Toxicology Intro

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Nathan Cleveland, MD, MS

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  • People often say EPs are the “Jacks of all trades, master’s of nothing.” The veiled insult is that, much like this swiss army knife, we’re capable of doing lots of things, but not really very good at any of them. I couldn’t disagree more. There are many areas in which we should be the best in the hospital. Here’s 4…
  • 1. Intubation – and it’s not really just intubation, but the emergent airway. 2. Resuscitation – not CPR, but the initial stabilization of the acutely ill or injured patient. 3. Coordination – because of our jack-of-all-trades training, we are uniquely qualified to coordinate care between multiple specialists who often have trouble seeing the big picture. 4. Toxicology – which will be the topic of today’s lecture.
  • Toxicology is OUR field. One of the oldest EM fellowships, and very few people other than emergency physicians get much toxicology training.
  • This is going to be an overview lecture which is not even close to comprehensive. I want to try to get you to think about HOW to approach the poisoned patient. There will be many gaps and we will only talk about specifics in a few areas. I’ll highlight a few guiding principles to take home.
  • I’m using a new ppt format. Kind of like the SportsCenter-style line-up of what’s to come on the left. Please let me know what you think of it.
  • Finally, like always, there’s beer and trivia.
  • Toxicologists are really smart, I’m not. It is a HUGE field (environmental, industrial, botanical, envenomations) and we will really only be talking about tox in the setting of the adultingestional poisoning patient. As always, we want to practice evidence-based medicine not eminence-based medicine. Don’t believe anything I say unless you’ve double checked it against the literature.
  • A quick refresher of the quality of evidence. Expert opinion is on the bottom – and I’m not even an expert! We should always strive to practice in light of the best available evidence – and in toxicology it is usually case series and animal studies. With the exception of a few very common and well described poisonings like tylenol, there’s few large randomized controlled trials in humans and even fewer systematic reviews. IRBs tend to frown on poisoning subjects.
  • When I started working on this talk I Googled “Intro to Toxicology.” This is what I found. From an unnamed medical school in the US, we get…
  • This is an insane way to approach medicine. This is his list just for poisonings. What if you had the same list for abdominal pain, chest pain, fever, cervical spine injuries, etc., etc. This is a very inefficient way of thinking. Hopefully I can give you a better approach to toxicology.
  • OK, first trivia question. Greek philosopher Socrates reportedly killed himself by ingesting a tea made from this substance in the 4th century BC.
  • The first step in the evidence based management of any disease is understanding the epidemiology. This report is put out every year by the NPDS and is actually pretty interesting reading.
  • Here is a look at the 4 most deadly classes of pharmaceuticals. The number of deaths from each is rising every year.
  • Again, this chart does not include street drugs but look at some of the most common culprits.
  • And when we look at the reason for overdose or poisoning, we see that intentional ingeestions are much more dangerous.
  • A few interesting facts from the NPDS data…
  • Our first principle comes straight out of the NPDS data.
  • In 1978 Bulgarian dissident was killed in classic cloak-and-dagger fashion when a tiny pellet of this substance was injected into his thigh – most likely by KGB agents.
  • Again lots of people try to think about poisoning like this. Lots of flowcharts about toxidromes, vitals signs, different treatments. It’s a very difficult way to function in the ED. This flowchart is actually supposed to show what to do in a zombie invasion
  • What we really need to do is focus our attention on common and deadly and silent poisons.
  • We’re not going to spend a lot of times on physical exam findings. But Golden Rule #2 definitely comes into play – vitals are vital!
  • In addition to your usual P.E., there are some other things you want to note. But again, we’re not gonna spend much time talking about the history and P.E. in poisonings… because it usually just won’t matter.
  • The classic teaching is to determine whether the patient is displaying a certain toxidrome. Here’s a really incomplete list – just off the top of my head. Suffice it to say that there are a lot of toxidromes.
  • I’d rather have you simplify it into only three common toxidromes.
  • Why simplify the toxidromes so much? Because of principle number 2. Which has two parts. A. And B.
  • In 1970, Janis Joplin was found dead after an overdose on this substance.
  • Alright, let’s move on to the toxicology work-up. You will hear lots of debate about what this should include. It will obviously depend to some degree on your history and physical exam. Here are the components that I feel are necessary.
  • Just a quick word on the EKG. The EKG is all about finding TCA overdose although it may help solve the puzzle in CCB, BB or antidysrrhythmic OD as well. This is the classic TCA EKG. A couple points. TCAs are sodium channel blockers. Important findings are stepwise – tachycardia, right axis deviation, QRS prolongation. The RAD is most easily identified in r wave of aVR. QRS > 100 portends 30% chance of seizure. QRS > 160 portends 50% chance of dysrrhythmia. I repeat EKGs if my poisoned pt is tachycardic. Depending on the story/comorbidities, I consider bicarb in pts with QRS > 100.
  • What about these other common orders? Let’s look at them one by one.
  • I love this article from ClinTox in 2009. It points out that what we really want to know when we order a tox screen is, “Could my patient’s current condition be caused by a street drug?” The problem is that this test was designed as a workplace screening tool. It was not designed to answer that question and it can’t.
  • Incidentally, they cost about $300.
  • The reasoning goes something like this: “My patient has an altered level of consciousness, I think it is from EtOH, let me get an EtOH level and make sure that is why they are altered.”
  • So what do we know about BALs? They’re easy to get. They cost your pt about $100. EPs are actually pretty good at determining IF someone is alcohol intoxicated. They’re not as good about predicting levels. But the level itself does not actually predict the degree of intoxication. We’ve all seen the rookie drinker that is blasted with a BAL of 90 and the pro who is walking around MSC asking for a sandwich with a BAL of 430. There is a great article out there that shows that BAL does not affect GCS in head-injured patients – so in that situation could an elevated BAL actually cause you to miss more serious head injuries? I don’t know.
  • At least the BAL (as opposed to a UDS) is reflecting the patient’s current physiology. But EtOHintox is really common. We should be pretty good at recognizing alcohol intoxication. If you are going to attribute a pts AMS to EtOH, I understand the people who want to at least prove there is EtOH on board. I would feel better about ordering this test if it were a qualitative EtOH.
  • Here’s the problem. The OG is very indirect in measurement. It is just telling you that “something is present.” And it can be elevated in DKA, shock, AKA, renal failure, pseudohyponatremia, proteinemia, lipemia, ethanol, methanol, ethylene glycol, propylene glycol and isopropyl ingestions.
  • What about salicylate as a standard part of your tox work-up?
  • What about salicylate as a standard part of your tox work-up?
  • Which brings us to principle #3. As with all testing in the ED, the test can only tell you what it can tell you.
  • A quick note on drug levels. We’re able to measure many drug levels. We are only measuring serum concentration, not total body concentration. The serum concentration depends entirely on time course of ingestion and volume of distribution. It’s a long discussion which we won’t get into today but suffice it to say…
  • Peoples Temple Agricultural Project had established a compound in Guyana. In 1978 their leader, Jim Jones convinced his people to commit mass suicide. 909 people died including 200 children. Name any 2 of the 4 compounds in the KoolAid.
  • There’s really only 4 options for managing poisons.
  • Supportive care is really the most important management strategy. It requires no special toxicology training or knowledge. It’s all about the ABCs. Protect the airway, maintain adequate oxygenation and perfusion and most patients will do fine. In fact this assertion is well-supported by the literature and is the basis for principle #5…
  • There’s really only 4 options for managing poisons.
  • There’s only four options to decrease absorption.
  • First of all, the dose is not weight based or standard. It depends on the amount of drug ingested. It’s a 10:1 ratio. If 25 grams tylenol ingested, pt needs 5 bottles of activated charcoal
  • First of all, the dose is not weight based or standard. It depends on the amount of drug ingested.
  • Aspiration of charcoal cares a very high morbidity and mortality. Wouldn’t it be awful if your pt’s CXR looked like this after you gave him charcoal for a non-life-threatening overdose.
  • Not effective for iron, caustics, hydrocarbons, alcohols, lithium
  • Binders – work by binding drug in the GI tract. Work like kayexelate for K+. Eg: succimer.
  • Former Ukrainian president was poisoned with this compound during the 2004 campaign.
  • Inhibitors – both competitive and non-competitive. Bind at the site of action of the drug preventing its action. Eg: narcan, flumazenil, ethanol. Antibodies – bind to the drug preventing its action. Eg: digibind, Cro-Fab. Reversal agents – counteract the effect of the drug, sometimes by a different pathway. Eg: NAC, pyridoxine in INH overdose, glucagon in BB or CCB overdose.
  • I, personally, would just remove flumazenil from your arsenal. How to BZDs kill you? Do we have a treatment for that? In addition, flumazenil has a very short half-life in comparison to most BZD. So all you are doing is delaying the effects unless you put someone on a drip. And flumazenil w/d is deadly – from sz and dysrrhythmia. So I just don’t use it.
  • Let’s talk for a minute about Tylenol. It’s is probably the most well-studied poison from both an evaluation and management perspective. I would highly recommend knowing this article from NEJM.
  • Let me point out a few things about the nomogram. 1. There is nothing prior to 4 hours. It’s ok to get a level before 4 hours – especially if you just want to know if any tylenol was ingested – but don’t make treatment decisions before a 4 hour level. You’ll be making it up and there will be no literature to support you. 2. There is a 25% margin of error built in. 3. If used before (probably 8 hrs) definitely 6 hours, NAC is 100% effective.
  • A quick word on costs. A course of oral NAC costs a few hundred dollars at our hospital. Last time I checked with Michelle, a single dose of IV NAC costs over $1000. And they’re equally effective. In fact there is some thought that oral might be preferred since it is delivered to the liver in higher concentration via the portal circulation. There is rarely a reason to use IV NAC.
  • Members of the AumShinrikyo cult released this substance killing 13 and injuring thousands.
  • SLUDGE and the KILLER Bs
  • Toxicology Intro

    1. 1. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE Nathan J. Cleveland, MD, University Medical Center, Emergency Medicine Physicians, December 2011
    2. 2. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE DISCLAIMER TRIVIA GOALS TOX MASTER JACK OF ALL TRADES TITLE E.B.M. WHAT NOT TO DO
    3. 3. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE TRIVIA DISCLAIMER TRIVIA GOALS TOX MASTER JACK OF ALL TRADES TITLE WHAT NOT TO DO E.B.M. 1. INTUBATION 2. RESUSCITATION 3. COORDINATION 4. TOXICOLOGY
    4. 4. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE DISCLAIMER TRIVIA GOALS TOX MASTER JACK OF ALL TRADES TITLE 4. TOXICOLOGY TRIVIA WHAT NOT TO DO E.B.M.
    5. 5. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE EPIDEMIOLOGY DISCLAIMER TRIVIA GOALS TOX MASTER JACK OF ALL TRADES GOALS • „Whirlwind‟ overview • Principles for evidence-based diagnosis/management • Few specifics TRIVIA WHAT NOT TO DO E.B.M.
    6. 6. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE GOALS TOX MASTER JACK OF ALL TRADES GOALS • New PPT style – feedback please! EPIDEMIOLOGY DISCLAIMER TRIVIA TRIVIA WHAT NOT TO DO E.B.M.
    7. 7. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE PRICIPLE #1 TRIVIA GOALS TRIVIA • 6 Questions • Famous Poisonings • Beer TOX MASTER EPIDEMIOLOGY DISCLAIMER TRIVIA WHAT NOT TO DO E.B.M.
    8. 8. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE TRIVIA PRINCIPLE #1 DISCLAIMER TRIVIA DISCLAIMERS • I‟m not a toxicologist • This is an overview • No eminence-based medicine!GOALS EPIDEMIOLOGY TRIVIA WHAT NOT TO DO E.B.M.
    9. 9. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE EVALUATION TRIVIA PRINCIPLE #1 E.B.M. DISCLAIMER TRIVIA EPIDEMIOLOGY TRIVIA WHAT NOT TO DO
    10. 10. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE HISTORY EVALUATION TRIVIA PRINCIPLE #1 EPIDEMIOLOGY TRIVIA E.B.M. WHAT NOT TO DO DISCLAIMER
    11. 11. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE HISTORY EVALUATION TRIVIA PRINCIPLE #1 EPIDEMIOLOGY TRIVIA E.B.M. WHAT NOT TO DO DISCLAIMER P.A.C.E.D. F.A.S.T. C.O.O.L.S. N.A.S.A. C.R.A.S.H.E.D. C.T.S.C.A.N. S.L.O.W. P.A.N.T. O.T.I.S.C.A.M.P.B.E.L.L. A.E.I.O.U.T.I.P.S. C.O.P.S. A.A.A.S. S.O.A.P. C.O.I.N.S. A.B.C.D.E. C.H.A.R.C.O.A.L. I.S.T.U.M.B.L.E.
    12. 12. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE PHYSICAL HISTORY EVALUATION TRIVIA PRINCIPLE #1 EPIDEMIOLOGY TRIVIA WHAT NOT TO DO E.B.M. THE DEATH OF SOCRATES 1787 – JACQUES-LOUIS DAVID Name this poison
    13. 13. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE PHYSICAL HISTORY EVALUATION TRIVIA PRINCIPLE #1 EPIDEMIOLOGY TRIVIA WHAT NOT TO DO DISCLAIMER HEMLOCK • Cicutoxin • GABA-receptor antagonist • CNS stimulation, seizures, death
    14. 14. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE PRINCIPLE #2 PHYSICAL HISTORY EVALUATION TRIVIA PRINCIPLE #1 EPIDEMIOLOGY TRIVIA POISON IN THE U.S. WHAT NOT TO DO
    15. 15. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE PHYSICAL HISTORY EVALUATION TRIVIA EPIDEMIOLOGY TRIVIA POISON IN THE U.S. • 2,384,825 encounters in NPDS • 1,730 Deaths (pharma) • Deaths rising since 1985 1985 1997 2010 Deaths 328 786 1730 % Suicide 53 53 45 % Peds 6.1 3.2 3.2WHAT NOT TO DO PRINCIPLE #1 PRINCIPLE #2
    16. 16. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE EPIDEMIOLOGY TRIVIA WHAT NOT TO DO PHYSICAL HISTORY EVALUATION TRIVIA PRINCIPLE #1 PRINCIPLE #2
    17. 17. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE EPIDEMIOLOGY TRIVIA WHAT NOT TO DO PHYSICAL HISTORY EVALUATION TRIVIA PRINCIPLE #1 PRINCIPLE #2
    18. 18. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE EPIDEMIOLOGY TRIVIA WHAT NOT TO DO PHYSICAL HISTORY EVALUATION TRIVIA PRINCIPLE #1 PRINCIPLE #2
    19. 19. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE EPIDEMIOLOGY TRIVIA WHAT NOT TO DO POISON IN THE U.S. • Interesting facts: • 87% are ingestional • 20% are intentional • Intentional is more deadly • 50% are peds • 50% (at least) are mixed PHYSICAL HISTORY EVALUATION TRIVIA PRINCIPLE #1 PRINCIPLE #2
    20. 20. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE TRIVIA PRINCIPLE #1 EPIDEMIOLOGY PRINCIPLE: • Poisoning is common • Poisoning is (rarely) deadly TRIVIA PHYSICAL HISTORY EVALUATION TRIVIA PRINCIPLE #2
    21. 21. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE WORK-UP TRIVIA PRINCIPLE #1 EPIDEMIOLOGY Georgi Markov PHYSICAL HISTORY EVALUATION PRINCIPLE #2 TRIVIA
    22. 22. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE TRIVIA RICIN • Inhibits protein synthesis • LD50 = 22mcg/kg!! • Organ failure, death over days EPIDEMIOLOGY PRINCIPLE #1 WORK-UP PHYSICAL HISTORY EVALUATION PRINCIPLE #2 TRIVIA
    23. 23. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE WORK-UP: EKG EVALUATION TRIVIA EVALUATING THE POISONED PATIENT PRINCIPLE #1 WORK-UP PHYSICAL HISTORY PRINCIPLE #2 TRIVIA
    24. 24. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE WORK-UP: EKG EVALUATION TRIVIA PRINCIPLE #1 WORK-UP PHYSICAL HISTORY PRINCIPLE #2 TRIVIA
    25. 25. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE COMMON DEADLY SILENT WORK-UP: EKG EVALUATION TRIVIA PRINCIPLE #1 WORK-UP PHYSICAL HISTORY PRINCIPLE #2 TRIVIA
    26. 26. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE WORK-UP HISTORY EVALUATION HISTORY Is everything… • Available meds/drugs • Missing meds/drugs • Time course • Intention TRIVIA WORK-UP: EKG WORK-UP PHYSICAL PRINCIPLE #2 TRIVIA
    27. 27. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE HISTORY …and nothing. • Unobtainable • Unreliable • Misleading WORK-UP HISTORY EVALUATION TRIVIA WORK-UP: EKG WORK-UP PHYSICAL PRINCIPLE #2 TRIVIA
    28. 28. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE PHYSICAL HISTORY EVALUATION PHYSICAL EXAM Rule #2: Vitals are vital!!WORK-UP WORK-UP: EKG WORK-UP PRINCIPLE #2 TRIVIA WORK-UP: UDS
    29. 29. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE PHYSICAL EXAM • Pupils – large/pinpoint/sluggish • Skin – dry/diaphoretic/piloerection • Reflexes – decreased/brisk/clonus • Tone – flaccid/fasciculations • Speech – slurred/pressuredPHYSICAL HISTORY EVALUATION WORK-UP WORK-UP: EKG WORK-UP PRINCIPLE #2 TRIVIA WORK-UP: UDS
    30. 30. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE PHYSICAL EXAM Toxidromes: • Cholinergic • Anticholinergic • Opiod • Sympathomimetic • Sedative/hypnotic • Salicylism • Hallucinogenic • Serotonergic • Withdrawal • Neuroleptic • Etc., etc., etc… PHYSICAL HISTORY EVALUATION WORK-UP WORK-UP: EKG WORK-UP PRINCIPLE #2 TRIVIA WORK-UP: UDS
    31. 31. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE AGITATED / DELERIOUS / SEIZURE SEDATED / COMATOSE / RESPIRATORY SILENT PHYSICAL HISTORY EVALUATION WORK-UP WORK-UP: EKG WORK-UP PRINCIPLE #2 TRIVIA WORK-UP: UDS
    32. 32. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE PRINCIPLE #2 PHYSICAL HISTORY PRINCIPLE: A. We rarely know (for certain)what has been ingested B. It will rarely matter WORK-UP WORK-UP: EKG WORK-UP TRIVIA WORK-UP: UDS WORK-UP: BAL
    33. 33. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE WORK-UP: OSM TRIVIA PRINCIPLE #2 PHYSICAL Janis Joplin WORK-UP WORK-UP: EKG WORK-UP WORK-UP: UDS WORK-UP: BAL
    34. 34. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE HEROIN • Derived from poppy • Diacetylmorphine • Morphine prodrug WORK-UP: OSM TRIVIA PRINCIPLE #2 PHYSICAL WORK-UP WORK-UP: EKG WORK-UP WORK-UP: UDS WORK-UP: BAL
    35. 35. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE WORK-UP: ASA WORK-UP TRIVIA PRINCIPLE #2 Essential components: • Glucose • BMP • APAP • EKG TOX TESTING WORK-UP: OSM WORK-UP WORK-UP: EKG WORK-UP: UDS WORK-UP: BAL
    36. 36. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE PRINCIPLE #3 TOX EKG WORK-UP: ASA WORK-UP TRIVIA WORK-UP: OSM WORK-UP WORK-UP: EKG WORK-UP: UDS WORK-UP: BAL
    37. 37. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE DRUG LEVELS • Urine drug screen? • Serum ethanol? • Osmolality? • Salicylate? TOX TESTING PRINCIPLE #3 WORK-UP: ASA WORK-UP WORK-UP: OSM WORK-UP WORK-UP: EKG WORK-UP: UDS WORK-UP: BAL
    38. 38. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE PRINCIPLE #4 • Urine drug screen? TOX TESTING DRUG LEVELS PRINCIPLE #3 WORK-UP: ASA WORK-UP: OSM WORK-UP WORK-UP: EKG WORK-UP: UDS WORK-UP: BAL
    39. 39. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE • Urine drug screen? TOX TESTING PRINCIPLE #4 DRUG LEVELS PRINCIPLE #3 WORK-UP: ASA WORK-UP: OSM WORK-UP WORK-UP: EKG WORK-UP: UDS WORK-UP: BAL
    40. 40. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE • Can only tell you what it is designed to tell you… …the SOCIAL HISTORY!!! UDS PRINCIPLE #4 DRUG LEVELS PRINCIPLE #3 WORK-UP: ASA WORK-UP: OSM WORK-UP WORK-UP: EKG WORK-UP: UDS WORK-UP: BAL
    41. 41. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE • Urine drug screen? No TOX TESTING PRINCIPLE #4 DRUG LEVELS PRINCIPLE #3 WORK-UP: ASA WORK-UP: OSM WORK-UP WORK-UP: EKG WORK-UP: UDS WORK-UP: BAL
    42. 42. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE • Urine drug screen? No • Serum ethanol? TOX TESTING PRINCIPLE #4 DRUG LEVELS PRINCIPLE #3 WORK-UP: ASA WORK-UP: OSM WORK-UP WORK-UP: UDS WORK-UP: BAL TRIVIA
    43. 43. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE SERUM ETOH PRINCIPLE #4 DRUG LEVELS PRINCIPLE #3 WORK-UP: ASA WORK-UP: OSM WORK-UP WORK-UP: UDS WORK-UP: BAL TRIVIA
    44. 44. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE SERUM ETOH • We should be able to recognize “straight up” EtOH • Cannot tell you if current AMS is due to alcohol. PRINCIPLE #4 DRUG LEVELS PRINCIPLE #3 WORK-UP: ASA WORK-UP: OSM WORK-UP WORK-UP: UDS WORK-UP: BAL TRIVIA
    45. 45. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE • Urine drug screen? No • Serum ethanol? Maybe TOX TESTING PRINCIPLE #4 DRUG LEVELS PRINCIPLE #3 WORK-UP: ASA WORK-UP: OSM WORK-UP WORK-UP: UDS WORK-UP: BAL TRIVIA
    46. 46. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE • Urine drug screen? No • Serum ethanol? Maybe • Osmolality? TOX TESTING PRINCIPLE #4 DRUG LEVELS PRINCIPLE #3 WORK-UP: ASA WORK-UP: OSM WORK-UP: UDS WORK-UP: BAL TRIVIA MANAGEMENT
    47. 47. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE • Osmotically active small ions 2[Na+]+gluc/18+BUN/2.8+EtOH/4.6 Normal < 10 mOsm/kg OSMOLALITY PRINCIPLE #4 DRUG LEVELS PRINCIPLE #3 WORK-UP: ASA WORK-UP: OSM WORK-UP: UDS WORK-UP: BAL TRIVIA MANAGEMENT
    48. 48. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE OSMOLALITY • Severe unexplained acidosis • MetOH and EG unavailable PRINCIPLE #4 DRUG LEVELS PRINCIPLE #3 WORK-UP: ASA WORK-UP: OSM WORK-UP: UDS WORK-UP: BAL TRIVIA MANAGEMENT
    49. 49. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE • Urine drug screen? No • Serum ethanol? Maybe • Osmolality? No TOX TESTING PRINCIPLE #4 DRUG LEVELS PRINCIPLE #3 WORK-UP: ASA WORK-UP: OSM WORK-UP: UDS WORK-UP: BAL TRIVIA MANAGEMENT
    50. 50. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE • Urine drug screen? No • Serum ethanol? Maybe • Osmolality? No • Salicylate? TOX TESTING ABCs PRINCIPLE #4 DRUG LEVELS PRINCIPLE #3 WORK-UP: ASA WORK-UP: OSM WORK-UP: BAL TRIVIA MANAGEMENT
    51. 51. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE ABCs SALICYLATE • Common • Deadly • Silent?PRINCIPLE #4 DRUG LEVELS PRINCIPLE #3 WORK-UP: ASA WORK-UP: OSM WORK-UP: BAL TRIVIA MANAGEMENT
    52. 52. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE ABCs SALICYLATE • Common • Deadly • Silent? • Resp alkalosis easy to miss • Acidosis could be anything • No tinnitus in acute ingestion • Test readily available PRINCIPLE #4 DRUG LEVELS PRINCIPLE #3 WORK-UP: ASA WORK-UP: OSM WORK-UP: BAL TRIVIA MANAGEMENT
    53. 53. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE • Urine drug screen? No • Serum ethanol? Maybe • Osmolarity? No • Salicylate? Yes TOX TESTING ABCs PRINCIPLE #4 DRUG LEVELS PRINCIPLE #3 WORK-UP: ASA WORK-UP: OSM WORK-UP: BAL TRIVIA MANAGEMENT
    54. 54. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE PRINCIPLE: A. A test can only tell you what it can tell you. B. Resist the false reassurance of a test result. ABCs PRINCIPLE #4 DRUG LEVELS PRINCIPLE #3 WORK-UP: ASA WORK-UP: OSM TRIVIA MANAGEMENT PRINCIPLE #5
    55. 55. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE • APAP, ASA, Dilantin, Depakote, Li++, Dig, etc. • Serum concentration DRUG LEVELS ABCs PRINCIPLE #4 DRUG LEVELS PRINCIPLE #3 WORK-UP: ASA TRIVIA MANAGEMENT PRINCIPLE #5 ABSORPTION
    56. 56. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE PRINCIPLE: • Drug level has different implications depending on chronic vs acute ingestion.ABCs PRINCIPLE #4 DRUG LEVELS PRINCIPLE #3 TRIVIA MANAGEMENT PRINCIPLE #5 ABSORPTION CHARCOAL
    57. 57. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE Jonestown, Guyana 1978 ABCs PRINCIPLE #4 DRUG LEVELS TRIVIA MANAGEMENT PRINCIPLE #5 ABSORPTION CHARCOAL PRINCIPLE #6
    58. 58. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE • Valium • Chloralhydrate • Phenergan • Cyanide ABCs PRINCIPLE #4 DRUG LEVELS TRIVIA MANAGEMENT PRINCIPLE #5 ABSORPTION CHARCOAL PRINCIPLE #6
    59. 59. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE MANAGING THE POISONED PATIENTABCs PRINCIPLE #4 TRIVIA MANAGEMENT PRINCIPLE #5 ABSORPTION CHARCOAL PRINCIPLE #6 ELIMINATION
    60. 60. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE MANAGMENT 1.Supportive Care ABCs PRINCIPLE #4 TRIVIA MANAGEMENT PRINCIPLE #5 ABSORPTION CHARCOAL PRINCIPLE #6 ELIMINATION
    61. 61. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE SUPPORTIVE CARE ABCs TRIVIA MANAGEMENT PRINCIPLE #5 ABSORPTION CHARCOAL PRINCIPLE #6 ELIMINATION DIALYSIS
    62. 62. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE TRIVIA PRINCIPLE: • “…most poisoned patients require only supportive therapy for recovery.” ABCs MANAGEMENT PRINCIPLE #5 ABSORPTION CHARCOAL PRINCIPLE #6 ELIMINATION DIALYSIS
    63. 63. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE MANAGMENT 1.Supportive Care 2.Decrease Absorption ANTIDOTES TRIVIA ABCs PRINCIPLE #5 ABSORPTION CHARCOAL PRINCIPLE #6 ELIMINATION DIALYSIS
    64. 64. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE ANTIDOTES ABSORPTION TRIVIA ABCs PRINCIPLE #5 ABSORPTION CHARCOAL PRINCIPLE #6 ELIMINATION DIALYSIS
    65. 65. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE CHARCOAL • Goal – Adsorbtion • Dose = 10 : 1 50 tabs APAP = ANTIDOTES TRIVIA PRINCIPLE #5 ABSORPTION CHARCOAL PRINCIPLE #6 ELIMINATION DIALYSIS PRINCIPLE #7
    66. 66. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE CHARCOAL • Goal – Adsorbtion • Dose = 10 : 1 • Time – within 2 hours ANTIDOTES TRIVIA PRINCIPLE #5 ABSORPTION CHARCOAL PRINCIPLE #6 ELIMINATION DIALYSIS PRINCIPLE #7
    67. 67. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE CHARCOAL • Risk – aspiration • Be extremely careful in ingestions of sedating drugs ANTIDOTES TRIVIA PRINCIPLE #5 ABSORPTION CHARCOAL PRINCIPLE #6 ELIMINATION DIALYSIS PRICIPLE #7
    68. 68. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE TRIVIA PRINCIPLE: • Charcoal (and lavage) should be reserved for recent ingestions of a lethal dose of a lethal substance for which there is no effective treatment. ANTIDOTES TRIVIA ABSORPTION CHARCOAL PRINCIPLE #6 ELIMINATION DIALYSIS PRINCIPLE #7
    69. 69. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE SUMMARY MANAGMENT 1.Supportive Care 2.Decrease Absorption 3.Increase elimination ANTIDOTES TRIVIA CHARCOAL PRINCIPLE #6 ELIMINATION DIALYSIS PRINCIPLE #7 TRIVIA
    70. 70. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE ELIMINATION 1. RENAL 2. BINDERS 3. DIALYSIS SUMMARY ANTIDOTES TRIVIA CHARCOAL PRINCIPLE #6 ELIMINATION DIALYSIS PRINCIPLE #7 TRIVIA
    71. 71. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE DIALYSIS • Best for small, water-soluble • Inherent risks • Serial dialysis for large VD SUMMARY ANTIDOTES TRIVIA PRINCIPLE #6 ELIMINATION DIALYSIS PRINCIPLE #7 TRIVIA
    72. 72. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE Viktor Yushenko SUMMARY ANTIDOTES TRIVIA ELIMINATION DIALYSIS PRINCIPLE #7 TRIVIA
    73. 73. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE DIOXIN • Hepatotoxicity, heme metabolism • Chloracne • A compound in Agent Orange SUMMARY ANTIDOTES TRIVIA ELIMINATION DIALYSIS PRINCIPLE #7 TRIVIA
    74. 74. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE MANAGMENT 1.Supportive Care 2.Decrease Absorption 3.Increase elimination 4.Antidotes SUMMARY ANTIDOTES TRIVIA DIALYSIS PRINCIPLE #7 TRIVIA
    75. 75. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE ANTIDOTES 1.Inhibitors 2.Antibodies 3.Reversal agents ANTIDOTES TRIVIA DIALYSIS PRINCIPLE #7 TRIVIA SUMMARY
    76. 76. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE FLUMAZENIL • BZD receptor antagonist • Days of the ‘coma cocktail’ are over ANTIDOTES TRIVIA DIALYSIS PRINCIPLE #7 TRIVIA SUMMARY
    77. 77. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE NARCAN • Opioid receptor antagonist • Narcotic withdrawal not deadly ANTIDOTES TRIVIA DIALYSIS PRINCIPLE #7 TRIVIA SUMMARY
    78. 78. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE TYLENOL OD • Common, deadly, silent ANTIDOTES TRIVIA DIALYSIS PRINCIPLE #7 TRIVIA SUMMARY
    79. 79. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE TYLENOL OD ANTIDOTES TRIVIA DIALYSIS PRINCIPLE #7 TRIVIA SUMMARY
    80. 80. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE NAC • Chronic (aka repeated supratherapeutic): • Elevated LFTs OR • [APAP] > 20 mcg/mL • Acute:ANTIDOTES TRIVIA DIALYSIS PRINCIPLE #7 TRIVIA SUMMARY
    81. 81. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE NAC ANTIDOTES TRIVIA DIALYSIS PRINCIPLE #7 TRIVIA SUMMARY
    82. 82. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE NAC ANTIDOTES TRIVIA DIALYSIS PRINCIPLE #7 TRIVIA SUMMARY $$ $$$$
    83. 83. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE PRINCIPLE: A. The existence of an antidote does not necessarily mean you should use it. They are for saving lives! B. Know NAC, atropine, pyridoxine, bicarb, DigiBind and CyanoKit ANTIDOTES TRIVIA PRINCIPLE #7 TRIVIA SUMMARY
    84. 84. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE Tokyo Subway 1995ANTIDOTES PRINCIPLE #7 TRIVIA SUMMARY
    85. 85. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE SARIN • Odorless, colorless, tasteless • Organophosphate • Cholinesterase inhibitor ANTIDOTES PRINCIPLE #7 TRIVIA SUMMARY
    86. 86. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE SUMMARY 1. We should be the best at Tox 2. Poisoning is common/deadly 3. Tox = managing the unknown 4. A test can only tell you what it tells you 5. Toxic level depends on ACUTE versus CHRONIC TRIVIA SUMMARY PRINCIPLE #7
    87. 87. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE SUMMARY 6. Management = Support (usually) 7. Charcoal is rarely useful 8. Know your emergent antidotes, look everything else up TRIVIA SUMMARY PRINCIPLE #7
    88. 88. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE THANKS! QUESTIONS? TRIVIA SUMMARY PRINCIPLE #7

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