THE APPROACH TO THE POISONED PATIENT Toxicology Skills WorkshopRegions Hospital Emergency Medicine Program
Develop a Systematic Approach Look for Toxidromes (“Talkingdromes”) Attention to ABCs and need for
Antidote Know the Indications for
Decontamination Procedures Enhance when possible and
appropriate
A – Antidote B – Basics ; ABCs C – Change catabolism D – Distribute differently;
Decontamination E – Enhance elimination
Antidote Toxin/Drug
Oxygen CO, CN, H2S
Naloxone Narcotics/Opiates
NAC APAP, Carbon tet
Atropine, Pralidoxime Organophosphates
Calcium HF, Fl, Oxalates
DMSA As, Lead, Hg
Sodium Bicarbonate TCA
Antidotes Toxin/Drug
Ethanol, 4MP EG, (methanol)
Digoxin-specific Fab Digoxin
Glucose Insulin
Hydroxocobalamin* CN
Physostigmine Anticholinergics, central
Pyridoxine INH, hydrazines
Glucagon Beta-blockers
Airway Breathing Circulation Do the DONT
Dextrose Oxygen Naloxone Thiamine
Reduce Adsorption
Vomiting (Ipecac) Generally not indicated or used in an ED setting Contraindicated in patients < 6 mos old, caustic ingestions,
actual or potential loss of airway reflexes, need to give oral antidote
Activated Charcoal Most effective if given within one hour Caution in the patient with altered mental status (need a
protected airway) Not effective for hydrocarbons, metals (Lead, Iron, Lithium)
Gastric Lavage Rarely used Consider in large, potentially life threatening ingestions not
amenable to activated charcoal
Hemodialysis STUMBLE(D) - Dialysis
Salicylates Theophylline Uremia Methanol Barbiturates, Bromide Lithium Ethylene Glycol Depakote (high levels)
Focused History and Brief Tox Exam History: what-when-how much
Reliability factor, relatives, paramedics Exam
Vital signs Mental status Pupillary response Skin changes, Odors/other prominent features.
MATTERS
MATTERS
Exam Vital signs
Pulse up or down or normal BP up or down or normal Temp up or down or normal Resp up or down or normal
Bradycardia (PACED) Propranolol or other Beta
blockers, Poppies (opiates) Anticholinesterase drugs Clonidine, CCBs, Ciguatera Ethanol or other alcohols,
Ergotamine Digoxin
Tachycardia (FAST) Free base or other forms of
cocaine Anticholinergics,
antihistamines, amphetamines
Sympathomimetics (ephedrine, amphetamines), Solvent abuse
Theophylline, Thyroid hormone
Hypothermia (COOLS) Carbon monoxide,
Clonidine Opiates Oral hypoglycemics, Insulin Liquor Sedative-hypnotics
Hyperthermia (NASA) Nicotine, Neuroleptic
malignant syndrome Antihistamines Salicylates,
Sympathomimetics Anticholinergics,
Antidepressants
Hypotension (CRASH) Clonidine, CCBs (and B-
blockers) Reserpine or other
antihypertensives Antidepressants,
Aminophylline, Alcohol Sedative-hypnotics Heroin or other opiates
Hypertension (CT SCAN) Cocaine Thyroid supplements
Sympathomimetics Caffeine Anticholinergics,
Amphetamines Nicotine
Rapid Respiration (PANT) PCP, Paraquat, Pneumonitis
(chemical) ASA and other salicylates,
Amphetamines Non-cardiogenic pulmonary
edema Toxin-induced metabolic
acidosis
Slow Respirations (SLOW) Sedative-hypnoptics,
Strychnine, Snakes Liquor Opiates, OPs Weed (marijuana)
Other causes: Nicotine, Clonidine, Chlorinated HC
Seizures? Hallucinations? CNS depressed?
WITH LA COPS Withdrawals (alcohol, benzos) INH, Insulin, Inderal Tricyclics, theophylline Hypoglycemics; Hemlock, water; Haldol
Lithium, Lidocaine, Lead, Lindane Anticholinergics, Antiseizure
WITH LA COPS Cocaine, Camphor, CN, CO, Cholinergics Organophosphates PCP, PPA, propoxyphene Sympathomimetics, Salicylates, Strychnine
Miosis (COPS) Cholinergics, Clonidine Opiates, organophosphates Phenothiazines, pilocarpine Sedative-hypnotics, SAH
MydriASis (A3S) Antihistamines,
Antidepressants, Atropine
Sympathomimetics
Diaphoretic (SOAP) Sympathomimetics Organophosphates ASA or salicylates Phencyclidine
(PCP)
Dry Skin Antihistamines,
Anticholinergics
Bullous Lesions Barbiturates and other
sedative-hypnotics Carbon monoxide Tricyclics (personal case
series)
www.acponline.org/graphics/bioterro/bullous.jpg
Flushed CO (rare) Anticholinergics Boric acid CN (rare)
Cyanosis Phenazopyridine Aniline dyes Nitrates Nitrites Ergotamine Dapsone Any agent hypoxia, hypotension MetHb
Bitter Almonds Carrots Fruity Garlic Gasoline
-Cyanide-Cicutoxin (water hemlock)-DKA, Isopropanol-OP, As, DMSO, selenium,
thallium, phosphorus-Petroleum distillates
Mothballs Pears Pungent aromatic Oil of wintergreen Rotten eggs
-Naphthlene, camphor-Chloral hydrate-Ethchlorvynol-Methylsalicylate-Sulfur dioxide,
hydrogen sulfide
Toxicology Screens Urine Stat Urine vs Serum Acetaminophen level
Routine Tests CBC SMA-7 Anion Gap ABGs
Drug Hrs Post-Ing Pos Interv
APAP 4 NAC
COHgb Immed* HBO
ASA 6-12* Dialysis
Iron 2-4* Antidote
Dig 2-4* Fab
Alcohols 1/2 - 1* Antidote
*Clinical Symptoms may dictate treatment, not level.
A MUD PILE CAT ASA Methanol Uremia DKA Paraldehyde, Phenformin INH, Iron, Ibuprofen Lactic acidosis Ethylene Glycol
A MUD PILE CAT CO, CN, Caffeine AKA Theophylline, Toluene
Others Benzyl alcohol Metaldehyde Formaldehyde H2S
Decreased Anion Gap Bromide Lithium Hypermagnesemia Hypercalcemia
Calculated 2(Na)+[Glu/18] + [BUN/2.8] +
EtOH(mg/dL)/4.6Osm Gap = measured - calculated
Significant if >10 Really significant if >19
Increased Osmolar Gap MAD GAS
Mannitol Alcohols (met, EG, Iso, eth) Dyes, Diuretics, DMSO Glycerol Acetone Sorbitol
A 40 year old man collapsed at work while moving his car. He has a hx of depression. He had recently attended his mother’s funeral the day before.
He was found slumped over the steering wheel of his car, lethargic and incoherent. A co-worker left the patient and went to call medics. He was intubated and transferred to Regions Hospital.
Examination • BP 130/88, P90, R-vent, T 1012
• Pupils 6mm unreactive but equal. • Skin warm, red, dry• Absent bowel sounds
Labs were unremarkable• ABG:pH 7.50, 32, 140• EKG - QRS 102, occasional PVC
Is there a Toxidrome? A. Opioid B. Anticholinergic C. Delayed Exercise Syndrome D. Cholinergic poisoningIs there an antidote?
Anticholinergic (antihistamines, cyclic antidepressants, Jimson weed)• Hot as a hare (hyperthermia)• Red as a beet (flushed)• Dry as a bone (dry skin, urinary retention)• Blind as a bat (mydriasis)• Mad as a hatter (hallucinations, delirium,
myoclonic jerking)
Also with anticholinergic• Mydriasis• Tachycardia• Hypertension• Hyperthermia• Seizures
How do you treat it?• Supportive care• TCAs – Sodium Bicarb for widened QRS• Benzodiazepenes for agitation, seizures• Consider physostigmine for pure anticholinergic
overdoses (contraindicated in TCA overdose or with dysrhythmias)
Toxidromes: Case #2
A 19 year old male presents after from a party after his friends noted he was “acting funny.” He was “out of control” and not making sense, so they decided to bring him into the Emergency Room.
The patient is agitated on arrival
Examination • BP 180/114, P120, R20, T 101• The patient is agitated and appears to
be hallucinating• Pupils 6mm sluggish but equal. • Skin warm, red, very diaphoretic
Labs were unremarkable• EKG – sinus tachycardia
Toxidromes: Case #2
Is there a Toxidrome?A. OpioidB. AnticholinergicC. SympathomimeticD. Cholinergic
Sympathomimetics (cocaine, amphetamines, ephedrine)• Mydriasis• Tachycardia• Hypertension• Hyperthermia• Seizures• Diaphoresis
Treatment• Supportive care• Benzodiazepines as needed
Toxidromes: Case #3
A 40 y/o female is brought by medics. A family member called after a suicide note was found and the patient was found unresponsive.
On medic arrival the patient was noted to be very somnolent. She was transported to Regions Hospital.
Examination • BP 100/65, P50, R6, T 98.6• The patient is arousable only to sternal
rub. • Pupils 2mm sluggish but equal. • Skin cool, dry
Labs were unremarkable• EKG – sinus bradycardia
Toxidromes: Case #3
Is there a Toxidrome?A. OpioidB. AnticholinergicC. SympathomimeticD. Cholinergic Is there an antidote?
Narcotic (heroin, methadone, other opioids)• Miosis• Bradycardia• Hypotension• Hypoventilation• Coma/CNS depression
Treatment• Naloxone
Clonidine Hypotension usually more profound May require HIGH dose naloxone to see any
effect Tetrahydrozaline
Periodic apnea in kids Kids should be admitted if symptomatic in
ED
Toxidromes: Case #4
A 50 y/o male is brought in after being found in his garage. According to paramedics, there were several containers of liquids in glass jars near the patient. They also noted a large amount of emesis. He was noted to have altered mental status and some respiratory distress prior to arrival. He was intubated prior to arrival and transported to Regions Hospital.
Examination • BP 110/65, P50, R - intubated, T 98.6• The patient is obtunded, intubated• Pupils 2mm sluggish but equal. • There are copious secretions in the
patient’s mouth and in the endotracheal tube
• Incontinent of both urine and stool• Skin is cool, diaphretic
Labs were unremarkable• EKG – sinus bradycardia
Toxidromes: Case #4
Is there a Toxidrome?A. Serotonin SyndromeB. AnticholinergicC. SympathomimeticD. Cholinergic Is there an antidote?
Cholinergic (DUMBELS or SLUG BAM) Salivation Lacrimation Urination GI complaints (nausea, vomiting, diarrhea) Bradycardia, Bronchoconstriction Abdominal cramping Miosis, Muscle fasciculations
Treatments: Pralidoxime (2PAM), Atropine
MORE TALKINGDROMES
Salicylates (ASPIRIN)Harris
Altered MS (lethargy to coma) Sweating Pulmonary edema Increased ventilation, temp, heart
rate Ringing in ears Irritable Nausea and vomiting
Serotonin Syndrome VS: T, HR, BP (unstable) MS: Agitation, coma Pupils: Mydriasis Skin: Diaphoresis Other: LE rigidity, myoclonus,
hyperreflexia, seizure
MAOI and other drug Idiosyncratic reaction
Alteration in MS Autonomic instability Neuromuscular abnormality
Treatment is supportive Symptoms resolve 24-72 hrs
Lactic acidosis, rhabdo, hyperthermia
Specific drugs SSRIs (i.e., Prozac) Dextromethorphan Demerol Ecstasy (MDMA): hallucinogenic
amphetamine Cocaine L-tryptophan
Acetaminophen Toxicity - Metabolism Metabolized in the liver primarily to nontoxic
glucoronide and sulfide conjugates, however small amount is converted via cytochrome P450 to potentially toxic NAPQI
Normally, NAPQI is conjugated with glutathione to nontoxic metabolites
In significant overdose, glutathione stores are depleted
NAPQI destroys hepatocytes leading to liver failure
Acetaminophen Toxicity – Clinical Presentation
First few hours Non-specific signs and symptoms Nausea, vomiting, pallor, diaphoresis Even severely poisoned patients may remain
symptomatic 18 – 24 hours
Asymptomatic phase No laboratory evidence of hepatotoxicity
After 24 – 36 hours Aminotransferases begin to rise Signs and symptoms of hepatotoxicity
N, V, RUQ pain, hepatic enlargement, jaundice 72 – 96 hours
Peak hepatotoxicity Although massive liver necrosis can occur, recovery is
the rule and usually complete if the patient survives
Acetaminophen Level
- Levels are important- Check levels in all cases of
suspected overdose or polydrug overdose
- Antidotal therapy is most effective if started within 8 – 10 hours
- Signs and symptoms are delayed for 18 – 36 hours
- Rumack-Matthew nomogram - Used to predict the severity
of toicity and need for antidotal therapy
- 4 hour level- Levels above the line
require antidotal therapy
Acetaminophen Toxicity - Antidote N-acetylcysteine (NAC)
Glutathione precursor and glutathione substitute
Increases substrate supply for the non-toxic sulfate conjugation pathway
Available as oral and IV form Extremely effective if initiated within 8
hours Standard of care to treat patients up to 24
hours
ABCs - Antidotes Decontaminate - Special Treatments? Toxidromes? Investigate - look closely REASSESS, MONITOR, SUPPORT