Download ED Toxicology

John Hiscox
2016
ED Toxicology
Toxbase
 Thank you for paying attention
 Any Questions?
When should I admit a person to hospital after
an episode of poisoning or overdose?
 Admit a person to hospital if:
 They have worrying symptoms after taking a poison or
drug.
 They are asymptomatic, but the poison or drug is
unknown, is potentially life threatening, or has a delayed
action.
 The poisoning was intentional.
 Consider admitting children, older people, pregnant
women, people with pre-existing comorbidities, or
people taking concomitant medication, even if the
drug is considered to have a good safety profile.
When should I admit a person to
hospital after an episode of
poisoning or overdose?
 Admit the person to hospital immediately if they develop worrying
symptoms suggestive of poisoning, or have taken a poison or drug
which could be potentially life threatening, or have a delayed onset of
action:
 Symptoms which are worrying include respiratory difficulty,
palpitations, and dizziness. However, minor gastrointestinal upset
(nausea, diarrhoea) is generally not considered to be an absolute
indication for admission to hospital in people who have taken nontoxic substances or substances with a low toxicity.
 Drugs which are potentially life threatening include opioids,
benzodiazepines, cocaine, antidepressants, antipsychotics,
antiepileptics, quinine, verapamil and diltiazem.
 Common delayed-action drugs and poisons include aspirin, iron
supplements, paracetamol, lithium, tricyclic antidepressants, cophenotrope (diphenoxylate with atropine, Lomotil® brand), and
paraquat. Also consider when a drug has been taken in a form
which delays release (delayed- or modified-release tablets or
capsules).
Where can I get more information
about poisonings?
 TOXBASE in the first instance for general information
(see www.toxbase.org but in the event of any difficulty
contact 0131 242 1381/1383).
 National Poisons Information Service (NPIS)
 UK Teratology Information Service (UKTIS),
formerly National Teratology Information Service
(NTIS) in the event of poisoning in a pregnant woman
(see www.uktis.org, 0844 8920909).
 UK Medicines Information (UKMI) service for
general medicine information including dosing and
drug interactions (see www.ukmi.nhs.uk).
does not need admission to
hospital?
 Admission to hospital is not usually indicated for
accidental poisoning with agents considered to be
non-toxic or of low toxicity, or if a person has
accidentally taken an additional tablet of their own
medication. However, all intentional poisonings, even
if the poison is considered of low toxicity will need
admission for further assessment.
How do I manage a person who
does not need admission to
hospital?
 Advise the person about expected adverse effects.
 Consider a full assessment for people more vulnerable to
complications. Review:
 Details of the drug taken
 The person's past medical history (especially renal and liver
impairment) and medication history.
 The person's age and social circumstances..
 Restart the person on their medication when possible.
 If there is any uncertainty regarding a poisoning or when to
restart medication after an additional tablet has been
taken, further advice should be sought
How do I manage a person who refuses
admission to hospital after a poisoning?
How do I assess a person's
capacity?
ED Management
 Prevention of absorption:
 Activated charcoal is the treatment of choice for most poisons and is used if
the person presents within an hour of ingestion (longer if a modified release
preparation or antimuscarinic properties). The charcoal binds to the poison and
prevent further absorption into the blood. It is particularly useful when small
amounts of a drug are toxic such as antidepressants.
 Active elimination is suitable for a limited number of drugs:
 Activated charcoal given in repeated doses also enhances the elimination of
some drugs even after they have been absorbed such as carbamazepine,
phenobarbitone, quinine, theophylline and dapsone.
 Alkalinisation of the urine for salicylate poisoning.
 Haemodialysis for ethylene glycol, lithium, methanol, phenobarbital,
salicylates, and sodium valproate.
 Removal from the gastrointestinal tract:
 Gastric lavage is rarely done. It is indicated only if a life-threatening amount has
been ingested within the previous hour. It may be useful for drugs such as
lithium and iron that are not absorbed by charcoal. Lavage should never be
done if a petroleum distillate or a corrosive substance has been ingested.
ED Management
 Antidotes (if available) may be given for certain poisons,
which either prevent the poison from working or reverse
the effects of the poison.
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N-acetylcysteine
Digoxin-specific antibody fragments
Flumazenil injection
Glucagon injection
Naloxone injection
Desferrioxamine mesilate
Fomepizole
 General supportive measures include sedative medication
if the person is agitated, ventilation if the person stops
breathing, and antiepileptic medication if seizures develop.
ED Management
 Investigations in ED ?
 Bloods ( timing)
 ECG
 X-rays
 Urine / gastric contents