Common Toxicological Errors: What’s the problem here?

Russell Berger, MDCo-Director of Medical Toxicology

Cambridge Health AllianceInstructor in Medicine

Harvard Medical School

Background

• This WILL be interactive. • You are going to have to figure out what you want to do.

• Introduce yourself first time through and read the prompt out loud.

• If you don’t know the answer, you can pass once to your colleague.

• 27 M heroin user is found in Starbucks bathroom with agonal respirations. EMS gives the patient 2mg narcan enroute to your ER. Patient is shaky and diaphoretic on arrival. He demands to be discharged. Your charge nurse wants him out of the ER.

• What is the problem here?

A 7 month old child mouths a 8mg suboxone tablet. He is brought to the ER by the babysitter. He is stable with a normal sat, respiratory rate, blood pressure, etc. The medical resident tells you she wants to send the patient home.

• A 24 female with bipolar disorder presents with ataxia. Lithium level is 2.0. She is 7 hours past her ingestion time. Renal says just give the patient normal saline and we’ll see the patient tomorrow in consultation.

• A 16 year old boy presents after taking a bottle of Aspirin. He has nausea and vomiting. Asa level is 14 mg/dl(nl < 10). Patient is medically cleared for psych.

• An aspirin overdose presents in clear respiratory distress. Your intern who has just finished their anesthesiology rotation wants to intubate the patient?

• A 44 type 2 diabetic overdoses on his glyburide. You give him d50 when his sugar returns at 46. When his sugar drops again, you give him another amp of d50 and place him on a d50 drip

• A 56 year old fire victim presents to your ER with singed nares. You intubate the patient and check labs. Carboxyhemoglobin level is 18%. Labs demonstrate lactate of 12. You give the complete lilly kit.

• A 78 F is brought to your ER with N/V and symptomatic bradycardia. You look at her med list and realize that she is on digoxin. You see that her level is 4.0 and she weighs 80 kg. Therefore, you give her 4 vials of digibind. You get a call from the medical resident scolding you for sending up an unstable patient to the floor with a dig level that now is 6.0.

• An 8 year old child is dared to eat a box of rat poison. You admit the child to the hospital after you learn that he has eaten several pellets.

• A 30M presents with chest pain. EKG demonstrates ST elevations. You suspect cocaine chest pain. Cardiology refuses to cath the patient.

• A 39 M is in recovery from substance abuse and is prescribed methadone. He develops nausea and vomiting in the ER because he missed his morning dose of methadone. You give him zofran.

• A 1 year old child presents to the ER after eating paint chips. The child is asymptomatic so is therefore discharged.

• A 24M presents following a TCA overdose with a QRS complex of 129. He is placed on a bicarb drip with narrowing of the complex to 108. Patient remains tachycardic and is admitted to the ICU. On arrival, citing the normalizing QRS complex, the bicarb drip is shut off.

• A 14F presents after ingesting her grandmother’s venlafaxine. Patient is tachycardic and hypertensive. You give her activated charcoal and admit her to the PICU.

• A 44M alcoholic presents with apparent intoxication. He has no evidence of trauma but he is new to your department so you decide to scan him? CT reveal basal ganglia hemorrhage. ETOH level results at 265. You admit the patient to the neurosurgical icu.

• A 22 year old South East Asian man presents with seizures. On arrival, he is still seizing. Therefore, you give

2 ativan-no effect2 ativan-no effectLoad with phenytoin-no effectIntubate with propofol-Still with EEG based seizures

• A 28M, presents with chest pain. Heart is racing at 165. Intern suggests beta blockade to help lower the HR.

• A 19F presents with TCA overdose. QRS is 150ms. Patient is on bicarb drip and, to this point, has not seized. Serum pH is 7.6. Attending states that it is critical to keep the bicarb going.

An 8 year old male presents with hypotension and bradycardia. His fingerstick is 34 on arrival. Your attending physician tells you the patient’s clinical presentation is completely consistent with a calcium channel blocker overdose.

• A 24M presents following an amlodipine ingestion. You assess him, find him to have warm extremities, borderline tachycardia, and an entirely reassuring physical exam. You decide that you can safely discharge him.

A 28F presents with an intentional overdose of 30 days worth of her 300 mg INH tablets. The patient is intubated, started on a versed drip, and given 3g of pyridoxine.

• A 15F presents with nausea and vomiting following a deliberate tylenol ingestion. She is started on the NAC protocol. She gets 150mg/kg over the first hour, then 100mg/kg/hr for the next four hours, then 50mg/kg/hr for the remainder of the 16 hours.

• A 22 year old college senior presents with hypertension, tachycardia, runs of v-tach, and extreme agitation. She is experiencing profound nausea and vomiting. Measured potassium results at 3.0. The medicine team wants you to replace the potassium aggressively before the patient comes to the ICU.

• A 6 year old presents after drinking kerosene accidentally. On arrival, his respiratory rate is slightly accelerated. After a brief period of observation and decontamination, he is discharged home

• 64 F, presents with nausea, vomiting, and altered mental status. Ca 7.5. Lactate is 4.0. Creatinine is 1.8(patient’s baseline is 0.8). pH is 7.18. You give vanc and zosyn and admit to the ICU.

• A rich, elderly, woman complains of nausea and vomiting. She notes that she has severe leg pain and believes that she is losing her hair. Thinking that she is FOS, you refer her to psych.

• A 86M presents with a large stroke. Because of the stroke, neurology tells you the patient is at risk for seizure, increased metabolic demand, and subsequent death. Therefore, they tell you to push dilantin.

A Brazilian woman presents with a dig level of 10. Despite this, she is asymptomatic. At the urging of your attending, you give the patient digibind.

The End