Toxidrome approach in emergency room
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The presentation covers an easy method to manage acute poisoning in Ed. It elaborates the tox presentations through four toxidromes and an algorithmic approach to solve the puzzle
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Toxidrome approach in emergency room
- 1. Toxidrome approach in Emergency room D V P P, D & L , A DM H : I L
- 2. ❏ Large number of Toxins ❏ Complex presentations of Overdoses ❏ Mimics of OD ❏ Diagnosis is nightmare in ED
- 3. Toxidrome ● Toxidrome (a portmanteau of toxic and syndrome) ● A syndrome caused by a dangerous level of toxins in the body ● The term was coined in 1970 by Mofenson and Greensher ● It is often the consequence of a drug overdose
- 4. Toxidrome ❏ A toxidrome may indicate a medical emergency ❏ Requiring treatment at a poison control center ❏ Aside from poisoning, a systemic infection may also lead to a toxidrome
- 5. Toxins Overdoses in emergency departments Patient presentations SignsSymptoms Toxidromes 1 32 4 ToxinsToxins
- 6. Major Toxidrome 1. Anticholinergics 2. Sympathomimetics / Withdrawal 3. Opiate / Sedative 4. Cholinergic / Anticholinesterase a.
- 7. 1 . Anticholinergics Interfere with binding of Ach with Muscarinic receptors
- 9. Anticholinergic Toxidrome ❏ Hyperthermia ❏ Dilated pupils (mydriasis) ❏ Dry skin ❏ Vasodilation causing flushed skin ❏ Agitation / Hallucinations ❏ Tachycardia and possibly dysrhythmias
- 10. Anticholinergics agents ❏ Tricyclic antidepressants ❏ Atropine ❏ Antihistamines ❏ Antipsychotics ❏ Antispasmodics ❏ Carbamazepine ❏ Jimson seed
- 11. Memory tips
- 12. Treatment for Overdose : Pre- Hospital ❏ Focus on Safe & Rapid transport ❏ Oxygen administration ❏ Cardiac monitoring ❏ Staying alert for complications such as vomiting, seizures or violent behaviour
- 13. Treatment for Overdose : In-Hospital ❏ Supportive measures in most cases ❏ Rarely used option is the administration of antidote drug ❏ Physostigmine, a short-acting cholinesterase inhibitor
- 14. 2.Sympathomimetics ❏ Mimics the sympathetic nervous system effects ❏ Alcohol and Drug withdrawals are also present with similar toxidrome features ❏ They are grouped together
- 15. Sympathomimetic Toxidrome ❏ Tachycardia, ❏ Dysrhythmias ❏ Hypertension ❏ Diaphoresis ❏ Goosebumps ❏ Delusions ❏ Paranoia, ❏ Seizures ❏ Increased temperature ❏ Dilated pupils
- 16. Sympathomimetic agents ❏ Ecstasy ❏ Amphetamine ❏ Theophylline ❏ Caffeine ❏ Cocaine EAT C&C
- 17. Treatment for Overdose : Pre- Hospital ❏ Focus on Safe & Rapid transport ❏ Oxygen administration ❏ Cardiac monitoring ❏ Staying alert for complications such as vomiting, seizures or violent behaviour
- 18. Treatment for Overdose : In - Hospital ❏ Supportive care ❏ Administration of Benzodiazepine to Calm agitated patients
- 20. 3. Opioids ❏ Mu Receptor agonists ❏ Morphin ❏ Pethidine ❏ Fentanyl ❏ Codeine ❏ Methadone ❏ Hydromorphone ❏ Propoxyphene Partial Agonists ❏ Buprenorphine ❏ Pentazocine
- 21. Opioids ❏ Analgesia ❏ Nausea ❏ Vomiting ❏ Sedation ❏ Euphoria ❏ Dizziness CNS ❏ Decreased motility ❏ Decreased pyloric tone ❏ Inhibition of intestinal contraction ❏ Increased absorption of fluid and electrolyte ❏ Increased Anal sphincter tone ENS
- 22. Opioid OD : Toxidrome CPR -3H C-Coma P-Pinpoint Pupil R- Respiratory Depression H-Hypotension H-Hypothermia H-Hyporeflexia
- 23. Opioid OD Always consider an opiate overdose when assessing elderly patients with altered LOC who have been prescribed an opiate for pain control - Increasing pain or confusion can cause accidental overdoses
- 24. Treatment in Opioid OD : Pre- Hospital ❏ Pre-hospital - focus on supporting the ABC’s ❏ Suctioning ❏ Placement of an airway adjunct ❏ Supported ventilations with a BVM
- 25. Treatment in Opioid OD : Pre- Hospital ❏ Even if the patient can be roused, monitor the respiratory effort carefully ❏ Sometimes patients need to be told to ‘take a few deep breaths’ to maintain adequate ventilations
- 26. Sedation exhibited by opiate overdose patients are often due to a combined effect of the drug itself, as well as high carbon dioxide levels
- 27. Treatment in Opioid OD : Pre- Hospital
- 28. Opioid OD - Treatment : In-Hospital ❏ Support ABC ❏ Administration of Naloxone ❏ Always use with caution “It can very quickly go from having an easily managed and sedate patient, to a combative individual in full withdrawal” A Airway & Antidote
- 29. Antidote Naloxone ❏ Start with 0.04mg ❏ Titrate up q 2-3 min as need for ventilation to 0.5 mg, 2mg, 5 mg up to max 10-15 mg
- 31. 4. Cholinergics Elevated levels of acetylcholine 1. Direct ‘cholinergic’ effects 2. Inhibiting the enzyme responsible for the breakdown of acetylcholine (cholinesterase)
- 32. Cholinergics
- 33. Chloninergic Toxidromes ❏ Diaphoresis, Diarrhea, Decreased BP ❏ Urination ❏ Miosis ❏ Bronchorrhea, Bronchospasm,Bradycardia ❏ Emesis, Excitation of skeletal muscles ❏ Lacrimation (tearing) ❏ Salivation, Seizures DUMBBELLS
- 34. Chloninergic Toxidromes ❏ Salivation ❏ Lacrimation ❏ Urination ❏ Defecation ❏ GI Stress ❏ Emesis SLUDGE
- 35. Cholinergics Cholinergic ❏ Nicotine ❏ Mushrooms Anticholinesterase ❏ Organophosphate insecticides ❏ Nerve gas (sarin)
- 36. Cholinergics
- 37. Treatment of Overdose Pre-hospital care ❏ Focuses on the ABC’s ❏ Vigorous monitoring ❏ Be prepared for seizures
- 38. Treatment of overdose In-hospital ❏ Advanced life support ❏ Atropine, an anticholinergic ❏ Antidote - Pralidoxime Triple A
- 39. Diagnosis of poisoning ❖ Ask patient or relatives/friends what drugs or poison have been taken (not always accurate) ❖ Self-poisoning ❏ Under the influence of alcohol ❏ May not know which tablets he/she took ❏ Check any bottles or packets for the names and quantities of drugs/poisons that were available
- 40. Diagnosis of poisoning ❏ Unconscious or severely poisoned, look in hospital notes for details of previous overdosed ❏ Record the time of ingestion of the drug or poison ❏ Examine the patient all over for signs of poisoning, injection marks or self-injury ❏ Mimicking poisoning (eg head injury, meningitis) ❏ Traditional Chinese medicines or herbs or Ayurvedic medicines can cause significant toxicity
- 41. Toxidrome : Features suggesting a particular poisoning 1. Coma 2. Dilated pupils 3. Divergent squint 4. Tachycardia 5. Increase muscle tone 6. Increase reflexes 7. Extensor plantars TCA Orphenadrine
- 42. Toxidrome : Features suggesting a particular poisoning 1. Coma 2. Hypotension 3. Respiratory depression 4. Decrease muscle tone Barbiturate Clomethiazole Benzodiazepines Alcohol Severe TCA OD
- 43. Toxidrome : Features suggesting a particular poisoning ❏ Coma ❏ Slow respiration ❏ Pinpoint pupils Opioid
- 44. Toxidrome : Features suggesting a particular poisoning ❏ Tinnitus ❏ Deafness ❏ Hyperventilation ❏ Sweating ❏ Nausea ❏ Tachycardia Salicylate OD
- 45. Toxidrome : Features suggesting a particular poisoning 1. Agitation 2. Tremor 3. Dilated pupils 4. Tachycardia ❏ Amphetamines ❏ Ecstasy ❏ Cocaine ❏ Sympathomimetics ❏ Tricyclic antidepressants ❏ Selective serotonin reuptake inhibitors
- 46. Assessment & Monitoring ❏ Assess and record conscious level ❏ Observe frequently ❏ Check blood glucose in patients with confusion, coma or fiits ❏ Monitor breathing and record respiratory rate ❏ Use a pulse oximeter ➢ SpO 2 may be misleadingly high in carbon monoxide (CO)poisoning
- 47. Assessment & Monitoring 1. Check ABG if patient is deeply unconscious or breathing abnormally 2. Record and monitor the ECG ➢ Unconscious ➢ Tachy- or bradycardia ➢ Taken drugs or poisons with risk of arrhythmias. 3. Record BP and temperature 290 × 443
- 48. Investigations Most useful tests ❏ Paracetamol ❏ Salicylate levels ❏ Blood glucose ❏ ABG ❏ Urea ❏ Electrolytes Record the time of the sample on the Bottle, and in the Notes
- 49. Investigations ❏ Measure paracetamol if there is any possibility of paracetamol poisoning (this includes all unconscious patients) ❏ Record the time of the sample on the bottle, and in the notes ❏ Many labs can measure salicylate, iron and lithium and also check for paraquat if necessary
- 50. ➢ ➢ Comprehensive drug screening is rarely needed and is only available in specialist centres
- 52. Toxidrome-oriented physical exam: ❏ Vital signs: temperature, heart rate, blood pressure, respiratory rate ❏ Neurologic: level of consciousness, pupils, motor response ❏ Skin moisture: check in patient’s axillae ❏ Lung sounds ❏ Bowel sounds Work-up consider ❏ Bedside glucose Lytes (anion gap) ❏ Serum osm ❏ CK ❏ Acetaminophen ❏ Salicylate ❏ Urine pregnancy ❏ ECG ❏ Tox screen Tachycardia +/- Hypertension Bradycardia +/- Hypotension ❏ Agitated ❏ Behavior ❏ Delirium ❏ Mydriasis ❏ Increased temp Nicot inic ❏ Muscle cramps Tachycardia ❏ Weakness ❏ Twitching ❏ Fasciculations
- 53. ❏ Agitated ❏ Behavior ❏ Delirium ❏ Mydriasis ❏ Increased temp ➢ Dry skin ➢ Decreased bowel sound ➢ Sweaty ➢ Hyperactive bowel Anticholinergic ❏ Anti-H1 ❏ TCA ❏ Anti- psychotics Sympathomimetic ❏ Cocaine ❏ Amphetamines ❏ PCP ❏ Ephedrine
- 54. Bradycardia +/- Hypotension Altered mental status, +/- resp depression Cholinergic ❏ Diarrhea ❏ Urination ❏ Miosis ❏ Bronchorrhea ❏ Bradycardia ❏ Emesis ❏ Lacrimation ❏ Salivation ❏ Sweating Pesticides: ❏ Organophos ❏ Carbamates Beta blocker Calcium channel blocker Hypoglycemia Hyperglycemia
- 55. Altered mental status, +/- resp depression Normal Pupil ❏ Opioid ❏ Clonidine Sedative- Hypnotic -ETOH -Benzos If anion gap, Toxic alcohol Pinpoint Pupil ❏ Vision changes ❏ N/V ❏ Abnormal ECG Digoxin Foxglove Oleander
- 56. Exposure Evaluation A-B-C-D &“D” ❏ Decontamination ❏ Data ❏ Documentation ❏ Dialysis Foleys Gastric Lavage Antidote ❏ Airway ❏ Breathing ❏ Circulation ❏ Disabilty