General Approach to Acutely Poisoned Patients

8/6/2019 General Approach to Acutely Poisoned Patients

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GENERAL APPROACH TOGENERAL APPROACH TO ACUTELY POISONED ACUTELY POISONED

PATIENTSPATIENTS

AYA KHATERSEPTEMBER , 2007

Faculty of Medicine,Ain Shams University.


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Obj ectivesObj ectives

To pr ovide a syst ema t ic a ppr oach t o t he re sus ci t a t ion , w o rk-up, diagno s is

and tr ea t men t of t he ac ut el yp oi s oned p a t ien ts.


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O utlineO utline Ca s e b a s ed a ppr oach t o:

Ini t ial st a b iliza t ion

Hi st o ryEval u a t ion of t he p oi s oned p a t ien t Techniq u e s t o pr even t a bs o rpt ion Techniq u e s t o enhance elimina t ion


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I mmediate Sta b ilizationI mmediate Sta b ilizationAirw a y w it h ce rvical sp ine con tr ol In tub a t e wha t do you w an t t o us e?

B rea t hing 100% O2 , ven t ila t ion

Circu la t ion In s e rt ne w IVs D ra w b lood s w it h IV st a rt Bol us 1 -2L NS

Ca rdiac moni t o rS ome t oxicological eme rgencie s r eq u ire sp ecific in t e rven t ion s d ur ing t he pr ima ry sur ve y ( eg .cyanide)


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Coma Cocktail Coma CocktailCurr en t DONT

Dex tr o s eOxygenNaloxone

Thiamine


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Dex tr o s eDex tr o s e Ra t ionale: Hyp ogl ycemia common ca us e of q LOC

D50W ( 50 - 100cc IV ) o r D2 5W 2-4 cc/ kg in p ed s

DDx h yp ogl ycemia Tox in su lin , o ral h yp ogl ycemic , EtO H, s alic y la t e s Non -t ox s e ps is, h yp e rt he rmia , he p a t ic fail ur e ,

m yxedema

Ca ut ion s dia b e t ic o r h yp e ro s mola r pts, ce re br al infa rc t


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ThiamineThiamine Co- fac t o r fo r pyru va t e deh yd rogena s e , and E-

ke t ogl ut a ra t e deh yd rogena s e .( Vit B1) Dec rea s ed level s in:

ch ronic live r d s, fola t e deficienc y, mala bs o rpt ion ,maln utr it ion , EtO H in t a ke

Deficienc y - We rnic ke s ence p halo p a t h y Op h t halmo p legia ,Nyst agm us. At axia Alt e red men t al st a tus

Dos e: 100 mg IVLitt le evidence t o supp o rt its us e , but s afe ,inex p en s ive , co st- effec t ive


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NaloxoneNaloxoneNa rcan - Pur e op ioid an tagoni st us ed fo rreve rs al of ac ut e in t oxica t ion

Diagno st ic and t he ra p e ut ic 0.4- 2 mg ( max 10mg) IV , IM , S C, ETT o rin tr aling u al

Ca ut ion s - Ass ocia t ed w it h life t h rea t ening

com p lica t ion s : s eiz ur e s, a rr h yt hmia s, ca rdiac a rr e st and

pr eci p it a t ion of violence


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Vital SignsVital Signs Hyp oven t ila t ion/h yp e rven t ila t ion Brad yca rdia PACED

Tach yca rdia FAS T Hyp o t en s ion CRAS H Hyp e rt en s ion CT S CAN Hyp e rt he rmia NAS A Hyp o t he rmia COOLSS eiz ur e s OTI S CAMPBELL


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Toxicologic Ph ys ical ExamToxicologic Ph ys ical Exam CNS level of a rous al , G CS, pup ils ,b ehavio ur, ne ur ologic exam

CVS ra t e , r h yt hm Re sp p a tt e rn , de pt h , w heezingGI b ow el s o u nd s, di st en t ion

Sk in colo r, t em p, s ign s of tr a u maOdo rs


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Toxid rome sToxid rome sSy m p a t homime t ic

Choline rgic

Ant icholine rgicOp ia t eS eda t ive h yp no t ic

Wit hd ra w al ( EtO H, BDZ , op ia t e s )


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Toxicological Hist o ryToxicological Hist o ryOf t en incom p le te , u n relia b le o ru no bt aina b le

S o ur ce s Pa t ien t, f r iend s, famil y, em ptydo s e tt e s o r p ill con taine rs

MHx, live r / renal di s ea s e , conc urr en tmedica t ion s, pr evio us ove rdo s e s,subst ance a bus e


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TheThe 5W s5W s of of t oxicolog yt oxicolog yWho pt s age , w eigh t, r ela t ion t o o t he rsWhat name and do s e of medica t ion ,coinge st an ts and amo u n t inge st edWhen t ime of inge st ion , s ingle vs.m u lt ip le inge st ion sWhere rout e of inge st ion , geog ra p hical

loca t ionWhy in t en t ional vs. u nin t en t ional


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La b o ra t o ryLa b o ra t o ryInve st iga t ion sInve st iga t ion s

Wha t la b t e sts s ho u ld w e o rde r?

Wha t sp ecial t e sts a re availa b le?


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La b o ra t o ry inve st iga t ion s ( con t d)La b o ra t o ry inve st iga t ion s ( con t d)

Gene ral la bs(r out ine): CBC , ECG,L FT,Elec tr ol yt e s, BUN, Cr, gl u co s e , ABG.

Sp ecial la b o ra t o ry inve st iga t ion indica t ed in follo w ing ca s e s In ten t ional inge st ion Subst ance u n kno w n Po ten t ial fo r mod t o s eve re t oxici ty


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La bs con s ide red e ss en t ial and availa b le :

E tO H, ace t amino p hen , s alic y la te ,digoxin , Ca rb amaze p ine , p heno b a rb,p hen yt oin , Val pr oa te , t heo p h y lline

Me t hanol , Et h y lene gl ycol , Is o pr op anol ,

I ron , L ithi u m Tox s creen doe s no t con tr ibut e t o p a t ien t managemen t

La b o ra t o ry inve st iga t ion s ( con t d)La b o ra t o ry inve st iga t ion s ( con t d)


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Addi t ional Te stsAddi t ional Te sts ECG TCA o r o the r ca rdio toxic d ru g s,a rr h yt hmia s, is chemia

Radiolog yCXR a sp ira t ion , nonca rdiogenic pu lmona ry edema

Ab dominal film s us ef u l in s creening fo ringe st ion s of radio - o p aq u e ma t e r ial s

Wha t subst ance s a re vis ib le on AXR?


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DEC ON TAMI NATI ONDEC ON TAMI NATI ON DERMAL: OP C,Ca rb olic acid .( r emove clo t he s,w a s h w it h s oa p & w a t e rfo r 15 min , NO f orce ful r ubbi ng)

EYE:w a s h conj . Wi t h ru nning w a t e r o rs aline fo r 2 0 min .

Inhala t ion:C O , CN.

1 . Remove t o f re s h ai r2. Ca re of re sp.

GIT


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Ip ecacIp ecacEmetic b oth peripherally and central acting>90% effectiveDose 30cc P O :adults, 15cc >2yrs, 10cc 6-2yrs.I F failed within 30 m,repeat,if not then GL..

Advantages Safe Efficient Less traumatic

Contraindications

- Su b stance- Patient- Time passed

Complications Diarrhea, lethargy/drowsiness, prolonged vomiting


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Never Never Never

( Us e S al ty H2O ) ????


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Ga str ic LavageGa str ic Lavage 36 -4 0 Fr NG, s eq u en t ial in st illa t ion and removal of s mall vol u me s of is o t onic flu id

Indica t ion s Recen t inge st ion (< 1 -2 h r ) Exceed s ad s o rpt ive ca p aci ty of ini t ial AC

do s ingAgen ts no t ad s o rb ed by AC Subst ance s likel y t o fo rm conc re t ion s

af t e r ove rdo s e Subst an t ial r isk of t oxici ty, o r q LOC

req u ir ing in tub a t ion ( chlo roq u ine ,colchicine , TCA, CCB s )


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Ga str ic LavageGa str ic Lavage Con tr aindica t ion s

A bs o lu te Co rr o s ive s, f ro t h - fo rmingRe l at iv e

Un pr o t ec t ed ai rw a y, comaConv u ls ion sHyd roca rb on sRisk of GI b leed o r p e r fo ra t ionTime fac t o r (u nle ss dela yed)

Com p lica t ion sAsp n p ne u monia , la ry ngo sp a s m , h yp oxia ,mechanical inj ury, flu id/elec tr olyt e im b alance s,br ad yca rdia , h yp e rt en s ion


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Act iva t ed Cha rcoalAct iva t ed Cha rcoal 1g/ kg PO o r NG Indica t ion s

Wi t hin 1 ho ur of inge st ion Nea r ly all susp ec t ed t oxic inge st ion s except Ma y b e con s ide red mo re t han 1 ho ur af t e r inge st ion but

in su fficien t da t a t o supp o rt o r excl u de us e Con tr aindica t ion s

Un pr o t ec t ed ai rw a y When AC t he ra py ma y inc rea s e r isk and s eve r ity of

a sp ira t ion Co rr os ive s (why??) , IO, h yd roca rb on s ,NOT A DSO RBE D.

Com p lica t ion s GIT obstru c t ion , con st ip a t ion , ad s o rb medica t ion


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Dru g s t ha t don t ad s o rb t o Dru g s t ha t don t ad s o rb t o ACAC

PHAI LS Pe st icide s ???

H yd roca rb on s, Heav y me t al s ( Fe , Hg ,Pb ) Acid s /Alkali s /Alcohol s I ron Lit hi u m S olven ts Ga s e s


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INDIC AT ION S INDIC AT ION S OF OF

M D A C M D A C Dru g s r emain in GIT:S R-pr e p : t heo p h y lline

conc re t ion s : s alic y l. P heno b a rb it.s lo w ing GIT mo t ility :an t ichol .

EHC:digoxine , da ps on , TCA

Pa ss ive diff us ion f rom b l t o lo w e r G I lu men: t heo p h y lline .


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Mu lt ip le Do s e Act iva t ed Mu lt ip le Do s e Act iva t ed Cha rcoalCha rcoal

Con s ide r onl y if life -t h rea tening amo u n tof: Ca rb amaze p ine Pheno b a rb it al Da ps one Q u inine Theo p h y lline

May al s o inc rea s e elimina t ion of : ami tr ipty line , pr o p ox yp hene , digi t oxin ,

digoxin , di s opyr amide , nadolol ,p hen y lbut azone , p hen yt oin , p iroxicam , s o t alol


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Whole b ow el irr iga t ionWhole b ow el irr iga t ionPEG via NG a t 1 -2 L /h ( 500cc/h in p ed s ) u n t il effl u en t clea r

Indica t ion s Po ten t iall y t oxic inge st ion of S R pr e pInge st ed p ac ke ts of illici t d ru g (stu ffe rs,

p ac ke rs ) Subst ance s no t ad s o rb ed by AC I ron inge st ion s


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Whole b owel Irr iga t ionWhole b owel Irr iga t ion Con tr aindica t ion s

Bo w el p e r fo ra t ion o r o bstru c t ion GI b leed Ile us Un pr o tec t ed ai rw a y Hemod ynamic in st a b ility

In tr ac t a b le vomi t ing Com p lica t ion s Na us ea , vomi t ing , a sp ira t ion , cram ps


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Enhancing eliminationEnhancing elimination Mu lt ip le do s e ac t iva t ed cha rcoal Diur e s is

Alkaliniza t ion Hemodial ys is Hemo p e r f us ion


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Alkaliniza t ionAlkaliniza t ion Enhance s elimina t ion of w ea k b a s e sby ion tr a pp ing

Us ef u l fo r : S alic y la te s, p heno b a rb ital ,

chlo rpr o p amide , me tho tr exa te ,m yoglo b in

NaHC O3

1 -2 mEq/ kg IV Aim fo r Ur ine p H 7-8 Must r e p lace K


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Hemodial ys isHemodial ys is

Blood p a ss ed ac ro ss mem br ane w ith co u n te rcurr en t dial ys a t e flo w

Toxin s r emoved by diff us ionP ropert i e s req ui red :

Molec u la r w eigh t < 500 dal t on s High w a t e r s olub ility Lo w o r s a tur a b le p la s ma pr o t ein b inding Lo w Vd (< 1 L / kg) Lo w endogeno us clea rance (


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Hemo p e r f us ionHemo p e r f us ion Blood p a ss ed t h rou gh ca rtr idge con t aining AC

Toxin s r emoved by ad s o rpt ionP ropert i e s req ui red : Lo w Vd < 1 L / kg Lo w endogeno us clea rance


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Su b stances amena b le toSu b stances amena b le to

hemodialysis or hemperfusionhemodialysis or hemperfusionLET M E SA V P Lit hi u m E t h y lene gl ycol Theo p h y lline

ME t hanol

S alic y la t e s

At enolol Val pr oic acid

P o t a ss iu m , p a raq u a t


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An t ido t e sAn t ido t e sIf af t e r st a b iliza t ion a t oxin isiden t ified , t he re ma y b e a sp ecific an t ido t e


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An t ido t e sAn t ido t e s ( Con t d)( Con t d)

an t ido t e p oi s on

ace ty lcyst eine ace t amino p hen

Cro t alid An t ivenin

Cro t alid s na ke b it e

a tr op ine Ca rb ama t e o r

o rgano p ho sp ha t eCa gl u cona t e o rCa chlo r ide

CCB o r h yd rogen flu o r ide

Cyanide k it cyanideDefe roxamine I ron

Digoxine imm u ne Fa b

Digoxin , digi t oxin

Dime rca pr ol ( BAL)

Ars enic , me rcury,lead

an t ido t e p oi s on

e t hanol Me OH, e t gl ycolflu mazenil BDZFome p izole Me OHgl u cagon -b loc ke r, CCB

Me t h y lene b lu e me t hemoglo b innaloxone o p ioid s

p h ys ost igmine an t icholine rgicpr alidoxime o rgano p ho sp ha t e

pyr idoxine i s oniazidS odi u m b ica rb ona t e

TCA, cocaine ,s alic y la t e s


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Su mma rySu mma ryAirw a y w it h ce rvical sp ine con tr olB rea t hingCircu la t ionD ru g s ( coma coc kt ail) ,D econ t amina t ionElimina t ionFind an an t ido t eGene ral managemen t


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BradycardiaBradycardiaP rop anolol ( -b loc ke rs ) ,p hen y lpr op anolamine ( E- agoni sts )

An t icholine st e ra s e d ru g s(OP C)Clonidine , CCB sE t hanol / alcohol s

D igoxin , Da rvon ( op ia t e s )


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TachycardiaTachycardiaF ree b a s e ( cocaine/ st im u lan ts )An t icholine rgic s, an t ihi st amine s

S ym p a t homime t icsTheo p h y lline ( me t h y lxan t hine s )


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H ypotensionH ypotensionClonidineR e s e rp ine ( an t ih yp e rt en s ive s )

An t ide pr e ss an tsS eda t ive h yp no t icsH e roin ( op ia t e s )


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H ypertensionH ypertensionCocaineTheo p h y lline , t h yr oid supp lemen ts

S ym p a t homime t icsCaffeine

An t icholine rgic s, am p he t amine sN ico t ine


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H yperthermiaH yperthermiaN e ur ole pt ic malignan t sy nd romeAn t ihi st amine s

S alic y la t e s, sy m p a t homime t ics,s e ro t onin sy nd romeAn t icholine rgic s, an t ide pr e ss an ts


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H ypothermiaH ypothermiaCa rb on monoxideO p ia t e s

O ral h yp ogl ycemic s /in su linLiq u o r ( EtO H)S eda t ive h yp no t ics


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SeizuresSeizuresO rgano p ho sp ha t e sTr icyclic an t ide pr e ss an tsI NH, in su linS ym p a t homime t ics

Cam p ho r, cocaineAm p he t amine s, an t icholine rgic sMe t h y lxan t hine sP henc yclidineBenzodiaze p ine w it hd ra w al , b o t anical sE t hanol w it hd ra w alLit hi u m , lidocaineLead , lindane


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Pup ilsPup ilsMiosis

O p ia t e s /o rgano p ho sp ha t e sP heno t hiazine s,

p iloca rp ine , p on t ine b leedS eda t ive h yp no t icsCholine rgic s /clonidine

Mydriasis An t ihi st amine s An t ide pr e ss an ts An t icholine rgic sS ym p a t homime t ics


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Odo rsOdo rs Bitt e r almond s c yanide Fru ity DKA, is o pr o p anol Minty me t h y l s alic y la t e s Rott en egg s su lf ur dioxide ,h yd rogen su lfidePea rs chlo ral h yd ra t eGa r lic o rgano p ho sp ha t e s, a rs enic

Mot h b all s - cam p ho r


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Radioden s e subst ance s t ha tRadioden s e subst ance s t ha tma y b e vis ib le on AXRma y b e vis ib le on AXR

CHIPES C hlo ral h yd ra t e H eav y me t al s I ron Pheno thiazine s E n t e r ic coa ted pr e ps S ust ained relea s e pr e ps

Dru g Pac ke ts


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Q uestionsQ uestions


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C PRC PR


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C PRC PRPo s it ion of the p a t ien t.

Art ificial re sp ira t ion ( mo ut h t o mo ut h br ea thing= re s cu e br ea t hing)

Ext. Che st com pr e ss ion w ith moni to r ing the ca ro t id o r femo ral pu ls e .

Ra t e: (2 r e sp. /15 b ea ts if one re s cu e r ) o r ( 1 re sp. /5 b ea ts if tw o re s cu e rs )

IV line , O xygen , in tub a t ion NaHC O3 , Adrenaline 1 mg /5min IV . Ca chlo r ide . DC s hoc k


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SEQUE NC E OF AC T ION SEQUE NC E OF AC T ION 1- En sur e s afe ty of re s cu e r and vic t im2- Chec k t he vic t im & s ee if he re

spond

s:gen

tly s

hak

e hi

s sho

ulde

rs& s ho ut lo u dl y : Are you all right?

3- If he re sp ond s by an sw e r ing o rmoving --- chec k him & ge t a ss ist ance

If he doe s n t r e sp ond: s ho ut fo r hel p


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4- Chec k p o s it ion , ai rw a y op en t henL OO K fo r che st movemen tsL I STE N a t hi s mo ut h fo r br ea t h s o u nd sF EE L fo r ai r on your chee k( fo r no mo re t han 10 s ec t o de t e rmine if he is br ea t hing no rmall y )


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5- If he is br ea t hing:

Tur n him in t o recove ry p o s it ionChec k fo r con t. br ea t hingS end fo r hel p

If no t :a sk fo r a ss ist ance- tur n him on hi s b ac k- t ilt head , chin lif t-p inch s of t p a rt of hi s no s e- o p en hi s mo ut h a litt le but main t ain chin

lif t-t a ke a br ea t h ,p lace yo ur lips a rou nd hi s mo ut h ,

ma ke good s eal-b lo w ,w a t ch hi s che st t a ke a b o ut 2 s ec- give him 2 r e s cu e br ea t h s

( each ma ke s hi s che st r is e & fall)


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6- ASSESS CI R C U L AT ION:

L OO K L I STE N & F EE L fo r no rmal br ea t hing , co u ghing o r an y movemen t

Chec k pu ls e ( fo r no mo re t han 10 s ec)


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7- If no s ign s of circ . ( ST A RT CH E ST C OM P RE SSION )C om b ine re s cu e br ea thing & com p.

Af t e r 15 com p. t ilt head , lif t chin & give 2effec t ive br ea t h s and s o on in a ra t io of 15: 2St op t o rechec k fo r s ign s of circ onl y if he ma ke s a movemen t o r t a ke s a sp on tbr ea th;o t he rw is e re sus ci t a t ion s ho u ld no t

b e in t e rrupt ed


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N otes O n Tech. O f B L S N otes O n Tech. O f B L S RES C UE BREATH ING :

onl y s ligh t r e s ist ance s ho u ld b e fel t each one s ho u ld ta ke a b out 2 s econd s Blow ing too q u ick ly w ill fo rce ai r in t o t he st omach & inc . t he r isk of reg ur gi t a t ion

each s ho u ld ma ke t he che st r is e clea r ly

The re s cu e r s ho u ld w ai t fo r t he che st t o fall f u lly d ur ing ex p( a b out 2-4 s ec)


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C HEST CO MPRESS ION:

The aim is t o pr e ss do w n a ppr ox .4- 5 cm & a pp ly eno u gh pr e ssur e t o achieve t hi sPr e ssur e s ho u ld b e firm , con tr olled & a pp lied ve rt icall y( e rr a t ic o r violen t ac t ion is dange ro us )

You s ho u ld no t w a st e t ime t o chec k t he pr e s ence of pu ls e .

The pr e s ence of dila t ed pup ils is an u n relia b le s ign & s ho u ldn t infl u ence


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General Approach to Acutely Poisoned Patients

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