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THE APPROACH TO THE POISONED PATIENT Toxicology Skills Workshop Regions Hospital Emergency Medicine Program Develop a Systematic Approach Look for Toxidromes (“Talkingdromes”) Attention to ABCs and need for Antidote Know the Indications for Decontamination Procedures Enhance when possible and appropriate A – Antidote B – Basics ; ABCs C – Change catabolism D – Distribute differently; Decontamination E – Enhance elimination Antidote Toxin/Drug Oxygen Naloxone CO, CN, H2S Narcotics/Opiates NAC APAP, Carbon tet Atropine, Pralidoxime Organophosphates Calcium DMSA HF, Fl, Oxalates As, Lead, Hg Sodium Bicarbonate TCA Antidotes Toxin/Drug Ethanol, 4MP EG, (methanol) Digoxin-specific Fab Digoxin Glucose Hydroxocobalamin* Insulin CN Physostigmine Pyridoxine Anticholinergics, central INH, hydrazines Glucagon Beta-blockers Airway Breathing Circulation Do the DONT Dextrose Oxygen Naloxone Thiamine Reduce Adsorption Vomiting (Ipecac) Activated Charcoal Generally not indicated or used in an ED setting Contraindicated in patients < 6 mos old, caustic ingestions, actual or potential loss of airway reflexes, need to give oral antidote Most effective if given within one hour Caution in the patient with altered mental status (need a protected airway) Not effective for hydrocarbons, metals (Lead, Iron, Lithium) Gastric Lavage Rarely used Consider in large, potentially life threatening ingestions not amenable to activated charcoal Hemodialysis STUMBLE(D) - Dialysis Salicylates Theophylline Uremia Methanol Barbiturates, Bromide Lithium Ethylene Glycol Depakote (high levels) Focused History and Brief Tox Exam History: what-when-how much Reliability factor, relatives, paramedics Exam Vital signs Mental status Pupillary response Skin changes, Odors/other prominent features. M A T T E R S Exam Vital signs Pulse up or down or normal BP up or down or normal Temp up or down or normal Resp up or down or normal Bradycardia (PACED) Propranolol or other Beta blockers, Poppies (opiates) Anticholinesterase drugs Clonidine, CCBs, Ciguatera Ethanol or other alcohols, Ergotamine Digoxin Tachycardia (FAST) Free base or other forms of cocaine Anticholinergics, antihistamines, amphetamines Sympathomimetics (ephedrine, amphetamines), Solvent abuse Theophylline, Thyroid hormone Hypothermia (COOLS) Carbon monoxide, Clonidine Opiates Oral hypoglycemics, Insulin Liquor Sedative-hypnotics Hyperthermia (NASA) Nicotine, Neuroleptic malignant syndrome Antihistamines Salicylates, Sympathomimetics Anticholinergics, Antidepressants Hypotension (CRASH) Clonidine, CCBs (and B-blockers) Reserpine or other antihypertensives Antidepressants, Aminophylline, Alcohol Sedative-hypnotics Heroin or other opiates Hypertension (CT SCAN) Cocaine Thyroid supplements Sympathomimetics Caffeine Anticholinergics, Amphetamines Nicotine Rapid Respiration (PANT) PCP, Paraquat, Pneumonitis (chemical) ASA and other salicylates, Amphetamines Non-cardiogenic pulmonary edema Toxin-induced metabolic acidosis Slow Respirations (SLOW) Sedative-hypnoptics, Strychnine, Snakes Liquor Opiates, OPs Weed (marijuana) Other causes: Nicotine, Clonidine, Chlorinated HC Seizures? Hallucinations? CNS depressed? WITH LA COPS Withdrawals (alcohol, benzos) INH, Insulin, Inderal Tricyclics, theophylline Hypoglycemics; Hemlock, water; Haldol Lithium, Lidocaine, Lead, Lindane Anticholinergics, Antiseizure WITH LA COPS Cocaine, Camphor, CN, CO, Cholinergics Organophosphates PCP, PPA, propoxyphene Sympathomimetics, Salicylates, Strychnine Miosis (COPS) Cholinergics, Clonidine Opiates, organophosphates Phenothiazines, pilocarpine Sedative-hypnotics, SAH MydriASis (A3S) Antihistamines, Antidepressants, Atropine Sympathomimetics Diaphoretic (SOAP) Sympathomimetics Organophosphates ASA or salicylates Phencyclidine (PCP) Dry Skin Antihistamines, Anticholinergics Bullous Lesions Barbiturates and other sedativehypnotics Carbon monoxide Tricyclics (personal case series) www.acponline.org/graphics/bioterro/bullous.jpg Flushed CO (rare) Anticholinergics Boric acid CN (rare) Cyanosis Phenazopyridine Aniline dyes Nitrates Nitrites Ergotamine Dapsone Any agent hypoxia, hypotension MetHb Bitter Almonds Carrots Fruity Garlic Gasoline -Cyanide -Cicutoxin (water hemlock) -DKA, Isopropanol -OP, As, DMSO, selenium, thallium, phosphorus -Petroleum distillates Mothballs Pears Pungent aromatic Oil of wintergreen Rotten eggs -Naphthlene, camphor -Chloral hydrate -Ethchlorvynol -Methylsalicylate -Sulfur dioxide, hydrogen sulfide Toxicology Screens Urine Stat Urine vs Serum Acetaminophen level Routine Tests CBC SMA-7 Anion Gap ABGs Drug Hrs Post-Ing Pos Interv APAP 4 NAC COHgb ASA Immed* 6-12* HBO Dialysis Iron 2-4* Antidote Dig 2-4* Fab Alcohols 1/2 - 1* Antidote *Clinical Symptoms may dictate treatment, not level. A MUD PILE CAT ASA Methanol Uremia DKA Paraldehyde, Phenformin INH, Iron, Ibuprofen Lactic acidosis Ethylene Glycol A MUD PILE CAT CO, CN, Caffeine AKA Theophylline, Toluene Others Benzyl alcohol Metaldehyde Formaldehyde H2 S Decreased Anion Gap Bromide Lithium Hypermagnesemia Hypercalcemia Calculated 2(Na)+[Glu/18] + [BUN/2.8] + EtOH(mg/dL)/4.6 Osm Gap = measured - calculated Significant if >10 Really significant if >19 Increased Osmolar Gap MAD GAS Mannitol Alcohols (met, EG, Iso, eth) Dyes, Diuretics, DMSO Glycerol Acetone Sorbitol A 40 year old man collapsed at work while moving his car. He has a hx of depression. He had recently attended his mother’s funeral the day before. He was found slumped over the steering wheel of his car, lethargic and incoherent. A coworker left the patient and went to call medics. He was intubated and transferred to Regions Hospital. Examination • • • • BP 130/88, P90, R-vent, T 1012 Pupils 6mm unreactive but equal. Skin warm, red, dry Absent bowel sounds Labs were unremarkable • • ABG:pH 7.50, 32, 140 EKG - QRS 102, occasional PVC Is there a Toxidrome? A. Opioid B. Anticholinergic C. Delayed Exercise Syndrome D. Cholinergic poisoning Is there an antidote? Anticholinergic (antihistamines, cyclic antidepressants, Jimson weed) • • • • • Hot as a hare (hyperthermia) Red as a beet (flushed) Dry as a bone (dry skin, urinary retention) Blind as a bat (mydriasis) Mad as a hatter (hallucinations, delirium, myoclonic jerking) Also with anticholinergic • • • • • Mydriasis Tachycardia Hypertension Hyperthermia Seizures How do you treat it? • • • • Supportive care TCAs – Sodium Bicarb for widened QRS Benzodiazepenes for agitation, seizures Consider physostigmine for pure anticholinergic overdoses (contraindicated in TCA overdose or with dysrhythmias) Toxidromes: Case #2 A 19 year old male presents after from a party after his friends noted he was “acting funny.” He was “out of control” and not making sense, so they decided to bring him into the Emergency Room. The patient is agitated on arrival Examination • • • • BP 180/114, P120, R20, T 101 The patient is agitated and appears to be hallucinating Pupils 6mm sluggish but equal. Skin warm, red, very diaphoretic Labs were unremarkable • EKG – sinus tachycardia Toxidromes: Case #2 Is there a Toxidrome? A. Opioid B. Anticholinergic C. Sympathomimetic D. Cholinergic Sympathomimetics (cocaine, amphetamines, ephedrine) • • • • • • Mydriasis Tachycardia Hypertension Hyperthermia Seizures Diaphoresis Treatment • • Supportive care Benzodiazepines as needed Toxidromes: Case #3 A 40 y/o female is brought by medics. A family member called after a suicide note was found and the patient was found unresponsive. On medic arrival the patient was noted to be very somnolent. She was transported to Regions Hospital. Examination • • • • BP 100/65, P50, R6, T 98.6 The patient is arousable only to sternal rub. Pupils 2mm sluggish but equal. Skin cool, dry Labs were unremarkable • EKG – sinus bradycardia Toxidromes: Case #3 Is there a Toxidrome? A. Opioid B. Anticholinergic C. Sympathomimetic D. Cholinergic Is there an antidote? Narcotic (heroin, methadone, other opioids) • • • • • Miosis Bradycardia Hypotension Hypoventilation Coma/CNS depression Treatment • Naloxone Clonidine Hypotension usually more profound May require HIGH dose naloxone to see any effect Tetrahydrozaline Periodic apnea in kids Kids should be admitted if symptomatic in ED Toxidromes: Case #4 A 50 y/o male is brought in after being found in his garage. According to paramedics, there were several containers of liquids in glass jars near the patient. They also noted a large amount of emesis. He was noted to have altered mental status and some respiratory distress prior to arrival. He was intubated prior to arrival and transported to Regions Hospital. Examination • • • • • • BP 110/65, P50, R - intubated, T 98.6 The patient is obtunded, intubated Pupils 2mm sluggish but equal. There are copious secretions in the patient’s mouth and in the endotracheal tube Incontinent of both urine and stool Skin is cool, diaphretic Labs were unremarkable • EKG – sinus bradycardia Toxidromes: Case #4 Is there a Toxidrome? A. Serotonin Syndrome B. Anticholinergic C. Sympathomimetic D. Cholinergic Is there an antidote? Cholinergic (DUMBELS or SLUG BAM) Salivation Lacrimation Urination GI complaints (nausea, vomiting, diarrhea) Bradycardia, Bronchoconstriction Abdominal cramping Miosis, Muscle fasciculations Treatments: Pralidoxime (2PAM), Atropine MORE TALKINGDROMES Salicylates (ASPIRIN)Harris Altered MS (lethargy to coma) Sweating Pulmonary edema Increased Ringing ventilation, temp, heart rate in ears Irritable Nausea and vomiting Serotonin Syndrome VS: T, HR, BP (unstable) MS: Agitation, coma Pupils: Mydriasis Skin: Diaphoresis Other: LE rigidity, myoclonus, hyperreflexia, seizure MAOI and other drug Idiosyncratic reaction Alteration in MS Autonomic instability Neuromuscular abnormality Treatment is supportive Symptoms resolve 24-72 hrs Lactic acidosis, rhabdo, hyperthermia Specific drugs SSRIs (i.e., Prozac) Dextromethorphan Demerol Ecstasy (MDMA): hallucinogenic amphetamine Cocaine L-tryptophan Acetaminophen Toxicity - Metabolism Metabolized in the liver primarily to nontoxic glucoronide and sulfide conjugates, however small amount is converted via cytochrome P450 to potentially toxic NAPQI Normally, NAPQI is conjugated with glutathione to nontoxic metabolites In significant overdose, glutathione stores are depleted NAPQI destroys hepatocytes leading to liver failure Acetaminophen Toxicity – Clinical Presentation First few hours 18 – 24 hours Non-specific signs and symptoms Nausea, vomiting, pallor, diaphoresis Even severely poisoned patients may remain symptomatic Asymptomatic phase No laboratory evidence of hepatotoxicity After 24 – 36 hours Aminotransferases begin to rise Signs and symptoms of hepatotoxicity 72 – 96 hours N, V, RUQ pain, hepatic enlargement, jaundice Peak hepatotoxicity Although massive liver necrosis can occur, recovery is the rule and usually complete if the patient survives Acetaminophen Level - - Levels are important - Check levels in all cases of suspected overdose or polydrug overdose - Antidotal therapy is most effective if started within 8 – 10 hours - Signs and symptoms are delayed for 18 – 36 hours Rumack-Matthew nomogram - Used to predict the severity of toicity and need for antidotal therapy - 4 hour level - Levels above the line require antidotal therapy Acetaminophen Toxicity - Antidote N-acetylcysteine (NAC) Glutathione precursor and glutathione substitute Increases substrate supply for the non-toxic sulfate conjugation pathway Available as oral and IV form Extremely effective if initiated within 8 hours Standard of care to treat patients up to 24 hours ABCs - Antidotes Decontaminate - Special Treatments? Toxidromes? Investigate - look closely REASSESS, MONITOR, SUPPORT
