poisoning by cardiovascular drugs
TRANSCRIPT
POISONING BY CARDIOVASCULAR DRUGS
Ayman Zaaqoq
Lecturer
Department of Forensic Medicine and Clinical Toxicology, ASU
2012-2013
CV TOXICITY
CV toxicity
Bradycardia
Digoxin
Beta-blockers
Calcium channel blockers
Tachycardia
Theophylline
CV TOXICITYINVESTIGATIONS
Investigation
Laboratory
S. drug level
Glucose
S.K+
KFTs
ABG
ECG
TOXICIT Y TREAT MEN TGENERAL GUID ELINES
Treatment
Stabilization Decontamination
GL
AC
Elimination
MDAC: dig., theo
Dialysis: theo
Antidote
Very high level
Serious C/P
Huge dose
Supportive
Bradycardia, AVB
Ventricular dysrhythmias
Hyperkalemia
MgSO4 IV
Overdrive pacing
Cardioversion
Phenytoin
TREATMENT OF SERIOUS DYSRHYTHMIAS
TdP V-tach
Cardioversion
NaHCO3 IV
Lignocaine
Phenytoin
Esmolol
DIGOXIN TOXICITY
Pharmaceutical
preparations: Lanoxin®,
Cardixin®
Plants: oleander
Animals: cane toad
DIGOXIN TOXICITYSOURCES
Accidental
Intentional
Therapeutic error
Decreased elimination
DIGOXIN TOXICITYFORMS
Acute Chronic
DIGOXIN TOXICITYMECHANISM
Digoxin
Θ Na+/K+-ATPase
↑ intracellular Na+
↑ extracellu
lar K+
Vagotonic Changes refractory period
↑ in AV node
↓ in atria and
ventricles
DIGOXIN TOXICITYACTIONS
Digoxin
↑ inotropy ↓ chronotropy ↑ automaticity ↑ potassium
DIGOXIN TOXICITYCLINICAL P ICTURE
C/P
CV GI Potassium imbalance Visual
DIGOXIN TOXICITYINVESTIGATIONS
Investigation
Laboratory
S.K+
SDC
KFTs
ABG
Glucose
ECG
ECG changes• Due to digoxin
intake• Due to digoxin
toxicity• Due to potassium
disturbances• Due to pre-existing
cardiac condition
DIGOXIN TOXICITYINVESTIGATIONS
DIGOXIN TOXICITYTREATMENT
Treatment
Stabilization (antidote)
Decontamination
GL (?)
AC
Elimination
MDAC
Antidote Supportive
Bradycardia, AVB
Ventricular
dysrhythmias
Hyperkalemi
a
DIGOXIN TOXICITYANTIDOTE: DIGIBIND
Indications
Laboratory
S.K+ SDC
High
Unavailable
Clinical History
BETA-BLOCKER TOXICITY
BETA-BLOCKER TOXICITYMECHANISM
BB
β-receptor blockade
Na channel blockade
Lipid solubility
BETA-BLOCKER TOXICITYACTIONS
BB
↓ inotropy ↓ chronotropy Wide QRS Θ CNS
BETA-BLOCKER TOXICITYCLINICAL P ICTURE
C/P
CVs CNS Metabolic
BETA-BLOCKER TOXICITYINVESTIGATIONS
Investigation
Laboratory
Glucose S.K+ KFTs
ECG
DIGOXIN TOXICITYTREATMENT
Treatment
Stabilization Decontamination
GL
AC
Antidote (Glucagon) Supportive
Bradycardia, hypotension
Wide QRS
Seizures
Hypoglycemia
CALCIUM CHANNEL BLOCKERS
CALCIUM CHANNEL BLOCKERS
They block slow Ca channels of vascular smooth muscles
and cardiac muscles.
Acute toxicity is similar to B-blockers
Treatment is as in B-blockers. In addition, CaCl2 10% 10ml
IV over 10 min for hypotension and myocardial depression.
THEOPHYLLINE TOXICITY
THEOPHYLLINE TOXICITYMODE
Mode of poisoning
Intentional Dosing errors
Parent error
Miscalculati
on
Change in the
frequency
Reduced clearanc
e
THEOPHYLLINE TOXICITYMECHANISM
Theophylline
↓cGMP & cAMP
Adenosine receptor block
↑catecholamines
THEOPHYLLINE TOXICITYC/P
GIT Nausea and vomiting Hematemesis Hypovolemic shock
CNS Anxiety Irritability, tremors Seizures, coma
CVS Sinus tachycardia Ventricular tachycardia Cardiogenic shock
Metabolic Hypokalemia Metabolic acidosis
THEOPHYLLINE TOXICITYINVESTIGATIONS
Investigation
Laboratory
S. Theophyllin
e
Glucose
S.K+
KFTs
ABG
ECG
THEOPHYLLINE TOXICITYTREATMENT
Treatment
Stabilization Decontamination
GL
Emesis (?)
Elimination
MDAC
Hemodialysis
Hemoperfusio
n
Antidote Supportive
THEOPHYLLINE TOXICITYTREATMENT
Supportive treatment
Tachycardia
Supraventriclua
r
Ventricular
Hypokalemia
Hypotension
Seizures
Vomiting
Thank you