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Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
Toxicology for primary care
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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.

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

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  • 1. Poisoning AKA: Stupid sailor/marine tricks. Tina F. Edwards, MD FAAEM LCDR MC USN
  • 2. Toxicology, in a nutshell O Supportive care O Seizure, coma, death
  • 3. Conclusion OQuestions? OJust Kidding!
  • 4. Overview O Basics of the poisoned patient O Anticholinergics O Cholinergics O Sedatives O Sympathomimetics O Carbon Monoxide O Toxic Alcohols
  • 5. What is a poison? O Too much of anything can be a bad thing.
  • 6. Why primary care? O Jus’ gonna send this patient to ED! O RecognizeStabilize O YOU might be the ED
  • 7. Basics O Stable or unstable? O Abnormal Vital signs O Respiratory distress O Altered Mental Status
  • 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. 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. Common Causes of Seizures O Bupropion O Tricyclic Antidepressants* O Tramadol O Isoniazid* O Cocaine, amphetamines O Antihistamines O Venlafaxine (Effexor)
  • 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. Treatments O Got Activated Charcoal? O 1 hour +/- O Cautions O Ineffective O Alcohols O Metals O Caustic agents
  • 13. Treatments O Decontamination O Naloxone (Narcan) O Benzodiazepines O Dialysis O Antidotes O Sodium Bicarb
  • 14. So there you are minding your own business… When...
  • 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. Anticholinergic Toxidrome O Benadryl O Cough syrup O TCA’s O Scopolamine O DM
  • 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. 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. 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. 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. Cholinergic Toxidrome O Nicotinic O Tachycardia O Hypertension O Fasciculation's O WeaknessParalysi s
  • 22. Cholinergic Toxidrome O Central O Agitation O Psychosis/confusion O Seizure/coma/death
  • 23. Cholinergic Poisoning O Muscarinic O Diarrhea O Urination O Miosis O Bradycardia O Bronchorrhea O Emesis O Lacrimation, salivation
  • 24. Cholinergic treatment O Protect yourself! O Stabilize, then decontaminate O Atropine until dry O Pralidoxime currently recommended O Aggressive supportive care
  • 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. Opioid Toxidrome O Classic Triad O Coma O Respiratory Depression O Pinpoint pupils
  • 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. Opioid Treatment O Naloxone O Aggressive supportive care
  • 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. 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. Sedative-hypnotic treatment O Aggressive supportive care O Airway management O Multiple-dose activated charcoal O Phenobarbital may require dialysis
  • 32. A note about flumazenil O Why? O Can precipitate seizures O Absolutely contraindicated in QRS widening O Doesn’t reverse Hypoventilation
  • 33. What to do?
  • 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. Sympathomimetic Toxidrome O Cocaine O Methamphetamine O Other CNS Stimulants O Withdrawal from sedative hypnotics
  • 36. Sympathomimetic Toxidrome O Hypertension O Tachycardia O Hyperpyrexia O Mydriasis O Anxiety or delirium
  • 37. Sympathomimetic treatment O Aggressive supportive care O Benzodiazepines O Active cooling if needed
  • 38. What to do?
  • 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. EKG
  • 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. Mechanism CO Poisoning O Running engine, closed space O Mechanics O Suicide attempt O Generators O Gas heaters O Camp stoves/Charcoal grills
  • 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. 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. Toxic Alcohols O Ethanol! O Ethylene Glycol O Methanol O Isopropanol/Aceton e O Other glycols
  • 46. Toxic Alcohols O Ethylene glycol – Ca oxalate monohydrate crystals O Methanol – Formic acid O Isopropanol – Acetone
  • 47. Toxic Alcohols O All – Airway compromise O Ethylene Glycol O Dysrhythmias O Nephrotoxicity O Meningoencephalitis O Cerebral/pulmonary edema
  • 48. Toxic Alcohols O Methanol O Visual symptoms, “snowfields” O Coma O Respiratory and circulatory failure O Parkinson-like syndrome
  • 49. Toxic Alcohols O Isopropanol O Ketonemia O CNS Depression (2 x EtOH) O GI effects O Increased Cr w/nl BUN suggests
  • 50. Toxic Alcohols O Other glycols O Effects O Neurologic toxicity O Renal failure O Hepatitis O Pancreatitis O Hemolysis O ARDS
  • 51. Toxic Alcohols O Diethylene glycol O Renal failure epidemics O Propylene glycol O “safer” antifreeze O Iatrogenic, IV Benzos
  • 52. Toxic Alcohol O Aggressive supportive care! O Fomepizole O Plain ol’ ethanol O Look for acidosis, ketones, other clues
  • 53. Are you ready?
  • 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. 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. 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. 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. Questions

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