Download RefresherMedical-7PoisoningsOverdose

Poisonings/
Overdose
1
Introduction
Poisoning- Exposure to substance that is toxic in any amount
• approx 775 fatalities annually
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0.03% of total exposures
•
ages 20 - 49 years = 56%
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>6 years = 2.1%
•Exposures by Age:
• < 6 years old
• < 3 years old
52.7%
39.6%
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Management Location
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Managed on site
Treated, released at ER
Admitted to critical care
Refused referral
75.2%
12.3%
2.7%
2.0%
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Therapy
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No therapy
11.9%
Observation only
12.7%
Decontamination only 59.6%
Activated charcoal
6.8%
Ipecac
1.2%
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Most Common Substances
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Cleaning substances
Analgesics
Cosmetics
Plants
Foreign bodies
Cough, cold
Bites, stings
10.2%
9.6%
9.4%
5.5%
4.6%
4.5%
4.1%
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Most Common Substances
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Insecticides, pesticides, rodenticides
Sedative, hypnotics, antipsychotics
Antidepressants
Hydrocarbons
Alcohols
3.9%
3.2%
3.0%
3.0%
2.5%
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Largest Number of Deaths
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Analgesics
Antidepressants
Stimulants, street drugs
Cardiovascular medication
Sedatives, hypnotics
Alcohols
56
264
152
118
118
89
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Indicators
• Sudden onset of CNS signs:
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Seizures
Coma
Decreased LOC
Bizarre behavior
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Indicators
• Sudden onset of:
• Abdominal pain
• Nausea
• Vomiting
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Indicators
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Sudden onset of unexplained illness
Bizarre, incomplete, evasive history
Trauma
(>50% of adult trauma alcohol, drug-related)
Pediatric patient with arrhythmias
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History
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What?
How much?
How long?
Multiple substances?
Treatment attempted? How? Whose
advice?
• Psychiatric history?
• History of suicide?
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General Management
• Support ABC’s
• Secure airway, intubate as needed
• Ensure adequate oxygenation, ventilation
• Maintain adequate circulation
• Monitor ECG
• Obtain vascular access
• Manage hypotension initially with volume
• Use vasopressors cautiously
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General Management
• Keep patient calm
• Maintain normal body temperature
• Evaluate nature/toxicity of poison
• Check container, package insert, poison center
information
• Treat the patient, not the poison
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General Management
• Rule out
• Trauma
• Neurological disease
• Metabolic disease
• Base general management on route of poison
entry
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Poison Entry
• Ingestion
• Inhalation
• Prevent absorption from GI
tract
• Remove from exposure;
Support oxygenation,
ventilation
• Absorption
• Remove from skin surface
• Injection
• Slow movement from
injection site throughout
body
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Ingested Poison Management
Ipecac
• RARELY used anymore
• If used, has to have been initiated within
few minutes after ingestion
• Vomiting in 20-30 minutes
• Only removes about 32% of contaminate
• Many contraindications
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Ingested Poison Management
Ipecac
• Dose
• 15 cc if 12 months to 12 years old
• 30 cc if >12 years old
• Follow with 2-3 glasses of water
• Keep patient ambulatory if possible
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Ingested Poison Management
Ipecac
• If no vomiting after 20 minutes, repeat
• When emesis occurs, keep head down
• Collect, save vomitus for analysis
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Ingested Poison Management
Ipecac
• Contraindications
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Comatose or no gag reflex
Seizing or has seized
Caustic (acid or alkali) ingestion
Low viscosity hydrocarbon ingestion
Late term pregnancy
Severe hypertension, cardiovascular insufficiency, possible AMI
Ingestion of:
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Strychnine
Phenothiazines (Thorazine, Stellazine, Compazine)
Tricyclic antidepressants
Iodides
Silver Nitrate
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Ingested Poison Management
Lavage
• Commonly used in ED’s
• Removes about 31% of substance
• Helps get activated charcoal in patient,
especially if patient is unconscious
• Not helpful for sustained release tablets
• Will not remove large tablets
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Ingested Poison Management
Activated Charcoal
• Adsorbs compounds, prevents movement
from GI tract
• Very effective at adsorbing substances
• Binds about 62% of toxin
• Dose
• 5 - 10X estimated weight of ingested chemical
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Ingested Poison Management
Activated Charcoal
• Inactivates Ipecac
• Do not give until vomiting stops
• Do not give with
• Cyanide
• Methanol
• Tylenol (+)
• Containers must be kept airtight
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Inhaled Poison Management
Objective: Move to fresh air; optimize
ventilation and protect yourself and other
personnel from exposure
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Absorbed Poison Management
Objective: Remove poison from skin
Liquid: Wash with copious amounts of
water
Powder: Brush off as much as possible,
then wash with copious amounts of water
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Absorbed Poison Management
Dilute / Irrigate / Wash
• Use soap, shampoo for hydrocarbons
• No need for chemical neutralization - heat
produced by reaction could be harmful
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Eye Irrigation
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Wash for 15 minutes
Use only water or balanced salt solutions
Remove contact lenses
Wash from medial to lateral
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Drug Abuse
•Definition: Self administration of drug or
drugs in manner not in accord with
accepted medical or social patterns
•Psychological Dependency (Habituation)
•Drug necessary to maintain user’s sense of wellbeing
•Physical Dependency
•Physical symptoms if intake reduced
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Drug Abuse
• Compulsive Drug Use
• Preoccupation with obtaining drug
• Rituals of preparing, using drug as important as drug effects
• Tolerance
• Increasing doses needed to obtain drug effect
• Addiction
• Includes
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Psychological dependence
Physical dependence
Compulsive use
Tolerance
• Plus, complete absorption with obtaining, using drug to exclusion
of all else
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Drug Abuse
• Suspect drug-related problem in patients with:
• Altered LOC
• Bizarre behavior
• Seizures
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Ask EVERY patient about recreational drugs.
Be non-judgmental.
Keep drug box/cabinet secured.
Use discretion.
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Narcotics
• Opium
• Opium derivatives
• Synthetic opium substitutes
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Narcotics
• Examples
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Opium
Morphine
Heroin
Codeine
Dilaudid
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Oxycodone (Percodan)
Meperidine (Demerol)
Propoxyphene (Darvon)
Talwin
Fentanyl
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Narcotics
• Effects
• Analgesia
• CNS depression
• Euphoria
• Drowsiness
• Apathy
• Antidiarrheal action
• Antitussitive action
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Narcotics
• Overdose
• Mild to
Moderate
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Lethargy
Pinpoint pupils
Bradycardia
Hypotension
Decreased bowel
sounds
• Flaccid muscles
• Severe
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Respiratory depression
Coma
Aspiration
Seizures with certain
compounds
(meperidine,
propoxyphene,
tramadol)
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Narcotics
• Overdose
• Management
• Support oxygenation/ventilation
• Vascular access
• D50W 50cc
• Narcan 0.4 to 2.0 mg
• Improve respirations
• Do NOT awaken completely
• Restrain before giving
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Narcotics
• Associated Dangers
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Skin abscesses
Phlebitis
Sepsis
Hepatitis
HIV
Endocarditis
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Adulterant toxicity
“Cotton fever”
Malnutrition
Tetanus
Malaria
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Narcotics
• Withdrawal:
• Lasts 7 to 10 days
NOT life threatening
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Insomnia
Restlessness
Irritability
Anorexia
Tremors
Back, extremity pain
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Watery eyes
Yawning
Rhinorrhea
Sneezing
Diarrhea
Diaphoresis
Resembles Severe Influenza
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Sedative-Hypnotics
• Categories
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Barbiturates
Benzodiazepine
Barbiturate-like non-barbiturates
Chloral hydrate
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Sedative-Hypnotics
• Mechanism of Action
• Most overdoses of sedative-hypnotics are from
benzodiazepines, barbiturates
• Both enhance effects of gamma-aminobutyric
acid (GABA)
• GABA enhancement results in down-regulation
of CNS activity
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Sedative-Hypnotics
• Use more then a week leads to tolerance to
effects on sleep patterns
• Withdrawal after long term results in
“rebound” increase in frequency of
occurrence, duration of REM sleep.
• In high doses, sedative-hypnotics depress
CNS to point of Stage III or general
anesthesia
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Sedative-Hypnotics
• Tolerance
• Happens with all sedative-hypnotics
• Appears very quickly even during shortterm use.
• Discontinuation will bring receptor response
back to normal after drug has been
metabolized
• Withdrawal symptoms may take up to a
week to see in some patients
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Chloral hydrate
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“Micky Finn” when mixed with alcohol
Rapidly absorbed, acts quickly
Drowsiness, sleep
Alcohol, chloral hydrate compete for
metabolism by same enzyme
• Prolonged action for both when mixed
• Not commonly abused
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Barbiturates
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Introduced in 1903
Replaced older sedative-hypnotics
Quickly became major health problem
In 1950’s-60’s barbiturates were implicated
in overdoses; were responsible for majority
of drug-related suicides
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Barbiturates
• Short-acting
• Amytal
• Pentathiol
• Intermediate-acting
• Nembutal
• Seconal
• Tuinal
• Long-acting
• Phenobarbital
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Barbiturates
• Initial overdose presentation
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Slurred speech
Ataxia
Lethargy
Nystagmus
Headache
Confusion
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Barbiturates
• As overdose progresses
• Depth of coma increases
• Patient anesthetized with loss of neurologic
function
• EEG may mimic brain death
• Respiratory depression occurs
• Peripheral vasodilation occurs
• Hypotension, shock
• Hypothermia
• Blisters (bullae) form on skin
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Barbiturates
• Early deaths
• Respiratory arrest
• Cardiovascular collapse
• Delayed deaths
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Acute renal failure
Pneumonia
Pulmonary edema
Cerebral edema
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Barbiturates
• Overdose management
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Secure airway
Support oxygenation/ventilation
IV with LR or NS
Prevent heat loss secondary to vasodilation
Bicarbonate to alkalinize urine (long-acting
only)
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Barbiturates
• Withdrawal signs/symptoms
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Apprehensiveness
Anxiety
Tremulousness
Diarrhea
Nausea
Vomiting
Seizures
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Barbiturate-like, non-barbiturates
• Examples
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Doriden (glutethimide)
Quaalude (methaqualone)
Placidyl (ethchlorvynol)
Noludar
Overdose produces sudden, prolonged apnea
Highly addictive
Withdrawal resembles barbiturate withdrawal
Only Placidyl, Doriden remain available in U.S.
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Placidyl (ethchlorvynol)
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“Pickles”, “jelly beans”, “Mr. Green Jeans”
Produces vinyl-like odor on breath
Concentrates in CNS, slow hepatic metabolism
Half-life >100 hrs
Prolonged deep coma (100 to 300 hrs),
hypothermia, respiratory depression, hypotension,
bradycardia
• EEG is flatline
• Keep patient on life support for a few days; they
wake up, are ok
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Doriden (gluthethimide)
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Abused in combination with codeine
“sets”, “hits”, “loads”, “fours and doors”
Prolonged coma (average 48 hours)
Hypotension, shock common
Anticholinergic signs: dilated pupils, tachycardia,
dry mouth, ileus, urinary retention, hyperthermia
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Benzodiazepines
• Developed due to overdoses, deaths related
to barbiturates, barbiturate-like nonbarbiturates
• Relatively few deaths
• In 1993, prescription rate for barbiturates
dropped to one-sixth that of benzos
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Benzodiazepines
• Examples
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Valium (diazepam)
Ativan (lorazepam)
Versed (midazolam)
Librium (chlorodiazepoxide)
Tranxene (chlorazepate dipotassium)
Dalmane (flurazepam)
Halcion (triaxolam)
Restoril (temazepam)
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Benzodiazepines
• Adverse Effects
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Weakness
Headache
Blurred vision
Vertigo
Nausea
Diarrhea
Chest pain
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Benzodiazepines
• Overdoses
• Relatively safe taken by themselves, even in
overdose
• Can be lethal with other CNS depressants especially
alcohol
• Look like other CNS depressant overdoses
• Antidote is Romazicon ( flumazenil )
• Only recommended in known, controlled
situations
• Can lead to seizures that cannot be controlled
• Produce withdrawal syndrome similar to
barbiturate withdrawal
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Benzodiazepine-like, non-benzos
• BuSpar (buspirone)
• Used for generalized anxiety disorder
• Less sedating than diazepam
• Less potentiation by other CNS depressants
• Ambien, Stilnox (zolpidem)
• Used for short-term insomnia treatment
• Toxic effects similar to benzos
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Neuroleptics
• Antipsychotics, major tranquilizers
• Used in treatment of schizophrenia, other
psychoses
• Examples
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Haldol
Mellaril
Thorazine
Stellazine
Compazine
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Neuroleptics
• Extrapyramidal muscle contractions
(dystonias)
• Bizarre, acute, involuntary movements,
spasms of skeletal muscles
• Reversible with Benadryl
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Neuroleptics
• Acute Overdose Presentation
• CNS depression
• Hypotension
• Anticholinergic symptoms: flushing, dry
mouth, hyperthermia, tachycardia, urinary
retention
• Ventricular arrhythmias, including Torsades
• Seizures
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Neuroleptics
• Acute Overdose Management
• ABCs
• Fluid, vasopressors for hypotension
• Lidocaine, phenytoin for ventricular
arrhythmia
• Magnesium, isoproterenol for Torsades
• Benzodiazepines, phenobarbital for seizures
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Neuroleptics
• Neuroleptic malignant syndrome
• Life-threatening reaction
• Signs, symptoms
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Hyperthermia
Muscular rigidity
Altered LOC
Tachycardia, hypotension
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Neuroleptics
• Neuroleptic malignant syndrome
• Management
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ABCs
Oxygen
Assist ventilation, as needed
Benzodiazepines
Rapid cooling
Volume for hypotension
62
Stimulants
• Examples
• Cocaine
• Amphetamines
• Benzedrine (bennies)
• Dexedrine (dexies, copilots)
• Methamphetamine (ice, black beauties)
• Ephedrine
• Caffeine
• Ritalin
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Stimulants
• Produce
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euphoria
hyperactivity
alertness
sense of enhanced energy
anorexia
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Stimulants
• Overdose signs/symptoms
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Euphoria, restlessness, agitation, anxiety
Paranoia, irritability, delirium, psychosis
Muscle tremors, rigidity
Seizures, coma
Nausea, vomiting, chills, sweating, headache
Elevated body temperature
Tachycardia, hypertension
Ventricular arrhythmias
65
Stimulants
• Overdose complications
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Hyperthermia, heat stroke
Hypertensive crisis
CVA
Acute MI
Intestinal infarctions
Rhabdomyolysis
Acute renal failure
66
Stimulants
• Chronic effects
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Weight loss
Cardiomyopathy
Paranoia
Psychosis
Stereotypic behavior: picking at skin
(“cocaine bugs”)
67
Stimulants
• Overdose management
• Oxygen, monitor, IV
• Activated charcoal for decontamination in
first hour
• Valium for sedation
• Hypertension control
• Nipride
• Phentolamine
• Avoid beta-blockers, including labetolol (Why?)
• Body temperature reduction
68
Stimulants
• Withdrawal
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Drowsiness
Profound depression (“cocaine blues”)
Increased appetite
Abdominal cramps, diarrhea, nausea
Headache
69
Hallucinogens
• Examples
• Amphetamine-like
hallucinogens
• Indole hallucinogens
• Peyote
• LSD (acid)
• Mescaline
• Morning-glory
seeds
• DOM
• Psilocybin
• MDA
• DMT
• MDMA (ecstasy)
70
Hallucinogens
• Produce altered/enhanced sensation
• Effects highly variable depending on
patient
• Increased dose does not intensify effect
• Toxic overdose virtually impossible
71
Hallucinogens
• Some patients may experience “bad trips”
• Depends on surroundings, emotional state
• Signs and symptoms
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Paranoia, fearfulness, combativeness
Anxiety, excitement
Nausea, vomiting
Tachycardia, tachypnea
Tearfulness
Bizarre Reasoning
72
Hallucinogens
• Moderate Intoxication
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Tachycardia
Mydriasis
Diaphoresis
Short attention span
Tremor
Hypertension
Hyperreflexia
Fever
73
Hallucinogens
• Life-threatening toxicity (rare)
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Seizures
Severe hyperthermia
Hypertension, arrhythmias
Obtunded, agitated, or thrashing about
Diaphoretic, hyperreflexic
Untreated hyperthermia can lead to hypotension,
coagulopathy, rhabdomyolysis and multiple organ
failure
74
Hallucinogens
• Management of “bad trip”
• Rule out other causes of hallucinations
• Hypoglycemia
• Alcohol, drug withdrawal
• Infection
• Quiet, supportive environment
• Benzodiazepines, haldol for agitation,
anxiety
75
Phencyclidine (PCP)
• Street names
• Angel dust
• Peace Pill
• Hog
• Krystal
• Animal tranquilizer
• Used as veterinary anesthetic
76
Phencyclidine (PCP)
• Actions
• Dissociative anesthesia
• Generalized loss of pain perception
• Little or no depression of airway reflexes or
ventilation
• CNS-stimulant, anticholinergic, opiate, and
alpha-adrenergic effects
77
Phencyclidine (PCP)
• Low Doses
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Lethargy, euphoria, hallucinations
Slurred speech
Blank stare
Insensitivity to pain
Midposition to dilated pupils
Vertical and horizontal nystagmus
Occasionally bizarre or violent
behavior
78
Phencyclidine (PCP)
• High Doses
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Diaphoresis
Salivation
Hypertension
Tachycardia
Hyperthermia
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Localized dystonic reactions
Wide-eyed coma
Rigidity
Seizures
79
Phencyclidine (PCP)
• Treatment
• Maintain airway
• Assist ventilations, as needed
• Treat coma, seizures, hypertension,
hypothermia as needed
• Quiet environment
• Sedation if needed to control agitation
• Haldol
• Benzodiazepines
80
Inhalants
• Examples
• Hydrocarbons (solvents, paints, aerosols)
• Gases (freon, halon fire extinguishing agent)
• Metallic paints (“huffing”)
81
Inhalants
• Effects
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Dysrhythmias including VF
CNS depression
Seizures
Respiratory irritation
Epinephrine may increase risk of dysrhythmias
• Treatment
• Oxygen
• Treat symptomatically
82
“Date rape” drugs
• Flunitrazepam (Rhohypnol)
• Gamma hydroxybutyrate
83
Flunitrazepam (Rhohypnol)
• Street names
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Rophies
Roofies
R2
Roofenol
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Roche
Roachies
La rocha
Rope
Rib
84
Flunitrazepam (Rhohypnol)
• Benzodiazepine
• Similar to Valium but 10x more potent
• Produced, sold legally in Europe, South
America
• Uses
• Short-term treatment of insomnia
• Sedative hypnotic
• Preanesthetic medication
85
Flunitrazepam (Rhohypnol)
• Effects
• Disinhibition and amnesia
• Onset within 30 minutes, peak within 2
hours, may persist 8 hours or more
• Frequently abused with alcohol or other
drugs
• Enhances high produced by heroin
86
Flunitrazepam (Rhohypnol)
• Adverse Effects
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Drowsiness
Dizziness
Confusion
Decreased BP
Memory impairment
GI disturbances
Excitability, aggressive behavior
87
Flunitrazepam (Rhohypnol)
• Management of overdose
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Lethal overdose very unlikely
Oxygenate, ventilate
Intubate if necessary to control airway
Vascular access
ECG
Fluid for hypotension
Dextrostick (rule out hypoglycemia)
Treat trauma resulting from assault
88
Flunitrazepam (Rhohypnol)
• Withdrawal
• Headache
• Anxiety, tension
• Numbness, tingling of
extremities
• Restlessness,
confusion
• Loss of identity
• Hallucinations
• Delirium
• Seizures (up to a
week after cessation)
• Shock
• Cardiovascular
collapse
89
Flunitrazepam (Rhohypnol)
• Management of withdrawal
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Oxygen/ventilation
Intubate if necessary
EKG
Vascular access
Fluid for hypotension
Dextrostick
Diazepam for seizures
90
Gamma hydroxybutyrate
• Street names
• Cherry meth
• Liquid X
• Liquid ecstacy
• Originally developed as anesthetic
• Banned in 1991 because of side effects
• Promoted as aphrodisiac
91
Gamma hydroxybutyrate
• Effects
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Odorless, nearly tasteless
Tremors
Seizures
Death
92
QUESTIONS
?
93