Yoan Lamarche

Intoxicated patient (s)

Yoan Lamarche

Yoan Lamarche

You are on call in the ICU at night as an ICU staff at Big Academic Serious and Sleepless General Hospital (BASS General) on a Friday when you have a phone call from the emergency physician. They are, of course, very busy with multiple patients, but they have just received 6 ambulances from a nursing home. At first, they were very curious about what were the events, but one of the patients was able to provide a history.

Yoan Lamarche

They were six young adults (all 18yo) that decided to party for the week-end. After a couple of beers, they started challenging each other with doing something crazy. They ended up with a plan. The plan was to break in the pharmacy of a nursing home, steal many boxes of medication, than to go in the nursing home garage and each use different ones. They also tried to find more alcohol in the nursing home (to be able to swallow the pills), but they did not all find what they were looking for (2 of the guys found different bottles in the garage and used them).

Yoan Lamarche

The six patients arrive at the same time in emerg. They put them in the brand new 6 bed trauma bay. The emergency physician asks you to coordinate the care of those 6 patients as he takes care of the rest of the emergency. You dispatch 1 ICU fellow per patient. (Naisan, Gordon, Scot, Steve, Dave, and Yoan)

Yoan Lamarche

Patient 1, 2, 3 and 4 are unconscious. Patient 5 is in respiratory distress. Patient 6 seems drunk. He gives the history, he also admits to be schizophrenic, chronically taking Orap. As your are listening to what patient 6 is saying, you notice that patient 5 has copious amounts of secretions from his mouth and is struggling to breathe. Patient 6 tells you it started after he sprayed him with something that looked like a fertilizer or something else whit a dead bug illustrated on the can, in the garage of the nursing home.

Yoan Lamarche

You look closely at patient 5 and notice he is wide awake, anxious and in distress. He is wheezing and has bronchorrhea. His vitals are HR 55, RR 40, BP 150/110, sat 82%, he is now starting to vomit. Steve is taking care of that patient 5.

Yoan Lamarche

As a coordinator, you ask that all unconscious patients receive O2, IV Dextrose + access, naloxone, and thiamine. You also order on all 6 patients a drug screen, CBC, lytes, osmolality, ABG, creatinine, BUN, glycemia, Abdominal flat plates and ECG. You also order 10 L of activated Charcoal, large bore OG tubes and 30 L of Golytely, to make sure your fellows have everything they need.

Yoan Lamarche

You get the six ECGs done first. They give them to you as follow (next page).

Patient 1 (Dave’s patient)

is confused, shivering, his skin is flushed, he is diaphoretic, had diarrhea on his way in and has myoclonus, he is tachycardic and febrile.

Yoan Lamarche

You also get more info as you go. Different drugs were found on the scene: Venlafaxine, Sumatriptan, Acetaminophen, codeine, Amlodipine, Nortriptyline, Ativan, 1 bottle of scotch

Yoan Lamarche

1-Identify the toxidromes in all the patients and what patient took what drug and the differential diagnosis (All)

Dave’s patient

Yoan Lamarche

Serotonergic toxidrome: venlafaxine, sumatriptan and nortriptyline all can contribute. Lack of anticholinergic (diarrhea, diaphoresis) suggest nortriptyline not a significant contributor. If was just massive venlafaxine od would likely get more QRS widening, QT prolongation, RBBB as can have similar Na+, K+ channel blocking effects as TCA. Peak plasma is 6-7 hours so may still get worse….can Sz up to 18 hours.

Yoan Lamarche

Yoan Lamarche

Drug interactions:

1) Excess of precursors of serotonin or its agonists (Buspirone, l-dopa, Li, LSD, L-tryptophan, trazodone, dextromethorphan, tramadol)

2) Inc release of serotonin (Amphetamines, cocaine, MDMA, fenfluramine, reserpine)

3) Reduced uptake of serotonin (SSRI, TCA, trazodone, venlafaxine, meperidine, linezolid, valproic acid)

4) Slowing down of serotonin metabolism (MAOI, selegiline)

DDx of cause or hyperthermia and confusion: SS, NMS, MH, Hyperthyroid, Exertional Hyperthermia, Adrenergics, Anticholinergics, Salicylates, 2,4 DNP (insecticide), Lithium, sepsis, meningitis, encephalitis.

Patient 2 (Yoan’s patient)

is comatose, has pinpoint pupils, is breathing at 5 per minutes, has no bowel sounds. He responds slowly to naloxone. The patient’s acetaminophen level is 350umol/l.

Patient 3 (Gordon)

is unstable, his HR is 25, he is very hypotensive (65/25), he was intubated on his way in. He also has received 3 mg of atropine on the way in and remains very bradycardic.

Patient 4 (Naisan)

is unconscious and has got normal vital signs. He is mildly bradypneic, has normal pupils. He did not respond to naloxone. He has got dry skin, no bowell sounds, his pupils are 6mm bilaterally.

Patient 5 (Steve)

remains very unstable, bradycardic despite atropine (now 10 mg given). There his pupils are still in myosis.

Patient 6 (Scot) continues to talk profusely. Scot is disappointed as

all the other patients seem a lot more active than his, while waiting for the labs, he decides to stop the patient’s non-stop talking by examining the patients mouth with a wood lamp, which shows some fluorescent staining.

Yoan Lamarche

Describe the different classic toxidromes, the classes of medications that lead to them and the initial management (Yoan)

Yoan Lamarche

Yoan Lamarche

Yoan Lamarche

Yoan Lamarche

2. Describe the general initial management to the intox patient after the coma cocktail and the physical exam: Indications for ipecacs, gastric lavage, activated charcoal (single vs multiple), Whole bowel irrigation, (Dave)

Yoan Lamarche

• None of these modalities has been shown to improve clinical outcome (Rosen) except maybe Lavage (if given within 1 hr) and MAC with yellow oleander in asia (Hoffman)

• IPECACS= probably never. If want to cause emisis….MAY….be indicated in small ingestions that were immediately witnessed but should use dishwashing soap (30ml)

Yoan Lamarche

Gastric Lavage Indications:

Indications:

Life-threatening overdoses when a drug or toxin is still expected to be in the stomach. Almost always need to begin within 1 hour of ingestion. Only in life threatening od and specifically in ods that have no antidotes or don’t bind AC.

Contraindications:

Caustic ingestions, Sharp object, drug packet ingestion (packers and stuffers), hemorrhagic diathesis, prior significant emesis, nontoxic ingestions, inability to protect airway

Adverse effects:

ETI, aspiration pneumonitis, Emesis, GI bleed + perforation

Yoan Lamarche

SINGLE DOSE CHARCOAL

• Should be given for most ingestions. If aspirated can cause SEVERE pneumonitis so not given in px with dec loc or impending dec loc. There is debate to whether place a ng and give that way if person unable to drink b/c of mild dec loc or confusion. I feel that it is always safer to place ETT then NG and give charcoal and concerned.

• Not absorbed by AC= Heavy Metals, iron, Ions(Li), Hydrocarbons (chloral hydrate), alcohols (b/c absorb so fast), acids, alkali.

MULTIDOSE CHARCOAL

• Quite effective for theophylline and perhaps Phenobarbital poisoning. Also tricyclic antidepressant, asa, or second dose for any on that took big dose of something bad. Also can try in:

Amitriptyline, atrazine, carbamazepine, chlorpropamide, cyclosporine, dapsone, desmethyldiaqepam, dextropropoxyphene, diazepam, digitoxin, digoxin, doxepin, glutethimide, imipramine, meprobamate, methotrexate, nadolol, nortriptyline, Phenobarbital, phenylbutazone, phenytoin, piroxicam, prophyrins, proscillardin,quinine, salicylates, sotalol,

theophylline.

Yoan Lamarche

WHOLE BOWEL IRRIGATION

• Give golytely or Colyte orally or by NG tube at a dose of 1-2 L/ hr. Most useful when radiopaque tablets or chemicals have been ingested.

• Indications for Whole bowel irrigation:• Sustained-release meds• Slowly dissolving (iron, pain, concretions)• Not absorbed by AC (litium, iron, metals)• Drug packets (packers, stuffers)• Not used in: quickly absorbed drugs, liquids, IV drugs,

acids, alkalis• Dose: 2 L/hr (adults) or 0.5 L/hr (kids) for 4-6 hours or until

rectal effluent is clear

Yoan Lamarche

Describe the initial management of patients with serotonin syndrome, what are the risks, what are the principles of treatment (Dave)

Yoan Lamarche

• ABC• Discontinue offending agents, cooling

blankets• Benzos (lorazepam 1-2 mg IV q30min prn)

Yoan Lamarche

• 5HT receptor antagonists (5-HT2 is now considered to be more significant) – 5–HT2 blockers

• chlorprothixene (0.43 nM) > chlorpromazine > cyproheptadine > haloperidol (36 nM)

• limited experience suggests haloperidol ineffective

– 5–HT1 blockers• chlorprothixene (230 nM) > haloperidol >

chlorpromazine > cyproheptadine (3200 nM)

Yoan Lamarche

• Moderate severity– when oral therapy suitable

• cyproheptadine 8 mg stat then 4-8 mg q4–6h

– when oral therapy unsuitable or cyproheptadine fails

• chlorpromazine 50 mg IMI/IVI stat then up to 50 mg orally or IMI/IVI q6h

Yoan Lamarche

• Severe– when symptoms are not progressive and fever < 39oC

• chlorpromazine 50–100 mg IMI/IVI stat then 50–100 mg orally or IMI/IVI q6h

– when symptoms are progressive and fever < 39oC

• chlorpromazine 100–400 mg IMI/IVI over first two hours

– when symptoms are progressive and fever > 39oC

• barbiturate anaesthesia, muscle relaxation ± active cooling

• chlorpromazine 100–400 mg IMI/IVI over first two hours

Yoan Lamarche

 

• Beta blockers (5-HT1 blocker)• propranolol 1-3 mg IV q5min prn (max 0.1 mg/kg)• ***high fever, dantrolene can be used to control the

muscular tremulousness. If temp>39 degrees the mortality goes up! These patients should be aggressively coolend an paralyzed and my need ventilation. Sever muscle spasm may cause resp failure and rhabdomyolysis.

• YOU DIE FROM HYPERTHERMIA AND THIS CAUSES 1) DIC AND MICROVASCULAR THROMBOSIS AND ALSO YOU GET ENDOTOXIN ABSORBED FROM GUT AS PERMABILITY INCREASES.

Yoan Lamarche

2.

In patients with acetaminophen overdose, how do you administer NAC, when do you stop it, what route, is it proven. When do you contact the liver transplant team. (Dave)

• We use exclusively IV….only recently approved in US. Oral associated with severe nausea and vomiting. IV can cause anaphylactoid reaction.

20 hr IV dosage: total dose 300mg/kg, given over 20 hr. load= 150mg/kg over 60min then 50mg/kg over 4 hr then 100mg/kg over 16hr. Need to repeat APAP at 20 hours when infusion stops. If APAP is still positive continue at the final rate you were infusing (case reports of mortalities in the US when this is not done as they were previously only using the long oral regiment). Continue till APAP is negative or as long as transaminases continue to rise and if evidence of liver failure continue NAC till transplantation. NAC may help people after they are already in hepatic failure. Proposed antioxidant effects. 10-36 hrs infusions reduced fulminant hepatic failure (Harrison, 1990), 18-36 hrs improved hemodynamics (Harrison 1991), 36-80 hrs inproved CNS sequelae, hemodynamics (keays, 1991).

Yoan Lamarche

When to contact transplant.

• If want to be conservative probably give them a heads up once there is evidence of a severe od with evidence of liver dysfunction. Can also follow:– King's college hospital criteria (O'grady, 1991).

Experience suggest that Px with serum pH less than 7.30 after appropriate resuscitation (especially on day two) are unlikely to recover without transplant. Coexistence of PT>100 (INR > 6.5), serum creatinine > 200 mmol/L, and severe hepatic encephalopathy (>III) poor outcome.

– ***Px who met criteria had a survival rate of 15% if they were not transplanted!

Yoan Lamarche

Newer markers-A coagulation factor of VIII/V ratio >30 suggests a poor prognosis. Arterial lactate > 3.0 mmol/L after fluid resuscitation predicted nonsurvivors (Bernal, 2002). Additionally survivors had lower phosphates!!

Yoan Lamarche

King College for Tx

Yoan Lamarche

2.

Gordon’s patient (patient 6) remains unstable and very hypotensive. The patient is obviously in low cardiac output and his heart rate remains around 30.

Yoan Lamarche

2.

Describe the approach to the patient with calcium channel blocker overdose. Describe the characteristics of patient with ingestion of different classes of CCB. (Gord)

Yoan Lamarche

Yoan Lamarche

Describe the presentation and management of the patient with B Blocker overdose. (Gord)

Yoan Lamarche

2.

What are the steps that can be initiated if the initial support does not reverse the clinical situation (2nd line therapies) (Gord)

Yoan Lamarche

Naisan’s patient (4) : What are the characteristic findings

on the ECG? (Naisan)

Yoan Lamarche

– Wide complex .16s Tachycardia 120 bpm(sodium channel blockade)

– In TCA OD occasionally, sinus tachycardia with QRS prolongation is difficult to distinguish from ventricular tachycardia

– I talked to 3 cardiologists and they had problems telling if it was V-Tach or not

Yoan Lamarche

• a limb-lead QRS interval >0.10 s has been shown to predict seizures and QRS duration >0.16 s has been associated with ventricular arrhythmias

• Various forms of atrioventricular block may accompany TCA overdose. Right bundle-branch block is common

Yoan Lamarche

What are the general indications indications to admit a patient with toxic ingestion to the ICU(Naisan)

Yoan Lamarche

• Brett et al identified eight clinical risk factors that can predict ICU interventions:

• (1) Paco2>45 mm Hg, (2) need for endotracheal intubation, (3) toxin-induced seizures, (4) cardiac arrhythmias, (5) QRS duration >0.12 s, (6) systolic BP <80 mm Hg, (7) second- or third degree atrioventricular block, and (8) unresponsiveness to verbal stimuli.

Criteria for ICU Admission

2.

What are the indications for monitoring in a patient with

TCA overdose(Naisan)

• Patients with altered mental status, • seizures, • hypotension, • metabolic acidosis, • and cardiac arrhythmias require ICU monitoring

What are the principles of management in the patient with TCA overdose (Naisan)

• ABCs as usual• Patients should immediately receive sodium

bicarbonate (1 to 2 mEq/kg IV) when there is widening of the QRS interval to decrease the fraction of free drug

Yoan Lamarche

When can you D/C the monitoring in a patient with TCA overdose (Naisan)

• bicarbonate should be continued until there is narrowing of the QRS interval or serum pH exceeds 7.55.

• Activated charcoal can be administered without gastric lavage; there is no role for multidose activated charcoal, particularly since ileus increases the risk of charcoal-induced bowel obstruction. Because of high lipid solubility and protein binding, dialysis and hemoperfusion are not effective.

Yoan Lamarche

Steve’s patient (5) : What is the initial management of the patient with organophosphate and carbamate poisoning (Steve)

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NEJM 2004 Chemical emergencies Review

Chest review Toxidromes 2008

2. What are the principles of management if multiple patients present with potential terrorist attack with cholinergic agents, what are the agents. (Steve)

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Yoan Lamarche

Are you at risk, as a health care worker, when treating these patients. (Steve)

Yoan Lamarche

What are the indications for Hemodialysis, hemoperfusion, in intoxicated patients (Steve)

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ExtraCorporealTxIntox-CurrOpCritCare2007dePons.pdfAdult toxicology inICUPart1-Chest2003.PDF

Yoan Lamarche

Scot’s patient initial blood gas is 7.45/38/130/24. His anion gap is normal. His osmolality is elevated, the osmolar gap is high

Yoan Lamarche

How do you exclude the presence of methanol or ethylene glycol in the presence of ethanol. (Scot)

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Yoan Lamarche

What are the toxic effects of ethylene glycol, methanol and isopropyl alcohol, what are the toxic doses? (Scot)

Yoan Lamarche

Yoan Lamarche

AlcoholToxIntCareMed2005Review.PDF

Yoan Lamarche

What are the treatments to avoid toxicity in ethylene glycol and methanol overdose?

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What is the role of Fomepizole?

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AlcoholToxIntCareMed2005Review.PDF

Yoan Lamarche

Why can the initial blood gas be normal in someone with ingestion of a toxic dose of ethylene glycol? (Scot)

Yoan Lamarche

• What are the conversion units for urea, ethanol, glucose, creatinine (umol/l to mg/dl) (Gord)

Yoan Lamarche

Are you all aware that the family needs support from social work, psychiatry, follow up and understanding from the treating physician in case of intox of the relative?

(cf royal college objectives)