Poisoning
AKA: Stupid sailor/marine tricks.
Tina F. Edwards, MD FAAEM
LCDR MC USN
Toxicology, in a nutshell
O Supportive care
O Seizure, coma, death
Conclusion
OQuestions?
OJust Kidding!
Overview
O Basics of the poisoned patient
O Anticholinergics
O Cholinergics
O Sedatives
O Sympathomimetics
O Carbon Monoxi...
What is a poison?
O Too much of anything can be a bad thing.
Why primary care?
O Jus’ gonna send this patient to ED!
O RecognizeStabilize
O YOU might be the ED
Basics
O Stable or unstable?
O Abnormal Vital signs
O Respiratory distress
O Altered Mental Status
Basics
O Nature of the syndrome?
O Mental status
O Agitated vs. Sedated
O Pupils
O Skin
O Vitals
O Mucous membranes
O Odors
Basics
O Emetics. Don’t.
O Charcoal, maybe.
O Aggressive supportive care:
O IV, monitors, fluids
O If it’s fast, slow it.
...
Common Causes of Seizures
O Bupropion
O Tricyclic Antidepressants*
O Tramadol
O Isoniazid*
O Cocaine, amphetamines
O Antih...
Workup
O EKG
O Finger stick blood sugar
O Chemistry
O Blood Gas
O CBC
O Tylenol, Aspirin, EtOH
O UA
O CXR,KUB
Treatments
O Got Activated Charcoal?
O 1 hour +/-
O Cautions
O Ineffective
O Alcohols
O Metals
O Caustic agents
Treatments
O Decontamination
O Naloxone (Narcan)
O Benzodiazepines
O Dialysis
O Antidotes
O Sodium Bicarb
So there you are minding
your own business…
When...
19 yr old AD Female
O Oriented x 1
O Agitated
O 140, 156/92, 20, 10
1.2, 98%
O Dry skin, MM’s
O Hypoactive BS
Anticholinergic Toxidrome
O Benadryl
O Cough syrup
O TCA’s
O Scopolamine
O DM
Anticholinergic Toxidrome
O Flushed, dry skin, dry mucous
membranes
O Mydriasis
O Delirium
O Hyper: -thermia, -tension
O T...
Anticholinergic Treatment
O Aggressive supportive care
O Physostigmine Why?
O Can’t use if any QRS widening
O Contraindic...
24 yr old AD male
O C/O frequent
diarrhea, vomiting
O Fatigued, mildly confused
O Acrid garlic smell
O 112/62, 52, 18, 98....
Cholinergic Toxidrome
O Muscarinic
O Nicotinic
O Central
O Causes
O Insecticides
O Pilocarpine
O Carbachol
O Betel nuts
O ...
Cholinergic Toxidrome
O Nicotinic
O Tachycardia
O Hypertension
O Fasciculation's
O WeaknessParalysi
s
Cholinergic Toxidrome
O Central
O Agitation
O Psychosis/confusion
O Seizure/coma/death
Cholinergic Poisoning
O Muscarinic
O Diarrhea
O Urination
O Miosis
O Bradycardia
O Bronchorrhea
O Emesis
O Lacrimation,
sa...
Cholinergic treatment
O Protect yourself!
O Stabilize, then decontaminate
O Atropine until dry
O Pralidoxime currently rec...
17 yr old boy
O Brought in by mom
O C/C “not himself”
O Sedated, barely
responsive
O Disheveled
O 90/58, 52, 10, 97.2, 94%...
Opioid Toxidrome
O Classic Triad
O Coma
O Respiratory
Depression
O Pinpoint pupils
Opioid Toxidrome
O Causes
O All the usual, plus Lomotil
O Dextromethorphan
O But wait!
O Random fact:
O Not all opioids ca...
Opioid Treatment
O Naloxone
O Aggressive supportive care
19 year old AD male
O Brought in by roommate,
“Seized”
O Moans, doesn’t open
eyes
O 88/52, 101, 10, 95.8,
93%
O PERRL, but...
Sedative Hypnotic Toxidrome
O Barbituates
O Benzodiazapines
O GHB
O Zolpidem (Ambien)
O Zaleplon (Sonata)
O Confusion/coma...
Sedative-hypnotic treatment
O Aggressive supportive care
O Airway management
O Multiple-dose activated charcoal
O Phenobar...
A note about flumazenil
O Why?
O Can precipitate seizures
O Absolutely contraindicated in QRS
widening
O Doesn’t reverse H...
What to do?
23 yr old AD male
O Brought in by
command, “not acting
right”
O Anxious
O 180/110, 142, 18, 103.2, 1
00%
O Flushed, sweati...
Sympathomimetic Toxidrome
O Cocaine
O Methamphetamine
O Other CNS Stimulants
O Withdrawal from sedative hypnotics
Sympathomimetic Toxidrome
O Hypertension
O Tachycardia
O Hyperpyrexia
O Mydriasis
O Anxiety or delirium
Sympathomimetic treatment
O Aggressive supportive care
O Benzodiazepines
O Active cooling if needed
What to do?
34 yr old AD male
O Losing
balance, headache,
chest
pain, vomiting
O 100/72, 120, 32, 98.
7, 99%
O A+O x 2
O Accessory mus...
EKG
Carbon Monoxide Poisoning
O Signs/Sx highly variable, non-specific
O Headache
O Dizziness
O Nausea/Vomiting/Diarrhea
O Con...
Mechanism CO Poisoning
O Running engine, closed space
O Mechanics
O Suicide attempt
O Generators
O Gas heaters
O Camp stov...
CO Poisoning Treatment
O Oxygen, more is better
O Aggressive supportive care
O Mild to moderate acidosis is helpful
O Move...
23 yr old AD
O Sent “I want to die”
text
O A+O x 1
O 102/62, 110, 12,
97.3, 97%
O Covered in vomit
O Slurred speech
O Atax...
Toxic Alcohols
O Ethanol!
O Ethylene Glycol
O Methanol
O Isopropanol/Aceton
e
O Other glycols
Toxic Alcohols
O Ethylene glycol – Ca oxalate monohydrate
crystals
O Methanol – Formic acid
O Isopropanol – Acetone
Toxic Alcohols
O All – Airway compromise
O Ethylene Glycol
O Dysrhythmias
O Nephrotoxicity
O Meningoencephalitis
O Cerebra...
Toxic Alcohols
O Methanol
O Visual symptoms, “snowfields”
O Coma
O Respiratory and circulatory failure
O Parkinson-like sy...
Toxic Alcohols
O Isopropanol
O Ketonemia
O CNS Depression (2 x EtOH)
O GI effects
O Increased Cr w/nl BUN suggests
Toxic Alcohols
O Other glycols
O Effects
O Neurologic toxicity
O Renal failure
O Hepatitis
O Pancreatitis
O Hemolysis
O AR...
Toxic Alcohols
O Diethylene glycol
O Renal failure epidemics
O Propylene glycol
O “safer” antifreeze
O Iatrogenic, IV Benz...
Toxic Alcohol
O Aggressive supportive care!
O Fomepizole
O Plain ol’ ethanol
O Look for acidosis, ketones, other clues
Are you ready?
24 year old male
O Found down
outside barracks
O 90/54, 48, 8, 92%, 9
6.2
O Non responsive
O PERRL
18 year old AD female
O Witnessed seizure
O 160/102, 120, 22, 1
02.4, 99%
O Flushed, Dry
O Pupils
dilated, reactive
O Abse...
22 year old AD male
O Working outside
O Vomiting
O 190/120, 130, 24,
104.2, 95%
O Diaphoretic
O Rigid, shaking
O Smells of...
Sources
O Harwood-Nuss, Clinical Practice of Emergency Medicine, 5th
Edition, Lippincott Williams & Wilkins, Philadelphia,...
Questions
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Toxicology for primary care

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Common toxidromes that may be encountered by primary care doctors, particularly military doctors.

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Toxicology for primary care

  1. 1. Poisoning AKA: Stupid sailor/marine tricks. Tina F. Edwards, MD FAAEM LCDR MC USN
  2. 2. Toxicology, in a nutshell O Supportive care O Seizure, coma, death
  3. 3. Conclusion OQuestions? OJust Kidding!
  4. 4. Overview O Basics of the poisoned patient O Anticholinergics O Cholinergics O Sedatives O Sympathomimetics O Carbon Monoxide O Toxic Alcohols
  5. 5. What is a poison? O Too much of anything can be a bad thing.
  6. 6. Why primary care? O Jus’ gonna send this patient to ED! O RecognizeStabilize O YOU might be the ED
  7. 7. Basics O Stable or unstable? O Abnormal Vital signs O Respiratory distress O Altered Mental Status
  8. 8. Basics O Nature of the syndrome? O Mental status O Agitated vs. Sedated O Pupils O Skin O Vitals O Mucous membranes O Odors
  9. 9. Basics O Emetics. Don’t. O Charcoal, maybe. O Aggressive supportive care: O IV, monitors, fluids O If it’s fast, slow it. O If it’s slow, speed it up. O If it’s low, raise it O If it’s high, lower it.
  10. 10. Common Causes of Seizures O Bupropion O Tricyclic Antidepressants* O Tramadol O Isoniazid* O Cocaine, amphetamines O Antihistamines O Venlafaxine (Effexor)
  11. 11. Workup O EKG O Finger stick blood sugar O Chemistry O Blood Gas O CBC O Tylenol, Aspirin, EtOH O UA O CXR,KUB
  12. 12. Treatments O Got Activated Charcoal? O 1 hour +/- O Cautions O Ineffective O Alcohols O Metals O Caustic agents
  13. 13. Treatments O Decontamination O Naloxone (Narcan) O Benzodiazepines O Dialysis O Antidotes O Sodium Bicarb
  14. 14. So there you are minding your own business… When...
  15. 15. 19 yr old AD Female O Oriented x 1 O Agitated O 140, 156/92, 20, 10 1.2, 98% O Dry skin, MM’s O Hypoactive BS
  16. 16. Anticholinergic Toxidrome O Benadryl O Cough syrup O TCA’s O Scopolamine O DM
  17. 17. Anticholinergic Toxidrome O Flushed, dry skin, dry mucous membranes O Mydriasis O Delirium O Hyper: -thermia, -tension O Tachycardia O Urinary retention O Hypoactive BS
  18. 18. Anticholinergic Treatment O Aggressive supportive care O Physostigmine Why? O Can’t use if any QRS widening O Contraindicated in asthma O Requires continuous cardiac monitoring O Usually won’t outlast the anticholinergic
  19. 19. 24 yr old AD male O C/O frequent diarrhea, vomiting O Fatigued, mildly confused O Acrid garlic smell O 112/62, 52, 18, 98.2, 95% O Productive cough O Tearing O Frequent spitting O Muscle twitches
  20. 20. Cholinergic Toxidrome O Muscarinic O Nicotinic O Central O Causes O Insecticides O Pilocarpine O Carbachol O Betel nuts O Indian Tobacco O Nicotine O Black widow
  21. 21. Cholinergic Toxidrome O Nicotinic O Tachycardia O Hypertension O Fasciculation's O WeaknessParalysi s
  22. 22. Cholinergic Toxidrome O Central O Agitation O Psychosis/confusion O Seizure/coma/death
  23. 23. Cholinergic Poisoning O Muscarinic O Diarrhea O Urination O Miosis O Bradycardia O Bronchorrhea O Emesis O Lacrimation, salivation
  24. 24. Cholinergic treatment O Protect yourself! O Stabilize, then decontaminate O Atropine until dry O Pralidoxime currently recommended O Aggressive supportive care
  25. 25. 17 yr old boy O Brought in by mom O C/C “not himself” O Sedated, barely responsive O Disheveled O 90/58, 52, 10, 97.2, 94% O Crackles O Decreased BS O Hypotonic reflexes
  26. 26. Opioid Toxidrome O Classic Triad O Coma O Respiratory Depression O Pinpoint pupils
  27. 27. Opioid Toxidrome O Causes O All the usual, plus Lomotil O Dextromethorphan O But wait! O Random fact: O Not all opioids cause miosis O Meperidine (Demerol) O Propoxyphene (Darvon)
  28. 28. Opioid Treatment O Naloxone O Aggressive supportive care
  29. 29. 19 year old AD male O Brought in by roommate, “Seized” O Moans, doesn’t open eyes O 88/52, 101, 10, 95.8, 93% O PERRL, but slowed O Nystagmus
  30. 30. Sedative Hypnotic Toxidrome O Barbituates O Benzodiazapines O GHB O Zolpidem (Ambien) O Zaleplon (Sonata) O Confusion/coma O Respiratory depression O Hypotension O Hypothermia O Pupillary changes O Vesicles or bullae O Seizures
  31. 31. Sedative-hypnotic treatment O Aggressive supportive care O Airway management O Multiple-dose activated charcoal O Phenobarbital may require dialysis
  32. 32. A note about flumazenil O Why? O Can precipitate seizures O Absolutely contraindicated in QRS widening O Doesn’t reverse Hypoventilation
  33. 33. What to do?
  34. 34. 23 yr old AD male O Brought in by command, “not acting right” O Anxious O 180/110, 142, 18, 103.2, 1 00% O Flushed, sweating O A+O x 3
  35. 35. Sympathomimetic Toxidrome O Cocaine O Methamphetamine O Other CNS Stimulants O Withdrawal from sedative hypnotics
  36. 36. Sympathomimetic Toxidrome O Hypertension O Tachycardia O Hyperpyrexia O Mydriasis O Anxiety or delirium
  37. 37. Sympathomimetic treatment O Aggressive supportive care O Benzodiazepines O Active cooling if needed
  38. 38. What to do?
  39. 39. 34 yr old AD male O Losing balance, headache, chest pain, vomiting O 100/72, 120, 32, 98. 7, 99% O A+O x 2 O Accessory muscle use
  40. 40. EKG
  41. 41. Carbon Monoxide Poisoning O Signs/Sx highly variable, non-specific O Headache O Dizziness O Nausea/Vomiting/Diarrhea O Confusion O Syncope O SOB O Chest pain O Cerebellar ataxia
  42. 42. Mechanism CO Poisoning O Running engine, closed space O Mechanics O Suicide attempt O Generators O Gas heaters O Camp stoves/Charcoal grills
  43. 43. CO Poisoning Treatment O Oxygen, more is better O Aggressive supportive care O Mild to moderate acidosis is helpful O Moves curve to right
  44. 44. 23 yr old AD O Sent “I want to die” text O A+O x 1 O 102/62, 110, 12, 97.3, 97% O Covered in vomit O Slurred speech O Ataxic gait
  45. 45. Toxic Alcohols O Ethanol! O Ethylene Glycol O Methanol O Isopropanol/Aceton e O Other glycols
  46. 46. Toxic Alcohols O Ethylene glycol – Ca oxalate monohydrate crystals O Methanol – Formic acid O Isopropanol – Acetone
  47. 47. Toxic Alcohols O All – Airway compromise O Ethylene Glycol O Dysrhythmias O Nephrotoxicity O Meningoencephalitis O Cerebral/pulmonary edema
  48. 48. Toxic Alcohols O Methanol O Visual symptoms, “snowfields” O Coma O Respiratory and circulatory failure O Parkinson-like syndrome
  49. 49. Toxic Alcohols O Isopropanol O Ketonemia O CNS Depression (2 x EtOH) O GI effects O Increased Cr w/nl BUN suggests
  50. 50. Toxic Alcohols O Other glycols O Effects O Neurologic toxicity O Renal failure O Hepatitis O Pancreatitis O Hemolysis O ARDS
  51. 51. Toxic Alcohols O Diethylene glycol O Renal failure epidemics O Propylene glycol O “safer” antifreeze O Iatrogenic, IV Benzos
  52. 52. Toxic Alcohol O Aggressive supportive care! O Fomepizole O Plain ol’ ethanol O Look for acidosis, ketones, other clues
  53. 53. Are you ready?
  54. 54. 24 year old male O Found down outside barracks O 90/54, 48, 8, 92%, 9 6.2 O Non responsive O PERRL
  55. 55. 18 year old AD female O Witnessed seizure O 160/102, 120, 22, 1 02.4, 99% O Flushed, Dry O Pupils dilated, reactive O Absent bowel sounds
  56. 56. 22 year old AD male O Working outside O Vomiting O 190/120, 130, 24, 104.2, 95% O Diaphoretic O Rigid, shaking O Smells of stool O Pupils pinpoint, reactive
  57. 57. Sources O Harwood-Nuss, Clinical Practice of Emergency Medicine, 5th Edition, Lippincott Williams & Wilkins, Philadelphia, PA, 2010 O Hamilton, Sanders, Strange, Trott. Emergency Medicine, An Approach to Clinical Problem Solving, 2nd Edition. Saunders. Philadelphia, PA. 2003. O http://www.mrcophth.com/plants.html O http://memorize.com/toxidromes-and-antidotes/erichf O http://emedicine.medscape.com/article/812411-clinical O Thundiyil JG, et. al, Evolving epidemiology of drug-induced seizures reported to a Poison Control Center System. J Med Toxicol, 2007, Mar, 3(1):15-9.
  58. 58. Questions
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