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Download Acute Poisoning (Basic Principles)
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Acute Poisoning (Basic Principles) Assoc.Prof.Tughan UTKU, MD Istanbul Univ.Cerrahpasa Med.Sch. Anaesthesiology Dept. ICU poisoning • Taking a substance that is injurious to health or can cause death Poisoning episodes • Accidental ( household products- children) • Suicidal • Therapeutical Poisoning can be caused • Solids • Liquids • Gases • Vapors Poison absorbing ways • Gastrointestinal • Lung • Skin • Parenteral How to diagnose 1. History of ingestion • • • • • • Patient and/or relatives Time of ingestion Quantity ingested Type of formulation Chronicity of ingestion Co-ingestants 2. Identify the poison 3. Estimate the severity of the poisoning 4. Time of exposure How to diagnose 5. Clinical examination of the patient 6. Investigations • Biochemical findings • Drug screening • Imaging findings cont’d Clinical examination of the patient (toxidromes) • Coma Alcohols Lead Anticholinergics Lithium Arsenic Opioids Beta Blockers Phenothiazines Cholinergic Agents Salycylates Carbon Monoxide Cyclic Antidepressants Sedative Hypnotics Clinical examination of the patient (toxidromes) • Pupils Miosis Mydriasis Cholinergics Anticholinergics Clonidine Glutethimide Nicotine Meperidine Phenothiazines Sympathomimetics Withdrawal Clinical examination of the patient (toxidromes) • Respiratory Effort Decreased Increased Alcohols CO Barbiturates Drug induced metabolic acidosis Benzodiazepine Drug induced hepatic failure Opioids Drug induced methemoglobinemia Salycylates Clinical examination of the patient (toxidromes) • Heart Rate Tachycardia Bradycardia Anticholinergics Alpha blockers Antihistamines Beta blockers Cyclic Antidepressants Calcium channel blockers Sympathomimetics Cardiac glycosides (cocaine, amphetamine, Clonidine theophylline) Cholinergics Withdrawal States Cyanide Nicotine Parasympathomimetics Clinical examination of the patient (toxidromes) • Blood Pressure Hypertension Hypotension Anticholinergics CO Antihistamines Cyclic Antidepressants Cyclic Antidepressants Iron Sympathomimetics Opioids (cocaine, amphetamine, Clonidine theophylline) Nitrites Withdrawal States Phenothiazines Sedative-Hypnotics Clinical examination of the patient (toxidromes) • Temperature Hyperthermia Hypothermia Anticholinergics Beta Blockers MAOIs CO Metals Cholinergics Phenothiazines Ethanol Salicylates Hypoglycemics Sympathomimetics Sedative-Hypnotics toxidromes Syndrome Common signs Common causes Anticholinergic Delirium, tachycardia, dry and flushed skin, dilated pupils, myoclonus, hyperpyrexia, urinary retention and decreased bowel sounds. Seizures and dysrhymias in severe cases. Antihistamines, scopolamines, antiparkinsonian drugs, antipsycotics, antidepressants, antispasmodics, muscle relaxants and many plants (jimson weed, amanitia muscaria) Cholinergic Confusion, weakness, salivation, lacrimation, urinary and faecal incontinence, GI cramping, emesis, miosis, bradycardia or tachycardia and seizures Organophosphate and carbamate insecticides, nerve gases, physostigmin, edrophonium and some mushrooms Cholinergic Syndrome • SLUDGE-BBB – S alivation – L acrimation – U rination – D efecation – G I symptoms – E mesis – B ronchorrhea – B ronchospasm – B radycardia • DUMBELS – D iarea and diaphoresis – U rination – M iosis – B ronchorrhea, bronchospasm, bradycardia – E mesis – L acrimation – S alivation toxidromes Syndrome Common signs Common causes Sympathomimetic Delusions, paranoia, tachycardia, hypertension, hyperpyrexia, diaphoresis, mydriasis and hyperreflexia. Seizures, hypotension and dysrythmias in severe cases Cocaine, amphetamines, methamphetamines, decongestants (phenylppropanolamine, ephedrine and pseudoephedrine), caffein and theophylline Sympatholytic Confusion, lethargy, bradycardia, hypotension, nause, vomiting, AV block, prolong QT, wide QRS, sinus bradycardia, ventricular arrhythmia, seizures, ataxia Alpha blokcers, beta blockers, TCA’s, digitalis toxidromes Syndrome Common signs Common causes Opiates Coma, respiratory depression, miosis, hypotension, bradycardia, hypothermia, decreased bowel sounds, and hyporeflexia Narcotics, codein, propoxyphene Sedatives/hypnotics Coma, respiratory depression, hypothermia, hyporeflexia Barbiturates, benzodiazepins, gluthetimide, meprobamate and ethanol Serotoninergic Confusion, agitation, tremor, muscle fasciculation, extrapyramidal symptoms, hypereflexia, hyperthermia, diaphoresis, tachycardia Selective serotonin reuptake blocking agents Case • 26 years-old, female • Found in a hotel room • Febrile • Unresponsive • Pupils dilated • Diffusely erythematous • Dry skin Case • Tachycardia • Urinary retention • Decreased bowel sounds ? • Hot as a pepper • Dry as a bone • Red as a beet • Mad as a hatter • Blind as a bat ! • Anticholinergic syndrome Biochemical findings • Tests should be selected based on the patient’s condition • Blood count • Electrolytes (anion gap) • ABG’s • Lactate • PT, aPTT • Plasma osmolarity (osmolar gap) • Liver function tests Drug analysis • Exact toxicological analysis – Time factor – Money – Formal procedures Imaging findings (potentially radiopaque substances) • C • H • I • P • E • S = chloral hydrate = heavy metals = iodine and iron =phenothiazine and TCA’s =enteric coated formulations =solvents Immediate actions • The initial brief patient survey is directed toward correcting immediate lifethreatening problems of – A irway – B reathing – C irculation – D rug-induced CNS depression Immediate actions • Maintain vital functions • Assess the level of consciousness • Give antidote if indicated • Prevent absorption of the poison if appropriate • Drug analysis requested • Consider increased elimination of the poison • Organise adequate observation and continuing care TOXIN ANTIDOTE / INTERVENTION Acetaminophen N-acetylcystein Amphetamines Benzodiazepins Arsenic/mercury/gold/lead BAL (dimercaprol) Benzodiazepins Flumazenil Beta blockers Glucagon, Ca, insulin, pacing Ca channel blockers Ca, Glucagon, insulin, pacing CO O2 Cocaine Benzodiazepins Coumadin derivatives Vit K Cyanide Nitrites, thiosuphate, hydroxocobalamine TCA’s Blood alkalinization, alpha agonist Digoxin Digoxin-specific Fab fragments Etylene glycol Ethanol, fomepizole Heparin Protamine Iron Deferoxamine INH Pyridoxine Methanol Ethanol, fomepizole Narcotics Naloxone, nalmefene Nitrites Methylene blue Organophosphate/carbamates Atropine, pralidoxime Salicylates Urine alkalinization, haemodialysis Theophilline Multiple dose charcoal, haemoperfusion Preventing absorption • Absorption of ingested poisons may potentially be minimised by; – Emptying the stomach by GASTRIC LAVAGE – Administration of ACTIVATED CHARCOAL – Whole bowel irrigation Gastric lavage • GL should only be considered within 1 hr of ingestion of an agent causing severe toxicity • There is no reason to perform GL in poisoning with relatively harmless compounds • GL > 1 hr after ingestion may be considered if the substance is highly toxic, the overdose is of a massive quantity • The decision to empty stomach depends on a risk vs benefit consideration taking into account the patient’s condition, age, level of consciousness and degree of cooperation. Gastric lavage • The airway must be protected • Induced emesis (ipecac ) is no longer recommended for adult or paediatric poisonings • GL is contraindicated in patients who have ingested petroleum distillates and corrosive substances • Potential complications of GL – – – – – Aspiration of gastric content Oesophageal perforation Cardiovascular instability Hypoxia Vomiting Activated charcoal • Single dose 1-2 g /kgBW • Ideally AC should be given within 1 hr after ingestion of the poison • Repeated doses of AC administered at 2-4 hr intervals should be considered for drugs that have important entero-hepatic recirculation and for slow released substances Activated charcoal • Does not adsorb – Iron – Lithium – Alcohols – Hydrocarbons – Cyanide – Strong acids – Strong bases Activated charcoal • Multiple doses of AC have been demonstrated to enhance elimination ; – – – – – – – – – – Carbamazepine Theophilline Quinidine Dapsone Antidepressants Dextropropoxyphene Paracetamol Salicylate Phenytoin Digoxin Elimination of poisons • Multiple doses of AC • Haemodialysis • Charcoal haemoperfusion • Forced diuresis ? (urine output: 3-5mL/kg/hr) • Urine alkalinization (urine pH >=8, 2-3mL/kg/hr)(salicylate, barbiturate) haemodialysis • CAVHF = CVVHF • Salicylate • Ethylene glycol • Methanol • Lithium • Theophylline • K+ haemoperfusion • Barbiturates • Meprobamate • Glutethimide • Theophylline • Phenytoin • Carbamazepine Poison centers in Turkey: • Ankara • Bursa • İzmir (Ege Univ.Pharm. Faculty) • Refik Saydam Hıfzısıhha Enst. Poison Centers • Ankara Zehir Danışma: 0800 314 7900 • Uludağ Zehir Danışma: 090-224-442 84 93 • Zehir Araştırmaları Müdürlüğü: [email protected]
