Bacterial Food Infection/Poisoning
• Signs/Symptoms – Nausea, vomiting– Abdominal cramps– Diarrhea– History of eating same foods in same place
as others with similar symptoms
Bacterial Food Infection/Poisoning
• Management– Prevention
• Cook thoroughly• Keep hot foods hot• Keep cold foods cold
– Replace lost fluids, electrolytes– Antiemetic agents
Botulism
• Pathophysiology– Neurotoxin from Clostridium botulinum– Produced in anaerobic environment at pH >4.6– Boiling will destroy toxin– Toxin binds to cholinergic nerve terminals;
Blocks acetylcholine release
Botulism
• Signs/Symptoms– GI upset– Dry mouth – Double vision (diplopia)– Drooping eyelids – Slurred speech– Descending paralysis - respiratory arrest
Beta Blockers
• Signs/Symptoms– Bradycardia– Hypotension, shock– AV blocks– Prolonged QRS complex– Heart failure– Bronchospasms
Beta Blockers
• Management– Bradycardia
• Atropine 0.5 - 1.0 mg• Glucagon 5mg every 30’• Cardiac pacing
– Hypotension• Glucagon 5mg every 30’• Dopamine 5mcg/kg/min
Calcium Channel Blockers
• Signs/Symptoms– Bradycardia– Hypotension, shock– AV blocks– Heart failure– QRS prolongation does NOT occur
Calcium Channel Blockers
• Management– Calcium reverses decrease in contractility– Fluid infusion increases BP
Digitalis
• Signs/Symptoms– Central Nervous System
• Headache• Irritability• Psychosis• Yellow-green vision
– Gastrointestinal• Anorexia• Nausea, vomiting
Digitalis
• Signs/Symptoms– Cardiac
• Atrial tachycardia with block• Non-paroxysmal junctional tachycardia• PACs, PJCs, PVCs
Tachyarrhythmias + Blocks =>Digitalis toxicity
Digitalis
• Management– ABC’s, oxygen– Check electrolytes, correct hypo/hyperkalemia– Atropine: bradycardia with hypotension– Dilantin: ectopy– Lidocaine/magnesium sulfate: ventricular ectopy– Digtalis immune Fab Fragments (Digibind)
Digitalis
• Precautions– Cardioversion, pacing attempts may cause VF– Vagal stimulation may cause bradycardia, AV
blocks– Calcium may worsen ventricular arrhythmias
TCAs
• Mechanism of Toxicity: Cardiovascular– Alpha-adrenergic blockade: vasodilation– Anticholinergic effects: tachycardia, mild hypertension– Quinidine-like effects: myocardial depression– Inhibition of sodium channels: conduction defects– Metabolic or respiratory acidosis may contribute to
cardiotoxicity by inhibition of fast sodium channels
TCAs
• Mechanism of Toxicity: CNS– Anticholinergic effects: sedation, coma– Inhibition of NE, serotonin re-uptake: seizures
Anticholinergic Effects
• Sedation, coma, delirium• Dilated pupils• Dry skin, mucous membranes• Tachycardia• Decreased bowel sounds• Urinary retention• Myoclonic jerking (often mistaken for seizures)
Cardiovascular Effects
• Arrhythmias, abnormal conduction, hypotension• Prolongation of PR, QRS, QT intervals
(QRS > 0.12 is a good predictor of toxicity) • Various degrees of AV block• Hypotension caused by vasodilatation• Cardiogenic shock• Pulmonary edema
Seizures
• Common with TCA toxicity• Recurrent or persistent• Combined with diminished sweating can lead to
– Severe hyperthermia, – Rhabdomyolysis– Brain damage– Multisystem failure– DEATH
Death
• Usually occurs within hours due to :– Ventricular fibrillation– Intractable cardiogenic shock– Status epilepticus with hyperthermia
TCAs
• Overdose Evaluation– Most have narrow therapeutic index– Doses <10x therapeutic daily dose may
produce severe poisoning– 10-20 mg/kg can be life threatening– In children one tablet can cause death
TCAs
• Management of Toxicity– ABCs– Decontamination
(Lavage even up to 4-6 hours post ingestion may be useful due to decreased GI motility)
– Activated charcoal
TCAs
• Management of Toxicity– Sodium Bicarbonate (1-2 mEq/kg)
• Maintain pH of 7.45 to 7.55• Protects cardiac membrane, corrects acidosis
– Hyperventilation to induce respiratory alkalosis can work for short time
TCAs
• Management of Toxicity– Pacing for bradyarrhythmias, high-degree
AV block– Overdrive pacing for Torsades des pointes– Do NOT use type 1a or 1c antiarrhythmic
agents for V-tach; can aggravate cardiotoxicity
TCAs
• Management of Toxicity– Hypotension
• Fluids• Vasopressors
– Seizures • Diazepam, phenobarbital. • If these do not work, paralyze patient
Iron
• Incidence (1995 AAPCC Annual Report)– 28,039 Exposures– 378 moderate, major effects– 3 deaths
Iron
• Overdose Evaluation– How much elemental Fe could have been
ingested (mg/kg)?• < 20mg/kg: not considered toxic, can be left at
home• 20-60mg/kg: mild to moderate toxicity, some
treatment required• > 60mg/kg: high toxicity; hospitalization required
Stage I
• 30 minutes-6 hours post ingestion• GI irritation, due to iron’s corrosive effects
– Nausea, vomiting– Epigastric pain – GI bleeding– Drowsiness– Hypotension– Metabolic acidosis– Leukocytosis– Hyperglycemia
Stage II
• 6-24 hours post ingestion
• Sometimes absent in severely poisoned patients
• Patient seem to improve; feels, looks better
Stage III
• 6-48 hours post ingestion
• Metabolic, systemic derangement – Cardiovascular collapse– Coma– Seizures– Coagulopathy– Pulmonary edema
Stage IV
• 2-7 days post ingestion– Hepatotoxicity (jaundice) – Coagulopathy– Metabolic acidosis– Renal insufficiency
Stage V
• 1-8 weeks post ingestion
• Primarily delayed GI complications– Gastric/duodenal fibrosis– Scarring of pylorus– Intestinal obstruction
Iron
• Overdose Treatment– Decontamination
• Lavage useful if done within first 60 minutes post ingestion
• Iron does NOT bind to activated charcoal
– Whole bowel irrigation
Iron
• Overdose Treatment– Desferal ( desferoximine )
• Chelating agent • Binds free iron, complex is excreted renally• “Vin rose’” urine color depending on urine pH
Carbon Monoxide
• Produced by incomplete combustion (autos, home heaters)
• Colorless, odorless, tasteless
• Binds to hemoglobin - blocks oxygen carrying capacity
Carbon Monoxide
• Signs/Symptoms– Headache, N/V, ringing in ears,
incontinence, seizures, coma, pulmonary edema
– Cherry-red skin - usually a terminal event– Suspect with a lot of “sick” patients at one
location
Organophosphates
• Pathophysiology– Block cholinesterase. – Cause build-up of acetylcholine in
synapses. – Produce cholinergic crisis.
Organophosphates• Signs and Symptoms
– Salivation– Lacrimation– Urination– Defecation– Gl Cramping– Emesis
– Pin-point pupils– Bradycardia– Bronchospasms– Muscle twitching– Weakness– Ventilatory failure
Organophosphates
• Management– 100% oxygen, assist ventilations– IV tko– Monitor ECG– Atropine 1mg IV, 2mg IM. Repeat until
atropinized– Pulmonary edema is non-cardiogenic in
origin; avoid lasix, morphine
Drug Abuse
Self administration of drug or drugs in manner not in accord with
accepted medical or social patterns
Drug Abuse
• Psychological Dependency (Habituation)– Drug necessary to maintain user’s sense of
well-being
• Physical Dependency– Physical symptoms if intake reduced
Drug Abuse
• Compulsive Drug Use– Preoccupation with obtaining drug– Rituals of preparing, using drug as
important as drug effects
• Tolerance– Increasing doses needed to obtain drug
effect
Drug Abuse
• Addiction– Includes
• Psychological dependence• Physical dependence• Compulsive use• Tolerance
– Plus, complete absorption with obtaining, using drug to exclusion of all else
Drug Abuse
• Suspect drug-related problem in patients with:– Altered LOC– Bizarre behavior– Seizures
Drug Abuse
• Ask EVERY patient about recreational drugs.• Be non-judgmental.• Keep drug box/cabinet secured.• Use discretion.• If held up, give them what they want!
Narcotics
• Examples– Opium– Morphine– Heroin– Codeine– Dilaudid
– Oxycodone (Percodan)
– Meperidine (Demerol)– Propoxyphene
(Darvon)– Talwin– Fentanyl
Narcotics
• Effects– Analgesia– CNS depression
• Euphoria• Drowsiness• Apathy
– Antidiarrheal action– Antitussitive action
Narcotics
• Overdose– Mild to Moderate
• Lethargy
• Pinpoint pupils
• Bradycardia
• Hypotension
• Decreased bowel sounds
• Flaccid muscles
– Severe• Respiratory depression• Coma• Aspiration• Seizures with certain
compounds (meperidine, propoxyphene, tramadol)
Narcotics
• Overdose– Management
• Support oxygenation/ventilation• Vascular access• D50W 50cc• Narcan 0.4 to 2.0 mg
– Improve respirations–Do NOT awaken completely–Restrain before giving
Narcotics
• Associated Dangers– Skin abscesses– Phlebitis– Sepsis– Hepatitis– HIV– Endocarditis
– Adulterant toxicity– “Cotton fever”– Malnutrition– Tetanus– Malaria
Narcotics• Withdrawal
– Insomnia– Restlessness– Irritability– Anorexia– Tremors– Back, extremity pain
– Watery eyes– Yawning– Rhinorrhea– Sneezing– Diarrhea– Diaphoresis
Resembles Severe Influenza
Mechanism of Action
• Most overdoses of sedative-hypnotics are from benzodiazepines, barbiturates
• Both enhance effects of gamma-aminobutyric acid (GABA)
• GABA enhancement results in down-regulation of CNS activity
Sedative-Hypnotics
• Use more then a week leads to tolerance to effects on sleep patterns
• Withdrawal after long term results in “rebound” increase in frequency of occurrence, duration of REM sleep.
• In high doses, sedative-hypnotics depress CNS to point of Stage III or general anesthesia
Sedative-Hypnotics
• Tolerance– Happens with all sedative-hypnotics– Appears very quickly even during short-term
use.– Discontinuation will bring receptor response
back to normal after drug has been metabolized
– Withdrawal symptoms may take up to a week to see in some patients
Chloral hydrate
• “Micky Finn” when mixed with alcohol
• Rapidly absorbed, acts quickly
• Drowsiness, sleep
• Alcohol, chloral hydrate compete for metabolism by same enzyme
• Prolonged action for both when mixed
• Not commonly abused
Barbiturates
• Introduced in 1903
• Replaced older sedative-hypnotics
• Quickly became major health problem
• In 1950’s-60’s barbiturates were implicated in overdoses; were responsible for majority of drug-related suicides
Barbiturates
• Short-acting– Amytal– Pentathiol
• Intermediate-acting– Nembutal– Seconal– Tuinal
• Long-acting– Phenobarbital
Barbiturates
• Initial overdose presentation – Slurred speech– Ataxia– Lethargy – Nystagmus– Headache – Confusion
Barbiturates
• As overdose progresses– Depth of coma increases
• Patient anesthetized with loss of neurologic function• EEG may mimic brain death
– Respiratory depression occurs– Peripheral vasodilation occurs
• Hypotension, shock• Hypothermia
– Blisters (bullae) form on skin
Barbiturates
• Early deaths– Respiratory arrest– Cardiovascular collapse
• Delayed deaths– Acute renal failure– Pneumonia– Pulmonary edema– Cerebral edema
Barbiturates
• Overdose management– Secure airway– Support oxygenation/ventilation– IV with LR or NS– Prevent heat loss secondary to
vasodilation– Bicarbonate to alkalinize urine (long-acting
only)
Barbiturates
• Withdrawal signs/symptoms– Apprehensiveness– Anxiety– Tremulousness– Diarrhea– Nausea– Vomiting– Seizures
Barbiturate-like, non-barbiturates
• Examples– Doriden (glutethimide)– Quaalude (methaqualone)– Placidyl (ethchlorvynol)– Noludar
• Overdose produces sudden, prolonged apnea• Highly addictive• Withdrawal resembles barbiturate withdrawal• Only Placidyl, Doriden remain available in U.S.
Placidyl (ethchlorvynol)
• “Pickles”, “jelly beans”, “Mr. Green Jeans”
• Produces vinyl-like odor on breath
• Concentrates in CNS, slow hepatic metabolism
• Half-life >100 hrs
• Prolonged deep coma (100 to 300 hrs), hypothermia, respiratory depression, hypotension, bradycardia
• EEG is flatline
• Keep patient on life support for a few days; they wake up, are ok
Doriden (gluthethimide)
• Abused in combination with codeine• “sets”, “hits”, “loads”, “fours and doors”• Prolonged coma (average 48 hours)• Hypotension, shock common• Anticholinergic signs: dilated pupils,
tachycardia, dry mouth, ileus, urinary retention, hyperthermia
Benzodiazepines
• Developed due to overdoses, deaths related to barbiturates, barbiturate-like non-barbiturates
• Relatively few deaths
• In 1993, prescription rate for barbiturates dropped to one-sixth that of benzos
Benzodiazepines
• Examples– Valium (diazepam)– Ativan (lorazepam)– Versed (midazolam)– Librium (chlorodiazepoxide)– Tranxene (chlorazepate dipotassium)– Dalmane (flurazepam)– Halcion (triaxolam)– Restoril (temazepam)
Benzodiazepines
• Adverse Effects– Weakness– Headache– Blurred vision– Vertigo– Nausea– Diarrhea– Chest pain
Benzodiazepines
• Overdoses– Relatively safe taken by themselves, even in
overdose– Can be lethal with other CNS depressants
especially alcohol – Look like other CNS depressant overdoses– Antidote is Romazicon ( flumazenil )
• Only recommended in known, controlled situations
• Can lead to seizures that cannot be controlled
Benzodiazepine-like non-benzos
• BuSpar (buspirone)– Used for generalized anxiety disorder– Less sedating than diazepam– Less potentiation by other CNS
depressants
• Ambien, Stilnox (zolpidem)– Used for short-term insomnia treatment– Toxic effects similar to benzos
Neuroleptics
• Antipsychotics, major tranquilizers• Used in treatment of schizophrenia, other
psychoses• Examples
– Haldol– Mellaril– Thorazine– Stellazine– Compazine
Neuroleptics
• Extrapyramidal muscle contractions (dystonias)– Bizarre, acute, involuntary movements,
spasms of skeletal muscles– Reversible with Benadryl
Neuroleptics
• Acute Overdose Presentation– CNS depression– Hypotension– Anticholinergic symptoms: flushing, dry
mouth, hyperthermia, tachycardia, urinary retention
– Ventricular arrhythmias, including Torsades– Seizures
Neuroleptics
• Acute Overdose Management– ABCs– Fluid, vasopressors for hypotension– Lidocaine, phenytoin for ventricular
arrhythmia– Magnesium, isoproterenol for Torsades– Benzodiazepines, phenobarbital for
seizures
Neuroleptics
• Neuroleptic malignant syndrome– Life-threatening reaction– Signs, symptoms
• Hyperthermia• Muscular rigidity• Altered LOC• Tachycardia, hypotension
Neuroleptics
• Neuroleptic malignant syndrome– Management
• ABCs• Oxygen• Assist ventilation, as needed• Benzodiazepines• Rapid cooling• Volume for hypotension
Stimulants
• Examples– Cocaine– Amphetamines
• Benzedrine (bennies)• Dexedrine (dexies, copilots)• Methamphetamine (ice, black beauties)
– Ephedrine– Caffeine– Ritalin
Stimulants
• Overdose signs/symptoms– Euphoria, restlessness, agitation, anxiety– Paranoia, irritability, delirium, psychosis– Muscle tremors, rigidity– Seizures, coma– Nausea, vomiting, chills, sweating, headache– Elevated body temperature– Tachycardia, hypertension– Ventricular arrhythmias
Stimulants
• Overdose complications– Hyperthermia, heat stroke – Hypertensive crisis– CVA– Acute MI– Intestinal infarctions– Rhabdomyolysis– Acute renal failure
Stimulants
• Chronic effects– Weight loss– Cardiomyopathy– Paranoia– Psychosis– Stereotypic behavior: picking at skin
(“cocaine bugs”)
Stimulants
• Overdose management– Oxygen, monitor, IV– Activated charcoal for decontamination in first hour– Valium for sedation– Hypertension control
• Nipride
• Phentolamine
• Avoid beta-blockers, including labetolol (Why?)
– Body temperature reduction
Stimulants
• Withdrawal– Drowsiness– Profound depression (“cocaine blues”)– Increased appetite– Abdominal cramps, diarrhea, nausea– Headache
Hallucinogens
• Examples– Indole hallucinogens
• LSD (acid)• Morning-glory
seeds• Psilocybin• DMT
– Amphetamine-like hallucinogens
• Peyote• Mescaline• DOM• MDA• MDMA (ecstasy)
Hallucinogens
• Produce altered/enhanced sensation
• Effects highly variable depending on patient
• Increased dose does not intensify effect
• Toxic overdose virtually impossible
Hallucinogens
• Some patients may experience “bad trips”
• Depends on surroundings, emotional state
• Signs and symptoms– Paranoia, fearfulness, combativeness– Anxiety, excitement– Nausea, vomiting– Tachycardia, tachypnea– Tearfulness– Bizarre Reasoning
Hallucinogens
• Moderate Intoxication– Tachycardia– Mydriasis– Diaphoresis– Short attention span– Tremor– Hypertension– Hyperreflexia– Fever
Hallucinogens
• Life-threatening toxicity (rare)– Seizures– Severe hyperthermia– Hypertension, arrhythmias– Obtunded, agitated, or thrashing about– Diaphoretic, hyperreflexic– Untreated hyperthermia can lead to hypotension,
coagulopathy, rhabdomyolysis and multiple organ failure
Hallucinogens
• Management of “bad trip”– Rule out other causes of hallucinations
• Hypoglycemia• Alcohol, drug withdrawal• Infection
– Quiet, supportive environment– Benzodiazepines, haldol for agitation,
anxiety
Phencyclidine (PCP)
• Street names– Angel dust– Peace Pill– Hog – Krystal– Animal tranquilizer
• Used as veterinary anesthetic
Phencyclidine (PCP)
• Actions– Dissociative anesthesia– Generalized loss of pain perception– Little or no depression of airway reflexes or
ventilation– CNS-stimulant, anticholinergic, opiate, and
alpha-adrenergic effects
Phencyclidine (PCP)
• Low Doses
– Lethargy, euphoria, hallucinations– Slurred speech– Blank stare– Insensitivity to pain– Midposition to dilated pupils– Vertical and horizontal nystagmus– Occasionally bizarre or violent behavior
Phencyclidine (PCP)
• High Doses– Diaphoresis– Salivation– Hypertension– Tachycardia– Hyperthermia
• Localized dystonic reactions
• Wide-eyed coma• Rigidity• Seizures
Phencyclidine (PCP)
• Treatment– Maintain airway– Assist ventilations, as needed– Treat coma, seizures, hypertension,
hypothermia as needed– Quiet environment– Sedation if needed to control agitation
• Haldol• Benzodiazepines
Inhalants
• Examples– Hydrocarbons (solvents, paints, aerosols)– Gases (freon, halon fire extinguishing
agent)– Metallic paints (“huffing”)
Inhalants
• Effects– Dysrhythmias including VF– CNS depression– Seizures– Respiratory irritation– Epinephrine may increase risk of dysrhythmias
• Treatment– Oxygen– Treat symptomatically
Flunitrazepam (Rhohypnol)
• Street names– Rophies– Roofies– R2– Roofenol
– Roche– Roachies – La rocha– Rope– Rib
Flunitrazepam (Rhohypnol)
• Benzodiazepine• Similar to Valium but 10x more potent• Produced, sold legally in Europe, South
America• Uses
– Short-term treatment of insomnia– Sedative hypnotic– Preanesthetic medication
Flunitrazepam (Rhohypnol)
• Effects– Disinhibition and amnesia– Onset within 30 minutes, peak within 2
hours, may persist 8 hours or more– Frequently abused with alcohol or other
drugs– Enhances high produced by heroin
Flunitrazepam (Rhohypnol)
• Adverse Effects– Drowsiness– Dizziness– Confusion– Decreased BP– Memory impairment– GI disturbances– Excitability, aggressive behavior
Flunitrazepam (Rhohypnol)
• Management of overdose– Lethal overdose very unlikely– Oxygenate, ventilate– Intubate if necessary to control airway– Vascular access– ECG– Fluid for hypotension– Dextrostick (rule out hypoglycemia)– Treat trauma resulting from assault
Flunitrazepam (Rhohypnol)
• Withdrawal– Headache– Anxiety, tension– Numbness, tingling
of extremities– Restlessness,
confusion– Loss of identity
– Hallucinations– Delirium– Seizures (up to a
week after cessation)– Shock– Cardiovascular
collapse
Flunitrazepam (Rhohypnol)
• Management of withdrawal– Oxygen/ventilation– Intubate if necessary– EKG– Vascular access– Fluid for hypotension– Dextrostick– Diazepam for seizures
Gamma hydroxybutyrate
• Street names– Cherry meth– Liquid X– Liquid ecstacy
• Originally developed as anesthetic
• Banned in 1991 because of side effects
• Promoted as aphrodisiac