Toxicologic Emergencies Case Studies and Management Ray Taylor Valencia Community College Department...

Toxicologic Emergencies

Case Studies and Management

Ray Taylor

Valencia Community College

Department of Emergency Medical Services

April 19, 2023 Orange County EMS System 2

Notice All rights reserved. Slide show used with permission only for the

purposes of educating emergency medical providers (EMTs and Paramedics)

No portion of this presentation may be reproduced, stored in a retrieval system in any form or by any means (including but not limited to electronic, mechanical, photocopying etc.) without prior written permission from the author


Toxicologic EmergenciesObjectives

Review key prehospital management features of each of the following poisonings:Tricyclic AntidepressantsAnticholinergicsAcute Dystonic ReactionBeta BlockersCalcium Channel BlockersCarbon MonoxideCocaine / SympathomimeticsGamma-hydroxybutyrate (GHB)


Drug Box


2004 Therapy Provided in Human Exposure Cases

0

2

4

6

8

10

12

# of Cases

(X 103)

Specific Antidote

N-ACNaloxoneAlkalinizationFlumazenil


Categories with Largest Numbers of Deaths (2004 TESS Data)

0

50

100

150

200

250

300

350

# deaths

Category

AnalgesicsAntidepressantsCV drugsStimulantsSed-hypAlcohols


Patient Scenario #1

Dispatch data: “man down”

Scene: safe; Private house; Rural location

Victims: one, 25y/o male found unresponsive, with an empty pill bottle in his hand

Historians: victim’s girlfriend


Patient Scenario #1

Empty pill bottle found in patient’s hand

Elavil®

50mg Tabs #50 3/2/14


Patient Scenario #1

Hx: patient’s girlfriend states he has been depressed and ingested 50 x 50mg tabs 1 hr ago, and progressively became more somnolent until he “passed out” about ½ hr ago


Patient Scenario #1 Primary Survey

LOC: unconscious, unresponsivenconscious, unresponsive Airway: open; Saliva accumulating; Gurgling open; Saliva accumulating; Gurgling Breathing: resp= 10/min; Sonorous; resp= 10/min; Sonorous; gag reflexgag reflex Circulation: pulse rapid & weak pulse rapid & weak


Patient Scenario #1 Secondary Survey

V/S: BP=70/40, HR=140, RR=assisted, 02 sat=82%

SKIN: dry, flushed, no track marks HEENT: pupils fixed & dilated (6-7mm), no evidence of

head trauma LUNGS: clear & equal bilaterally COR: RRR ABD: soft, decreased bowel sounds NEURO: unresponsive, no gross focal deficits


Patient Scenario #1Prehospital Secondary Interventions

Cardiac monitor:

What is the antidote?


Tricyclic Antidepressant Toxicity

Specific Treatment NaHCO3 IS

THE TREATMENT OF CHOICE


Tricyclic AntidepressantsDefine the Toxidrome

Anticholinergic

Hyperthermia, blurred vision, dry mouth, flushed skin, hallucinations, tachycardia, and seizures

Quinidine-like=Na channel blockade

Negative inotropy, prolonged Q-T, hypotension, and ventricular dysrhythmias

Alpha-adrenergic blockade

Hypotension

Antihistamine CNS sedation


Tricyclic Antidepressant Toxicity

Clinical FeaturesMild-to-moderate toxicity Sinus tachycardia Slurred speech Dry mouth Drowsinesslethargy

Severe toxicity Coma Seizures Dysrrhythmias Hypotension

RAPID PROGRESSION OF SYMPTOMS IS

CHARACTERISTIC OF SEVERE TCA

TOXICITY

Can we predict who will go on to severe toxicity?


Review of Clinical Findings

2500 Cases of TCA Toxicity

21%

14% 8% 6%

51%

35%

tachycardiacomaincreased qrshypotensionseizuresarrhythmias


2004 Poisoning Fatalaties

0

100

200

300

400

500

600

700

800

900

Fatalities

TotalAntidepressants


Distribution of Poisoning Fatalities (2004) due to Antidepressants

0

20

40

60

80

100

120

Antidepressant

TotalAmitriptylineDoxepinBupropionNortriptyline


Overdose And Poisonings – Overdose And Poisonings – General ApproachGeneral Approach


Overdose And Poisonings – General Approach

General considerationsFor any overdose or poisoning include determining the particular agent(s) involved, the time of the ingestion/exposure, and the amount ingested. Bring empty pill bottles, etc., to the receiving facility.



Basic Life Support Secure airway while maintaining cervical spine

immobilization, as necessary. Administer supplemental oxygen (100%) Record and monitor vital signs Nothing by mouth (depending on agent, patient may be at

risk for seizure or rapid loss of consciousness with subsequent aspiration)



Advanced Life Support Advanced airway/ventilatory management as needed Initiate cardiac monitoring, record and evaluate ECG strip

Record & monitor 02 saturation & end-tidal C02 (if

available by nasal cannula) IV NaCl 0.9% KVO or IV lock

If systolic BP remains < 90, administer boluses of 0.9% NaCl at 200-300 ml until systolic BP > 90 Contraindicated if evidence of congestive heart failure (e.g.

rales)



Advanced Life Support If patient has an altered level of consciousness: Obtain a Glucometer reading. If hypoglycemic (reading 70 [< 60 in stroke]) with IV access:

Dextrose 25 gm, IV bolus. May repeat as needed q 5 or 10 minutes to blood glucose > 100 mg/dl Thiamine 100 mg, IV with initial dextrose

If hypoglycemic (reading 70 [< 60 in stroke]) without IV access: Glucose paste (Glutose) or other glucose agent (e.g. orange juice) if patient alert

enough to self administer oral agent, or Glucagon 1 mg, IM If there is no change in mental status, administer Naloxone (Narcan) 2.0 mg, IV bolus.

If no respiratory depression, use 0.4 mg IV dose If IV access has not been established, administer Naloxone (Narcan) 2.0 mg, IM.

NOTE: If drug overdose is strongly suspected, administer Naloxone prior to Dextrose and Thiamine.

Refer to specific subprotocols when a specific agent has been identified or is strongly

suspected.



Medical ControlContact Medical Control for further orders


AntidepressantsAntidepressants


Antidepressants


Tricyclic and Tetracyclic Antidepressants

Basic Life SupportSecure airwayAdminister supplemental oxygen 100%Record and monitor vital signs



Advanced Life SupportAdvanced airway/ventilatory management as

neededBegin cardiac monitoring, record and evaluate ECG

stripRecord and evaluate 12-lead ECGRecord & monitor 02 saturation & end-tidal C02 (if

available by nasal cannulae)IV 0.9% NaCl KVO



Advanced Life Support If Altered Mental Status

See Altered Mental Status Protocol If Seizures

See Seizure Protocol If wide complex (QRS >0.12sec), hypotension, or any arrhythmias

Sodium Bicarbonate 1 meq/kg IV Repeat in 5 or 10 minutes

If Torsades de pointes Magnesium Sulfate 2 gm, IV in 100 ml NS bolus (if no renal

disease).



Medical ControlContact medical control for further orders


Patient Scenario #2

Dispatch data: “man in custody”

Scene: airport police station

Victims: one

Historians: patient and police

Hx: patient states he swallowed a handful of rocks, is now

extremely agitated, and is c/o feeling too shaky


Patient Scenario #2

Primary SurveyLOC: alert, anxious and agitated

Airway: clear

Breathing: clear and equal

Circulation: bounding and rapid pulse


Patient Scenario #2Secondary SurveyV/S: BP=180/120, HR=140, RR=30,

O2 sat=96%Skin: profusely diaphoreticHeent: clearLungs: clearCOR: rapid and regularABD: soft, nontenderNeuro: extreme psychomotor agitation


Patient Scenario #2

Cardiac monitor: SINUS TACHYCARDIA,

RATE 140



Patient Scenario #2

BenzodiazepinesDiazepam/ValiumLorezapam/AtivanMidazolam/Versed


Hyperdynamic/Hyperadrenergic Agents

Cocaine (crack)Ketamine/phencyclidine (PCP)Amphetamine/methamphetamine

(ice, crystal meth)Ephedrine and derivatives, 2-agonists

Caffeine, nicotine, theophyllineDextromethorphan


Adrenergic Agent OverdoseAdrenergic Agent Overdose

Toxidrome Tachycardia Hypertension Hyperthermia Agitation Diaphoresis

Complications Angina/infarction Dissecting aorta Seizures Intracranial bleed Rhabdomyolysis

What are critical acute problems?


Cocaine and Sympathomimetic Overdose

Basic Life SupportSecure airwayAdminister supplemental oxygenRecord and monitor vital signs



Advanced Life Support Advanced airway/ventilatory management as needed Begin cardiac monitoring, record and evaluate ECG strip Record and evaluate 12-lead ECG Record & monitor 02 saturation & end-tidal C02 (if

available by nasal cannulae) IV NaCl 0.9% KVO



Advanced Life Support If seizures, refer to Seizure Protocol For patients with sympathomimetic toxidrome (hypertension,

tachycardia, agitation): Diazepam (Valium) 5 mg, slow IV Or Midazolam (Versed) slow IVP or IM

Less than 60 y/o 1 mg/minute titrated to effect (Maximum 5 mg)

Greater than 60 y/o 0.5 mg/minute titrated to effect (Maximum 3 mg)

Repeat either medication in 5-10 minutes if signs and symptoms

continue



Medical ControlCall Medical Control for any additional

orders or questions


Drug Induced TachycardiasManagement Considerations

Consider sodium bicarbonate for wide complex rhythms

Standard ACLS algorithms may not be effective

Utilize pressors if patient hypotensive


Patient Scenario #3

Patient information:35 year-old farmer was working in his field

when it was unexpectedly crop-dusted by a confused pilot

1 hour later: he complains of difficulty breathing


Patient Scenario #3

ROS:GI:+ N/V/D, abdominal crampsSkin: + profuse sweatingEye: + blurred visionCNS: +dizziness and restlessnessGU: + incontinence


Patient Scenario #3

VS: T=100.8°F, BP=90/50 mm Hg,HR=42 bpm, RR=36/min, O2 sat=86%

PE:HEENT: profuse diaphoresis, BL constricted

pupils, visual acuity, copius tearingLungs: diffuse BL rales, rhonchi, and wheezesABD: hyperactive bowel sounds


Patient Scenario #3

Cardiac monitor:

SINUS BRADYCARDIA, RATE 42



Patient Scenario #3

Atropine


Mechanism of Action

Organophosphates and nerve agents inhibit acetylcholinesteraseThis allows acetylcholine to accumulate

Acetylcholine produces hyperstimulation of cholinergic nervous systemMuscarinic stimulation: smooth muscles contract (eg,

airway constriction); glands produce mega-secretionsNicotinic stimulation: skeletal muscles contract

(twitching)


Cholinergic Toxidrome“SLUDGE”

SalivationLacrimationUrinationDefecationGastrointestinal (nausea, cramps)Emesis

Look for pinpoint pupils!


Cholinergic Toxic Effects

General: sweating

Eye: lacrimation, miosis, blurred vision

Pulmonary: wheezing, rales, bronchorrhea

GI: salivation, n/v/d, cramps

CV: bradycardia, hypotension

GU: urinary incontinence

Muscle: fasciculations, cramps, weakness, twitchingSympathetic ganglia: tachycardia, hypertensionCNS: anxiety, restlessness, confusion, ataxia, coma, seizures, insomnia


Anticholinergic Poisoning/Organophosphates

Basic Life Support Wear protective clothing including masks, gloves, and eye protection.

Toxicity to ambulance crew may result from inhalation or topical exposure.

Any traces of contamination must be removed from the vehicle prior to the next transport.

Secure airway Administer supplemental oxygen Record and monitor vital signs Decontaminate patient

Remove clothing Irrigate with normal saline – may also use soap and water

Contain run-off of toxic chemicals when flushing



Advanced Life Support Advanced airway/ventilatory management as needed Begin cardiac monitoring, record and evaluate ECG strip Record and evaluate 12-lead ECG


available by nasal cannulae)

IV 0.9% NaCl KVO or IV lock



Advanced Life Support If Altered Mental Status

See Altered Mental Status Protocol If Seizures

See Seizure Protocol If signs of severe toxicity, (severe respiratory distress,

bradycardia, heavy respiratory secretions – do not rely on pupil constriction to diagnose or to titrate mediations) Atropine 2.0 mg IVP every 5 min – titrate until respiratory

secretions/distress begins to decrease.



Medical ControlContact medical control for further orders


Patient Scenario #4

Patient Information:28 year-old female c/o inability to open her

mouth, and tightness in the muscles of her jaw and face

Patient states she thought she was given a “valium” at a party earlier


Patient Scenario #4

P.E. is unremarkable except for decreased range of motion of the jaw due to muscle contractions

VS: all within normal limits



Patient Scenario #4

Benadryl


Antipsychotics/Acute Dystonic Reaction

Commonly used antipsychotic-antipsychotic related medicines (e.g. antiemetics) in medical practice include but, are not limited to the following:

1. Prochlorperazine (Compazine)2. Promethazine (Phenergan)3. Thorazine4. Prolixin5. Haloperidol



Basic Life SupportSecure airwayAdminister supplemental oxygen

Record and monitor vital signs




Record & monitor 02 saturation & end-tidal C02 (if available by nasal

cannulae) IV 0.9% NaCl KVO or IV lock For dystonic reactions, administer Diphenhydramine (Benadryl) 25 mg, IV.

Repeat Diphenhydramine (Benadryl) 25 mg, IV if inadequate

response, in 10 minutes



Medical ControlCall Medical Control for any additional

orders or questions


Patient Scenario #5

Patient Information:You respond to a basement apartment in

January. The apartment is being heated with a portable gas heater.

You find an elderly male who is confused and c/o headache associated with general malaise and nausea

You note an extremely strong gas odor


Patient Scenario #5

V/S: BP=110/50, HR=102, RR=30, O2 sat=95%Mucous membranes: “cherry red”Lungs: clearNeuro: no focal findings



Carbon MonoxideSerious CO Toxicity

LOC or near syncopeConfusionFocal neurologic changesMyocardial ischemiaHypotensionAcidosis


Carbon Monoxide

Type of Air T ½ (minutes)

Room 320

100% oxygen 60

Hyperbaric 02 20


Carbon MonoxideBasic Life SupportRemove the patient from the contamination sourceSecure airwayAdminister supplemental oxygen (100%) and

note time oxygen started



Carbon Monoxide

Advanced Life SupportAdvanced airway/ventilatory management as neededBegin cardiac monitoring, record and evaluate ECG

stripRecord and evaluate 12-lead ECG


available by nasal cannulae)

IV NaCl 0.9% KVO


Carbon Monoxide

Medical ControlContact Medical Control for further orders


Patient Scenario #6

Patient Information:75 y/o is dropped off at the station and is

c/o of “weakness and dizziness”PMH: hypertension

After probing several family members who arrive, you discover she has actually been taking Calan 240 mg TID instead of QD


Patient Scenario #6

Primary SurveyLOC: waxing and waning

Airway: clear

Breathing: clear and equal

Circulation: slow weak pulse


Patient Scenario #6

Secondary SurveyV/S: BP=80/50, HR=35, RR=16, O2

sat=88%Skin: pale and diaphoreticCOR: slow and weakNeuro: no focal findingsGlucose check: 280 mg/dl


Patient Scenario #6

Cardiac monitor:



Ca++ Channel Blockers and -Blockers

Define the toxidrome (signs and symptoms)Does it fit with the clinical picture?

Bradycardia (± AV block)HypotensionAltered level of consciousnessHyperglycemia/hypoglycemia


Ca++ Channel Blockers and -Blockers: Specific Therapy

Standard ACLS Atropine — often not

effective TCP Dopamine Epinephrine

Toxicologic Approach High-dose pressors Glucagon: 5 to 10 mg IV

bolus: 3 to 5 mg/h drip

Calcium: 1 to 3 g, slow IV bolus


Calcium Channel Blockers

Calcium Channel Blockers include:Amlodipine (Norvasc)Felodipine (Plendil, Renedil) Isradipine (DynaCirc)Nicardipine (Cardene)Nifedipine (Procardia, Adalat)Verapamil (Calan)Diltiazem (Cardizem)



Basic Life SupportSecure airwayAdminister supplemental oxygen






available by nasal cannulae) IV 0.9% NaCl KVO or IV lock


Calcium Channel BlockersAdvanced Life Support For patients with cardiovascular toxicity with (1) bradycardia with rate < 60 or (2) Heart block,

including third degree heart block and high grade second degree heart blocks i. e. - Mobitz Type II second degree Administer the following agents for bradycardia or high degree heart block

Atropine 0.5 mg IV, may repeat X 2 If no response, Calcium Chloride 1 gram IV (avoid if patient taking digoxin/

Lanoxin) If no response, may repeat Calcium Chloride 1 gram IV If no response, Glucagon 3 mg IV If no response, may repeat Glucagon 3 mg IV If no response, begin transcutaneous pacing

If hypotension 300 ml NaCl 0.9% bolus, repeat as needed Administer Calcium Chloride 1 gram IV, may repeat X 1

• Avoid if patient on digoxin/Lanoxin Glucagon 3 mg IV, may repeat X 1



Medical ControlDopamine IV infusion, titrate


Patient Scenario #7

Patient Information:“48 year-old man-suicidal OD-looks bad”Friend states: “overdosed on some pills, got

weak and drowsy, called 911”Happened: 2 hours ago

Friend presents empty bottle of Propranolol (prescription filled yesterday for 20 mg tabs, #60)


Patient Scenario #7

Primary SurveyLOC: obtunded, minimal response to

stimuliAirway: clearBreathing: clear and equalCirculation: slow weak pulse


Patient Scenario #7

Secondary SurveyV/S: HR=30 bpm, BP=50 mm Hg/palp,

RR=10/min (shallow), O2 sat=78%Skin: pale and diaphoreticCOR: slow and weakNeuro: no focal findingsGlucose: 40 mg/dl


Patient Scenario #7

Cardiac monitor:



Common NamesPropranolol (Inderal)Atenolol (Tenormin)Metoprolol (Lopressor)NadololTimololLabetololEsmololAcebutolol


Common Namesß ß Combination Drugs

Corzide (nadolol/thiazide)Inderide (inderal/HCTZ)TenoreticLopressor HCTTimolideZiac


Beta Blocker Toxicity

Basic Life Support Secure airway Administer supplemental oxygenRecord and monitor vital signs





available by nasal cannula)

IV 0.9% NaCl KVO or IV lock



Advanced Life Support For patients with cardiovascular toxicity with (1) bradycardia with rate

< 60 or (2) Heart block, including third degree heart block and high grade second degree heart blocks i. e. - Mobitz Type II second degree Administer the following agents

Atropine 0.5 mg IV, may repeat X 2 If no response, Glucagon 3 mg IV If no response, may repeat Glucagon 3 mg IV If no response, begin transcutaneous pacing

If hypotension 300 ml NaCl 0.9% bolus, repeat as needed Glucagon 3 mg IV, may repeat X 1



Medical ControlDopamine infusion


Drug Induced Bradycardia

Beta blockersCalcium channel blockersDigoxinOrganophosphatesMushroomClonidine (Alpha 2 agonist)


Dispatch

It’s 3 a.m. and you and your partner, both paramedics, are dispatched to an “unknown problem” in an alley behind a popular nightclub.

As you pull up, you see a police unit already on scene.

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ


Initial Assessment

Patient presentation20 y/o maleRight lateral recumbent

positionAppears to be

unconsciousSnoringVomit on ground



Discussion

How would you describe the patient’s status?

What are your immediate concerns?

What are your next, most immediate actions?



Assessment

Your partner opens the patient’s airway and prepares the suction unit and airway equipment.

You cut the patient’s clothes down his back.



Assessment

You note:Patient unresponsive to painful stimuliAirway open, some vomit visible

Your partner suctions the vomit from the airway.Respiratory rate slow, shallow

Lung sounds bilaterallyPulse rapid, full, regularNo gross bleeding or trauma apparent



Discussion

Have your concerns changed?If so, how?

Does this patient require spinal immobilization?




Assessment/Treatment

Your partner holds c-spine while you continue your exam

You perform a rapid exam of the patient’s posterior chest, back, and buttocks.You note that lung sounds are clear in all

posterior fields.



Assessment/Treatment


With the police officer’s assistance, the patient is rolled onto a backboard.


Treatment

Your partner inserts an oropharyngeal airway (OPA) into the patient’s airway, which he accepts.



Discussion

What does this indicate?

Does this change your assessment of the situation?How?



Treatment

Your partner assists the patient’s respirations while continuing to hold c-spine.



Initial Assessment

You note equal breath sounds bilaterally.Vital signs

HR = 72 regularRR = 12 shallowBP = 116/72SaO2 = 100% with oxygen



Discussion

What additional information would you like to have?

More importantly, how do you get it?



Assessment

You ask the officer for any information he may have, and he says:Patient was alone when the officer arrived.9-1-1 caller is not on scene.No one in area admits to knowing patient.It’s “rave night” at the club, and “there have

been problems with ODs before.”



Detailed Assessment

Your physical exam revealsNo smell of alcohol on patient’s breathSkin cool, dry, slightly paleNo signs of trauma anywhere on bodyPEARLNo “track marks” or tattoosNo burns to fingers or lipsNothing in patient’s pockets



Detailed Assessment

Blood glucose = 80 mg/dL



Discussion

Based on the information you have, what do you think is wrong with the patient?

What are the various substances of abuse that may be involved? How do they compare to your physical exam findings?




Treatment

Patient is moved to the ambulance



Ongoing Assessment

Patient is placed in the ambulance, and you begin transport to the ED.

Repeat vital signsHR = 78 regularRR = 12 shallowBP = 122/74SaO2 = 100% with oxygen



Discussion

As a paramedic, what are your next, most immediate actions?



Ongoing AssessmentTransport to the ED is started.Patient is placed on the cardiac monitor,

and a large-bore IV is started.



Detailed Assessment

Cardiac rhythm



Discussion

Do you administerIV glucose?

Why or why not?IV naloxone?

Why or why not?



Treatment

The paramedic decides not to administer D50, since patient’s blood glucose is 80 mg/dL.

IV naloxone (2mg) is administered without effect.



Discussion

Based on all the information you have, what do you think may be wrong with the patient?



TreatmentWith the failure of the naloxone, the

paramedic elects to intubate the patient.



Treatment

Intubation is performed successfully, and the patient is bagged at 12 per minute with 100% oxygen.

Tube placement in the trachea is confirmed byET CO2 detector with positive waveformBilateral breath soundsOxygen saturation of 100%



Treatment


A radio report is given to the ED attending.


ED Treatment and Beyond

Patient placed on ventilatorRepeat primary and secondary exams

confirm prehospital findings.Venous blood drawn for lab analysisAttending physician informs you that she

also suspects GHB overdose.No serum or urine tests availableBased on clinical exam, history



ED Treatment and Beyond

Radiographs of c-spine, chest, and abdomen obtained

CT scan of head performedPatient “wakes up” two hours later

without any recollection of incident, admits to GHB ingestion, and would like something to eat.



Epidemiology

Gamma-hydroxybutyrate (GHB) first synthesized in 1962 for use as an anesthetic.

Popular with bodybuilders in the 1980sThought to enhance muscle building

Became “rave” drug in 1990s Produces euphoric feeling



Epidemiology

Sedative and hypnotic effects + colorless and odorless = date-rape drugBanned by FDA in 1990Illegalized as Schedule I controlled substance in

2000Legal version, Xyrem, introduced in 2002

Schedule III controlled substance used for narcolepsyLow cost and ease of synthesis permit its

continued prevalence.Instructions available on the Internet



Epidemiology

9600 documented adverse reactions since 1992

71 GHB-related deaths; 15 with GHB as the sole drug

Emergency Department visits for GHB-related complaints are up 100-fold since 1994.Although a decline has begun in recent years

Two-thirds of patients are male.



A & P Review

GHB is a naturally occurring neurotransmitter.Binds the GABA-B receptorThis receptor is found throughout the brain,

mostly in basal ganglia.



A & P Review

Exact function in body is unknown.Possible involvement with

Sleep cycles Temperature regulation Cerebral glucose metabolism Blood flow Memory Emotions



Pathophysiology

GHB rapidly crosses blood-brain barrier following ingestion.

Many observed effects are a result of the increased binding to GABA-B receptors in the brain by GHB.

Alters the release of other neurotransmitters in the brainNoradrenalin: inhibitionDopamine: stimulates high doses while

inhibiting low doses



Pathophysiology

Central nervous system effects are largely dose dependent.10 mg/kg: amnesia, relaxation

Also decrease in heart rate and respiratory rate20–30 mg/kg: drowsiness, sleep

Interference with motor and speech abilities50–70 mg/kg: coma

Severe respiratory depression, up to arrest

Death secondary to overdose is rare.



Pathophysiology

Typical street dose, 1–5 gramsOnset of effects within 5–15 minutesPeak effect in 30 minutesEffects can last 3–6 hours

Elimination occurs via respiration



Pathophysiology

GHB withdrawal Observed in chronic GHB usersSymptoms arise within 1–6 hours of last use.Similar presentation to opiate withdrawalExact pathophysiology is unknown.Typically self-resolving within 5–15 days



Clinical Assessment

Scene cluesMost common usage is in nightclubs, raves,

and other party environments.Often used in conjunction with alcohol or

other drugsCommonly used in gyms by bodybuildersPrevalence as a “date-rape” drug



Clinical Assessment

AirwaySudden decreases in level of consciousness can

place patient’s airway at risk. Obstruction Vomiting Aspiration

Gag reflex may or may not be present.



Clinical Assessment

BreathingDecreased respiratory rate secondary to central

nervous system depression

CirculationBradycardia found in one-third of cases.Dysrhythmias are uncommon.



Clinical Assessment

Altered mental statusVarying degrees, from euphoria to coma

Patients tend to respond violently to arousal attempts.Exercise caution when providing painful

stimuli.

Symptoms frequently spontaneously resolve, only to recur minutes later.



Clinical Assessment

Nausea and vomitingCommon findingPotential for airway complications

SeizuresUsually focal, rarely grand malIntervention rarely required, typically self-

resolving



Clinical Assessment

Be alert for possible multiple drug interactions.

GHB is rarely the sole drug ingested when used recreationally.



TreatmentAirway management

A priority in the GHB overdose patientLevel of consciousness and presence of gag reflex

dictates extent of management. Test with OPA insertion. Defer to nasopharyngeal airway (NPA) if needed.



Treatment

Airway managementEndotracheal intubation

Laryngoscope introduction may arouse patient. Failed attempt may

worsen situation. RSI indicated if

available



Treatment

Provide high-flow oxygen.Ventilate with BVM if respirations are

inadequate.Monitor respirations.

Pulse oximetry ECG monitoring

Administer atropine for symptomatic bradycardia.



Treatment

Altered mental status (AMS)Blood glucose testingAdminister D-50 if patient is

hypoglycemic.Follow D-50 administration

with thiamine.Naloxone is indicated if AMS

is not resolved or if opiate coingestion is suspected.



Treatment

SeizuresBenzodiazepines indicated for

prolonged seizure activity Diazepam Lorezapam



Treatment

Suspected comatose patient can be suddenly aroused with painful stimuli.Movement of patient may awaken him.GHB patients often agitated, potentially

violent when arousedCaution should be used during movement and

transport.



Treatment: Hospital

Maintenance of ABCs is the priority.Perform RSI-facilitated intubation immediately

if patient cannot protect his own airway.Continuous cardiac monitoringCT scan

Rule out a cerebrovascular accident (CVA).Lab studies

No standard blood or urine testing is available.Forensic analysis is available for suspected

date-rape cases.



Treatment: Hospital

Treatment is often palliative only.Effects typically self-resolve within six

hours.



Thank You

I’M OUTTA HERE

Date post:	27-Dec-2015
Category:	Documents
Upload:	justin-manning
View:	218 times
Download:	3 times

Toxicologic Emergencies Case Studies and Management Ray Taylor Valencia Community College Department...

Documents