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Management of Acute Overdose
By: Peter RempelMarch 27th, 2013
Presentation Outline Introduction and Statistics
General management strategy
Identification of Toxidromes
Management of overdose for specific medications
Role of pharmacist
Introduction - Overdose Definition: The use of a substance in quantities greater
than recommended. Accidental vs. Intentional misuse
Epidemiology - Overdose Approximately 2.3 million cases reported (US)
50% caused by pharmaceutics
41,592 deaths occurred in the US (2009) 76% were unintentional
91% caused by medications
Prevalence higher in males during the early years (0-12y) Rates in females surpass males in older populations
Epidemiology (Continued)Most common pharmaceutics: Analgesics (Opioids) Sedative/hypnotic/antipsychotics Antidepressants Antihistamines Cardiovascular drugs Vitamins, cough and cold products
Rates of unintentional overdose has been steadily increasing
General Management Strategy1) ABC management (vital signs)2) Call Poison Control3) Obtain best possible medical history4) Order Labs5) Prevent absorption of toxin6) Enhance elimination (antidote)
General management strategy1) ABC management
• Airway patency- head-tilt and chin-lift, removal of obstructions
• Breathing- assisted ventilation
• Circulation- colour change, sweating, decreased LOC- EKG, saline infusion, vasopressers
General Management Strategy2) Call Poison Control
Available 24/7 to provide poison treatment information Help guide treatment strategy Prevent unnecessary use of health care resources http://www.capcc.ca/provcentres/on/on.html
General Management Strategy3) Obtain accurate history
Determine the causative agent Dose Time since exposure Route Demographics (age, weight) Symptoms* Physical Examination
What if you don’t know what medication/poison was
ingested?
Identification of Toxidromes
What is a Toxidrome? Characteristic symptoms that are associated with a
specific group of medications.
These group of symptoms are known as a “Toxidrome”
Identification of ToxidromesCholinergic Toxidrome “SLUDGE”
Salivation, Lacrimation, Urination, Defecation, GI upset, Emesis Miosis, diaphoresis, bradycardia
Causative Agents: Physostigmine, Organophosphates, Carbamate
Identification of ToxidromesAnticholinergic Toxidrome Hot as a Hare - fever Red as a Beet - flushing Mad as a Hatter – confusion, delirium Dry as a bone – dry skin/mucus membranes Mydriasis, tachycardia, urinary retention
Causative Agents: Antihistamines, TCA`s, Anti-parkinson medications
Identification of ToxidromesSympathomimetic Toxidrome Anxiety, Delusions, Sweating, Piloerrection, Seizures,
Hyperreflexia, Mydriasis
Causative Agents: cocaine, salbutamol,, amphetamines, ephedrine, pseudoephedrine, methamphetamine
Identification of ToxidromesSedative/Hypnotic/Opiate Toxidrome Slurred speech, confusion , stupor, coma, apnoea,
respiratory depression Hypotension, bradycardia, miosis
Causative agents: opioids, anticonvulsants, antipyschotics, barbiturates, benzodiazepines, ethanol
Back to the Management Strategy
General Management Strategy4) Order lab tests
Confirm offending agent(s) Predict prognosis Direct therapy/monitoring
Includes: Toxicology screen, anion gap, osmol gap, CBC, BUN, SCr, blood glucose, electrolytes, EKG monitoring
General Management Strategy5) Prevent absorption *Activated Charcoal- first line therapy in most emergency
departments Whole Bowel Irrigations- clears the GI tract using high
volumes of PEG Orogastric Lavage- No benefit over the use of activated
charcoal Syrup of Ipecac- NO LONGER RECOMMENDED
http://www.freepatentsonline.com/7077825.html
General Management StrategyActivated Charcoal Ability to adsorb substances due to its high surface
area Offending agent(s) become trapped by the charcoal
and are excreted in the fecesDosing: 1g/kg po OR by NG tube (usually given multiple
times)AE: aspiration pneumonia, GI obstructionContraindications: presence of ileus
General Management StrategyActivated Charcoal Does not adsorb the following compounds:
Iron Lithium Lead Cyanide Alcohol
General Management Strategy6) Enhance Elimination Hemodialysis/Hemoperfusion Administer Antidote
General Management StrategyAdminister Antidote:
*See my website for a more exhaustive listwww.ODmanagement.weebly.com
Offending Agent Antidote
Tylenol N-acetylcysteine
Anticholinergics Physostigmine
Benzodiazepines Flumazenil
CCB Glucagon, Calcium
Beta Blockers Glucagon
Opioids Naloxone
Opioid Overdose Managment
Opioid Overdose ManagementSigns and Symptoms?
Hint: Remember the toxidrome!
Opioid Overdose ManagementSigns and Symptoms?
Hint: Remember the toxidrome! Decreased LOC, RR, GI motility Hypotension, bradycardia, miosis
Naloxone Reverses effects from opioid overdose Pure opioid receptor antagonist Duration of action 30-120 minutes 0.4-2mg (IV,IM,SC); repeat q2-3 minutes until reversal of
symptoms Use continuous IV infusion for exposure to long-acting
opioids or SR formulations
Acetaminophen Overdose
Hamm J. Acute acetaminophen overdose in adolescents and adults.Critical Care Nurse; Jun 2000; 20(3) 69-74
Hamm J. Acute acetaminophen overdose in adolescents and adults.Critical Care Nurse; Jun 2000; 20(3) 69-74
N-acetylcysteine Indicated for the reversal of Acetaminophen toxicity Hepatoprotective agent Restores hepatic glutathione and acts as a glutathione
substitute Prevents the production of the toxic by-product of
acetaminophen
N-acetylcysteine Dosing 21 hour IV dosing regimen (3 doses)
LD: 150 mg/kg (Max 15g) over 1 hour 2nd dose: 50 mg/kg (max 5g) over 4 hours 3rd dose: 100 mg/kg (max 10g) over 16 hours
Oral dosing regimen also available (72 hours) Therapy is guided by the Matthew-Rumack
Nomogram
Matthew-Rumack Nomogram
The Merck Manual for Health Professionals. Acetaminophen Poisoning.http://www.merckmanuals.com/professional/injuries_poisoning/poisoning/acetaminophen_poisoning.html
Anaesthetic Overdose/Refractory Cases
Lipids 20%- Intralipid® Used in anaesthetic overdose and refractory cases
(unlabelled use) Mechanism unknown Effective for lipophilic medication overdose Suggested Dose:
1.5 mL/kg bolus infused over 1 minute (may repeat up to 2 times) Followed by 0.25 mL/kg/minute continuous infusion
http://www.lipidrescue.org/
Role of the Pharmacist Role in both the community and hospital setting
Educating patients on the dangers of drug misuse
Identifying potential at risk patients
Identifying inappropriate medication regimens
Medication Reconciliation
Highlights Majority of overdoses are accidental
Rates of accidental overdose is steadily increasing
Identifying Toxidromes plays a vital role in the management of overdose
Activated charcoal and whole bowel irrigation are effective at lowering absorption
Pharmacists can play a role in both the prevention and treatment of an overdose
References1) Clinical Practice Guidelines. Management of Drug Overdose
& Poisoning. Ministry of Health, Singapore. May 2000.2) Green SL, Dargan PI, Jones AL. Acute poisoning:
understanding 90% of cases in a nutshell. Postgrad Med J. 2005;81:204-216.
3) Tenenbein M et al. Efficacy of ipecac-induced emesis, orogastric lavage, and activated charcoal for acute drug overdose. Annals of Emergency Medicine; 16(8): 838-841
4) Lab Tests Online. Emergency and Overdose Drug Tests. http://labtestsonline.org/understanding/analytes/emergency/tab/test: Accessed March 22, 2013
5) Thim T, Niels HV, et al. Initial assessment and treatment with the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach. International Journal of General Medicine; 2012:5 117-121
References 6) Centers for disease control and prevention. Home and
Recreational Safety. Unintentional Poisoning Data and Statistics. Retrieved from http://www.cdc.gov/HomeandRecreationalSafety/Poisoning/data.html ; accessed March 3, 2013
7) Hodgman MJ et al. A review of Acetaminophen Toxicity. Crit Care Clin. 28 (2012) 499-516
8) G Cave et al. Intravenous Lipid Emulsion as Antidote Beyond Local Anesthetic Toxicity: A Systematic Review. Academic Emergency Medicine: 2009; 16:815-824
9) Boyer EW. Management of Opioid Analgesic Overdose.. N Engl J Med: 367;2 146-155
Thank you for listening
ANY QUESTIONS?
www.odmanagement.weebly.com