poisoning 2004 kent r. olson, md, facep medical director, sf division california poison control...
TRANSCRIPT
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POISONING 2004
Kent R. Olson, MD, FACEPMedical Director, SF Division
California Poison Control System
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Case 1: Metabolic Acidosis
20 year old woman found in her parked car, comatose (GCS 8)
3 empty bottles of Tylenol
BP 100/50 HR 140-160 RR 38
Na 150 K 3.5 Cl 124 HCO3 6
pH 6.98 pCO2 12 pO2 198
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“MUDPILES”
Methanol
Uremia
DKA
Phenformin, Paraldehyde
INH
Lactate
Ethylene glycol, Ethanol
Salicylate
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Lactic Acidosis
Many possible causes:
Hypoxia-ischemia
Cyanide poisoning
Carbon monoxide poisoning
Metformin
INH . . . and many others
Order a serum lactate level
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“SALAD”
Gives you a quick “what to order”:
Salicylate (order a stat [ASA])
Alcohols (toxic alcohols – order Osm)
Lactate (order a state [Lactate])
Anuria (BUN, Cr)
DKA (check glucose)
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If the [Lactate] = normal
Then, you have fewer things to consider, e.g.:
Toxic alcohols
Methanol = formic acidosis
Ethylene glycol = glycolic acidosis
Ketoacidosis
Mostly beta-hydroxybutyrate
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Case, continued . . .
Salicylate negative
BUN/Cr = 5/1.1
Glucose 400 mg/dL
Lactate 18 mmol/L
COHgb not detected
Osmolality not sent
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“MUDPILES”
Methanol
Uremia
DKA
Phenformin, Paraldehyde
INH
Lactate
Ethylene glycol, Ethanol
Salicylate
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What was it?
Serum acetaminophen = 917 mg/L !!
She was treated with NAC, IV NaHCO3 (repeat pH 7.29), insulin
Next day AST, ALT began to rise
Peak measured ALT 5318
Bili to 2.8, INR 3.1
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Acetaminophen overdose
Acidosis, coma uncommon without fulminant liver failure as prior cause
Occasional cases of early coma, severe acidosis with very high drug levels - despite absent liver failure
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Mnemonics . . just remember:
“Today’s clinical pearl
may end up as
tomorrow’s fecalith.”
. . .John Wallace, MD c.1979
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1
10
100
1000
0 5 10 15 20 25
APAP(mg/L)
Possibly Toxic
Probably Toxic
hrs
Serum APAP level
Note: co-ingestion of Nyquil plus up to 44 g Tylenol ERRef: Bizovi K et al: J Toxicol Clin Toxicol 1995; 33:510
Serum acetaminophen (APAP) levels afteringestion of “Tylenol Extended Relief”
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New drug: Acetadote™
IV formulation of N-acetylcysteine
FDA approved January 2004
Not yet on the market
Dose? The UK-European protocol:
150 mg/kg in 200 mL D5W over 15 min +
50 mg/kg in 500 mL D5W over 4 hours +
100 mg/kg in 1 L, over 16 hrs
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Duration of NAC treatment?
Current US oral NAC protocol = 72 hr
Acetadote IV = 20 hr
Onset of rising AST, ALT ~ 24-30 hr
We recommend Rx (or at least observation) until ~36 hrs after the ingestion to r/o liver damage
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Case 2: Little Blue Lady
80 year old woman just returned from transeophageal echocardiogram
Perioral cyanosis and blue nail beds
Otherwise asymptomatic
Pulse oximetry 87% - did not improve with high-flow oxygen
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Arterial blood gases:
pH = 7.43
pCO2 = 36
pO2 = 266
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Methemoglobinemia
Fe2+ in heme is oxidized to Fe3+
Unable to carry oxygen
Many causes: (oxidants)
Benzocaine spray (in Hurricaine™)
Dapsone
Phenazopyridine
Nitrites (eg, amyl nitrite)
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Another crappy hemoglobin
67 year old man found unresponsive and covered with vomitus
Barbeque was heating the trailer
COHgb 33%
Intubated, hypotensive on Levophed
Candidate for HBO?
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Carbon monoxide poisoning
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CO poisoning, continued . . .
Can cause coma, seizures, death
Survivors may have varying degrees of neurological sequelae
Persistent coma, vegetative state, etc
Subtle mood and memory disorders
Incidence up to 30-40%
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Controversy over treatment
Hyperbaric oxygen (2.5 ATM)
versus
Normobaric oxygen ?
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Literature is inconclusive
Most reports are uncontrolled case series
Only two RCTs
Australian study: no difference
Weaver study: small benefit with HBO
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Weaver recommends HBO if:
COHgb > 25%
History of loss of consciousness
Metabolic acidosis
Age > 50 years
Cerebellar findings on neuro exam
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Another CO case:
55 year old man found unconscious on his yacht
He had gone downstairs 10 min earlier to check on a burning odor
Pulled out to fresh air, awake in 10 minutes
In ER 2.5 hrs later, COHgb 14.4%alert and normal neuro exam
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Child with a Seizure
14 month old boy had a seizure at home. No prior Hx of seizures.
Had been playing with Effexor bottle
Second seizure on arrival in ER
BP 138/87 HR 150 RR 28 T nl
Pupils dilated
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Common causes of seizures
Tricyclic antidepressants
Newer antidepressants (SSRIs)
especially bupropion (Wellbutrin™)
Amphetamines/cocaine
INH
Diphenhydramine
Tramadol (Ultram™)
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Toxicology screen showed:
Positive for methamphetamine
Not tested for venlafaxine (Effexor™)
Potential false (+) for amphetamines:
Ephedrine, MDMA, pseudoephedrine, etc
Bupropion, Labetalol, Ranitidine, Sertraline, Selegiline, Trazodone,others . . .
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Final case:
22 year old man ingested 60 lithium tablets (300 mg)
Asymptomatic 1 hour later in ER
How to decontaminate the stomach?
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Gut decontamination
Goal: limit systemic absorption
Possible methods:
Induced emesis
Gastric lavage
Activated charcoal
Cathartics/whole bowel irrigation
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Induced emesis
Don’t use:
Salt water
Finger gag
Ipecac?
Soapy water?
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Ipecac syrup
Easy to perform, but
NOT very effective
Risks:
Pulmonary aspiration
Wretching, GI injury
Delay in administering charcoal
Bottom line: OUTDATED
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“Pumping the stomach”
NOT very effective
Risks:
Aspiration
GI trauma
Delay to administering AC
Bottom line: RARELY used
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Activated charcoal
Finely divided powder
Huge surface area
Drugs and poisons areadsorbed to surface
Does NOT bind:
Iron
Lithium
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Activated charcoal . . .
More effective than ipecac, lavage
First choice for most drugs & poisons
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Whole Bowel Irrigation
Mechanical flush
GoLytely or COLYTE
Balanced salt solution
Nonabsorbable PEG
No net fluid loss or gain
Good for:
Lithium, iron, foreign bodies
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1-800-222-1222
New national toll-free hotline #
Dial from anywhere in the USA
Connects to regional poison center
24-hr consultation
PharmDs with physician back-up