Download Toxicology

Toxicology
Thomas Perera MD
Toxicology
 What
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is it?
Poisonings
Overdoses
Side affects
Exaggerated affects
Exposures
General
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Poisoning-The generally predictable and dose
dependent effects of exposure to a potentially lethal
substance.
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Almost anything is toxic if one uses enough
Seen most in adults alcohol-crack-opioid
Kids will put anything in their mouth
Toxicology is not just ingestion but also
inhaled, splashed, irradiated
General
• 2 million poisonings reported to tox centers per year
– about 7% of ER visits
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92% at home
94%single agent
peak between 5pm-9pm
62% kids
88% accidental
7% with clear suicidal intent
– 23% kids 13-17yrs
• with adults fewer ingestion's but 82% intentional and accounting
for 94% of deaths (total rate 1 in 300 attempts)
General
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This is on of the areas where one can make a great impact
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Need for immediate therapy
Acute action can save life
Few areas like this
Potential saves(narcan, oxygen)
Where to start
 What
we don’t have.
• Exact information
• patient-doctor bond
• Time
– extensive tests
– gathering all necessary info
• Cures for all toxins
Where to start
 What
we do have
• Some history
– EMS, Family, ID bracelets, patient’s account
• Physical exam
• Some quick tests
• Some cures?
Where to start
 A-airway
 B-breathing
 C-circulation
• Now what?
Toxidromes
a common group of signs and symptoms
which are associated with an overdose
Toxidromes
 Opioid (5% of calls to poison control centers)
• Depressed respiration -(Number and depth)
– Due to loss of co2 drive stimulate remind to breath
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Small-pinpoint pupils (parasympathetic)
Decreased level of consciousness
Hypotension
Decreased bowel sounds
Urinary retention
Toxidromes
 Opioid
• Also can have
– pulmonary edema
– hypoglycemia(not eating)
– flushed skin
– urticaria
 Examples:Herion,
lomotil, etc.
Demerol, Codeine,
Toxidromes
 Sympathomimetics -fight or flight
– stimulants- a drug that effects one or more
organ system to produce an excitatory
arousing effect, increased physical activity
and vivaciousness and a promotes a sense of
well being.
Toxidromes
 Sympathomimetics -fight or flight
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dilated pupils
sweating
Increased HR, RR, BP
dilated bronchi (epi does this)
decreased bowel sounds, urine
increased mental activity, reflexes, psychosis
Toxidromes
 Sympathomimetics
• Also can
– pulmonary edema
– seizures
– focal neurologic changes
Cocaine
 Not
thought to be drug of abuse until 1970
• purer forms
• increased popularity
 Many forms same effects but onset and duration
vary
• cocaine burns when lit but when changed to
free base-crack
• onset related to rush
Cocaine
Rout
Inhaled7sec
IV
nasal
oral
onset
peak
1-5min
15sec
3min
10min
duration
20min
3-5min
15min
60min
20-30min
45-90min
60min
Cocaine
 Chest
pain
 ?antidote
• dog study in 80’s
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increased vitals
seizures
increased agitation
increased temp
death
Toxidromes
 Anticholinergic(atropine,scopolamine,Benadryl,cogentin,
flexeril,nightshade, jimson weed)
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warm
dry
psychotic
flushed
decreased bowel sounds
urinary retention
dilated pupils
Toxidromes
 Anticholinergic
• ?cure -physostigmine
Examples:
• Atropine,Scopolamine
• Benadryl, Cogentin
• Flexeril
• nightshade, jimson weed
cyclic antidepressants
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uses in depression, chronic pain, enuresis, insomnia
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manifestation
• As anticholinergic
• CNS depression
• Cardiac tox
– Disrhythmia: Many types
cyclic antidepressants
 treatment
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No physostigmine--seizures
Cardiac -Na channel block-type 1a- no procaine
agitation no haldol
seizure-even valium not great
Toxidromes
 Cholinergic--pesticides,
serin gas
• S alivation
• L acrimation
• U rination
• D efication
• G astric irritation
• E mesis
Also-small pupils, confusion, pulmonary edema.
bardycardia, seizures
Toxidromes
Cholinergic
• Cure -- atropine
Toxidromes
 Sedative
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Hypnotic
normal pupils (unless hypoxic)
decreased respiration
flaccid tone
hypotension
hypothermia
Skin-vesicles on errythematous base
Toxidromes
 Sedative
Hypnotic
• Cure - supportive measures
– intubate early
Toxidromes
 Hallucinogens
• behavioral changes
• altered perception
• tachy,hypertesive,large pupils, tremor,
piloerrection, hyperthermia
Toxidromes
 Hallucinogens
• PCP
– Like cocaine but with hallucinations
• nystagmus
– Complications
• Rhabdo, hypertension, seizures, hypoglycemia,
bronchospasm
Cocktail-Coma/AMS
 Oxygen-always
• Tox patients usually younger low likelihood of COPD
so do not worry about decreased CO2 drive
• Opioids-stimulate respiration- sometimes only need to
remind to breath even if apnic.
• watch out for vomiting in to mask
Cocktail-Coma/AMS
 Glucose
• its use based on the number of times AMS caused by
hypoglycemia(can do anything)
• Also hypoglycemia can accompany toxic exposure
– Hyperactivity, seizure etc.-uses up glucose stores
– Drug users not well nourished
– Alcoholics with bad livers
– Children also with decreased stores
Cocktail-Coma/AMS
 Glucose
• Potential risk of worsening stroke
– risk benefit
– presentation
– different disease
Cocktail-Coma/AMS
 Thiamin
• given on theoretical ground that glucose load
can precipitate Wernickes
• No down side
• Side note
Cocktail-Coma/AMS
 Narcan-Naloxone
HCL
• competitive antagonist
• IV, IM, ET, SQ, SL, PO
• good for many opioids but not all
– methadone, pentazosine, propoxyphene, Demerol
– initial dose 2mg if response or high suspicion more
Cocktail-Coma/AMS
 Narcan
• very safe(large doses for body packers)
• short lived
• downside
– withdrawal-vomiting, agitation, abdominal pain,
sweating, diarrhea, piloerrection
– unmasking co-ingestion
Cocktail-Coma/AMS
 no
physostigmine
 no ipecac
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delayed charcoal
ruptured esophagus
Mallory-Wise
aspiration
Treating complications
 Hypotension
• Fluid, fluid, fluid
• pressers not dopamine-levaphed
 Hyperthermia
• cooling
• decrease agitation
Treating complications
 Agitation
• benzodiazapine
• hypoxia, glucose, etc.
Treating complications
 seizures
• Benzodiazipine
• not dilantin-interacts with to many drugs
wrong mechanism
• hx important -INH-pyridoxine
Treating complications
 Arrhythmia-protocol
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mostly sinus tach
deal with hypoxia, agitation, etc.
tricyclic-bicarb--not procaine
dig-avoid Ca-dilantin
B Blocker, Ca channel Blocker-glucagon
Other stuff
Protect
 Hx
yourself
what, how, when
 consider associated trauma
 Intubate early