1. TOXICOLOGY
An Overview
Jordan B. Barnett, M.D., FACEP
Interim Director, Department of Emergency
Medicine
Episcopal Hospital

2. POISONING
® Estimated 4 Million Annual
® Pediatric
®Child Abuse
® Adult
®Recreational
®Suicide

3. HISTORY
® What Poison?
® How Much?
® How?
® When?
® Why?
® What Else Taken?

4. PHYSICAL EXAM
® Vital Signs
® ABC’s
® Temperature
® Toxic Syndrome
® Respiratory
® Cardiovascular
® Neurologic

5. TREATMENT
® ABC’s
® Treat Other Injuries
® Decontamination
® Supportive Care
® Definitive Care
® Antidotes
® Elimination

6. DECONTAMINATION:
IPECAC
® Absorption Reduced By 30%
® Interferes With Further
Decontamination
® Interferes With Further Treatment
® Home Use
® NOEMERGENCY DEPARTMENT
USE!

7. DECONTAMINATION:
GASTRIC LAVAGE
® 250 - 300 cc Aliquots Of Fluid
® 36 - 40F Tube
® Advantages
® Immediate Recovery Of Gastric
Contents
® Direct access For Charcoal Instillation
® LeftLateral Decubitus With
Trendelenburg
® Intubation May Be Needed

8. DECONTAMINATION:
GASTRIC LAVAGE
® Disadvantages
® NotComplete Gastric Emptying
® 30% Recovery At 1 Hour
® Labor Intensive
® Complications
® 3% Overall
® Esophageal Rupture
® Aspiration
® Hypoxia

9. DECONTAMINATION:
CHARCOAL
® Not Absorbed From GI Tract
® Binds Most Substances
® Prevents Absorption
® Enhance Excretion
® MultipleDose
® Enterohepatic Circulation

10. DECONTAMINATION:
CHARCOAL
Ampicillin Model
Decreased Absorption
® Charcoal 57%
® Emesis 38%
® Lavage 32%

11. ACTIVATED CHARCOAL
® Dose 1g/kg
® Repeat Dose
® Disadvantages
® Messy
® Aspiration

12. SUBSTANCES NOT BOUND
BY CHARCOAL
® Alcohols And ® Heavy Metals
Glycols ® Iron
® Corrosives ® Lead
® Alkalis ® Lithium
® Acids ® Mercury
® Cyanide ® Hydrocarbons
® Saline Cathartics

13. CATHARTICS
® Mechanism
® Types
® Mixture With Charcoal
® Disadvantages
® Use In Children

14. OTHER MODALITIES
® Whole Bowel Irrigation
® Indications
® Technique
® Skin
® Eye

15. RESPIRATORY
COMPLICATIONS
® Airway Protection
® Ventilatory Insufficiency
® Bronchospasm
® Noncardiogenic Pulmonary Edema
® Aspiration

16. CARDIOVASCULAR
COMPLICATIONS
® Tachycardia
® Bradycardia
® Hypotension
® Hypertension

17. NEUROLOGIC
COMPLICATIONS
® Coma
® Seizures
® Behavioral Abnormalities

18. DIAGNOSTIC STUDIES
® Drug Screens/Levels
® Acetaminophen
® ABG
® Electrolytes
® Organ Function
® EKG
® X-RAY

19. SERUM OSMOLARITY
® Serum Osmolarity= 2 (Na+) + BUN/2.8
+ Glucose/18
® Osmolar Gap 10 mOsm or less
® Methanol, Ethylene Glycol, Ethanol
® Glycerol, Mannitol
® +ETOH/4.6

20. ETHANOL
C2H5OH
Molecular Weight=________

21. DEFINITIVE CARE
® Decontamination
® Supportive Care
® Antidotes
® Oxygen/Glucose/Narcan/?Flumazenil
® Elimination
® Alkalinization
® Repeated Dose Charcoal
® Dialysis

22. DISCHARGE
® StableIn Emergency Department
® Psychiatric Issues

23. TOXIDROME
Toxic Syndromes

24. TOXIDROMES: CASE 1
25 Year Old PA Student Just
Back From Spring Break In
Mexico. He's Been Having
Terrible Diarrhea Since Returning
and Has Been Using Pills to
Alleviate the Symptoms.

25. TOXIDROMES: CASE 1
® Dry Skin And Mucous Membranes
® Thirst
® Blurred Vision
® Fixed Dilated Pupils
® Flushing
® Urinary Urgency And Retention
® Hallucinations

26. TOXIDROMES: CASE 1
® Anticholinergic
®Hot As Hades
®Blind As A Bat
®Dry As A Bone
®Red As A Beet
®Mad As A Hatter

27. TOXIDROMES: CASE 1
® Belladonna Alkaloids
® Atropine/Scopolamine
® Scopolamine
® Synthetic Anticholinergics
® Dicyclomine
® Other
® Antihistamines/Phenothiazines/TCA

28. TOXIDROMES: CASE 2
A 50 Year Old Farmer Is
Found Unresponsive at His
Barn.

29. TOXIDROMES: CASE 2
® Sweating
® Constricted Pupils
® Lacrimation
® Excessive Salivation
® Wheezing
® Vomiting/Diarrhea
® Fasiculations

30. TOXIDROMES: CASE 2
® Acetylcholinesterase Inhibitors
® Pesticides
® Organophosphate
® Carbamates
® Mechanism
® Treatment
® Atropine
® Pralidoxime (2-PAM)

31. TOXIDROMES: CASE 3
An 8 Year Old Child Is Brought
to the Emergency Department
After Being Given a
Compazine Suppository for
Vomiting.

32. TOXIDROMES: CASE 3
® Dysphonia
® Oculogyric Crises
® Rigidity
® Torticollis/Opisthotonos

33. TOXIDROMES: CASE 3
® Extrapyramidal Effects
® Medications
®Antipsychotic
®Antiemetic
® Treatment

34. TOXIDROMES: CASE 4
During a Visit to Grandma in the
Nursing Home, You Find That
You Can Not Wake Her Up.

35. TOXIDROMES: CASE 4
® CNS Depression
® Pinpoint Pupils
® Slowed Respirations
® Hypotension

36. TOXIDROMES: CASE 4
® Narcotic
® Medications
®Prescribed
®Illicit
® Treatment

37. TOXIDROMES: CASE 5
A Movie Star Presents to Your
Hospital.

38. TOXIDROMES: CASE 5
® CNS Excitation
® Seizures
® Hypertension
® Tachycardia

39. TOXIDROMES: CASE 5
® Sympathomimetic
® Medication
®Prescribed
®Illicit
® Treatment

40. TOXIDROMES: CASE 6
A Family of 6 Presents to Your
Office in the Middle of Winter
and All Complain of “the Flu”.

41. TOXIDROMES: CASE 6
® Headache
® “Flu”Symptoms
® Nausea, Vomiting, Dizziness
® Dyspnea
® Seizures
® Death
® Cyanosis
® “Chocolate” Blood

42. TOXIDROMES: CASE 6
® Hemoglobinopathies
® Carbon Monoxide
® Methemoglobin
® Treatment

43. TRICYCLIC
ANTIDEPRESSANTS
® Mortality
2 - 5 Percent
® Low Therapeutic/Toxic Ratio
® Mechanism
®InhibitionOf Amine Uptake
®Anticholinergic
®Alpha Receptor Blocker
®Sodium Channel Blockade

44. TCA
CLINICAL FEATURES
® Anticholinergic Symptoms
® Tachycardia
® CNS Toxicity
® Coma
® Hypotension
® Arrhythmia
® Seizures

45. TCA
CLINICAL FEATURES
® ECG
®“rightaxis deviation of the terminal
40ms of QRS greater than 1200 “
®Sinus Tach-Wide QRS-Decreased
Inotropy-Increased PRI-
Bradycardia
®Wide QRS=Life Threatening
Toxicity

46. TCA
TREATMENT
® GIDecontamination
® Sodium Bicarbonate-Indications
® QRS Widening
® Hypotension
® Ventricular Arrhythmias
® Sodium Bicarbonate-Mechanism
® 1 - 2 mEq/Kg To pH 7.50-7.55

47. TCA
TREATMENT
® Physostigmine
® Peripheral Anticholinergic Symptoms
® Agitation/Seizures/Hypotension When
Other Methods Fail
® Side Effects
® Seizures
® Benzodiazepines/Barbiturates
® Hypotension

48. SALICYLATES
® Gastroenteritis
® Mixed Respiratory And Metabolic
Acidosis
® CNS
® Cardiac Toxicity
® Pulmonary
® ARDS
® Tinnitus

49. SALICYLATES
TOXIC DOSE
® Done Nomogram
® Acute, Single Ingestion
® Cannot Use For:
® Acute Ingestion With Salicylate Taken
Within Last 24 Hours
® Chronic Salicylate Poisoning
® Ingestion Of Enteric Coated Tablets
® Treat Patient If Symptomatic

50. SALICYLATES
TREATMENT
® Charcoal
® IVFluids
® Urine Alkalinization
® Mechanism “Ion Trapping”
® Un-ionized Salicylate Reabsorbed By
Renal Tubules
® Alkaline Urine Favors Ionized Salicylate
Which Cannot Be Reabsorbed
® Dialysis

51. SALICYLATES
DISPOSITION
® Asymptomatic Nomogram After 6
Hours
® Patient Asymptomatic
® Enteric Coated
® 150 mg/kg
® Psychiatric Evaluation
® Follow-up