general management of toxicological cases

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general management of toxicological cases

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general management of toxicological cases

  1. 1. GENERAL APPROACH TO ACUTELY POISONED PATIENTS Prof. Enas El Taftazani Prof. of clinical toxicology
  2. 2. Objectives <ul><li>To provide a systematic approach to the resuscitation, work-up, diagnosis and treatment of the acutely poisoned patients. </li></ul>
  3. 3. Outline <ul><li>Case based approach to: </li></ul><ul><ul><li>initial stabilization </li></ul></ul><ul><ul><li>History </li></ul></ul><ul><ul><li>Evaluation of the poisoned patient </li></ul></ul><ul><ul><li>Techniques to prevent absorption </li></ul></ul><ul><ul><li>Techniques to enhance elimination </li></ul></ul>
  4. 4. Immediate Stabilization <ul><li>A irway with cervical spine control </li></ul><ul><ul><li>Intubate…what do you want to use? </li></ul></ul><ul><li>B reathing </li></ul><ul><ul><li>100% O 2 , ventilation </li></ul></ul><ul><li>C irculation </li></ul><ul><ul><li>Insert new IVs </li></ul></ul><ul><ul><li>Draw bloods with IV start </li></ul></ul><ul><ul><li>Bolus 1-2L NS </li></ul></ul><ul><ul><li>Cardiac monitor </li></ul></ul>
  5. 7. History Personal history History of present illness Past history Family history
  6. 8. Toxicological History <ul><li>Often incomplete, unreliable or unobtainable </li></ul><ul><li>Sources – Patient, friends, family, pill containers </li></ul><ul><li>liver/renal disease, concurrent medications, previous overdoses, substance abuse </li></ul>
  7. 9. The 5W’s of toxicology <ul><li>Who – pt’s age, weight, relation to others </li></ul><ul><li>What – name and dose of medication, coingestants and amount ingested,pre-consultation treatment. </li></ul><ul><li>When – time of ingestion, single vs. multiple ingestions </li></ul><ul><li>Where – route of ingestion, geographical location </li></ul><ul><li>Why – intentional vs. unintentional </li></ul>
  8. 10. Ask about : Respiratory symptoms:Cough,chest pain,dyspnea,,sputum GIT: N,V,diarhea,pain ch.ch. Of vomitus. Neurological: weakness,rigidity, CVS: palpitation ,chest pain,.dyspnea. Urinary: urine retention,…
  9. 11. Examination <ul><li>General : </li></ul><ul><li>vital data-Pupil, conscious state </li></ul><ul><li>Pupil : miosis,mydriasis, </li></ul><ul><li>Consciousness :grading of coma,agitation, hallucination. </li></ul><ul><li>Systemic examination </li></ul>
  10. 12. Vital signs Pulse Temperature Blood pressure Respiratory rate
  11. 13. Pulse Bradycardia: Organophosphates,digoxin,opiate,barbiturates,B-blockers Tachycardia: Anticholinergics, sympathomimetics Irregular pulse: digoxin,TCA,sympathomimetics,CO
  12. 14. Blood pressure Hypotension: Decreased peripheral resistance Hypovolemia Decreased myocardial contractility Hypertension: Sympathomimetics Scorpion anticholinergics
  13. 15. Temperature Hyperthermia Salicylates Sympathomimetics Anticholinergics Antidepressents Hypothermia: CO,oral hypoglycemics Hypnotics ethanol
  14. 16. Respiratory rate Tachypnea: Hypoxia Acidosis With dyspnea as irritant gas Bradypnea : CNS depression,neuromuscular blockade
  15. 17. Toxicologic Physical Exam <ul><li>CNS – level of arousal, GCS, pupils , behaviour, neurologic exam </li></ul><ul><li>CVS – rate, rhythm </li></ul><ul><li>Resp – pattern, depth, wheezing </li></ul><ul><li>GI – bowel sounds, distention </li></ul><ul><li>Skin – color, temp, signs of trauma </li></ul><ul><li>Odors </li></ul>
  16. 18. Laboratory Investigations <ul><li>What lab tests should we order? </li></ul><ul><li>What special tests are available? </li></ul>
  17. 19. Laboratory investigations (cont’d) <ul><li>General labs(routine): CBC,ECG,LFT, Electrolytes, BUN, Cr, glucose, ABG. </li></ul><ul><li>Special laboratory investigation indicated in following cases </li></ul><ul><ul><li>Intentional ingestion </li></ul></ul><ul><ul><li>Substance unknown </li></ul></ul><ul><ul><li>Potential for mod to severe toxicity </li></ul></ul>
  18. 20. <ul><li>Labs considered essential and available : </li></ul><ul><ul><li>EtOH, acetaminophen , salicylate, digoxin, Carbamazepine, phenobarb, phenytoin, Valproate, theophylline </li></ul></ul><ul><ul><li>Methanol, Ethylene glycol, Isopropanol, Iron, Lithium </li></ul></ul><ul><li>Tox screen – does not contribute to patient management </li></ul>Laboratory investigations (cont’d)
  19. 21. Additional Tests <ul><li>ECG – TCA or other cardiotoxic drugs, arrhythmias, ischemia </li></ul><ul><li>Radiology </li></ul><ul><ul><li>CXR – aspiration, noncardiogenic pulmonary edema </li></ul></ul><ul><ul><li>Abdominal films useful in screening for ingestions of radio-opaque materials </li></ul></ul><ul><ul><li>What substances are visible on AXR? </li></ul></ul>
  20. 22. DECONTAMINATION <ul><li>DERMAL: OPC,Carbolic acid. </li></ul><ul><li>( remove clothes,wash with soap & water for 15 min, NO forceful rubbing) </li></ul><ul><li>EYE:wash conj. With running water or saline for 20 min. </li></ul><ul><li>Inhalation :CO ,CN. </li></ul><ul><li>1.Remove to fresh air </li></ul><ul><li>2.Care of resp. </li></ul><ul><li>GIT </li></ul>
  21. 23. Gastrointestinal Decontamination <ul><li>Emesis. </li></ul><ul><li>Gastric lavage </li></ul><ul><li>Whole bowel irrigation </li></ul><ul><li>Activated charcoal </li></ul><ul><li>Cathartics </li></ul>
  22. 24. GIT emptying <ul><li>Removal of poison from stomach by emesis or g. lavage: </li></ul><ul><li>Causes of limitation of its use nowadays: time factor, small dose, previous vomiting, presence of other methods (charcoal). </li></ul><ul><li>Indications: high lethal dose, if other measures are applicable. </li></ul>
  23. 25. Ipecac <ul><li>Emetic – both peripherally and central acting </li></ul><ul><li>>90% effective </li></ul><ul><li>Dose 30cc PO :adults, 15cc >2yrs, 10cc 6-2yrs. </li></ul><ul><li>IF failed within 30 m,repeat,if not then GL.. </li></ul><ul><li>Advantages over lavage: </li></ul><ul><ul><li>Safe </li></ul></ul><ul><ul><li>Efficient </li></ul></ul><ul><ul><li>Less traumatic </li></ul></ul><ul><li>Contraindications </li></ul><ul><li>- Substance </li></ul><ul><li>- Patient </li></ul><ul><li>- Time passed </li></ul><ul><li>Complications </li></ul><ul><ul><li>Diarrhea, lethargy/drowsiness, prolonged vomiting </li></ul></ul>
  24. 26. <ul><li>Never Never Never </li></ul><ul><li>(Use Salty H2O) ???? </li></ul>
  25. 27. Gastric Lavage <ul><li>Contraindications </li></ul><ul><li>Absolute Corrosives, froth-forming </li></ul><ul><li>Relative </li></ul><ul><ul><li>Unprotected airway, coma </li></ul></ul><ul><ul><li>Convulsions </li></ul></ul><ul><ul><li>Hydrocarbons </li></ul></ul><ul><ul><li>Risk of GI bleed or perforation </li></ul></ul><ul><ul><li>Time factor (unless delayed) </li></ul></ul><ul><li>Complications </li></ul><ul><ul><li>Aspn pneumonia, laryngospasm, hypoxia, mechanical injury, fluid/electrolyte imbalances, bradycardia, hypertension </li></ul></ul>
  26. 28. Activated Charcoal <ul><li>1g/kg PO or NG </li></ul><ul><li>Indications </li></ul><ul><ul><li>Nearly all suspected toxic ingestions except </li></ul></ul><ul><ul><li>May be considered more than 1 hour after ingestion but insufficient data to support or exclude use </li></ul></ul><ul><li>Contraindications </li></ul><ul><ul><li>Unprotected airway </li></ul></ul><ul><ul><li>When AC therapy may increase risk and severity of aspiration </li></ul></ul><ul><ul><li>Corrosives (why??) , IO, hydrocarbons ,NOT ADSORBED. </li></ul></ul><ul><li>Complications </li></ul><ul><ul><li>GIT obstruction, constipation, adsorb medication </li></ul></ul>
  27. 29. Drugs that don’t adsorb to AC <ul><li>PHAILS </li></ul><ul><ul><li>P esticides ??? </li></ul></ul><ul><ul><li>H ydrocarbons, Heavy metals (Fe,Hg,Pb) </li></ul></ul><ul><ul><li>A cids/Alkalis/Alcohols </li></ul></ul><ul><ul><li>I ron </li></ul></ul><ul><ul><li>L ithium </li></ul></ul><ul><ul><li>S olvents </li></ul></ul><ul><ul><li>Gases </li></ul></ul>
  28. 30. INDICATIONS OFMDAC <ul><li>Drugs remain in GIT: </li></ul><ul><li>SR-prep:theophylline </li></ul><ul><li>concretions:salicyl. Phenobarbit. </li></ul><ul><li>slowing GIT motility:antichol. </li></ul><ul><li>EHC:digoxine,dapson,TCA </li></ul><ul><li>Passive diffusion from bl to lower GI lumen:theophylline. </li></ul>
  29. 31. Whole bowl irrigation <ul><li>A newer method for decontamination , well tolerated ,safe in pregnancy </li></ul>
  30. 32. Whole bowel irrigation <ul><li>PEG via NG at 1-2 L/h (500cc/h in peds) until effluent clear </li></ul><ul><li>Indications </li></ul><ul><ul><li>Potentially toxic ingestion of SR prep </li></ul></ul><ul><ul><li>Ingested packets of illicit drug (stuffers, packers) </li></ul></ul><ul><ul><li>Substances not adsorbed by AC </li></ul></ul><ul><ul><li>Iron ingestions </li></ul></ul>
  31. 33. Whole bowel Irrigation <ul><li>Contraindications </li></ul><ul><ul><li>Bowel perforation or obstruction </li></ul></ul><ul><ul><li>GI bleed </li></ul></ul><ul><ul><li>Ileus </li></ul></ul><ul><ul><li>Unprotected airway </li></ul></ul><ul><ul><li>Hemodynamic instability </li></ul></ul><ul><ul><li>Intractable vomiting </li></ul></ul><ul><li>Complications </li></ul><ul><ul><li>Nausea, vomiting, aspiration, cramps </li></ul></ul>
  32. 34. TYPES OF CATHASIS <ul><li>OSMOTIC:MgSO4(15-30g)in glass of water. </li></ul><ul><li>IRRITANT:Castor oil(60-100ml) </li></ul><ul><li>Contraind.: GI Hge, IO,ileus,recent bowel surgery,RF(Mg load) </li></ul><ul><li>Complications: dehydration & elec.imb </li></ul>
  33. 35. Cathartics <ul><li>Sorbitol, Mg citrate, Phosphosoda </li></ul><ul><li>May be an argument for adding to initial dose of multiple dose activated charcoal </li></ul><ul><li>No studies have demonstrated a benefit in clinical outcome with cathartics </li></ul>
  34. 36. Enhancing elimination <ul><li>Multiple dose activated charcoal </li></ul><ul><li>Diuresis </li></ul><ul><li>Alkalinization </li></ul><ul><li>Hemodialysis </li></ul><ul><li>Hemoperfusion </li></ul>
  35. 37. Alkalinization <ul><li>Enhances elimination of weak bases by ion trapping </li></ul><ul><li>Useful for: </li></ul><ul><ul><li>Salicylates, phenobarbital, myoglobin </li></ul></ul><ul><li>NaHCO 3 1-2 mEq/kg IV </li></ul><ul><li>Aim for Urine pH 7-8 </li></ul><ul><li>Must replace K </li></ul>
  36. 38. Hemodialysis <ul><li>Blood passed across membrane with countercurrent dialysate flow </li></ul><ul><li>Toxins removed by diffusion </li></ul><ul><li>Properties required: </li></ul><ul><ul><li>Molecular weight < 500 daltons </li></ul></ul><ul><ul><li>Low or saturable plasma protein binding </li></ul></ul><ul><ul><li>Low Vd (<1L/kg) </li></ul></ul>
  37. 39. Hemoperfusion <ul><li>Blood passed through cartridge containing AC </li></ul><ul><li>Toxins removed by adsorption </li></ul><ul><li>Properties required: </li></ul><ul><ul><li>Low Vd <1L/kg </li></ul></ul><ul><ul><li>Low endogenous clearance <4cc/min/kg </li></ul></ul><ul><ul><li>Adsorbable to AC </li></ul></ul>
  38. 40. Substances amenable to hemodialysis or hemperfusion <ul><li>LET ME SAV P </li></ul><ul><ul><li>L ithium </li></ul></ul><ul><ul><li>E thylene glycol </li></ul></ul><ul><ul><li>T heophylline </li></ul></ul><ul><ul><li>ME thanol </li></ul></ul><ul><ul><li>S alicylates </li></ul></ul><ul><ul><li>A tenolol </li></ul></ul><ul><ul><li>V alproic acid </li></ul></ul><ul><ul><li>P otassium, paraquat </li></ul></ul>
  39. 41. Complications of hemodialysis <ul><li>Bleeding at venous puncture site </li></ul><ul><li>hypotension </li></ul><ul><li>Bleeding due to systemic anticoagulation </li></ul><ul><li>Infection </li></ul><ul><li>Air embolus </li></ul>
  40. 42. Antidotes <ul><li>If after stabilization a toxin is identified, there may be a specific antidote </li></ul>
  41. 43. Antidotes (Cont’d) poison antidote Arsenic, mercury, lead Dimercaprol (BAL) Digoxin, digitoxin Digoxine immune Fab Iron Deferoxamine cyanide Cyanide kit CCB or hydrogen fluoride Ca gluconate or Ca chloride Carbamate or organophosphate atropine Crotalid snake bite Crotalid Antivenin acetaminophen acetylcysteine MeOH, et glycol ethanol TCA, cocaine, salicylates Sodium bicarbonate isoniazid pyridoxine organophosphate pralidoxime anticholinergic physostigmine opioids naloxone methemoglobin Methylene blue Β -blocker, CCB glucagon MeOH Fomepizole BDZ flumazenil poison antidote
  42. 44. Summary <ul><li>A irway with cervical spine control </li></ul><ul><li>B reathing </li></ul><ul><li>C irculation </li></ul><ul><li>D rugs (coma cocktail), D econtamination </li></ul><ul><li>E limination </li></ul><ul><li>F ind an antidote </li></ul><ul><li>G eneral management </li></ul>
  43. 45. <ul><li>Thank You </li></ul>
  44. 46. Bradycardia <ul><li>P ropanolol ( β -blockers ), phenylpropanolamine (  -agonists) </li></ul><ul><li>A nticholinesterase drugs(OPC) </li></ul><ul><li>C lonidine, CCBs </li></ul><ul><li>E thanol / alcohols </li></ul><ul><li>D igoxin , Darvon (opiates) </li></ul>
  45. 47. Tachycardia <ul><li>F ree base (cocaine/stimulants) </li></ul><ul><li>A nticholinergics, antihistamines </li></ul><ul><li>S ympathomimetics </li></ul><ul><li>T heophylline (methylxanthines) </li></ul>
  46. 48. Hypotension <ul><li>C lonidine </li></ul><ul><li>R eserpine (antihypertensives) </li></ul><ul><li>A ntidepressants </li></ul><ul><li>S edative hypnotics </li></ul><ul><li>H eroin (opiates) </li></ul>
  47. 49. Hypertension <ul><li>C ocaine </li></ul><ul><li>T heophylline, thyroid supplements </li></ul><ul><li>S ympathomimetics </li></ul><ul><li>C affeine </li></ul><ul><li>A nticholinergics, amphetamines </li></ul><ul><li>N icotine </li></ul>
  48. 50. Hyperthermia <ul><li>N euroleptic malignant syndrome </li></ul><ul><li>A ntihistamines </li></ul><ul><li>S alicylates, sympathomimetics, serotonin syndrome </li></ul><ul><li>A nticholinergics, antidepressants </li></ul>
  49. 51. Hypothermia <ul><li>C arbon monoxide </li></ul><ul><li>O piates </li></ul><ul><li>O ral hypoglycemics/insulin </li></ul><ul><li>L iquor (EtOH) </li></ul><ul><li>S edative hypnotics </li></ul>
  50. 52. Seizures <ul><li>O rganophosphates </li></ul><ul><li>T ricyclic antidepressants </li></ul><ul><li>I NH, insulin </li></ul><ul><li>S ympathomimetics </li></ul><ul><li>C amphor, cocaine </li></ul><ul><li>A mphetamines, anticholinergics </li></ul><ul><li>M ethylxanthines </li></ul><ul><li>P hencyclidine </li></ul><ul><li>B enzodiazepine withdrawal, botanicals </li></ul><ul><li>E thanol withdrawal </li></ul><ul><li>L ithium, lidocaine </li></ul><ul><li>L ead, lindane </li></ul>
  51. 53. Pupils <ul><li>Miosis </li></ul><ul><li>O piates/organophosphates </li></ul><ul><li>P henothiazines, pilocarpine, pontine bleed </li></ul><ul><li>S edative hypnotics </li></ul><ul><li>C holinergics/clonidine </li></ul><ul><li>Mydriasis </li></ul><ul><li>A ntihistamines </li></ul><ul><li>A ntidepressants </li></ul><ul><li>A nticholinergics </li></ul><ul><li>S ympathomimetics </li></ul>
  52. 54. Odors <ul><li>Bitter almonds – cyanide </li></ul><ul><li>Fruity – DKA, isopropanol </li></ul><ul><li>Minty – methyl salicylates </li></ul><ul><li>Rotten eggs – sulfur dioxide, hydrogen sulfide </li></ul><ul><li>Pears – chloral hydrate </li></ul><ul><li>Garlic – organophosphates, arsenic </li></ul><ul><li>Mothballs - camphor </li></ul>
  53. 55. Radiodense substances that may be visible on AXR <ul><li>CHIPES </li></ul><ul><ul><li>C hloral hydrate </li></ul></ul><ul><ul><li>H eavy metals </li></ul></ul><ul><ul><li>I ron </li></ul></ul><ul><ul><li>P henothiazines </li></ul></ul><ul><ul><li>E nteric coated preps </li></ul></ul><ul><ul><li>S ustained release preps </li></ul></ul><ul><li>Drug Packets </li></ul>
  54. 56. Questions <ul><li>?? </li></ul>
  55. 57. CPR
  56. 58. CPR <ul><li>Position of the patient. </li></ul><ul><li>Artificial respiration (mouth to mouth breathing=rescue breathing) </li></ul><ul><li>Ext. Chest compression with monitoring the carotid or femoral pulse. </li></ul><ul><li>Rate: (2 resp. /15 beats if one rescuer) or (1 resp. /5 beats if two rescuers) </li></ul><ul><li>IV line, Oxygen, intubation NaHCO3, </li></ul><ul><li>Adrenaline 1 mg /5min IV. </li></ul><ul><li>Ca chloride. </li></ul><ul><li>DC shock </li></ul>
  57. 60. SEQUENCE OF ACTION <ul><li>1-Ensure safety of rescuer and victim </li></ul><ul><li>2-Check the victim & see if he responds:gently shake his shoulders & shout loudly:” Are you all right?” </li></ul><ul><li>3-If he responds by answering or moving---check him & get assistance </li></ul><ul><li>If he doesn’t respond:shout for help </li></ul>
  58. 61. <ul><li>4-Check position,airway open then </li></ul><ul><li>LOOK for chest movements </li></ul><ul><li>LISTEN at his mouth for breath sounds </li></ul><ul><li>FEEL for air on your cheek </li></ul><ul><li>(for no more than 10 sec to determine if he is breathing normally) </li></ul>
  59. 62. <ul><li>5- If he is breathing: </li></ul><ul><li>Turn him into recovery position </li></ul><ul><li>Check for cont. breathing </li></ul><ul><li>Send for help </li></ul><ul><li>If not:ask for assistance </li></ul><ul><li>- turn him on his back </li></ul><ul><li>- tilt head, chin lift </li></ul><ul><li>-pinch soft part of his nose </li></ul><ul><li>-open his mouth a little but maintain chin </li></ul><ul><li>lift </li></ul><ul><li>-take a breath,place your lips around his mouth, make good seal </li></ul><ul><li>-blow ,watch his chest take about 2 sec </li></ul><ul><li>- give him 2 rescue breaths </li></ul><ul><li>(each makes his chest rise & fall) </li></ul>
  60. 63. <ul><li>6- ASSESS CIRCULATION: </li></ul><ul><li>LOOK LISTEN & FEEL for normal </li></ul><ul><li>breathing,coughing or any movement </li></ul><ul><li>Check pulse(for no more than 10 sec) </li></ul>
  61. 64. <ul><li>7-If no signs of circ. (START CHEST COMPRESSION) </li></ul><ul><li>C ombine rescue breathing & comp. </li></ul><ul><li>After 15 comp. tilt head,lift chin & give 2 effective breaths and so on in a ratio of 15:2 </li></ul><ul><li>Stop to recheck for signs of circ only if he makes a movement or takes a spont breath;otherwise resuscitation should not be interrupted </li></ul>
  62. 65. CONTINUE UNTIL?? <ul><li>QUALIFIED help arrives & takes over </li></ul><ul><li>The victim shows signs of life </li></ul><ul><li>YOU become exhausted </li></ul>
  63. 66. Notes On Tech. Of BLS <ul><li>RESCUE BREATHING : </li></ul><ul><li>only slight resistance should be felt </li></ul><ul><li>each one should take about 2 seconds </li></ul><ul><li>Blowing too quickly will force air into the stomach & inc. the risk of regurgitation </li></ul><ul><li>each should make the chest rise clearly </li></ul><ul><li>The rescuer should wait for the chest to fall fully during exp(about 2-4 sec) </li></ul>
  64. 67. <ul><li>CHEST COMPRESSION: </li></ul><ul><li>The aim is to press down approx.4-5 cm & apply enough pressure to achieve this </li></ul><ul><li>Pressure should be firm,controlled & applied vertically(erratic or violent action is dangerous) </li></ul><ul><li>You should not waste time to check the presence of pulse. </li></ul><ul><li>The presence of dilated pupils is an unreliable sign & shouldn’t influence </li></ul>

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