EMS Tox Update

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EMS Tox Update

  1. 1. TOX UPDATEKENT EMS ROUNDSKevin OConnell MD
  2. 2. STUPID THINGS PEOPLE DO
  3. 3. BATH SALTS
  4. 4. BATH SALTSSimilar to amphetaminesSynthetic drugs sold in gas stations as “not for human consumptionStarted in Europe few years agoNow in US and a cause for frequent ER visits
  5. 5. BATH SALTSCrystal or powder that is smoked, ingested, snorted, or injectedFrequently overdosingLegal status of drugs
  6. 6. BATH SALTSCathinones:MDPV – methylenedioxypyrovaleroneMethyloneMephedroneKeeps changing to ingredients to avoid legal issues
  7. 7. BATH SALTSIncreases catecholamines at synapsesHallucinations, paranoia, violenceTachycardia, MIRenal or Liver failureTrend toward increased use in mental health patients
  8. 8. BATH SALTSSupportive care, IV fluidsSedation: Ativan/HaldolSocial Service issuesMay show up on Tox screen as PCP
  9. 9. SYNTHETIC CANABIS
  10. 10. SYNTHETIC CANNABISInitially marketed as mixture of legal herbs with cannabis-like affectIs actually a bunch of herbs sprayed with synthetic cannabinoids“K2”“SPICE”
  11. 11. NATURAL CANABIS
  12. 12. SYNTHETIC CANABIS
  13. 13. SYNTHETIC CANABISJohn W. Huffman from Clemson University invented most synthetic canabinoids“It bothers me that people are so stupid as to use this stuff”
  14. 14. SYNTHETIC CANNIBISSimilar affect as cannabis, except less predictableIncreased psychotic features - ? If natural cannabis has “antipsychotic chemical”Increased agitation and vomitingMore addictive behaviorPossible cardiac and seizure increase
  15. 15. BEFORE COCAINE
  16. 16. AFTER COCAINE
  17. 17. COCAINEFrom Coca leaves in South America1884 – Dr Halstead first used cocaine medically for nerve block1885 - Dr Halstead became first cocaine impaired physicianSigmond Freud recommended cocaine for various ailments1885 – Coca Cola contained 60 mg cocaine/8oz
  18. 18. COCAINEBenzoylmethylecgoninePowder form – topically absorbed“Crack” - freebase form, vaporizes with heatCan be smoked – eliminates vasoconstriction associated with topical cocaine
  19. 19. COCAINE
  20. 20. BILL COSBY“They say that cocaine intensifies your personality”“Well, what if your an asshole?”
  21. 21. COCAINECauses euphoria, increased energyBUT, also puts strain on every organ systemCan cause stroke, MI, arrythmias, deathDoes have high addiction potential
  22. 22. METHAMPHETAMINEProduce euphoria and stimulant effect similar to cocaineVery addictiveEffects last longer than cocaineEasily synthesized“Ice” form can be smoked – similar to crack
  23. 23. METHAMPHETAMINE
  24. 24. “METH MOUTH”
  25. 25. METHANOL Organic solvent Industrial uses Common problem in developing world
  26. 26. Methanol Metabolized in liver – ADH to formadehyde Aldehyde dehydrogenase to to formic acid Tetrahydrofolate to CO2 and H2O (slow) resulting in formic acid buildup Causes metabolic acidosis
  27. 27. METHANOL SYMPTOMS Initially similar to alcohol 12 – 24 hours until toxic effects – depends on competitive inhibition with alcohol Somnolence, vomiting, headache, abdominal pain, seizures, vision loss, neuropathies, cardiac failure, death
  28. 28. OSMOLAL GAP Calc osm= 2(NA) + (glucose/18) + (BUN/2.8) +ETOH/4.6 + Isopropol/6.0 + Meth/3.2 + Ethy Glycol/6.2 Difference between measured serum osm and calculated osm = osmolar gap Osmolar Gap > 10 is definitely abnormal Caution with normal gap with early presentation
  29. 29. METHANOL TREATMENT IV Fluids, Bicarb, supportive care Delay methanol metabolism – ethanol or fomepizole Dialysis if serum methanol > 20mg/dl, if > 30ml ingested, visual complications or acidosis not responsive to bicarb
  30. 30. ANTIDOTES ETHANOL – competitive inhibition, >10 times affinity for ADH than methanol 7.5ml/kg IV load over 1 hour, then 1.4ml/kg/hour drip FOMEPIZOLE – same mech, but fewer complications than ethanol (expensive) 15mg/kg IV loading dose, then 10mg/kg IV q12 hours times 4 doses
  31. 31. ETHYLENE GLYCOL Found in most radiator fluid Suicide attempts Alcoholics Accidental - children
  32. 32. ETHYLENE GLYCOL Metabolized by ADH to glycoaldehyde Aldehyde dehydrogenase to glycolic acid (profound acidosis), then to oxalate or glutamate Oxalate can cause kidney problems and hypocalcemia
  33. 33. ETHYLENE GLYCOL SYMPTOMS Somnolence , vomiting , severe metabolic acidosis, neurological problems, death More rapid toxicity than methanol After 12 – 24 hours problems result from oxalate crystal deposition in lung, heart, kidney and brain Leads to multiorgan failure
  34. 34. OSMOLAL GAP Calc osm= 2(NA) + (glucose/18) + (BUN/2.8) +ETOH/4.6 + Isopropol/6.0 + Meth/3.2 + Ethy Glycol/6.2 Difference between measured serum osm and calculated osm = osmolar gap Osmolar Gap > 10 is definitely abnormal Caution with normal gap with early presentation
  35. 35. ETHYLENE GLYCOL TREATMENT IV Fluids, bicarb, supportive treatment Ethanol or Fomepizole Thiamine and Pyridoxine – to encourage less toxic metabolic pathways than oxalate Dialysis if persistent acidosis, Ethylene glycol level > 50, or worsening renal function
  36. 36. ANTIDOTES ETHANOL – competitive inhibition, >15 times affinity for ADH than ethylene glycol 7.5ml/kg IV load over 1 hour, then 1.4ml/kg/hour drip FOMEPIZOLE – same mech, but fewer complications than ethanol (expensive) 15mg/kg IV loading dose, then 10mg/kg IV q12 hours times 4 doses
  37. 37. ISOPROPOL Rubbing alcohol Readily available Suicide Abuse in alcoholics
  38. 38. ISOPROPOL Effect similar to ethanol, but more GI symptoms and more ketones, but does not usually cause significant metabolic acidosis
  39. 39. ISOPROPOL Metabolized by ADH to acetone Peak acetone at 4 hours after ingestion Significant toxicity only in massive ingestions
  40. 40. ISOPROPOL TREATMENT IV FLUIDS GI meds – H2/PPI Supportive care
  41. 41. Case #148 y/o male alcoholic presents intoxicatedVomited, mild epigastric pain, somnolentP=120 RR=26 T=37 BP= 180/80 sat= 99%Charge nurse asks if he can go to CT2
  42. 42. CASE #1 LABSNA = 147 K= 3.4 BUN= 42 Creat= 1.8Glucose= 78 anion gap= 38Venous pH = 7.16ETOH = 80
  43. 43. CASE #1Measured serum osm = 426WHAT BEDSIDE TEST SHOULD YOU DO?
  44. 44. OSMOLAL GAP Calc osm= 2(NA) + (glucose/18) + (BUN/2.8) +ETOH/4.6 + Isopropol/6.0 + Meth/3.2 + Ethy Glycol/6.2 Difference between measured serum osm and calculated osm = osmolar gap Osmolar Gap > 10 is definitely abnormal Caution with normal gap with early presentation

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