ABCs of Poisoning Care 2006.ppt

8/14/2019 ABCs of Poisoning Care 2006.ppt

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MANAGEMENT OF ACUTEPOISONING

Kent R. Olson, MD

Medical Director

California Poison Control System

San Francisco Division


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Lessons from history

A young princess ate part of an apple

given to her by a wicked witchShe was found comatose and

unresponsive, as if in a deep sleep

Airway positioning and mouth tomouth ventilation were performed, and

she recovered fully


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Lesson:

Best antidote is good supportive care

(Loves first kiss)


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Case 1:

Young woman found unconscious,

several empty pill bottles nearbyUnresponsive to painful stimuli

Shallow breathing


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Initial management: ABCDs

Airway

Breathing

Circulation

Dextrose, drugs, decontamination


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Airway issues

Risks:

Floppy tongue can obstruct airway

Loss of protective reflexes may permit

pulmonary aspiration of gastric contents

Major cause of morbidity in poisonedpatients


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Assessing the airway

Gag reflex

Indirect measure

May be misleading

Can stimulate vomiting

Alternatives


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Breathing

Assess visually

pCO2 reflects ventilation - ABG useful

pulse oximetry provides convenient,

noninvasive evaluation of O2

saturation


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Pitfalls

pO2 measures dissolved oxygen

can be normal despite abnormalhemoglobin states, eg COHgb, MetHgb

Pulse oximetry also fails to detect COpoisoning


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Interventions

Endotracheal intubation

Protects airway

Allows for mechanical ventilation

Reverse coma?

Naloxone: note T = 60 min

Flumazenil?


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Dont forget GLUCOSE

A stroke is never a stroke until its

had 50 of D50 Dr. Larry Tierney , 1976

Give Thiamine 100 mg IM or in IV


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Case 2

47 year old man calls 911, suicidal

BP 70/50, HR 50/min

Junctional rhythm

Hx: uses an antihypertensive


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Circulation = plumbing

Pump working?

Enough volume (is it primed)?

Adequate resistance (no leaks)?


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Management of Hypotension

Hypovolemia?

IV f luid chal lenge

Pump?

Dopamine

Inadequate vascular resistance? Norepinephr ine, phenylephr ine


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Antihypertensives

Diuretics

Beta blockersCalcium channel blockers

ACE Inhibitors

Centrally acting agents

Vasodilators


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Calcium channel blockers

Bad ODs!!

Low Toxic:Therapeutic ratioHigh mortality


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Negative

Inotropic

Effects

Decreased

Automaticity

& Conduction

Dilated Vascular

Smooth Muscle

SVRCOHR

AV Block

SHOCK


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Calcium antagonists - treatment

Calcium: most effective

High doses may be needed

Glucagonvariable results

Insulin plus glucose? (experimental)


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Case 3:

An 18 month old takes some of his

grandmothers sleeping pillsBrought to the ER after a seizure

HR 150/min

Pupils dilated, skin flushed, mucousmembranes dry


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Common causes of seizures

Amphetamines/cocaine

Tricyclic and other antidepressants

Isoniazid (INH)

Diphenhydramine

Alcohol withdrawal

Many others . . .


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30 minutes later, the ECG shows:


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Tricyclic antidepressants

Anticholinergic syndrome

Seizures

Cardiotoxicity


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TCA overdose treatment(similar tox possible w/ massive diphenhydramine)

Stop the seizures

Benzodiazepines, phenobarb i tal

Treat cardiotoxicity

Sodium bicarbonate 1 mEq/kg IV

IV f luids

Dopam ine and/or NE


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Case 4: now were cookin

24 year old man with Hx depression

Agitated, confused

BP 110/70 HR 120 RR 20 T 40.4 C

Muscle tone increased, LE clonus

Tox screen negative for cocaine,

amphetamines


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Drug-induced Hyperthermia

Heat StrokeMalignant Hyperthermia

Neuroleptic Malignant Syndrome

Serotonin Syndrome


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Drug-induced heat stoke

Altered judgment leads to excessive

sun/heat exposureAnticholinergic drugs prevent

sweating

Excessive muscle hyperactivity fromseizures, or from extreme agitation


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Malignant hyperthermia

Rare, familial myopathy

Triggered by general anesthesia Succinylcholine

Inhalational agents (eg, Halothane)

Muscle rigidity, hypermetabolic state

Treatment: dantrolene


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Neuroleptic Malignant Syndrome

Patient on dopamine-blocking drugs

Haloperidol classic cause Also with newer agents (eg, clozapine)

Rigidity (lead-pipe)

Autonomic instability

Hyperthermia


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Serotonin Syndrome

Current hot diagnosis

Serotonin-enhancing Rx SSRIs in OD or multiple combos

MAOI + serotonin-ergic drug

Hypertonicity/clonus (esp. lower extr.)

Autonomic instability

Hyperthermia


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Hyperthermia treatment

Act quickly!

Remove cloth ing sp ray and fan Sedat ion and ant iconvulsants PRN

Neuromuscu lar paralys is i f T >40 C

Dantroleneif NM paralys is ineffect ive

Consider bromoc ript ine, cyproheptadine


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Gut decontamination after OD

Goal: reduce systemic absorption

Induce vomiting? Pump the stomach?

Activated charcoal


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Ipecac-induced emesis

Easy to perform, but

not very effectiveContraindicated:

Comatose/convulsing

Ingested corrosive or hydrocarbon

Bottom line: nobody uses it anymore


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Pumping the stomach

Cooperation not required

MD sense ofcontrol

Punitive value?


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Gastric lavage

May stimulate gagging, vomiting

Risky if airway reflexes dulledLack of proven efficacy

Bottom line: used only rarely


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Activated charcoal

Finely divided powdered material

Huge surface area

Binds most drugs/poisons

Exceptions:

Lithium Iron


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Activated charcoal

More effective than SI, GL

First choice for most ODs


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Whole bowel irrigation

Mechanical flush

Balanced salt solution with PEG No net fluid gain/loss

Good for:

Iron Lithium

Sustained-release pills,foreign bodies


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Call the Poison Center

1-800-222-1222 - 24 hours

Immediate consultation byclinical pharmacists

Back-up by MD toxicologists

Identify pills, discuss diagnosis & Rx


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I dont think we should go up there, especially without a paddle

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