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?

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