Approaching the Poisoned Patient!!<br />
Objectives<br />Provide a general overview of toxicology<br />How to approach the poisoned patient<br />Understanding comm...
What is Toxicology<br />What is it not a poison? All things are poison and nothing is without poison. Solely the dose dete...
Why do people OD?<br />Significant portion intend to die at time of overdose<br />Most want to escape an intolerable situa...
What Drugs do they OD on?<br />ETOH<br />Paracetamol<br />Benzo’s<br />Antipsychotics<br />Antidepressants<br />Antiepilep...
Risk Assessment<br />RRSIDEAD Approach<br />Resuscitation<br />Risk Assessment<br />Supportive Care & Monitoring<br />Inve...
Resuscitation<br />Airway<br />Breathing<br />Circulation<br />Control seizures<br />Correct hypoglycaemia<br />Correct hy...
Risk Assessment<br />Agent<br />Dose<br />Time since ingestion<br />Clinical features and course<br />Patient factors<br /...
Supportive Care & Monitoring<br />Supportive Care<br />Airway: Intubation<br />Breathing: O2, Ventilation<br />Circulation...
Can good supportive care can be done at home?<br />
Supportive Care & Monitoring<br />Monitoring & investigation:<br />12 lead ECG <br />Paracetamol Level<br />BSL below 4 co...
Drug Levels<br />
The ECG in TOX<br />Valuable inexpensive screening tool<br />QRS widening R/T sodium channel blockade, common with TCA ove...
Urine Drug Screen<br />Why don’t we do it?<br />In general it rarely if ever changes management.<br />Expensive<br />Takes...
Gastrointestinal Decontamination<br />Methods:<br /><ul><li>Induced Emesis (Syrup of ipecac)
Gastric Lavage
Activated Charcoal
Whole Bowel Irrigation</li></ul>Activated charcoal has most benefits in a limited number of poisoning, other methods have ...
Enhanced Elimination<br />Multiple-dose activated charcoal<br />Urinary alkalinisation<br />Haemodialysis and haemofiltrat...
Antidotes<br />Limited number of antidotes available for limited number of poisonings.<br />Common Antidotes:<br />NAC<br ...
Common Complications in the Critically Poisoned Patient<br />Aspiration Pneumonia<br />ARDS<br />ARF<br />DVT/PE<br />Rhab...
Disposition<br />The patients journey can be:<br />RESUS <br />ICU <br />Assessment<br />Obs ward<br />Psych<br />Or patie...
Poisoning in Children<br />Most paediatric poisoning are benign, as children generally ingest small quantities.<br />Alway...
2 tablets that can KILL a 10kg toddler<br />
Management of child who ingest unidentified poison<br />Admit for minimum of 12-hour observation<br />Ensure health care f...
Poisoning in Pregnancy<br />Need to assess risk to fetus or infant if lactating<br /> Management rarely differs from non p...
Common poisoning in the Elderly<br />Digoxin<br />Metformin<br />Lithium<br />Disposition= Generally elderly patients end ...
Toxidromes<br />
Coma<br />Patients presenting with coma have generally overdosed on a drug with CNS depressant effects.<br />Can be caused...
Coma Management<br />RRSIDEAD<br />Good supportive care & airway management<br />Treat secondary effects<br />Look at what...
Why do we use Diazepam so much in TOX?<br />Good safety profile<br />Long half life<br />Controls agitation well<br />Used...
Anticholinergic Syndrome<br />Results from the competitive, reversible blockade of central & peripheral cholinergic blocka...
Types of Anticholinergic Agents<br />Antipakinson drugs (benztropine, amantadine)<br />Antihistamines (prometazine, doxyla...
Clinical Features of Anticholinergic Syndrome<br />
Remember the saying!!!<br />Hyperthermia (HOT as a hare)<br />Flushed (RED as a beet)<br />Dry Skin (DRY as a bone)<br />D...
Management <br />Good Supportive Care<br />IV fluids<br />IDC<br />Diazepam to control agitation<br />Avoid drugs with ant...
Reverse anticholinergic delirium in selected patients that don’t respond to benzo’s</li></li></ul><li>Serotonin Syndrome<b...
Clinical features of serotonin syndrome<br />
Life threatening serotonin syndrome<br />Characterised by:<br /><ul><li>Generalised rigidity
Autonomic instability
Delirium
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Toxicology

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Toxicology

  1. 1. Approaching the Poisoned Patient!!<br />
  2. 2. Objectives<br />Provide a general overview of toxicology<br />How to approach the poisoned patient<br />Understanding common toxidromes<br />
  3. 3. What is Toxicology<br />What is it not a poison? All things are poison and nothing is without poison. Solely the dose determines that a thing is not a poison.<br />-Paracelsus (1943-1541), the Renaissance Father of Toxicology, in his Third defence<br />
  4. 4. Why do people OD?<br />Significant portion intend to die at time of overdose<br />Most want to escape an intolerable situation or state of mind<br />Small minority of patients want to punish someone or make someone feel guilty<br />Mental health difficulties particularly, depression, ETOH or substance misuse, and personality disorders are frequently seen<br />Inability to tolerate life stressor or events, relationship breakdowns, anniversaries of bereavement, ect.<br />Mitchell, A. Dennis, M. Self harm and attempted suicide in adults: 10 practical questions and answers for emergency department staff. Emerg Med J, 2006: 26, 251-255<br />
  5. 5. What Drugs do they OD on?<br />ETOH<br />Paracetamol<br />Benzo’s<br />Antipsychotics<br />Antidepressants<br />Antiepileptic<br />Opiods<br />And many many more!!!<br />
  6. 6. Risk Assessment<br />RRSIDEAD Approach<br />Resuscitation<br />Risk Assessment<br />Supportive Care & Monitoring<br />Investigations<br />Decontamination<br />Enhanced Elimination<br />Antidotes<br />Disposition<br />
  7. 7. Resuscitation<br />Airway<br />Breathing<br />Circulation<br />Control seizures<br />Correct hypoglycaemia<br />Correct hyperthermia<br />Consider resuscitation antidotes<br />
  8. 8. Risk Assessment<br />Agent<br />Dose<br />Time since ingestion<br />Clinical features and course<br />Patient factors<br />Geographical location<br />
  9. 9. Supportive Care & Monitoring<br />Supportive Care<br />Airway: Intubation<br />Breathing: O2, Ventilation<br />Circulation: IVIH, Inotropes, Defib or pacing<br />Sedation: Titrate Benzo’s<br />Seizure control/prophylaxis: Titrate Benzo’s<br />Metabolic: control pH, normoglycaemia<br />Fluids & Electrolytes: Monitor<br />Renal function: hydrate, haemodialysis<br />General: Bladder care? IDC, Nutrition, DVT & Stress ulcerprophylaxis, PAC, Monitor mental state<br />
  10. 10. Can good supportive care can be done at home?<br />
  11. 11. Supportive Care & Monitoring<br />Monitoring & investigation:<br />12 lead ECG <br />Paracetamol Level<br />BSL below 4 correct with D50<br />Temp above 38.5 requires continuous monitoring<br />
  12. 12. Drug Levels<br />
  13. 13.
  14. 14. The ECG in TOX<br />Valuable inexpensive screening tool<br />QRS widening R/T sodium channel blockade, common with TCA overdose<br />QT prolongation is a potassium channel effect associated with TDP, common in some antidepressant, antiarrythmics, & antipsychotic overdoses.<br />
  15. 15. Urine Drug Screen<br />Why don’t we do it?<br />In general it rarely if ever changes management.<br />Expensive<br />Takes 1-2 days to get back<br />When would we consider it?<br />
  16. 16. Gastrointestinal Decontamination<br />Methods:<br /><ul><li>Induced Emesis (Syrup of ipecac)
  17. 17. Gastric Lavage
  18. 18. Activated Charcoal
  19. 19. Whole Bowel Irrigation</li></ul>Activated charcoal has most benefits in a limited number of poisoning, other methods have limited if any evidence to support their use.<br />
  20. 20. Enhanced Elimination<br />Multiple-dose activated charcoal<br />Urinary alkalinisation<br />Haemodialysis and haemofiltration<br />Charcoal haemoperfusion<br />
  21. 21. Antidotes<br />Limited number of antidotes available for limited number of poisonings.<br />Common Antidotes:<br />NAC<br />Naloxone<br />Sodium Bicarb<br />Digoxin Immune Fab<br />5. Octreotide<br />
  22. 22. Common Complications in the Critically Poisoned Patient<br />Aspiration Pneumonia<br />ARDS<br />ARF<br />DVT/PE<br />Rhabdomyolysis<br />Compartment Syndrome<br />Hepatotoxicity<br />
  23. 23. Disposition<br />The patients journey can be:<br />RESUS <br />ICU <br />Assessment<br />Obs ward<br />Psych<br />Or patients with DSP need Pysch R/V<br />
  24. 24. Poisoning in Children<br />Most paediatric poisoning are benign, as children generally ingest small quantities.<br />Always base your assessment on worse case scenario:<br />The time of ingestion is assumed to be the latest possible time<br />Assume all missing or unaccounted for agent(s) have been ingested<br />Do not attempt to account for spillage, which is difficult to estimate<br />If more than child involved, it is assumed that each child ingested all the missing or unaccounted for agent(s)<br />
  25. 25. 2 tablets that can KILL a 10kg toddler<br />
  26. 26. Management of child who ingest unidentified poison<br />Admit for minimum of 12-hour observation<br />Ensure health care facility can cope<br />Defer IV access until evidence of toxicity<br />Check BSL at presentation and on D/C <br />Monitor GCS & vital signs<br />Cardiac monitor if decreased GCS or abnormal vital signs<br />D/C during daylight hours<br />
  27. 27. Poisoning in Pregnancy<br />Need to assess risk to fetus or infant if lactating<br /> Management rarely differs from non pregnant patients<br />Agents that pose greater risk to fetus:<br />Carbon Monoxide<br />Methaemoglobin-inducing agents<br />Lead<br />Salicylates<br /><ul><li>Need to provide risk/benefit analysis if breastfeeding is to continue as the mother recovers</li></li></ul><li>Poisoning in the Elderly<br />Can be challenging to manage R/T co-morbidities, decreased physiological reserve, and multiple prescribed medications.<br />Higher complication rate and longer hospital admission:<br />Pharmacokinetic changes:<br />Delayed gastrointestinal absorption<br />Decreased protein binding ^ free drug levels<br />Reduced hepatic metabolic function<br />Decreased GFR which impairs elimination<br />
  28. 28. Common poisoning in the Elderly<br />Digoxin<br />Metformin<br />Lithium<br />Disposition= Generally elderly patients end up in Gen Med units for prolonged periods of care<br />
  29. 29. Toxidromes<br />
  30. 30. Coma<br />Patients presenting with coma have generally overdosed on a drug with CNS depressant effects.<br />Can be caused by secondary effects:<br />Hypoxaemia<br />Hypoglcaemia<br />Hyponatraemia<br />Hypotension<br />Seizures <br />Cerebral oedema<br />
  31. 31. Coma Management<br />RRSIDEAD<br />Good supportive care & airway management<br />Treat secondary effects<br />Look at what else can cause coma<br />Neurotrauma<br />Metabolic encepathopathy<br />Menigioencephalopathy<br />Space occupying lesion<br />Patients generally go to ICU, till conscious states improve<br />Look for complication’s (Asp Pneumonia)<br />
  32. 32. Why do we use Diazepam so much in TOX?<br />Good safety profile<br />Long half life<br />Controls agitation well<br />Used to treat toxic seizures<br />Generally drug of choice in managing withdrawals<br />Dose adult 5-10mg, child 0.1-0.3mg/kg/dose every 3-5mins<br />
  33. 33. Anticholinergic Syndrome<br />Results from the competitive, reversible blockade of central & peripheral cholinergic blockade.<br />Is potentially life threatening<br />Diagnosed clinically by agitated delirium and peripheral muscarinic blockade<br />History of ingestion of known anticholinergic agent<br />
  34. 34. Types of Anticholinergic Agents<br />Antipakinson drugs (benztropine, amantadine)<br />Antihistamines (prometazine, doxylamine)<br />Antitussives (dextromethorphan)<br />Antidepressants (TCA)<br />Antipsychotic agents including atypical (Haloperidol, olazapine, Quetiapine)<br />Anticonvulsant agents (carbamazapine)<br />Motion sickness agents (hyoscine-scopolamine)<br />Antimuscarinic agents (Atropine)<br />Topical ophthalmological agents<br />Bronchodilators (Ipratropium)<br />Urinary antispasmodic agents (oxybutynin)<br />Muscle relaxants<br />Plants & herbal remedies (Selected mushrooms)<br />
  35. 35. Clinical Features of Anticholinergic Syndrome<br />
  36. 36. Remember the saying!!!<br />Hyperthermia (HOT as a hare)<br />Flushed (RED as a beet)<br />Dry Skin (DRY as a bone)<br />Dilated pupils (Blind as a bat)<br />Delirium, hallucinations (Mad as a hatter)<br />Tachycardia<br />Urinary Retention<br />
  37. 37. Management <br />Good Supportive Care<br />IV fluids<br />IDC<br />Diazepam to control agitation<br />Avoid drugs with anticholinergic effects<br />Antidote:<br /><ul><li> Physostigimine
  38. 38. Reverse anticholinergic delirium in selected patients that don’t respond to benzo’s</li></li></ul><li>Serotonin Syndrome<br />Clinical diagnosis based on history of ingestion of one or more serotonergic agents, the presence of characteristic symptoms, & high index of suspicion<br />Clinical features fall into 3 categories<br />CNS<br />Autonomic<br />Neuromuscular<br />
  39. 39. Clinical features of serotonin syndrome<br />
  40. 40. Life threatening serotonin syndrome<br />Characterised by:<br /><ul><li>Generalised rigidity
  41. 41. Autonomic instability
  42. 42. Delirium
  43. 43. Coma
  44. 44. Hyperthermia
  45. 45. Secondary multiple-organ failure</li></li></ul><li>Agents implicated in serotonin syndrome<br />SSRIs (fluoxetine, setraline, paroxetine)<br />SNRIs (venlafaxine, citalopram, bupropion)<br />TCAs (amitriptyline, dothiep)<br />MAOIs (phenelzine, moclobemide)<br />Lithium<br />Analgesic (pethidine, tramadol, dextromethorphan)<br />Antiemetics (metaclopramide, ondansetron)<br />Anticonvulsants (valproic acid)<br />Drugs of abuse (amphetamine, MDMA)<br />
  46. 46. Managing Serotonin Syndrome<br />RRSIDEAD<br />Check BSL<br />Check temp >38.5 continuous core monitoring, temp > 39.5 paralysis and intubate<br />Give benzo’s to achieve gentle sedation<br />HT & tachycardia generally respond to benzo’s, if refractory trial of GTN infusion<br />Antidote: Cyproheptadine, given orally or via NG<br />
  47. 47. The Tox Bible<br />
  48. 48. THE END!!<br />
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