emergency medicine management of poisonings in the ed - jordan barnett md
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TOXICOLOGYAn Overview
Jordan B. Barnett, M.D., FACEPJordan B. Barnett, M.D., FACEPInterim Director, Department of Emergency Interim Director, Department of Emergency
MedicineMedicineEpiscopal HospitalEpiscopal Hospital
POISONING
Estimated 4 Million AnnualPediatric
Child AbuseAdult
RecreationalSuicide
HISTORY
What Poison?How Much?How?When?Why?What Else Taken?
PHYSICAL EXAM
Vital SignsABC’sTemperature
Toxic Syndrome Respiratory Cardiovascular Neurologic
TREATMENT
ABC’s Treat Other Injuries Decontamination Supportive Care Definitive Care
AntidotesElimination
DECONTAMINATION: IPECAC
Absorption Reduced By 30% Interferes With Further
Decontamination Interferes With Further Treatment Home UseNO EMERGENCY DEPARTMENT
USE!
DECONTAMINATION:GASTRIC LAVAGE
250 - 300 cc Aliquots Of Fluid 36 - 40F Tube Advantages
Immediate Recovery Of Gastric ContentsDirect access For Charcoal Instillation
Left Lateral Decubitus With Trendelenburg
Intubation May Be Needed
DECONTAMINATION:GASTRIC LAVAGE
Disadvantages Not Complete Gastric Emptying 30% Recovery At 1 Hour Labor Intensive Complications
3% Overall Esophageal Rupture Aspiration Hypoxia
DECONTAMINATION:CHARCOAL
Not Absorbed From GI Tract Binds Most Substances Prevents Absorption Enhance Excretion
Multiple DoseEnterohepatic Circulation
DECONTAMINATION:CHARCOAL
CharcoalCharcoalEmesisEmesisLavageLavage
57%57%38%38%32%32%
Ampicillin ModelDecreased Absorption
ACTIVATED CHARCOAL
Dose 1g/kgDose 1g/kg Repeat DoseRepeat Dose DisadvantagesDisadvantages
MessyMessy AspirationAspiration
SUBSTANCES NOT BOUND BY CHARCOAL
Alcohols And Alcohols And GlycolsGlycols
CorrosivesCorrosives AlkalisAlkalis AcidsAcids
CyanideCyanide Saline CatharticsSaline Cathartics
Heavy MetalsHeavy Metals IronIron LeadLead LithiumLithium MercuryMercury
HydrocarbonsHydrocarbons
CATHARTICS
Mechanism Types Mixture With Charcoal Disadvantages Use In Children
OTHER MODALITIES
Whole Bowel Irrigation IndicationsTechnique
Skin Eye
RESPIRATORY COMPLICATIONS
Airway Protection Ventilatory Insufficiency Bronchospasm Noncardiogenic Pulmonary Edema Aspiration
CARDIOVASCULAR COMPLICATIONS
Tachycardia Bradycardia Hypotension Hypertension
NEUROLOGIC COMPLICATIONS
Coma Seizures Behavioral Abnormalities
DIAGNOSTIC STUDIES
Drug Screens/Levels Acetaminophen ABG Electrolytes Organ Function EKG X-RAY
SERUM OSMOLARITY
Serum Osmolarity= 2 (Na+) + BUN/2.8 + Glucose/18
Osmolar Gap 10 mOsm or less Methanol, Ethylene Glycol, Ethanol Glycerol, Mannitol +ETOH/4.6
ETHANOL
C2H5OHMolecular Weight=________
DEFINITIVE CARE
Decontamination Supportive Care Antidotes
Oxygen/Glucose/Narcan/?Flumazenil Elimination
AlkalinizationRepeated Dose Charcoal
Dialysis
DISCHARGE
Stable In Emergency Department Psychiatric Issues
TOXIDROME
Toxic Syndromes
TOXIDROMES: CASE 1
25 Year Old PA Student Just Back From Spring Break In Mexico. He's Been Having Terrible Diarrhea Since Returning and Has Been Using Pills to Alleviate the Symptoms.
TOXIDROMES: CASE 1
Dry Skin And Mucous Membranes Thirst Blurred Vision Fixed Dilated Pupils Flushing Urinary Urgency And Retention Hallucinations
TOXIDROMES: CASE 1
AnticholinergicHot As HadesBlind As A BatDry As A BoneRed As A BeetMad As A Hatter
TOXIDROMES: CASE 1
Belladonna AlkaloidsAtropine/ScopolamineScopolamine
Synthetic AnticholinergicsDicyclomine
OtherAntihistamines/Phenothiazines/TCA
TOXIDROMES: CASE 2
A 50 Year Old Farmer Is Found Unresponsive at His Barn.
TOXIDROMES: CASE 2
Sweating Constricted Pupils Lacrimation Excessive Salivation Wheezing Vomiting/Diarrhea Fasiculations
TOXIDROMES: CASE 2
Acetylcholinesterase Inhibitors Pesticides
Organophosphate Carbamates
Mechanism Treatment
Atropine Pralidoxime (2-PAM)
TOXIDROMES: CASE 3
An 8 Year Old Child Is Brought to the Emergency Department After Being Given a Compazine Suppository for Vomiting.
TOXIDROMES: CASE 3
Dysphonia Oculogyric Crises Rigidity Torticollis/Opisthotonos
TOXIDROMES: CASE 3
Extrapyramidal EffectsMedications
AntipsychoticAntiemetic
Treatment
TOXIDROMES: CASE 4
During a Visit to Grandma in the Nursing Home, You Find That You Can Not Wake Her Up.
TOXIDROMES: CASE 4
CNS DepressionPinpoint PupilsSlowed RespirationsHypotension
TOXIDROMES: CASE 4
NarcoticNarcoticMedicationsMedications
PrescribedPrescribedIllicit
TreatmentTreatment
TOXIDROMES: CASE 5
A Movie Star Presents to Your Hospital.
TOXIDROMES: CASE 5
CNS ExcitationSeizuresHypertensionTachycardia
TOXIDROMES: CASE 5
SympathomimeticMedication
PrescribedIllicit
Treatment
TOXIDROMES: CASE 6
A Family of 6 Presents to Your Office in the Middle of Winter and All Complain of “the Flu”.
TOXIDROMES: CASE 6
Headache “Flu” Symptoms Nausea, Vomiting, Dizziness Dyspnea Seizures Death Cyanosis “Chocolate” Blood
TOXIDROMES: CASE 6
HemoglobinopathiesCarbon MonoxideMethemoglobinTreatment
TRICYCLIC ANTIDEPRESSANTS
Mortality 2 - 5 PercentLow Therapeutic/Toxic RatioMechanism
Inhibition Of Amine UptakeAnticholinergicAlpha Receptor BlockerSodium Channel Blockade
TCACLINICAL FEATURES
Anticholinergic SymptomsTachycardiaCNS ToxicityComaHypotensionArrhythmiaSeizures
TCACLINICAL FEATURES
ECG“right axis deviation of the terminal
40ms of QRS greater than 1200 “Sinus Tach-Wide QRS-Decreased
Inotropy-Increased PRI-BradycardiaWide QRS=Life Threatening Toxicity
TCATREATMENT
GI Decontamination Sodium Bicarbonate-Indications
QRS WideningHypotensionVentricular Arrhythmias
Sodium Bicarbonate-Mechanism 1 - 2 mEq/Kg To pH 7.50-7.55
TCATREATMENT
PhysostigminePeripheral Anticholinergic SymptomsAgitation/Seizures/Hypotension When
Other Methods FailSide Effects
SeizuresBenzodiazepines/Barbiturates
Hypotension
SALICYLATES
Gastroenteritis Mixed Respiratory And Metabolic
Acidosis CNS Cardiac Toxicity Pulmonary
ARDS Tinnitus
SALICYLATESTOXIC DOSE
Done Nomogram Acute, Single Ingestion Cannot Use For:
Acute Ingestion With Salicylate Taken Within Last 24 Hours
Chronic Salicylate Poisoning Ingestion Of Enteric Coated Tablets
Treat Patient If Symptomatic
SALICYLATESTREATMENT
Charcoal IV Fluids Urine Alkalinization
Mechanism “Ion Trapping” Un-ionized Salicylate Reabsorbed By Renal
Tubules Alkaline Urine Favors Ionized Salicylate Which
Cannot Be Reabsorbed Dialysis
SALICYLATESDISPOSITION
Asymptomatic Nomogram After 6 Hours
Patient Asymptomatic Enteric Coated
150 mg/kg Psychiatric Evaluation Follow-up
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