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TOXICOLOGYAn Overview
TOXICOLOGYAn Overview
Jordan B. Barnett, M.D., FACEPJordan B. Barnett, M.D., FACEP
Interim Director, Department of Emergency Interim Director, Department of Emergency MedicineMedicine
Episcopal HospitalEpiscopal Hospital
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POISONINGPOISONING
Estimated 4 Million AnnualPediatric
Child AbuseAdult
RecreationalSuicide
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HISTORYHISTORY
What Poison?How Much?How?When?Why?What Else Taken?
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PHYSICAL EXAMPHYSICAL EXAM
Vital SignsABC’sTemperature
Toxic Syndrome Respiratory Cardiovascular Neurologic
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TREATMENTTREATMENT
ABC’s Treat Other Injuries Decontamination Supportive Care Definitive Care
AntidotesElimination
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DECONTAMINATION: IPECACDECONTAMINATION: IPECAC
Absorption Reduced By 30% Interferes With Further
Decontamination Interferes With Further Treatment Home UseNO EMERGENCY DEPARTMENT
USE!
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DECONTAMINATION:GASTRIC LAVAGEDECONTAMINATION: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
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DECONTAMINATION:GASTRIC LAVAGEDECONTAMINATION:GASTRIC LAVAGE
DisadvantagesNot Complete Gastric Emptying 30% Recovery At 1 HourLabor IntensiveComplications
3% Overall Esophageal Rupture Aspiration Hypoxia
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DECONTAMINATION:CHARCOALDECONTAMINATION:CHARCOAL
Not Absorbed From GI Tract Binds Most Substances Prevents Absorption Enhance Excretion
Multiple DoseEnterohepatic Circulation
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DECONTAMINATION:CHARCOALDECONTAMINATION:CHARCOAL
CharcoalCharcoalEmesisEmesisLavageLavage
57%57%
38%38%
32%32%
Ampicillin ModelDecreased Absorption
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ACTIVATED CHARCOALACTIVATED CHARCOAL
Dose 1g/kgDose 1g/kg Repeat DoseRepeat Dose DisadvantagesDisadvantages
MessyMessy AspirationAspiration
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SUBSTANCES NOT BOUND BY CHARCOALSUBSTANCES NOT BOUND BY CHARCOAL
Alcohols And Alcohols And GlycolsGlycols
CorrosivesCorrosives AlkalisAlkalis AcidsAcids
CyanideCyanide Saline CatharticsSaline Cathartics
Heavy MetalsHeavy Metals IronIron LeadLead LithiumLithium MercuryMercury
HydrocarbonsHydrocarbons
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CATHARTICSCATHARTICS
Mechanism Types Mixture With Charcoal Disadvantages Use In Children
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OTHER MODALITIESOTHER MODALITIES
Whole Bowel Irrigation IndicationsTechnique
Skin Eye
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RESPIRATORY COMPLICATIONSRESPIRATORY COMPLICATIONS
Airway Protection Ventilatory Insufficiency Bronchospasm Noncardiogenic Pulmonary Edema Aspiration
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CARDIOVASCULAR COMPLICATIONSCARDIOVASCULAR COMPLICATIONS
Tachycardia Bradycardia Hypotension Hypertension
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NEUROLOGIC COMPLICATIONSNEUROLOGIC COMPLICATIONS
Coma Seizures Behavioral Abnormalities
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DIAGNOSTIC STUDIESDIAGNOSTIC STUDIES
Drug Screens/Levels Acetaminophen ABG Electrolytes Organ Function EKG X-RAY
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SERUM OSMOLARITYSERUM 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
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ETHANOLETHANOL
C2H5OH
Molecular Weight=________
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DEFINITIVE CAREDEFINITIVE CARE
Decontamination Supportive Care Antidotes
Oxygen/Glucose/Narcan/?Flumazenil Elimination
AlkalinizationRepeated Dose Charcoal
Dialysis
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DISCHARGEDISCHARGE
Stable In Emergency Department Psychiatric Issues
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TOXIDROMETOXIDROME
Toxic Syndromes
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TOXIDROMES: CASE 1TOXIDROMES: 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.
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TOXIDROMES: CASE 1TOXIDROMES: CASE 1
Dry Skin And Mucous Membranes Thirst Blurred Vision Fixed Dilated Pupils Flushing Urinary Urgency And Retention Hallucinations
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TOXIDROMES: CASE 1TOXIDROMES: CASE 1
AnticholinergicHot As HadesBlind As A BatDry As A BoneRed As A BeetMad As A Hatter
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TOXIDROMES: CASE 1TOXIDROMES: CASE 1
Belladonna AlkaloidsAtropine/ScopolamineScopolamine
Synthetic AnticholinergicsDicyclomine
OtherAntihistamines/Phenothiazines/TCA
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TOXIDROMES: CASE 2TOXIDROMES: CASE 2
A 50 Year Old Farmer Is Found Unresponsive at His Barn.
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TOXIDROMES: CASE 2TOXIDROMES: CASE 2
Sweating Constricted Pupils Lacrimation Excessive Salivation Wheezing Vomiting/Diarrhea Fasiculations
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TOXIDROMES: CASE 2TOXIDROMES: CASE 2
Acetylcholinesterase Inhibitors Pesticides
OrganophosphateCarbamates
Mechanism Treatment
AtropinePralidoxime (2-PAM)
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TOXIDROMES: CASE 3TOXIDROMES: CASE 3
An 8 Year Old Child Is Brought to the Emergency Department After Being Given a Compazine Suppository for Vomiting.
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TOXIDROMES: CASE 3TOXIDROMES: CASE 3
Dysphonia Oculogyric Crises Rigidity Torticollis/Opisthotonos
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TOXIDROMES: CASE 3TOXIDROMES: CASE 3
Extrapyramidal EffectsMedications
AntipsychoticAntiemetic
Treatment
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TOXIDROMES: CASE 4TOXIDROMES: CASE 4
During a Visit to Grandma in the Nursing Home, You Find That You Can Not Wake Her Up.
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TOXIDROMES: CASE 4TOXIDROMES: CASE 4
CNS DepressionPinpoint PupilsSlowed RespirationsHypotension
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TOXIDROMES: CASE 4TOXIDROMES: CASE 4
NarcoticNarcoticMedicationsMedications
PrescribedPrescribedIllicit
TreatmentTreatment
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TOXIDROMES: CASE 5TOXIDROMES: CASE 5
A Movie Star Presents to Your Hospital.
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TOXIDROMES: CASE 5TOXIDROMES: CASE 5
CNS ExcitationSeizuresHypertensionTachycardia
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TOXIDROMES: CASE 5TOXIDROMES: CASE 5
SympathomimeticMedication
PrescribedIllicit
Treatment
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TOXIDROMES: CASE 6TOXIDROMES: CASE 6
A Family of 6 Presents to Your Office in the Middle of Winter and All Complain of “the Flu”.
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TOXIDROMES: CASE 6TOXIDROMES: CASE 6
Headache “Flu” Symptoms Nausea, Vomiting, Dizziness Dyspnea Seizures Death Cyanosis “Chocolate” Blood
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TOXIDROMES: CASE 6TOXIDROMES: CASE 6
HemoglobinopathiesCarbon MonoxideMethemoglobinTreatment
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TRICYCLIC ANTIDEPRESSANTSTRICYCLIC ANTIDEPRESSANTS
Mortality 2 - 5 PercentLow Therapeutic/Toxic RatioMechanism
Inhibition Of Amine UptakeAnticholinergicAlpha Receptor BlockerSodium Channel Blockade
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TCACLINICAL FEATURESTCACLINICAL FEATURES
Anticholinergic SymptomsTachycardiaCNS ToxicityComaHypotensionArrhythmiaSeizures
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TCACLINICAL FEATURESTCACLINICAL 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
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TCATREATMENTTCATREATMENT
GI Decontamination Sodium Bicarbonate-Indications
QRS WideningHypotensionVentricular Arrhythmias
Sodium Bicarbonate-Mechanism 1 - 2 mEq/Kg To pH 7.50-7.55
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TCATREATMENTTCATREATMENT
PhysostigminePeripheral Anticholinergic SymptomsAgitation/Seizures/Hypotension When
Other Methods FailSide Effects
SeizuresBenzodiazepines/Barbiturates
Hypotension
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SALICYLATESSALICYLATES
Gastroenteritis Mixed Respiratory And Metabolic
Acidosis CNS Cardiac Toxicity Pulmonary
ARDS Tinnitus
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SALICYLATESTOXIC DOSESALICYLATESTOXIC 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
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SALICYLATESTREATMENTSALICYLATESTREATMENT
Charcoal IV Fluids Urine Alkalinization
Mechanism “Ion Trapping”Un-ionized Salicylate Reabsorbed By Renal
TubulesAlkaline Urine Favors Ionized Salicylate
Which Cannot Be Reabsorbed Dialysis
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SALICYLATESDISPOSITIONSALICYLATESDISPOSITION
Asymptomatic Nomogram After 6 Hours
Patient Asymptomatic Enteric Coated
150 mg/kg Psychiatric Evaluation Follow-up