of glycogen
to glucose
Diazoxide (Hyperstat)
› Increases glucose by
inhibiting pancreatic insulin
release
› Hyperglycemic effect within
1 hr, lasts 8 hrs
Octreotide (Sandostatin)
› Acts on somatostatin
receptors
› Hyperpolarization of β cells
inhibits Ca++ influx & insulin
release
If 1st gen sulfonylurea admit for
minimum 24 hrs regardless of
symptomatology
If 2nd gen sulfonylurea may
discharge home if asymptomatic
& euglycemic for 8-12 hrs
If AMS, lethargic or seizure, admit
to PICU
Parental education!
Patient known to EMS & ED for multiple visits for hypoglycemia
Presents via ambulance with AMS. FSBG 120 “but we already
gave an amp of D50 because that what he always needs”
Patient remained altered during transport, did not respond as
usual. Upon arrival, lethargic, maintaining gag, FSBG 135
IV, O2, monitor placed & following noted:
• Vitals: HR 28, BP 64/34, T 98, Sat 82% NRB
• Differential Diagnosis?
Dependent on
history + vitals
Bradycardia
pathway if
cannot obtain
history
Beta Blockers
› Lipophillic, large VOD
› Wide variations in pharmakokinetics, but generally
absorbed in GIT, eliminated hepatically or renally
(atenolol, nadolol, esmolol)
› Inhibit β adrenergic stimuli with (-) inotropy & chronotropy
Calcium Channel Blockers
› Highly protein bound, large VOD
› 1st pass effect via hepatic metabolism (low bioavailability)
› Decreased calcium influx, causing (-) inotropy,
chronotropy, dromotropy & vasodilation (decreased PVR)
Narrow therapeutic to toxic ratio
Most common features: hypotension + bradycardia
EKG: sinus bradycardia with PR prolongation
› BBs > CCBs cause QRS prolongation
BBs cause additional symptoms due to effects on
systemic beta receptors:
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Bronchospasm
Hypoglycemia
Hyperkalemia
CNS toxicity
Regulatory hormone with (+)
inotropic & chronotropic effects on
myocardium via increasing cAMP
Effects independent of betaadrenergic stimulation
Reverses hypotension, bradycardia &
myocardial depression
Does not significantly reverse
conduction disturbances (i.e. QRS
prolongation)
Epinephrine
› β adrenergic to treat hypotension+ bradycardia
Calcium Gluconate or Chloride
› 30 mL gluconate =1 gm of calcium
› Rapid contractility improvement, limited effect on
nodal depression or PVR
› If critical hyperkalemia, chloride > gluconate
NaHCO3
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Treatment of QRS prolongation
Dopamine
› a & β adrenergic actions
Magnesium
› Hypocalcemia refractory to treatment if
hypomagnesemia
ABC, IV, O2, Monitor
Central line
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Glucagon
CaCl
MgSO4
Epinephrine gtt
RSI: vecuronium & etomidate
Ventilation with low PEEP
Atropine
Med Flight to MGH
External pacing
D/C at day 7…to be seen at
Tobey 10 days later with ~
hypoglycemia!
42 yo WF presents via police with SI. Arguing with husband,
stated SI including driving off a cliff. Calm & forthcoming
during interview, denying current SI
Tox screen: negative
Crisis arrived 3 hrs after interview to find pt unresponsive,
“twitchy” with “odd jerking motions”. Tech noted pt restless x
30-45 mins
MD called to room to find patient seizing
Airway controlled, ativan given, placed on monitor
› HR 120, BP 90/60, Sat 90%ra, T not done
Differential Diagnosis?
IV, O2, Monitor
2 large bore IVs, 2 L NS bolus
2 amps NaHCO3. then NaHCO3 drip
2 grams MgSO4
Partially awake intubation, followed by
vecuronium
Ventilation w/ low PEEP
Dopamine
CNS Catastrophe
Heatstroke
Metabolic:
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› Hyperkalemia
› Hypocalcemia
› Hyponatremia
Status Epilepticus
Arrythmias:
› Sinus Brady
› Heat Block
› WPW
› VF / VF / Torsades
OD:
Anticholinergic
Antidepressant
Antihistamine
Digitalis
INH
Local Anesthetic
Salicylate
TCA
Antiarrythmic
Withdrawal Syndromes
Metabolic Acidosis
en
1
isch
674
1024
Extensively protein bound, large VOD
Hepatic metabolism, excreted as
active metabolites with long ½ life
Toxic effects mediated through:
› Anticholinergic
› a 1 blockade
› Class 1a quinidine-like effects
› Postganglionic norepinephrine
reuptake blockade
Narrow therapeutic index
Rapid onset of CNS & CV effects
Unlikely to develop life-threatening
events 6 hrs post ingestion
May appear to have a pure
anticholinergic toxidrome
Sinus tach 1st sign of toxicity
Class 1A antiarrhythmic effect
decreases Na+ influx through
fast Na+ channels
Decreased phase 0 slope
prolongs QRS / QT / PR
Delays myocardial &
conducting tissue
depolarization
QRS >0.16 with predicts seizures /
arrhythmias > drug levels
› >130 msec, 90% required
mechanical ventilation
› >120 msec, 1/3 seized
› >160 msec, 75% VT / VF
aVR terminal R >3mm better
predictor of seizures or arrhythmias
than QRS duration
Right axis shift in last 40ms of
QRS, deep S wave in lead 1,
large R wave in aVr suggestive
of TCA cardiotoxitiy
TCA anti–a adrenergic effects
Negative inotropy
Peripheral vasodilatation
(decreased PVR)
Inhibition of Na+ flux into
myocardium depresses inotropy
CARDIOVASCULAR
CNS
ANTICHOLINGERGIC
Sinus Tachycardia
Drowsiness
Dry Mouth
Prolonged PR/ QRS/ QT
Opthalmoplegia
Blurred Vision
ST Wave Abnormalities
Seizures*
Dilated Pupils
Heart Blocks
Pyramidal SSX
Urinary Retention
Vasodilation
Rigidity
Absent Bowel Sounds
Hypotension
Delirium
Pyrexia
Cardiogenic Shock
Respiratory Depression
Myoclonic Twitching
VT / VF
Coma
Asystole
*Serotonin or norepinephrine mediated effects
ABC, IV x 2, O2, Monitor, EKG
Correcting hypotension,
hypoxia, acidosis reduces
cardiotoxicity & arrhythmias
Unlike pure anticholinergic
toxicity, no physostigmine
(decreases seizure threshold,
arrythmogenic)
ICU admission
Many common meds have
“TCA-Like” toxicity
QRS >100 ms, seizures, acidosis, hypotension, ventricular
arrhythmias, cardiac arrest
Corrects acidosis by increasing extracellular Na+
› Narrows QRS
› Stabilizes Na+ channels
› Raises BP even if no acidosis
› Increases TCA plasma protein binding
› Improves inotropy
Patient decompensated en route to Boston
At MGH, placed on epinephrine gtt, Swan-Ganz placed,
intralipids started
Hemodialysis initiated when creatinine bumped to 5 &
potassium elevated
After 4 days in the ICU, extubated
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OD cocktail: amitriptyline, flexeril, diphenhydramine
Discharged to psychiatric rehab on day 7 of hospital stay
www.emedicine.com~“INRReversal”, “Sulfonylurea Toxicity”, “TCA Overdose” 2011.
Leissinger CA, Blatt PM, Hoots WK, et al. Role of prothrombin complex concentrates
in reversing warfarin anticoagulation: A review of the literature. Am J Hematol.
2008;83:137-43
Weber JE, Jaggi FM, Pollack, CV. Anticoagulants, antiplatelet agents, and
fibrinolytics. In: Tintinalli JE, Kelen GD, Stapczynski JS, eds. Emergengy Medicine: A
Comprehensive Study Guide. 6th ed. McGraw-Hill; 2004: 1354-60
Hirsh J, Guyatt G, Albers GW, et al. Executive Summary: American College of Chest
Physicians Evidence-Based Clinical Practice Guidelines. Chest 2008;133:72S-3S
Poison Control Center Data. 2010
AHA Cardiovascular Care Recommendations; Warfarin reversal: consensus
guidelines, on behalf of the Australasian Society of Thrombosis & Haemostasis.
Circulation. 2010.
Baker R. Wood; the Warfarin Reversal Consensus Group recommendations. MJA
2004; 181 (9): 492-497
Bonow RO, Carabello BA, Chatterjee K, et al. 2008 Focused update incorporated
into the ACC/AHA 2006 guidelines for the management of patients with valvular
heart disease”. Circulation 2008; 118(15):e523-661.
Tintanelli. “Emergency Medicine”. 2009.
www.cdc.gov~Poisoning statistics 2010.
www.aapcc.org~American Association of Poison Control Website. 2011.
www.toxicology.org~Toxicologyand Critical Care Management Updates. 2011
Carr D. Successful resuscitation of a doxepin overdose using intravenous fat
emulsion (IFE). Clinical Toxicology 2009; 47(7): 710.
Review of the epidemiology, pathophysiology, differential
diagnosis & emergency management of four common
overdoses
Implications for internal medicine & pediatrics
Importance of a broad differential diagnosis & early
recognition and aggressive emergency management
Questions?
Thank you for your time ~ find me nights at Tobey ED or at
[email protected]