THE APPROACH TO THE POISONED PATIENT Toxicology Skills WorkshopRegions Hospital Emergency Medicine Program

Develop a Systematic Approach Look for Toxidromes (“Talkingdromes”) Attention to ABCs and need for

Antidote Know the Indications for

Decontamination Procedures Enhance when possible and

appropriate

A – Antidote B – Basics ; ABCs C – Change catabolism D – Distribute differently;

Decontamination E – Enhance elimination

Antidote Toxin/Drug

Oxygen CO, CN, H2S

Naloxone Narcotics/Opiates

NAC APAP, Carbon tet

Atropine, Pralidoxime Organophosphates

Calcium HF, Fl, Oxalates

DMSA As, Lead, Hg

Sodium Bicarbonate TCA

Antidotes Toxin/Drug

Ethanol, 4MP EG, (methanol)

Digoxin-specific Fab Digoxin

Glucose Insulin

Hydroxocobalamin* CN

Physostigmine Anticholinergics, central

Pyridoxine INH, hydrazines

Glucagon Beta-blockers

Airway Breathing Circulation Do the DONT

Dextrose Oxygen Naloxone Thiamine

Reduce Adsorption

Vomiting (Ipecac) Generally not indicated or used in an ED setting Contraindicated in patients < 6 mos old, caustic ingestions,

actual or potential loss of airway reflexes, need to give oral antidote

Activated Charcoal Most effective if given within one hour Caution in the patient with altered mental status (need a

protected airway) Not effective for hydrocarbons, metals (Lead, Iron, Lithium)

Gastric Lavage Rarely used Consider in large, potentially life threatening ingestions not

amenable to activated charcoal

Hemodialysis STUMBLE(D) - Dialysis

Salicylates Theophylline Uremia Methanol Barbiturates, Bromide Lithium Ethylene Glycol Depakote (high levels)

Focused History and Brief Tox Exam History: what-when-how much

Reliability factor, relatives, paramedics Exam

Vital signs Mental status Pupillary response Skin changes, Odors/other prominent features.

MATTERS

MATTERS

Exam Vital signs

Pulse up or down or normal BP up or down or normal Temp up or down or normal Resp up or down or normal

Bradycardia (PACED) Propranolol or other Beta

blockers, Poppies (opiates) Anticholinesterase drugs Clonidine, CCBs, Ciguatera Ethanol or other alcohols,

Ergotamine Digoxin

Tachycardia (FAST) Free base or other forms of

cocaine Anticholinergics,

antihistamines, amphetamines

Sympathomimetics (ephedrine, amphetamines), Solvent abuse

Theophylline, Thyroid hormone

Hypothermia (COOLS) Carbon monoxide,

Clonidine Opiates Oral hypoglycemics, Insulin Liquor Sedative-hypnotics

Hyperthermia (NASA) Nicotine, Neuroleptic

malignant syndrome Antihistamines Salicylates,

Sympathomimetics Anticholinergics,

Antidepressants

Hypotension (CRASH) Clonidine, CCBs (and B-

blockers) Reserpine or other

antihypertensives Antidepressants,

Aminophylline, Alcohol Sedative-hypnotics Heroin or other opiates

Hypertension (CT SCAN) Cocaine Thyroid supplements

Sympathomimetics Caffeine Anticholinergics,

Amphetamines Nicotine

Rapid Respiration (PANT) PCP, Paraquat, Pneumonitis

(chemical) ASA and other salicylates,

Amphetamines Non-cardiogenic pulmonary

edema Toxin-induced metabolic

acidosis

Slow Respirations (SLOW) Sedative-hypnoptics,

Strychnine, Snakes Liquor Opiates, OPs Weed (marijuana)

Other causes: Nicotine, Clonidine, Chlorinated HC

Seizures? Hallucinations? CNS depressed?

WITH LA COPS Withdrawals (alcohol, benzos) INH, Insulin, Inderal Tricyclics, theophylline Hypoglycemics; Hemlock, water; Haldol

Lithium, Lidocaine, Lead, Lindane Anticholinergics, Antiseizure

WITH LA COPS Cocaine, Camphor, CN, CO, Cholinergics Organophosphates PCP, PPA, propoxyphene Sympathomimetics, Salicylates, Strychnine

Miosis (COPS) Cholinergics, Clonidine Opiates, organophosphates Phenothiazines, pilocarpine Sedative-hypnotics, SAH

MydriASis (A3S) Antihistamines,

Antidepressants, Atropine

Sympathomimetics

Diaphoretic (SOAP) Sympathomimetics Organophosphates ASA or salicylates Phencyclidine

(PCP)

Dry Skin Antihistamines,

Anticholinergics

Bullous Lesions Barbiturates and other

sedative-hypnotics Carbon monoxide Tricyclics (personal case

series)

www.acponline.org/graphics/bioterro/bullous.jpg

Flushed CO (rare) Anticholinergics Boric acid CN (rare)

Cyanosis Phenazopyridine Aniline dyes Nitrates Nitrites Ergotamine Dapsone Any agent hypoxia, hypotension MetHb

Bitter Almonds Carrots Fruity Garlic Gasoline

-Cyanide-Cicutoxin (water hemlock)-DKA, Isopropanol-OP, As, DMSO, selenium,

thallium, phosphorus-Petroleum distillates

Mothballs Pears Pungent aromatic Oil of wintergreen Rotten eggs

-Naphthlene, camphor-Chloral hydrate-Ethchlorvynol-Methylsalicylate-Sulfur dioxide,

hydrogen sulfide

Toxicology Screens Urine Stat Urine vs Serum Acetaminophen level

Routine Tests CBC SMA-7 Anion Gap ABGs

Drug Hrs Post-Ing Pos Interv

APAP 4 NAC

COHgb Immed* HBO

ASA 6-12* Dialysis

Iron 2-4* Antidote

Dig 2-4* Fab

Alcohols 1/2 - 1* Antidote

*Clinical Symptoms may dictate treatment, not level.

A MUD PILE CAT ASA Methanol Uremia DKA Paraldehyde, Phenformin INH, Iron, Ibuprofen Lactic acidosis Ethylene Glycol

A MUD PILE CAT CO, CN, Caffeine AKA Theophylline, Toluene

Others Benzyl alcohol Metaldehyde Formaldehyde H2S

Decreased Anion Gap Bromide Lithium Hypermagnesemia Hypercalcemia

Calculated 2(Na)+[Glu/18] + [BUN/2.8] +

EtOH(mg/dL)/4.6Osm Gap = measured - calculated

Significant if >10 Really significant if >19

Increased Osmolar Gap MAD GAS

Mannitol Alcohols (met, EG, Iso, eth) Dyes, Diuretics, DMSO Glycerol Acetone Sorbitol

A 40 year old man collapsed at work while moving his car. He has a hx of depression. He had recently attended his mother’s funeral the day before.

He was found slumped over the steering wheel of his car, lethargic and incoherent. A co-worker left the patient and went to call medics. He was intubated and transferred to Regions Hospital.

Examination • BP 130/88, P90, R-vent, T 1012

• Pupils 6mm unreactive but equal. • Skin warm, red, dry• Absent bowel sounds

Labs were unremarkable• ABG:pH 7.50, 32, 140• EKG - QRS 102, occasional PVC

Is there a Toxidrome? A. Opioid B. Anticholinergic C. Delayed Exercise Syndrome D. Cholinergic poisoningIs there an antidote?

Anticholinergic (antihistamines, cyclic antidepressants, Jimson weed)• Hot as a hare (hyperthermia)• Red as a beet (flushed)• Dry as a bone (dry skin, urinary retention)• Blind as a bat (mydriasis)• Mad as a hatter (hallucinations, delirium,

myoclonic jerking)

Also with anticholinergic• Mydriasis• Tachycardia• Hypertension• Hyperthermia• Seizures

How do you treat it?• Supportive care• TCAs – Sodium Bicarb for widened QRS• Benzodiazepenes for agitation, seizures• Consider physostigmine for pure anticholinergic

overdoses (contraindicated in TCA overdose or with dysrhythmias)

Toxidromes: Case #2

A 19 year old male presents after from a party after his friends noted he was “acting funny.” He was “out of control” and not making sense, so they decided to bring him into the Emergency Room.

The patient is agitated on arrival

Examination • BP 180/114, P120, R20, T 101• The patient is agitated and appears to

be hallucinating• Pupils 6mm sluggish but equal. • Skin warm, red, very diaphoretic

Labs were unremarkable• EKG – sinus tachycardia

Toxidromes: Case #2

Is there a Toxidrome?A. OpioidB. AnticholinergicC. SympathomimeticD. Cholinergic

Sympathomimetics (cocaine, amphetamines, ephedrine)• Mydriasis• Tachycardia• Hypertension• Hyperthermia• Seizures• Diaphoresis

Treatment• Supportive care• Benzodiazepines as needed

Toxidromes: Case #3

A 40 y/o female is brought by medics. A family member called after a suicide note was found and the patient was found unresponsive.

On medic arrival the patient was noted to be very somnolent. She was transported to Regions Hospital.

Examination • BP 100/65, P50, R6, T 98.6• The patient is arousable only to sternal

rub. • Pupils 2mm sluggish but equal. • Skin cool, dry

Labs were unremarkable• EKG – sinus bradycardia

Toxidromes: Case #3

Is there a Toxidrome?A. OpioidB. AnticholinergicC. SympathomimeticD. Cholinergic Is there an antidote?

Narcotic (heroin, methadone, other opioids)• Miosis• Bradycardia• Hypotension• Hypoventilation• Coma/CNS depression

Treatment• Naloxone

Clonidine Hypotension usually more profound May require HIGH dose naloxone to see any

effect Tetrahydrozaline

Periodic apnea in kids Kids should be admitted if symptomatic in

ED

Toxidromes: Case #4

A 50 y/o male is brought in after being found in his garage. According to paramedics, there were several containers of liquids in glass jars near the patient. They also noted a large amount of emesis. He was noted to have altered mental status and some respiratory distress prior to arrival. He was intubated prior to arrival and transported to Regions Hospital.

Examination • BP 110/65, P50, R - intubated, T 98.6• The patient is obtunded, intubated• Pupils 2mm sluggish but equal. • There are copious secretions in the

patient’s mouth and in the endotracheal tube

• Incontinent of both urine and stool• Skin is cool, diaphretic

Labs were unremarkable• EKG – sinus bradycardia

Toxidromes: Case #4

Is there a Toxidrome?A. Serotonin SyndromeB. AnticholinergicC. SympathomimeticD. Cholinergic Is there an antidote?

Cholinergic (DUMBELS or SLUG BAM) Salivation Lacrimation Urination GI complaints (nausea, vomiting, diarrhea) Bradycardia, Bronchoconstriction Abdominal cramping Miosis, Muscle fasciculations

Treatments: Pralidoxime (2PAM), Atropine

MORE TALKINGDROMES

Salicylates (ASPIRIN)Harris

Altered MS (lethargy to coma) Sweating Pulmonary edema Increased ventilation, temp, heart

rate Ringing in ears Irritable Nausea and vomiting

Serotonin Syndrome VS: T, HR, BP (unstable) MS: Agitation, coma Pupils: Mydriasis Skin: Diaphoresis Other: LE rigidity, myoclonus,

hyperreflexia, seizure

MAOI and other drug Idiosyncratic reaction

Alteration in MS Autonomic instability Neuromuscular abnormality

Treatment is supportive Symptoms resolve 24-72 hrs

Lactic acidosis, rhabdo, hyperthermia

Specific drugs SSRIs (i.e., Prozac) Dextromethorphan Demerol Ecstasy (MDMA): hallucinogenic

amphetamine Cocaine L-tryptophan

Acetaminophen Toxicity - Metabolism Metabolized in the liver primarily to nontoxic

glucoronide and sulfide conjugates, however small amount is converted via cytochrome P450 to potentially toxic NAPQI

Normally, NAPQI is conjugated with glutathione to nontoxic metabolites

In significant overdose, glutathione stores are depleted

NAPQI destroys hepatocytes leading to liver failure

Acetaminophen Toxicity – Clinical Presentation

First few hours Non-specific signs and symptoms Nausea, vomiting, pallor, diaphoresis Even severely poisoned patients may remain

symptomatic 18 – 24 hours

Asymptomatic phase No laboratory evidence of hepatotoxicity

After 24 – 36 hours Aminotransferases begin to rise Signs and symptoms of hepatotoxicity

N, V, RUQ pain, hepatic enlargement, jaundice 72 – 96 hours

Peak hepatotoxicity Although massive liver necrosis can occur, recovery is

the rule and usually complete if the patient survives

Acetaminophen Level

- Levels are important- Check levels in all cases of

suspected overdose or polydrug overdose

- Antidotal therapy is most effective if started within 8 – 10 hours

- Signs and symptoms are delayed for 18 – 36 hours

- Rumack-Matthew nomogram - Used to predict the severity

of toicity and need for antidotal therapy

- 4 hour level- Levels above the line

require antidotal therapy

Acetaminophen Toxicity - Antidote N-acetylcysteine (NAC)

Glutathione precursor and glutathione substitute

Increases substrate supply for the non-toxic sulfate conjugation pathway

Available as oral and IV form Extremely effective if initiated within 8

hours Standard of care to treat patients up to 24

hours

ABCs - Antidotes Decontaminate - Special Treatments? Toxidromes? Investigate - look closely REASSESS, MONITOR, SUPPORT