Toxicology Management in The Emergency Department  - Jordan Barnett MD
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Toxicology Management in The Emergency Department - Jordan Barnett MD

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Overview of toxicologic management in the Emergency Department

Overview of toxicologic management in the Emergency Department

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Toxicology Management in The Emergency Department  - Jordan Barnett MD Toxicology Management in The Emergency Department - Jordan Barnett MD Presentation Transcript

  • TOXICOLOGY An Overview Jordan B. Barnett, M.D., FACEP Interim Director, Department of Emergency Medicine Episcopal Hospital
  • POISONING
    • Estimated 4 Million Annual
    • Pediatric
      • Child Abuse
    • Adult
      • Recreational
      • Suicide
  • HISTORY
    • What Poison?
    • How Much?
    • How?
    • When?
    • Why?
    • What Else Taken?
    View slide
  • PHYSICAL EXAM
    • Vital Signs
      • ABC’s
      • Temperature
    • Toxic Syndrome
    • Respiratory
    • Cardiovascular
    • Neurologic
    View slide
  • TREATMENT
    • ABC’s
    • Treat Other Injuries
    • Decontamination
    • Supportive Care
    • Definitive Care
      • Antidotes
      • Elimination
  • DECONTAMINATION: IPECAC
    • Absorption Reduced By 30%
    • Interferes With Further Decontamination
    • Interferes With Further Treatment
    • Home Use
    • NO EMERGENCY DEPARTMENT USE!
  • DECONTAMINATION: GASTRIC LAVAGE
    • 250 - 300 cc Aliquots Of Fluid
    • 36 - 40F Tube
    • Advantages
      • Immediate Recovery Of Gastric Contents
      • Direct access For Charcoal Instillation
    • Left Lateral Decubitus With Trendelenburg
    • Intubation May Be Needed
  • DECONTAMINATION: GASTRIC LAVAGE
    • Disadvantages
      • Not Complete Gastric Emptying
      • 30% Recovery At 1 Hour
      • Labor Intensive
      • Complications
        • 3% Overall
        • Esophageal Rupture
        • Aspiration
        • Hypoxia
  • DECONTAMINATION: CHARCOAL
    • Not Absorbed From GI Tract
    • Binds Most Substances
    • Prevents Absorption
    • Enhance Excretion
      • Multiple Dose
      • Enterohepatic Circulation
  • DECONTAMINATION: CHARCOAL
    • Charcoal
    • Emesis
    • Lavage
    • 57%
    • 38%
    • 32%
    Ampicillin Model Decreased Absorption
  • ACTIVATED CHARCOAL
    • Dose 1g/kg
    • Repeat Dose
    • Disadvantages
      • Messy
      • Aspiration
  • SUBSTANCES NOT BOUND BY CHARCOAL
    • Alcohols And Glycols
    • Corrosives
      • Alkalis
      • Acids
    • Cyanide
    • Saline Cathartics
    • Heavy Metals
      • Iron
      • Lead
      • Lithium
      • Mercury
    • Hydrocarbons
  • CATHARTICS
    • Mechanism
    • Types
    • Mixture With Charcoal
    • Disadvantages
    • Use In Children
  • OTHER MODALITIES
    • Whole Bowel Irrigation
      • Indications
      • Technique
    • Skin
    • Eye
  • RESPIRATORY COMPLICATIONS
    • Airway Protection
    • Ventilatory Insufficiency
    • Bronchospasm
    • Noncardiogenic Pulmonary Edema
    • Aspiration
  • CARDIOVASCULAR COMPLICATIONS
    • Tachycardia
    • Bradycardia
    • Hypotension
    • Hypertension
  • NEUROLOGIC COMPLICATIONS
    • Coma
    • Seizures
    • Behavioral Abnormalities
  • DIAGNOSTIC STUDIES
    • Drug Screens/Levels
    • Acetaminophen
    • ABG
    • Electrolytes
    • Organ Function
    • EKG
    • X-RAY
  • 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
  • ETHANOL C 2 H 5 OH Molecular Weight=________
  • DEFINITIVE CARE
    • Decontamination
    • Supportive Care
    • Antidotes
      • Oxygen/Glucose/Narcan/?Flumazenil
    • Elimination
      • Alkalinization
      • Repeated Dose Charcoal
    • Dialysis
  • DISCHARGE
    • Stable In Emergency Department
    • Psychiatric Issues
  • TOXIDROME Toxic Syndromes
  • 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.
  • TOXIDROMES: CASE 1
    • Dry Skin And Mucous Membranes
    • Thirst
    • Blurred Vision
    • Fixed Dilated Pupils
    • Flushing
    • Urinary Urgency And Retention
    • Hallucinations
  • TOXIDROMES: CASE 1
    • Anticholinergic
      • Hot As Hades
      • Blind As A Bat
      • Dry As A Bone
      • Red As A Beet
      • Mad As A Hatter
  • TOXIDROMES: CASE 1
    • Belladonna Alkaloids
      • Atropine/Scopolamine
      • Scopolamine
    • Synthetic Anticholinergics
      • Dicyclomine
    • Other
      • Antihistamines/Phenothiazines/TCA
  • TOXIDROMES: CASE 2 A 50 Year Old Farmer Is Found Unresponsive at His Barn.
  • TOXIDROMES: CASE 2
    • Sweating
    • Constricted Pupils
    • Lacrimation
    • Excessive Salivation
    • Wheezing
    • Vomiting/Diarrhea
    • Fasiculations
  • TOXIDROMES: CASE 2
    • Acetylcholinesterase Inhibitors
    • Pesticides
      • Organophosphate
      • Carbamates
    • Mechanism
    • Treatment
      • Atropine
      • Pralidoxime (2-PAM)
  • TOXIDROMES: CASE 3 An 8 Year Old Child Is Brought to the Emergency Department After Being Given a Compazine Suppository for Vomiting.
  • TOXIDROMES: CASE 3
    • Dysphonia
    • Oculogyric Crises
    • Rigidity
    • Torticollis/Opisthotonos
  • TOXIDROMES: CASE 3
    • Extrapyramidal Effects
    • Medications
      • Antipsychotic
      • Antiemetic
    • Treatment
  • TOXIDROMES: CASE 4 During a Visit to Grandma in the Nursing Home, You Find That You Can Not Wake Her Up.
  • TOXIDROMES: CASE 4
    • CNS Depression
    • Pinpoint Pupils
    • Slowed Respirations
    • Hypotension
  • TOXIDROMES: CASE 4
    • Narcotic
    • Medications
      • Prescribed
      • Illicit
    • Treatment
  • TOXIDROMES: CASE 5 A Movie Star Presents to Your Hospital.
  • TOXIDROMES: CASE 5
    • CNS Excitation
    • Seizures
    • Hypertension
    • Tachycardia
  • TOXIDROMES: CASE 5
    • Sympathomimetic
    • Medication
      • Prescribed
      • Illicit
    • Treatment
  • TOXIDROMES: CASE 6 A Family of 6 Presents to Your Office in the Middle of Winter and All Complain of “the Flu”.
  • TOXIDROMES: CASE 6
    • Headache
    • “ Flu” Symptoms
    • Nausea, Vomiting, Dizziness
    • Dyspnea
    • Seizures
    • Death
    • Cyanosis
    • “ Chocolate” Blood
  • TOXIDROMES: CASE 6
    • Hemoglobinopathies
    • Carbon Monoxide
    • Methemoglobin
    • Treatment
  • TRICYCLIC ANTIDEPRESSANTS
    • Mortality 2 - 5 Percent
    • Low Therapeutic/Toxic Ratio
    • Mechanism
      • Inhibition Of Amine Uptake
      • Anticholinergic
      • Alpha Receptor Blocker
      • Sodium Channel Blockade
  • TCA CLINICAL FEATURES
    • Anticholinergic Symptoms
    • Tachycardia
    • CNS Toxicity
    • Coma
    • Hypotension
    • Arrhythmia
    • Seizures
  • TCA CLINICAL FEATURES
    • ECG
      • “ right axis deviation of the terminal 40ms of QRS greater than 120 0 “
      • Sinus Tach-Wide QRS-Decreased Inotropy-Increased PRI-Bradycardia
      • Wide QRS=Life Threatening Toxicity
  • TCA TREATMENT
    • GI Decontamination
    • Sodium Bicarbonate-Indications
      • QRS Widening
      • Hypotension
      • Ventricular Arrhythmias
    • Sodium Bicarbonate-Mechanism
    • 1 - 2 mEq/Kg To pH 7.50-7.55
  • TCA TREATMENT
    • Physostigmine
      • Peripheral Anticholinergic Symptoms
      • Agitation/Seizures/Hypotension When Other Methods Fail
      • Side Effects
    • Seizures
      • Benzodiazepines/Barbiturates
    • Hypotension
  • SALICYLATES
    • Gastroenteritis
    • Mixed Respiratory And Metabolic Acidosis
    • CNS
    • Cardiac Toxicity
    • Pulmonary
      • ARDS
    • Tinnitus
  • 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
  • SALICYLATES TREATMENT
    • Charcoal
    • IV Fluids
    • Urine Alkalinization
      • Mechanism “Ion Trapping”
      • Un-ionized Salicylate Reabsorbed By Renal Tubules
      • Alkaline Urine Favors Ionized Salicylate Which Cannot Be Reabsorbed
    • Dialysis
  • SALICYLATES DISPOSITION
    • Asymptomatic Nomogram After 6 Hours
    • Patient Asymptomatic
    • Enteric Coated
      • 150 mg/kg
    • Psychiatric Evaluation
    • Follow-up