GENERAL GENERAL APPROACH TO APPROACH TO

ACUTELY ACUTELY POISONED PATIENTSPOISONED PATIENTS

GENERAL GENERAL APPROACH TO APPROACH TO

ACUTELY ACUTELY POISONED PATIENTSPOISONED PATIENTS

Prof. Enas El TaftazaniProf. Enas El Taftazani

Prof. of clinical toxicologyProf. of clinical toxicology

Objectives•To provide a systematic approach to

the resuscitation, work-up, diagnosis and treatment of the acutely poisoned patients.

Outline• Case based approach to:

– initial stabilization– History– Evaluation of the poisoned patient– Techniques to prevent absorption– Techniques to enhance elimination

Immediate Stabilization

• Airway with cervical spine control– Intubate…what do you want to use?

• Breathing– 100% O2 , ventilation

• Circulation– Insert new IVs– Draw bloods with IV start– Bolus 1-2L NS – Cardiac monitor

History

Personal history

History of present illness

Past historyFamily history

Toxicological History• Often incomplete, unreliable or

unobtainable

• Sources – Patient, friends, family, pill containers

• liver/renal disease, concurrent medications, previous overdoses, substance abuse

The 5W’s of toxicology• Who – pt’s age, weight, relation to others• What – name and dose of medication,

coingestants and amount ingested,pre-consultation treatment.

• When – time of ingestion, single vs. multiple ingestions

• Where – route of ingestion, geographical location

• Why – intentional vs. unintentional

Ask about :

Respiratory symptoms:Cough,chest pain,dyspnea,,sputum

GIT: N,V,diarhea,pain ch.ch. Of vomitus.

Neurological: weakness,rigidity,

CVS: palpitation ,chest pain,.dyspnea.

Urinary: urine retention,…

Examination • General :General : vital data-Pupil, conscious state• Pupil: miosis,mydriasis,• Consciousness:grading of

coma,agitation, hallucination.• Systemic examinationSystemic examination

Vital signs

Pulse

TemperatureBlood pressure

Respiratory rate

Pulse

Bradycardia:

Organophosphates,digoxin,opiate,barbiturates,B-blockers

Tachycardia:

Anticholinergics,

sympathomimetics

Irregular pulse: digoxin,TCA,sympathomimetics,CO

Blood pressure

Hypotension:

Decreased peripheral resistance

Hypovolemia

Decreased myocardial contractility

Hypertension:

Sympathomimetics

Scorpion

anticholinergics

Temperature

Hyperthermia

Salicylates

Sympathomimetics

Anticholinergics

Antidepressents

Hypothermia:

CO,oral hypoglycemics

Hypnotics

ethanol

Respiratory rate

Tachypnea:

Hypoxia

Acidosis

With dyspnea as irritant gas

Bradypnea :

CNS depression,neuromuscular blockade

Toxicologic Physical Exam

•CNS – level of arousal, GCS, pupils, behaviour, neurologic exam

•CVS – rate, rhythm•Resp – pattern, depth, wheezing•GI – bowel sounds, distention•Skin – color, temp, signs of trauma•Odors

Laboratory Investigations

• What lab tests should we order?

• What special tests are available?

Laboratory investigations (cont’d)

• General labs(routine): CBC,ECG,LFT, Electrolytes, BUN, Cr, glucose, ABG.

• Special laboratory investigation indicated in following cases– Intentional ingestion– Substance unknown– Potential for mod to severe toxicity

•Labs considered essential and available: –EtOH, acetaminophen, salicylate, digoxin,

Carbamazepine, phenobarb, phenytoin, Valproate, theophylline

–Methanol, Ethylene glycol, Isopropanol, Iron, Lithium

•Tox screen – does not contribute to patient management

Laboratory investigations (cont’d)

Additional Tests•ECG – TCA or other cardiotoxic drugs,

arrhythmias, ischemia

•Radiology –CXR – aspiration, noncardiogenic

pulmonary edema–Abdominal films useful in screening for

ingestions of radio-opaque materials–What substances are visible on AXR?

DECONTAMINATION• DERMAL:OPC,Carbolic acid. ( remove clothes,wash with soap & water

for 15 min,NO forceful rubbing)• EYE:wash conj. With running water or saline

for 20 min.• Inhalation:CO ,CN. 1.Remove to fresh air 2.Care of resp.• GIT

Gastrointestinal Decontamination

• Emesis.• Gastric lavage• Whole bowel irrigation • Activated charcoal• Cathartics

GIT emptying• Removal of poison from stomach

by emesis or g. lavage:• Causes of limitation of its use

nowadays: time factor, small dose, previous vomiting, presence of other methods (charcoal).

• Indications: high lethal dose, if other measures are applicable.

Ipecac• Emetic – both peripherally and central acting• >90% effective• Dose 30cc PO :adults, 15cc >2yrs, 10cc 6-

2yrs.• IF failed within 30 m,repeat,if not then GL..• Advantages over lavage:

– Safe – Efficient– Less traumatic

• Contraindications- Substance- Patient - Time passed

• Complications– Diarrhea, lethargy/drowsiness, prolonged

vomiting

Never Never Never

( Use Salty H2O???? )

Gastric Lavage• ContraindicationsAbsolute Corrosives, froth-forming

Relative Unprotected airway, comaConvulsions HydrocarbonsRisk of GI bleed or perforationTime factor (unless delayed)

• ComplicationsAspn pneumonia, laryngospasm, hypoxia, mechanical injury, fluid/electrolyte imbalances, bradycardia, hypertension

Activated Charcoal• 1g/kg PO or NG• Indications

– Nearly all suspected toxic ingestions except– May be considered more than 1 hour after

ingestion but insufficient data to support or exclude use

• Contraindications– Unprotected airway– When AC therapy may increase risk and

severity of aspiration– Corrosives (why??) , IO, hydrocarbons ,NOT

ADSORBED.• Complications

– GIT obstruction, constipation, adsorb medication

Drugs that don’t adsorb to AC

• PHAILS– Pesticides ???– Hydrocarbons, Heavy metals (Fe,Hg,Pb)– Acids/Alkalis/Alcohols– Iron– Lithium– Solvents– Gases

INDICATIONS OFMDAC

• Drugs remain in GIT:• SR-prep:theophylline• concretions:salicyl. Phenobarbit.• slowing GIT motility:antichol.• EHC:digoxine,dapson,TCA• Passive diffusion from bl to lower GI

lumen:theophylline.

Whole bowl irrigation

• A newer method for decontamination, well tolerated ,safe in pregnancy

Whole bowel irrigation• PEG via NG at 1-2 L/h (500cc/h in peds) until

effluent clear

• Indications– Potentially toxic ingestion of SR prep– Ingested packets of illicit drug (stuffers,

packers)– Substances not adsorbed by AC– Iron ingestions

Whole bowel Irrigation• Contraindications

– Bowel perforation or obstruction– GI bleed – Ileus– Unprotected airway– Hemodynamic instability– Intractable vomiting

• Complications– Nausea, vomiting, aspiration, cramps

TYPES OF CATHASIS• OSMOTIC:MgSO4(15-30g)in glass of

water.• IRRITANT:Castor oil(60-100ml)• Contraind.:GI Hge, IO,ileus,recent

bowel surgery,RF(Mg load)• Complications:dehydration &

elec.imb

Cathartics•Sorbitol, Mg citrate, Phosphosoda•May be an argument for adding to

initial dose of multiple dose activated charcoal

•No studies have demonstrated a benefit in clinical outcome with cathartics

Enhancing elimination

• Multiple dose activated charcoal • Diuresis • Alkalinization • Hemodialysis • Hemoperfusion

Alkalinization• Enhances elimination of weak

bases by ion trapping• Useful for:

– Salicylates, phenobarbital, myoglobin

• NaHCO3 1-2 mEq/kg IV • Aim for Urine pH 7-8• Must replace K

Hemodialysis

• Blood passed across membrane with countercurrent dialysate flow

• Toxins removed by diffusionProperties required:

– Molecular weight < 500 daltons– Low or saturable plasma protein binding– Low Vd (<1L/kg)

Hemoperfusion• Blood passed through cartridge

containing AC• Toxins removed by adsorptionProperties required:

– Low Vd <1L/kg– Low endogenous clearance <4cc/min/kg– Adsorbable to AC

Substances amenable to hemodialysis or hemperfusion• LET ME SAV P

– Lithium– Ethylene glycol– Theophylline

– MEthanol

– Salicylates– Atenolol– Valproic acid

– Potassium, paraquat

Complications of hemodialysis

• Bleeding at venous puncture site• hypotension• Bleeding due to systemic

anticoagulation• Infection• Air embolus

AntidotesIf after stabilization a toxin is identified, there may be a specific antidote

Antidotes (Cont’d)

antidote poison

acetylcysteine acetaminophen

Crotalid Antivenin

Crotalid snake bite

atropine Carbamate or organophosphate

Ca gluconate or Ca chloride

CCB or hydrogen fluoride

Cyanide kit cyanide

Deferoxamine Iron

Digoxine immune Fab

Digoxin, digitoxin

Dimercaprol (BAL)

Arsenic, mercury, lead

antidote poison

ethanol MeOH, et glycol

flumazenil BDZ

Fomepizole MeOH

glucagon Β-blocker, CCB

Methylene blue

methemoglobin

naloxone opioids

physostigmine anticholinergic

pralidoxime organophosphate

pyridoxine isoniazid

Sodium bicarbonate

TCA, cocaine, salicylates

Summary• Airway with cervical spine control• Breathing• Circulation• Drugs (coma cocktail),

Decontamination• Elimination• Find an antidote• General management

Thank You

Bradycardia• Propanolol (β-blockers),

phenylpropanolamine (-agonists)• Anticholinesterase drugs(OPC)• Clonidine, CCBs• Ethanol / alcohols• Digoxin, Darvon (opiates)

Tachycardia• Free base (cocaine/stimulants)• Anticholinergics, antihistamines • Sympathomimetics• Theophylline (methylxanthines)

Hypotension• Clonidine• Reserpine (antihypertensives)• Antidepressants• Sedative hypnotics • Heroin (opiates)

Hypertension• Cocaine• Theophylline, thyroid supplements

• Sympathomimetics• Caffeine• Anticholinergics, amphetamines• Nicotine

Hyperthermia• Neuroleptic malignant syndrome• Antihistamines• Salicylates, sympathomimetics,

serotonin syndrome• Anticholinergics, antidepressants

Hypothermia• Carbon monoxide• Opiates• Oral hypoglycemics/insulin• Liquor (EtOH)• Sedative hypnotics

Seizures• Organophosphates• Tricyclic antidepressants• INH, insulin• Sympathomimetics

• Camphor, cocaine• Amphetamines, anticholinergics• Methylxanthines• Phencyclidine• Benzodiazepine withdrawal, botanicals• Ethanol withdrawal• Lithium, lidocaine• Lead, lindane

PupilsMiosis

•Opiates/organophosphates•Phenothiazines,

pilocarpine, pontine bleed•Sedative hypnotics•Cholinergics/clonidine

Mydriasis•Antihistamines•Antidepressants•Anticholinergics•Sympathomimetics

Odors• Bitter almonds – cyanide• Fruity – DKA, isopropanol• Minty – methyl salicylates• Rotten eggs – sulfur dioxide, hydrogen

sulfide• Pears – chloral hydrate• Garlic – organophosphates, arsenic• Mothballs - camphor

Radiodense substances that may be visible on

AXR• CHIPES

– Chloral hydrate– Heavy metals– Iron– Phenothiazines– Enteric coated preps– Sustained release preps

• Drug Packets

Questions

??

CPRCPRCPRCPR

CPR•Position of the patient.•Artificial respiration (mouth to mouth breathing=rescue

breathing)•Ext. Chest compression with monitoring the carotid or

femoral pulse.•Rate: (2 resp. /15 beats if one rescuer) or

(1 resp. /5 beats if two rescuers)•IV line, Oxygen, intubation NaHCO3,•Adrenaline 1 mg /5min IV.•Ca chloride.•DC shock

SEQUENCE OF ACTION

•1-Ensure safety of rescuer and victim•2-Check the victim & see if he

responds:gently shake his shoulders & shout loudly:”Are you all right”?

•3-If he responds by answering or moving---check him & get assistance

•If he doesn’t respond:shout for help

•4-Check position,airway open then•LOOK for chest movements•LISTEN at his mouth for breath

sounds•FEEL for air on your cheek•(for no more than 10 sec to

determine if he is breathing normally)

• 5- If he is breathing: Turn him into recovery position Check for cont. breathing Send for help If not:ask for assistance - turn him on his back - tilt head, chin lift -pinch soft part of his nose -open his mouth a little but maintain chin lift -take a breath,place your lips around his mouth, make

good seal -blow ,watch his chest take about 2 sec - give him 2 rescue breaths (each makes his chest rise & fall)

•6-ASSESS CIRCULATION:

LOOK LISTEN & FEEL for normal

breathing,coughing or any movement

Check pulse(for no more than 10 sec)

•7-If no signs of circ.(START CHEST COMPRESSION)

•Combine rescue breathing & comp.•After 15 comp. tilt head,lift chin & give 2

effective breaths and so on in a ratio of 15:2

•Stop to recheck for signs of circ only if he makes a movement or takes a spont

breath;otherwise resuscitation should not be interrupted

CONTINUE UNTIL??•QUALIFIED help arrives &

takes over

•The victim shows signs of life

•YOU become exhausted

Notes On Tech. Of BLSRESCUE BREATHING:

• only slight resistance should be felt• each one should take about 2 seconds• Blowing too quickly will force air into the

stomach & inc. the risk of regurgitation• each should make the chest rise clearly•The rescuer should wait for the chest to fall

fully during exp(about 2-4 sec)

CHEST COMPRESSION:•The aim is to press down approx.4-5 cm &

apply enough pressure to achieve this•Pressure should be firm,controlled &

applied vertically(erratic or violent action is dangerous)

•You should not waste time to check the presence of pulse.

•The presence of dilated pupils is an unreliable sign & shouldn’t influence