Poisoning

AKA: Stupid sailor/marine tricks.Tina F. Edwards, MD FAAEM

LCDR MC USN

Toxicology, in a nutshell

OSupportive careOSeizure, coma, death

Conclusion

OQuestions? OJust Kidding!

OverviewO Basics of the poisoned patientO AnticholinergicsO CholinergicsO SedativesO SympathomimeticsO Carbon MonoxideO Toxic Alcohols

What is a poison?O Too much of anything can be a bad

thing.

Why primary care? O Jus’ gonna send this patient to ED!O RecognizeStabilizeO YOU might be the ED

BasicsO Stable or unstable?

O Abnormal Vital signsO Respiratory distressO Altered Mental Status

BasicsO Nature of the syndrome?

O Mental statusO Agitated vs. SedatedO PupilsO SkinO VitalsO Mucous membranesO Odors

BasicsO Emetics. Don’t. O Charcoal, maybe.O Aggressive supportive care:

O IV, monitors, fluidsO If it’s fast, slow it.O If it’s slow, speed it up.O If it’s low, raise itO If it’s high, lower it.

Common Causes of Seizures

O BupropionO Tricyclic Antidepressants*O TramadolO Isoniazid*O Cocaine, amphetaminesO AntihistaminesO Venlafaxine (Effexor)

WorkupO EKGO Finger stick blood

sugarO ChemistryO Blood GasO CBCO Tylenol, Aspirin, EtOHO UAO CXR,KUB

TreatmentsO Got Activated Charcoal?

O 1 hour +/-O CautionsO Ineffective

O AlcoholsO MetalsO Caustic agents

TreatmentsO DecontaminationO Naloxone

(Narcan)O BenzodiazepinesO DialysisO AntidotesO Sodium Bicarb

So there you are minding your own

business…When...

19 yr old AD Female

O Oriented x 1O AgitatedO 140, 156/92, 20,

101.2, 98%O Dry skin, MM’sO Hypoactive BS

Anticholinergic Toxidrome

O BenadrylO Cough syrupO TCA’sO ScopolamineO DM

Anticholinergic Toxidrome

O Flushed, dry skin, dry mucous membranes

O MydriasisO DeliriumO Hyper: -thermia, -tensionO TachycardiaO Urinary retentionO Hypoactive BS

Anticholinergic Treatment

O Aggressive supportive careO Physostigmine Why?

O Can’t use if any QRS wideningO Contraindicated in asthmaO Requires continuous cardiac

monitoringO Usually won’t outlast the

anticholinergic

24 yr old AD maleO C/O frequent diarrhea,

vomitingO Fatigued, mildly confusedO Acrid garlic smellO 112/62, 52, 18, 98.2,

95%O Productive coughO TearingO Frequent spittingO Muscle twitches

Cholinergic Toxidrome

O MuscarinicO NicotinicO Central

O CausesO InsecticidesO PilocarpineO CarbacholO Betel nutsO Indian

TobaccoO NicotineO Black widow

Cholinergic ToxidromeO Nicotinic

O TachycardiaO HypertensionO Fasciculation'sO WeaknessParalys

is

Cholinergic ToxidromeO Central

O AgitationO Psychosis/

confusionO Seizure/coma/

death

Cholinergic PoisoningO Muscarinic

O DiarrheaO UrinationO MiosisO BradycardiaO BronchorrheaO EmesisO Lacrimation,

salivation

Cholinergic treatmentO Protect yourself!O Stabilize, then decontaminateO Atropine until dryO Pralidoxime currently recommendedO Aggressive supportive care

17 yr old boyO Brought in by momO C/C “not himself”O Sedated, barely

responsiveO Disheveled O 90/58, 52, 10, 97.2,

94%O CracklesO Decreased BSO Hypotonic reflexes

Opioid ToxidromeO Classic Triad

O ComaO Respiratory

DepressionO Pinpoint pupils

Opioid ToxidromeO Causes

O All the usual, plus LomotilO Dextromethorphan

O But wait!

O Random fact:O Not all opioids cause miosis

O Meperidine (Demerol)O Propoxyphene (Darvon)

Opioid TreatmentO NaloxoneO Aggressive supportive care

19 year old AD maleO Brought in by

roommate, “Seized”O Moans, doesn’t open

eyesO 88/52, 101, 10, 95.8,

93%O PERRL, but slowed O Nystagmus

Sedative Hypnotic Toxidrome

O BarbituatesO BenzodiazapinesO GHBO Zolpidem

(Ambien)O Zaleplon (Sonata)

O Confusion/comaO Respiratory

depressionO HypotensionO HypothermiaO Pupillary changes O Vesicles or bullaeO Seizures

Sedative-hypnotic treatment

O Aggressive supportive careO Airway managementO Multiple-dose activated charcoalO Phenobarbital may require dialysis

A note about flumazenilO Why?

O Can precipitate seizuresO Absolutely contraindicated in QRS

wideningO Doesn’t reverse Hypoventilation

What to do?

23 yr old AD maleO Brought in by

command, “not acting right”

O AnxiousO 180/110, 142, 18,

103.2, 100%O Flushed, sweatingO A+O x 3

Sympathomimetic Toxidrome

O CocaineO MethamphetamineO Other CNS StimulantsO Withdrawal from sedative hypnotics

Sympathomimetic Toxidrome

O HypertensionO TachycardiaO HyperpyrexiaO MydriasisO Anxiety or

delirium

Sympathomimetic treatment

O Aggressive supportive careO BenzodiazepinesO Active cooling if needed

What to do?

34 yr old AD maleO Losing balance,

headache, chest pain, vomiting

O 100/72, 120, 32, 98.7, 99%

O A+O x 2O Accessory muscle

use

EKG

Carbon Monoxide Poisoning

O Signs/Sx highly variable, non-specificO HeadacheO DizzinessO Nausea/Vomiting/DiarrheaO ConfusionO SyncopeO SOBO Chest painO Cerebellar ataxia

Mechanism CO Poisoning

O Running engine, closed spaceO MechanicsO Suicide attemptO GeneratorsO Gas heatersO Camp stoves/Charcoal grills

CO Poisoning Treatment

O Oxygen, more is betterO Aggressive supportive careO Mild to moderate acidosis is helpful

O Moves curve to right

23 yr old ADO Sent “I want to

die” textO A+O x 1O 102/62, 110, 12,

97.3, 97%O Covered in vomitO Slurred speechO Ataxic gait

Toxic AlcoholsO Ethanol!O Ethylene GlycolO MethanolO Isopropanol/

AcetoneO Other glycols

Toxic AlcoholsO Ethylene glycol – Ca oxalate

monohydrate crystalsO Methanol – Formic acidO Isopropanol – Acetone

Toxic AlcoholsO All – Airway compromiseO Ethylene Glycol

O DysrhythmiasO NephrotoxicityO MeningoencephalitisO Cerebral/pulmonary edema

Toxic AlcoholsO Methanol

O Visual symptoms, “snowfields”O ComaO Respiratory and circulatory failureO Parkinson-like syndrome

Toxic AlcoholsO Isopropanol

O KetonemiaO CNS Depression (2 x EtOH)O GI effectsO Increased Cr w/nl BUN suggests

Toxic AlcoholsO Other glycolsO Effects

O Neurologic toxicity

O Renal failureO HepatitisO PancreatitisO HemolysisO ARDS

Toxic AlcoholsO Diethylene glycol

O Renal failure epidemicsO Propylene glycol

O “safer” antifreezeO Iatrogenic, IV Benzos

Toxic AlcoholO Aggressive supportive care! O FomepizoleO Plain ol’ ethanolO Look for acidosis, ketones, other

clues

Are you ready?

24 year old maleO Found down

outside barracksO 90/54, 48, 8,

92%, 96.2O Non responsiveO PERRL

18 year old AD femaleO Witnessed

seizureO 160/102, 120, 22,

102.4, 99%O Flushed, DryO Pupils dilated,

reactiveO Absent bowel

sounds

22 year old AD maleO Working outsideO VomitingO 190/120, 130, 24,

104.2, 95%O DiaphoreticO Rigid, shakingO Smells of stoolO Pupils pinpoint,

reactive

SourcesO Harwood-Nuss, Clinical Practice of Emergency Medicine,

5th Edition, Lippincott Williams & Wilkins, Philadelphia, PA, 2010

O Hamilton, Sanders, Strange, Trott. Emergency Medicine, An Approach to Clinical Problem Solving, 2nd Edition. Saunders. Philadelphia, PA. 2003.

O http://www.mrcophth.com/plants.htmlO http://memorize.com/toxidromes-and-antidotes/erichfO http://emedicine.medscape.com/article/812411-clinicalO Thundiyil JG, et. al, Evolving epidemiology of drug-

induced seizures reported to a Poison Control Center System. J Med Toxicol, 2007, Mar, 3(1):15-9.

Questions