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Intoxicated patient (s)
Yoan Lamarche
Yoan
Lamarche
You are on call in the ICU at night as an ICU
staff at Big Academic Serious and Sleepless
General Hospital (BASS General) on a Friday
when you have a phone call from the
emergency physician. They are, of course,
very busy with multiple patients, but they
have just received 6 ambulances from a
nursing home. At first, they were very curious
about what were the events, but one of the
patients was able to provide a history.
Yoan
Lamarche
They were six young adults (all 18yo) that decided to
party for the week-end. After a couple of beers, they
started challenging each other with doing something
crazy. They ended up with a plan. The plan was to
break in the pharmacy of a nursing home, steal many
boxes of medication, than to go in the nursing home
garage and each use different ones. They also tried
to find more alcohol in the nursing home (to be able
to swallow the pills), but they did not all find what they
were looking for (2 of the guys found different bottles
in the garage and used them).
Yoan
Lamarche
The six patients arrive at the same time
in emerg. They put them in the brand
new 6 bed trauma bay. The
emergency physician asks you to
coordinate the care of those 6
patients as he takes care of the rest
of the emergency. You dispatch 1 ICU
fellow per patient. (Naisan, Gordon,
Scot, Steve, Dave, and Yoan)
Yoan
Lamarche
Patient 1, 2, 3 and 4 are unconscious. Patient 5 is in
respiratory distress. Patient 6 seems drunk. He gives
the history, he also admits to be schizophrenic,
chronically taking Orap. As your are listening to what
patient 6 is saying, you notice that patient 5 has
copious amounts of secretions from his mouth and is
struggling to breathe. Patient 6 tells you it started
after he sprayed him with something that looked like
a fertilizer or something else whit a dead bug
illustrated on the can, in the garage of the nursing
home.
Yoan
Lamarche
You look closely at patient 5 and
notice he is wide awake, anxious
and in distress. He is wheezing
and has bronchorrhea. His vitals
are HR 55, RR 40, BP 150/110,
sat 82%, he is now starting to
vomit. Steve is taking care of that
patient 5.
Yoan
Lamarche
As a coordinator, you ask that all unconscious
patients receive O2, IV Dextrose + access,
naloxone, and thiamine. You also order on all
6 patients a drug screen, CBC, lytes,
osmolality, ABG, creatinine, BUN, glycemia,
Abdominal flat plates and ECG. You also
order 10 L of activated Charcoal, large bore
OG tubes and 30 L of Golytely, to make sure
your fellows have everything they need.
Yoan
Lamarche
You get the six ECGs done first. They
give them to you as follow (next page).
Yoan
Lamarche
Patient 1 (Dave’s patient)
is confused, shivering, his skin is
flushed, he is diaphoretic, had
diarrhea on his way in and has
myoclonus, he is tachycardic and
febrile.
You also get more info as you go. Different
drugs were found on the scene: Venlafaxine,
Sumatriptan, Acetaminophen, codeine,
Amlodipine, Nortriptyline, Ativan, 1 bottle of
scotch
Yoan
Lamarche
1-Identify the toxidromes in all the patients and
what patient took what drug and the
differential diagnosis (All)
Dave’s patient
Yoan
Lamarche
Serotonergic toxidrome: venlafaxine, sumatriptan
and nortriptyline all can contribute. Lack of
anticholinergic (diarrhea, diaphoresis) suggest
nortriptyline not a significant contributor. If was
just massive venlafaxine od would likely get more
QRS widening, QT prolongation, RBBB as can
have similar Na+, K+ channel blocking effects as
TCA. Peak plasma is 6-7 hours so may still get
worse….can Sz up to 18 hours.
Yoan
Lamarche
Yoan
Lamarche
Drug interactions:
1) Excess of precursors of serotonin or its agonists (Buspirone, ldopa, Li, LSD, L-tryptophan, trazodone, dextromethorphan,
tramadol)
2) Inc release of serotonin (Amphetamines, cocaine, MDMA,
fenfluramine, reserpine)
3) Reduced uptake of serotonin (SSRI, TCA, trazodone, venlafaxine,
meperidine, linezolid, valproic acid)
4) Slowing down of serotonin metabolism (MAOI, selegiline)
DDx of cause or hyperthermia and confusion: SS, NMS, MH,
Hyperthyroid, Exertional Hyperthermia, Adrenergics,
Anticholinergics, Salicylates, 2,4 DNP (insecticide), Lithium,
sepsis, meningitis, encephalitis.
Yoan
Lamarche
Patient 2 (Yoan’s patient)
is comatose, has pinpoint pupils, is
breathing at 5 per minutes, has no
bowel sounds. He responds slowly
to naloxone. The patient’s
acetaminophen level is 350umol/l.
Patient 3 (Gordon)
is unstable, his HR is 25, he is very
hypotensive (65/25), he was intubated
on his way in. He also has received 3
mg of atropine on the way in and
remains very bradycardic.
Patient 4 (Naisan)
is unconscious and has got normal vital signs.
He is mildly bradypneic, has normal pupils.
He did not respond to naloxone. He has got
dry skin, no bowell sounds, his pupils are
6mm bilaterally.
Patient 5 (Steve)
remains very unstable, bradycardic
despite atropine (now 10 mg
given). There his pupils are still
in myosis.
Patient 6 (Scot)
continues to talk profusely. Scot is disappointed as
all the other patients seem a lot more active than
his, while waiting for the labs, he decides to stop
the patient’s non-stop talking by examining the
patients mouth with a wood lamp, which shows
some fluorescent staining.
Describe the different classic
toxidromes, the classes of
medications that lead to them
and the initial management
(Yoan)
Yoan
Lamarche
Yoan
Lamarche
Yoan
Lamarche
Yoan
Lamarche
2. Describe the general initial
management to the intox patient
after the coma cocktail and the
physical exam: Indications for
ipecacs, gastric lavage,
activated charcoal (single vs
multiple), Whole bowel irrigation,
(Dave)
Yoan
Lamarche
• None of these modalities has been shown to
improve clinical outcome (Rosen) except maybe
Lavage (if given within 1 hr) and MAC with yellow
oleander in asia (Hoffman)
• IPECACS= probably never. If want to cause
emisis….MAY….be indicated in small ingestions
that were immediately witnessed but should use
dishwashing soap (30ml)
Yoan
Lamarche
Gastric Lavage Indications:
Indications:
Life-threatening overdoses when a drug or toxin is still expected
to be in the stomach. Almost always need to begin within 1 hour
of ingestion. Only in life threatening od and specifically in ods
that have no antidotes or don’t bind AC.
Contraindications:
Caustic ingestions, Sharp object, drug packet ingestion (packers
and stuffers), hemorrhagic diathesis, prior significant emesis,
nontoxic ingestions, inability to protect airway
Adverse effects:
ETI, aspiration pneumonitis, Emesis, GI bleed + perforation
Yoan
Lamarche
SINGLE DOSE CHARCOAL
• Should be given for most ingestions. If aspirated can
cause SEVERE pneumonitis so not given in px with
dec loc or impending dec loc. There is debate to
whether place a ng and give that way if person
unable to drink b/c of mild dec loc or confusion. I
feel that it is always safer to place ETT then NG and
give charcoal and concerned.
• Not absorbed by AC= Heavy Metals, iron, Ions(Li),
Hydrocarbons (chloral hydrate), alcohols (b/c absorb
so fast), acids, alkali.
Yoan
Lamarche
MULTIDOSE CHARCOAL
• Quite effective for theophylline and perhaps
Phenobarbital poisoning. Also tricyclic
antidepressant, asa, or second dose for any on that
took big dose of something bad. Also can try in:
Amitriptyline, atrazine, carbamazepine, chlorpropamide,
cyclosporine, dapsone, desmethyldiaqepam,
dextropropoxyphene, diazepam, digitoxin, digoxin, doxepin,
glutethimide, imipramine, meprobamate, methotrexate, nadolol,
nortriptyline, Phenobarbital, phenylbutazone, phenytoin,
piroxicam, prophyrins, proscillardin,quinine, salicylates, sotalol,
theophylline.
WHOLE BOWEL IRRIGATION
• Give golytely or Colyte orally or by NG tube at a dose of 1-2
L/ hr. Most useful when radiopaque tablets or chemicals
have been ingested.
• Indications for Whole bowel irrigation:
• Sustained-release meds
• Slowly dissolving (iron, pain, concretions)
• Not absorbed by AC (litium, iron, metals)
• Drug packets (packers, stuffers)
• Not used in: quickly absorbed drugs, liquids, IV drugs,
acids, alkalis
• Dose: 2 L/hr (adults) or 0.5 L/hr (kids) for 4-6 hours or until
rectal effluent is clear
Yoan
Lamarche
Describe the initial management of
patients with serotonin syndrome, what
are the risks, what are the principles of
treatment (Dave)
Yoan
Lamarche
• ABC
• Discontinue offending agents, cooling
blankets
• Benzos (lorazepam 1-2 mg IV q30min prn)
Yoan
Lamarche
• 5HT receptor antagonists (5-HT2 is now
considered to be more significant)
– 5–HT2 blockers
• chlorprothixene (0.43 nM) > chlorpromazine
> cyproheptadine > haloperidol (36 nM)
• limited experience suggests haloperidol
ineffective
– 5–HT1 blockers
• chlorprothixene (230 nM) > haloperidol >
chlorpromazine > cyproheptadine (3200 nM)
Yoan
Lamarche
• Moderate severity
– when oral therapy suitable
• cyproheptadine 8 mg stat then 4-8 mg q4–
6h
– when oral therapy unsuitable or
cyproheptadine fails
• chlorpromazine 50 mg IMI/IVI stat then up to
50 mg orally or IMI/IVI q6h
Yoan
Lamarche
• Severe
– when symptoms are not progressive and fever < 39oC
• chlorpromazine 50–100 mg IMI/IVI stat then 50–100
mg orally or IMI/IVI q6h
– when symptoms are progressive and fever < 39oC
• chlorpromazine 100–400 mg IMI/IVI over first two
hours
– when symptoms are progressive and fever > 39oC
• barbiturate anaesthesia, muscle relaxation ± active
cooling
• chlorpromazine 100–400 mg IMI/IVI over first two
hours
Yoan
Lamarche
• Beta blockers (5-HT1 blocker)
• propranolol 1-3 mg IV q5min prn (max 0.1 mg/kg)
• ***high fever, dantrolene can be used to control the
muscular tremulousness. If temp>39 degrees the mortality
goes up! These patients should be aggressively coolend
an paralyzed and my need ventilation. Sever muscle spasm
may cause resp failure and rhabdomyolysis.
• YOU DIE FROM HYPERTHERMIA AND THIS CAUSES 1) DIC
AND MICROVASCULAR THROMBOSIS AND ALSO YOU
GET ENDOTOXIN ABSORBED FROM GUT AS
PERMABILITY INCREASES.
Yoan
Lamarche
2.
In patients with acetaminophen
overdose, how do you administer NAC,
when do you stop it, what route, is it
proven. When do you contact the liver
transplant team. (Dave)
Yoan
Lamarche
• We use exclusively IV….only recently approved in
US. Oral associated with severe nausea and
vomiting. IV can cause anaphylactoid reaction.
20 hr IV dosage: total dose 300mg/kg, given over 20 hr. load= 150mg/kg
over 60min then 50mg/kg over 4 hr then 100mg/kg over 16hr. Need to
repeat APAP at 20 hours when infusion stops. If APAP is still positive
continue at the final rate you were infusing (case reports of mortalities in
the US when this is not done as they were previously only using the long
oral regiment). Continue till APAP is negative or as long as transaminases
continue to rise and if evidence of liver failure continue NAC till
transplantation. NAC may help people after they are already in hepatic
failure. Proposed antioxidant effects. 10-36 hrs infusions reduced
fulminant hepatic failure (Harrison, 1990), 18-36 hrs improved
hemodynamics (Harrison 1991), 36-80 hrs inproved CNS sequelae,
hemodynamics (keays, 1991).
When to contact transplant.
• If want to be conservative probably give them a heads up
once there is evidence of a severe od with evidence of liver
dysfunction. Can also follow:
– King's college hospital criteria (O'grady, 1991).
Experience suggest that Px with serum pH less than
7.30 after appropriate resuscitation (especially on day
two) are unlikely to recover without transplant.
Coexistence of PT>100 (INR > 6.5), serum creatinine >
200 mmol/L, and severe hepatic encephalopathy (>III)
poor outcome.
– ***Px who met criteria had a survival rate of 15% if they
were not transplanted!
Yoan
Lamarche
Newer markers-A coagulation factor of VIII/V
ratio >30 suggests a poor prognosis.
Arterial lactate > 3.0 mmol/L after fluid
resuscitation predicted nonsurvivors
(Bernal, 2002). Additionally survivors had
lower phosphates!!
Yoan
Lamarche
King College for Tx
Yoan
Lamarche
Gordon’s patient (patient 6) remains
unstable and very hypotensive.
The patient is obviously in low
cardiac output and his heart rate
remains around 30.
Yoan
Lamarche
2.
Describe the approach to the patient with
calcium channel blocker overdose.
Describe the characteristics of patient
with ingestion of different classes of
CCB. (Gord)
Yoan
Lamarche
Yoan
Lamarche
Describe the presentation and
management of the patient with B
Blocker overdose. (Gord)
Yoan
Lamarche
2.
What are the steps that can be initiated if
the initial support does not reverse the
clinical situation (2nd line therapies)
(Gord)
Yoan
Lamarche
Yoan
Lamarche
Naisan’s patient (4) : What
are the characteristic findings
on the ECG? (Naisan)
– Wide complex .16s Tachycardia 120 bpm(sodium
channel blockade)
– In TCA OD occasionally, sinus tachycardia with
QRS prolongation is difficult to distinguish from
ventricular tachycardia
– I talked to 3 cardiologists and they had problems
telling if it was V-Tach or not
Yoan
Lamarche
• a limb-lead QRS interval >0.10 s has been
shown to predict seizures and QRS duration
>0.16 s has been associated with ventricular
arrhythmias
• Various forms of atrioventricular block may
accompany TCA overdose. Right bundlebranch block is common
Yoan
Lamarche
What are the general indications indications to
admit a patient with toxic ingestion to the
ICU(Naisan)
Yoan
Lamarche
• Brett et al identified eight clinical risk factors
that can predict ICU interventions:
• (1) Paco2>45 mm Hg, (2) need for
endotracheal intubation, (3) toxin-induced
seizures, (4) cardiac arrhythmias, (5) QRS
duration >0.12 s, (6) systolic BP <80 mm Hg,
(7) second- or third degree atrioventricular
block, and (8) unresponsiveness to verbal
stimuli.
Yoan
Lamarche
Criteria for ICU Admission
2.
What are the indications for
monitoring in a patient with
TCA overdose(Naisan)
•
•
•
•
•
Patients with altered mental status,
seizures,
hypotension,
metabolic acidosis,
and cardiac arrhythmias require ICU monitoring
What are the principles of
management in the patient with TCA
overdose (Naisan)
• ABCs as usual
• Patients should immediately receive sodium
bicarbonate (1 to 2 mEq/kg IV) when there is
widening of the QRS interval to decrease the
fraction of free drug
When can you D/C the monitoring in
a patient with TCA overdose
(Naisan)
• bicarbonate should be continued until there is
narrowing of the QRS interval or serum pH exceeds
7.55.
• Activated charcoal can be administered without
gastric lavage; there is no role for multidose
activated charcoal, particularly since ileus increases
the risk of charcoal-induced bowel obstruction.
Because of high lipid solubility and protein binding,
dialysis and hemoperfusion are not effective.
Yoan
Lamarche
Steve’s patient (5) : What is the initial
management of the patient with
organophosphate and carbamate poisoning
(Steve)
Yoan
Lamarche
NEJM 2004 Chemical emergencies Review
Chest review Toxidromes 2008
Yoan
Lamarche
What are the principles of management if
2.
multiple patients present with potential
terrorist attack with cholinergic agents,
what are the agents. (Steve)
Yoan
Lamarche
Yoan
Lamarche
Are you at risk, as a health care worker,
when treating these patients. (Steve)
Yoan
Lamarche
What are the indications for Hemodialysis,
hemoperfusion, in intoxicated patients (Steve)
Yoan
Lamarche
ExtraCorporealTxIntox-CurrOpCritCare2007dePons.pdf
Adult toxicology inICUPart1-Chest2003.PDF
Yoan
Lamarche
Scot’s patient initial blood gas is
7.45/38/130/24. His anion gap is normal. His
osmolality is elevated, the osmolar gap is
high
Yoan
Lamarche
How do you exclude the presence of
methanol or ethylene glycol in the presence
of ethanol. (Scot)
Yoan
Lamarche
Yoan
Lamarche
What are the toxic effects of ethylene glycol,
methanol and isopropyl alcohol, what are the
toxic doses? (Scot)
Yoan
Lamarche
Yoan
Lamarche
AlcoholToxIntCareMed2005Review.PDF
Yoan
Lamarche
What are the treatments to avoid toxicity in
ethylene glycol and methanol overdose?
Yoan
Lamarche
Yoan
Lamarche
Yoan
Lamarche
What is the role of Fomepizole?
Yoan
Lamarche
AlcoholToxIntCareMed2005Review.PDF
Yoan
Lamarche
Why can the initial blood gas be
normal in someone with ingestion
of a toxic dose of ethylene glycol?
(Scot)
Yoan
Lamarche
• What are the conversion units for urea,
ethanol, glucose, creatinine (umol/l to mg/dl)
(Gord)
Yoan
Lamarche
Are you all aware that the family needs
support from social work, psychiatry,
follow up and understanding from the
treating physician in case of intox of the
relative?
(cf royal college objectives)
Yoan
Lamarche