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Poison2 1285794193199-phpapp01

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Poison2 1285794193199-phpapp01

  1. 1. TOXICOLOGY An Overview Jordan B. Barnett, M.D., FACEPInterim Director, Department of Emergency Medicine Episcopal Hospital
  2. 2. POISONING® Estimated 4 Million Annual® Pediatric ®Child Abuse® Adult ®Recreational ®Suicide
  3. 3. HISTORY® What Poison?® How Much?® How?® When?® Why?® What Else Taken?
  4. 4. PHYSICAL EXAM® Vital Signs ® ABC’s ® Temperature® Toxic Syndrome® Respiratory® Cardiovascular® Neurologic
  5. 5. TREATMENT® ABC’s® Treat Other Injuries® Decontamination® Supportive Care® Definitive Care ® Antidotes ® Elimination
  6. 6. DECONTAMINATION: IPECAC® Absorption Reduced By 30%® Interferes With Further Decontamination® Interferes With Further Treatment® Home Use® NOEMERGENCY DEPARTMENT USE!
  7. 7. DECONTAMINATION: GASTRIC LAVAGE® 250 - 300 cc Aliquots Of Fluid® 36 - 40F Tube® Advantages ® Immediate Recovery Of Gastric Contents ® Direct access For Charcoal Instillation® LeftLateral Decubitus With Trendelenburg® Intubation May Be Needed
  8. 8. DECONTAMINATION: GASTRIC LAVAGE® Disadvantages ® NotComplete Gastric Emptying ® 30% Recovery At 1 Hour ® Labor Intensive ® Complications ® 3% Overall ® Esophageal Rupture ® Aspiration ® Hypoxia
  9. 9. DECONTAMINATION: CHARCOAL® Not Absorbed From GI Tract® Binds Most Substances® Prevents Absorption® Enhance Excretion ® MultipleDose ® Enterohepatic Circulation
  10. 10. DECONTAMINATION: CHARCOALAmpicillin Model Decreased Absorption ® Charcoal 57% ® Emesis 38% ® Lavage 32%
  11. 11. ACTIVATED CHARCOAL® Dose 1g/kg® Repeat Dose® Disadvantages ® Messy ® Aspiration
  12. 12. SUBSTANCES NOT BOUND BY CHARCOAL® Alcohols And ® Heavy Metals Glycols ® Iron® Corrosives ® Lead ® Alkalis ® Lithium ® Acids ® Mercury® Cyanide ® Hydrocarbons® Saline Cathartics
  13. 13. CATHARTICS® Mechanism® Types® Mixture With Charcoal® Disadvantages® Use In Children
  14. 14. OTHER MODALITIES® Whole Bowel Irrigation ® Indications ® Technique® Skin® Eye
  15. 15. RESPIRATORY COMPLICATIONS® Airway Protection® Ventilatory Insufficiency® Bronchospasm® Noncardiogenic Pulmonary Edema® Aspiration
  16. 16. CARDIOVASCULAR COMPLICATIONS® Tachycardia® Bradycardia® Hypotension® Hypertension
  17. 17. NEUROLOGIC COMPLICATIONS® Coma® Seizures® Behavioral Abnormalities
  18. 18. DIAGNOSTIC STUDIES® Drug Screens/Levels® Acetaminophen® ABG® Electrolytes® Organ Function® EKG® X-RAY
  19. 19. 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
  20. 20. ETHANOL C2H5OHMolecular Weight=________
  21. 21. DEFINITIVE CARE® Decontamination® Supportive Care® Antidotes ® Oxygen/Glucose/Narcan/?Flumazenil® Elimination ® Alkalinization ® Repeated Dose Charcoal® Dialysis
  22. 22. DISCHARGE® StableIn Emergency Department® Psychiatric Issues
  23. 23. TOXIDROMEToxic Syndromes
  24. 24. TOXIDROMES: CASE 125 Year Old PA Student JustBack From Spring Break InMexico. Hes Been HavingTerrible Diarrhea Since Returningand Has Been Using Pills toAlleviate the Symptoms.
  25. 25. TOXIDROMES: CASE 1® Dry Skin And Mucous Membranes® Thirst® Blurred Vision® Fixed Dilated Pupils® Flushing® Urinary Urgency And Retention® Hallucinations
  26. 26. TOXIDROMES: CASE 1® Anticholinergic ®Hot As Hades ®Blind As A Bat ®Dry As A Bone ®Red As A Beet ®Mad As A Hatter
  27. 27. TOXIDROMES: CASE 1® Belladonna Alkaloids ® Atropine/Scopolamine ® Scopolamine® Synthetic Anticholinergics ® Dicyclomine® Other ® Antihistamines/Phenothiazines/TCA
  28. 28. TOXIDROMES: CASE 2A 50 Year Old Farmer IsFound Unresponsive at HisBarn.
  29. 29. TOXIDROMES: CASE 2® Sweating® Constricted Pupils® Lacrimation® Excessive Salivation® Wheezing® Vomiting/Diarrhea® Fasiculations
  30. 30. TOXIDROMES: CASE 2® Acetylcholinesterase Inhibitors® Pesticides ® Organophosphate ® Carbamates® Mechanism® Treatment ® Atropine ® Pralidoxime (2-PAM)
  31. 31. TOXIDROMES: CASE 3An 8 Year Old Child Is Broughtto the Emergency DepartmentAfter Being Given aCompazine Suppository forVomiting.
  32. 32. TOXIDROMES: CASE 3® Dysphonia® Oculogyric Crises® Rigidity® Torticollis/Opisthotonos
  33. 33. TOXIDROMES: CASE 3® Extrapyramidal Effects® Medications ®Antipsychotic ®Antiemetic® Treatment
  34. 34. TOXIDROMES: CASE 4During a Visit to Grandma in theNursing Home, You Find ThatYou Can Not Wake Her Up.
  35. 35. TOXIDROMES: CASE 4® CNS Depression® Pinpoint Pupils® Slowed Respirations® Hypotension
  36. 36. TOXIDROMES: CASE 4® Narcotic® Medications ®Prescribed ®Illicit® Treatment
  37. 37. TOXIDROMES: CASE 5A Movie Star Presents to YourHospital.
  38. 38. TOXIDROMES: CASE 5® CNS Excitation® Seizures® Hypertension® Tachycardia
  39. 39. TOXIDROMES: CASE 5® Sympathomimetic® Medication ®Prescribed ®Illicit® Treatment
  40. 40. TOXIDROMES: CASE 6A Family of 6 Presents to YourOffice in the Middle of Winterand All Complain of “the Flu”.
  41. 41. TOXIDROMES: CASE 6® Headache® “Flu”Symptoms® Nausea, Vomiting, Dizziness® Dyspnea® Seizures® Death® Cyanosis® “Chocolate” Blood
  42. 42. TOXIDROMES: CASE 6® Hemoglobinopathies® Carbon Monoxide® Methemoglobin® Treatment
  43. 43. TRICYCLIC ANTIDEPRESSANTS® Mortality 2 - 5 Percent® Low Therapeutic/Toxic Ratio® Mechanism ®InhibitionOf Amine Uptake ®Anticholinergic ®Alpha Receptor Blocker ®Sodium Channel Blockade
  44. 44. TCA CLINICAL FEATURES® Anticholinergic Symptoms® Tachycardia® CNS Toxicity® Coma® Hypotension® Arrhythmia® Seizures
  45. 45. TCA CLINICAL FEATURES® ECG ®“rightaxis deviation of the terminal 40ms of QRS greater than 1200 “ ®Sinus Tach-Wide QRS-Decreased Inotropy-Increased PRI- Bradycardia ®Wide QRS=Life Threatening Toxicity
  46. 46. TCA TREATMENT® GIDecontamination® Sodium Bicarbonate-Indications ® QRS Widening ® Hypotension ® Ventricular Arrhythmias® Sodium Bicarbonate-Mechanism® 1 - 2 mEq/Kg To pH 7.50-7.55
  47. 47. TCA TREATMENT® Physostigmine ® Peripheral Anticholinergic Symptoms ® Agitation/Seizures/Hypotension When Other Methods Fail ® Side Effects® Seizures ® Benzodiazepines/Barbiturates® Hypotension
  48. 48. SALICYLATES® Gastroenteritis® Mixed Respiratory And Metabolic Acidosis® CNS® Cardiac Toxicity® Pulmonary ® ARDS® Tinnitus
  49. 49. 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
  50. 50. SALICYLATES TREATMENT® Charcoal® IVFluids® Urine Alkalinization ® Mechanism “Ion Trapping” ® Un-ionized Salicylate Reabsorbed By Renal Tubules ® Alkaline Urine Favors Ionized Salicylate Which Cannot Be Reabsorbed® Dialysis
  51. 51. SALICYLATES DISPOSITION® Asymptomatic Nomogram After 6 Hours® Patient Asymptomatic® Enteric Coated ® 150 mg/kg® Psychiatric Evaluation® Follow-up

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