Toxicology Management in The Emergency Department - Jordan Barnett MD

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Overview of toxicologic management in the Emergency Department

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Toxicology Management in The Emergency Department - Jordan Barnett MD

  1. 1. TOXICOLOGY An Overview Jordan B. Barnett, M.D., FACEP Interim Director, Department of Emergency Medicine Episcopal Hospital
  2. 2. POISONING <ul><li>Estimated 4 Million Annual </li></ul><ul><li>Pediatric </li></ul><ul><ul><li>Child Abuse </li></ul></ul><ul><li>Adult </li></ul><ul><ul><li>Recreational </li></ul></ul><ul><ul><li>Suicide </li></ul></ul>
  3. 3. HISTORY <ul><li>What Poison? </li></ul><ul><li>How Much? </li></ul><ul><li>How? </li></ul><ul><li>When? </li></ul><ul><li>Why? </li></ul><ul><li>What Else Taken? </li></ul>
  4. 4. PHYSICAL EXAM <ul><li>Vital Signs </li></ul><ul><ul><li>ABC’s </li></ul></ul><ul><ul><li>Temperature </li></ul></ul><ul><li>Toxic Syndrome </li></ul><ul><li>Respiratory </li></ul><ul><li>Cardiovascular </li></ul><ul><li>Neurologic </li></ul>
  5. 5. TREATMENT <ul><li>ABC’s </li></ul><ul><li>Treat Other Injuries </li></ul><ul><li>Decontamination </li></ul><ul><li>Supportive Care </li></ul><ul><li>Definitive Care </li></ul><ul><ul><li>Antidotes </li></ul></ul><ul><ul><li>Elimination </li></ul></ul>
  6. 6. DECONTAMINATION: IPECAC <ul><li>Absorption Reduced By 30% </li></ul><ul><li>Interferes With Further Decontamination </li></ul><ul><li>Interferes With Further Treatment </li></ul><ul><li>Home Use </li></ul><ul><li>NO EMERGENCY DEPARTMENT USE! </li></ul>
  7. 7. DECONTAMINATION: GASTRIC LAVAGE <ul><li>250 - 300 cc Aliquots Of Fluid </li></ul><ul><li>36 - 40F Tube </li></ul><ul><li>Advantages </li></ul><ul><ul><li>Immediate Recovery Of Gastric Contents </li></ul></ul><ul><ul><li>Direct access For Charcoal Instillation </li></ul></ul><ul><li>Left Lateral Decubitus With Trendelenburg </li></ul><ul><li>Intubation May Be Needed </li></ul>
  8. 8. DECONTAMINATION: GASTRIC LAVAGE <ul><li>Disadvantages </li></ul><ul><ul><li>Not Complete Gastric Emptying </li></ul></ul><ul><ul><li>30% Recovery At 1 Hour </li></ul></ul><ul><ul><li>Labor Intensive </li></ul></ul><ul><ul><li>Complications </li></ul></ul><ul><ul><ul><li>3% Overall </li></ul></ul></ul><ul><ul><ul><li>Esophageal Rupture </li></ul></ul></ul><ul><ul><ul><li>Aspiration </li></ul></ul></ul><ul><ul><ul><li>Hypoxia </li></ul></ul></ul>
  9. 9. DECONTAMINATION: CHARCOAL <ul><li>Not Absorbed From GI Tract </li></ul><ul><li>Binds Most Substances </li></ul><ul><li>Prevents Absorption </li></ul><ul><li>Enhance Excretion </li></ul><ul><ul><li>Multiple Dose </li></ul></ul><ul><ul><li>Enterohepatic Circulation </li></ul></ul>
  10. 10. DECONTAMINATION: CHARCOAL <ul><li>Charcoal </li></ul><ul><li>Emesis </li></ul><ul><li>Lavage </li></ul><ul><li>57% </li></ul><ul><li>38% </li></ul><ul><li>32% </li></ul>Ampicillin Model Decreased Absorption
  11. 11. ACTIVATED CHARCOAL <ul><li>Dose 1g/kg </li></ul><ul><li>Repeat Dose </li></ul><ul><li>Disadvantages </li></ul><ul><ul><li>Messy </li></ul></ul><ul><ul><li>Aspiration </li></ul></ul>
  12. 12. SUBSTANCES NOT BOUND BY CHARCOAL <ul><li>Alcohols And Glycols </li></ul><ul><li>Corrosives </li></ul><ul><ul><li>Alkalis </li></ul></ul><ul><ul><li>Acids </li></ul></ul><ul><li>Cyanide </li></ul><ul><li>Saline Cathartics </li></ul><ul><li>Heavy Metals </li></ul><ul><ul><li>Iron </li></ul></ul><ul><ul><li>Lead </li></ul></ul><ul><ul><li>Lithium </li></ul></ul><ul><ul><li>Mercury </li></ul></ul><ul><li>Hydrocarbons </li></ul>
  13. 13. CATHARTICS <ul><li>Mechanism </li></ul><ul><li>Types </li></ul><ul><li>Mixture With Charcoal </li></ul><ul><li>Disadvantages </li></ul><ul><li>Use In Children </li></ul>
  14. 14. OTHER MODALITIES <ul><li>Whole Bowel Irrigation </li></ul><ul><ul><li>Indications </li></ul></ul><ul><ul><li>Technique </li></ul></ul><ul><li>Skin </li></ul><ul><li>Eye </li></ul>
  15. 15. RESPIRATORY COMPLICATIONS <ul><li>Airway Protection </li></ul><ul><li>Ventilatory Insufficiency </li></ul><ul><li>Bronchospasm </li></ul><ul><li>Noncardiogenic Pulmonary Edema </li></ul><ul><li>Aspiration </li></ul>
  16. 16. CARDIOVASCULAR COMPLICATIONS <ul><li>Tachycardia </li></ul><ul><li>Bradycardia </li></ul><ul><li>Hypotension </li></ul><ul><li>Hypertension </li></ul>
  17. 17. NEUROLOGIC COMPLICATIONS <ul><li>Coma </li></ul><ul><li>Seizures </li></ul><ul><li>Behavioral Abnormalities </li></ul>
  18. 18. DIAGNOSTIC STUDIES <ul><li>Drug Screens/Levels </li></ul><ul><li>Acetaminophen </li></ul><ul><li>ABG </li></ul><ul><li>Electrolytes </li></ul><ul><li>Organ Function </li></ul><ul><li>EKG </li></ul><ul><li>X-RAY </li></ul>
  19. 19. SERUM OSMOLARITY <ul><li>Serum Osmolarity= 2 (Na + ) + BUN/2.8 + Glucose/18 </li></ul><ul><li>Osmolar Gap 10 mOsm or less </li></ul><ul><li>Methanol, Ethylene Glycol, Ethanol </li></ul><ul><li>Glycerol, Mannitol </li></ul><ul><li>+ETOH/4.6 </li></ul>
  20. 20. ETHANOL C 2 H 5 OH Molecular Weight=________
  21. 21. DEFINITIVE CARE <ul><li>Decontamination </li></ul><ul><li>Supportive Care </li></ul><ul><li>Antidotes </li></ul><ul><ul><li>Oxygen/Glucose/Narcan/?Flumazenil </li></ul></ul><ul><li>Elimination </li></ul><ul><ul><li>Alkalinization </li></ul></ul><ul><ul><li>Repeated Dose Charcoal </li></ul></ul><ul><li>Dialysis </li></ul>
  22. 22. DISCHARGE <ul><li>Stable In Emergency Department </li></ul><ul><li>Psychiatric Issues </li></ul>
  23. 23. TOXIDROME Toxic Syndromes
  24. 24. TOXIDROMES: CASE 1 25 Year Old PA Student Just Back From Spring Break In Mexico. He's Been Having Terrible Diarrhea Since Returning and Has Been Using Pills to Alleviate the Symptoms.
  25. 25. TOXIDROMES: CASE 1 <ul><li>Dry Skin And Mucous Membranes </li></ul><ul><li>Thirst </li></ul><ul><li>Blurred Vision </li></ul><ul><li>Fixed Dilated Pupils </li></ul><ul><li>Flushing </li></ul><ul><li>Urinary Urgency And Retention </li></ul><ul><li>Hallucinations </li></ul>
  26. 26. TOXIDROMES: CASE 1 <ul><li>Anticholinergic </li></ul><ul><ul><li>Hot As Hades </li></ul></ul><ul><ul><li>Blind As A Bat </li></ul></ul><ul><ul><li>Dry As A Bone </li></ul></ul><ul><ul><li>Red As A Beet </li></ul></ul><ul><ul><li>Mad As A Hatter </li></ul></ul>
  27. 27. TOXIDROMES: CASE 1 <ul><li>Belladonna Alkaloids </li></ul><ul><ul><li>Atropine/Scopolamine </li></ul></ul><ul><ul><li>Scopolamine </li></ul></ul><ul><li>Synthetic Anticholinergics </li></ul><ul><ul><li>Dicyclomine </li></ul></ul><ul><li>Other </li></ul><ul><ul><li>Antihistamines/Phenothiazines/TCA </li></ul></ul>
  28. 28. TOXIDROMES: CASE 2 A 50 Year Old Farmer Is Found Unresponsive at His Barn.
  29. 29. TOXIDROMES: CASE 2 <ul><li>Sweating </li></ul><ul><li>Constricted Pupils </li></ul><ul><li>Lacrimation </li></ul><ul><li>Excessive Salivation </li></ul><ul><li>Wheezing </li></ul><ul><li>Vomiting/Diarrhea </li></ul><ul><li>Fasiculations </li></ul>
  30. 30. TOXIDROMES: CASE 2 <ul><li>Acetylcholinesterase Inhibitors </li></ul><ul><li>Pesticides </li></ul><ul><ul><li>Organophosphate </li></ul></ul><ul><ul><li>Carbamates </li></ul></ul><ul><li>Mechanism </li></ul><ul><li>Treatment </li></ul><ul><ul><li>Atropine </li></ul></ul><ul><ul><li>Pralidoxime (2-PAM) </li></ul></ul>
  31. 31. TOXIDROMES: CASE 3 An 8 Year Old Child Is Brought to the Emergency Department After Being Given a Compazine Suppository for Vomiting.
  32. 32. TOXIDROMES: CASE 3 <ul><li>Dysphonia </li></ul><ul><li>Oculogyric Crises </li></ul><ul><li>Rigidity </li></ul><ul><li>Torticollis/Opisthotonos </li></ul>
  33. 33. TOXIDROMES: CASE 3 <ul><li>Extrapyramidal Effects </li></ul><ul><li>Medications </li></ul><ul><ul><li>Antipsychotic </li></ul></ul><ul><ul><li>Antiemetic </li></ul></ul><ul><li>Treatment </li></ul>
  34. 34. TOXIDROMES: CASE 4 During a Visit to Grandma in the Nursing Home, You Find That You Can Not Wake Her Up.
  35. 35. TOXIDROMES: CASE 4 <ul><li>CNS Depression </li></ul><ul><li>Pinpoint Pupils </li></ul><ul><li>Slowed Respirations </li></ul><ul><li>Hypotension </li></ul>
  36. 36. TOXIDROMES: CASE 4 <ul><li>Narcotic </li></ul><ul><li>Medications </li></ul><ul><ul><li>Prescribed </li></ul></ul><ul><ul><li>Illicit </li></ul></ul><ul><li>Treatment </li></ul>
  37. 37. TOXIDROMES: CASE 5 A Movie Star Presents to Your Hospital.
  38. 38. TOXIDROMES: CASE 5 <ul><li>CNS Excitation </li></ul><ul><li>Seizures </li></ul><ul><li>Hypertension </li></ul><ul><li>Tachycardia </li></ul>
  39. 39. TOXIDROMES: CASE 5 <ul><li>Sympathomimetic </li></ul><ul><li>Medication </li></ul><ul><ul><li>Prescribed </li></ul></ul><ul><ul><li>Illicit </li></ul></ul><ul><li>Treatment </li></ul>
  40. 40. TOXIDROMES: CASE 6 A Family of 6 Presents to Your Office in the Middle of Winter and All Complain of “the Flu”.
  41. 41. TOXIDROMES: CASE 6 <ul><li>Headache </li></ul><ul><li>“ Flu” Symptoms </li></ul><ul><li>Nausea, Vomiting, Dizziness </li></ul><ul><li>Dyspnea </li></ul><ul><li>Seizures </li></ul><ul><li>Death </li></ul><ul><li>Cyanosis </li></ul><ul><li>“ Chocolate” Blood </li></ul>
  42. 42. TOXIDROMES: CASE 6 <ul><li>Hemoglobinopathies </li></ul><ul><li>Carbon Monoxide </li></ul><ul><li>Methemoglobin </li></ul><ul><li>Treatment </li></ul>
  43. 43. TRICYCLIC ANTIDEPRESSANTS <ul><li>Mortality 2 - 5 Percent </li></ul><ul><li>Low Therapeutic/Toxic Ratio </li></ul><ul><li>Mechanism </li></ul><ul><ul><li>Inhibition Of Amine Uptake </li></ul></ul><ul><ul><li>Anticholinergic </li></ul></ul><ul><ul><li>Alpha Receptor Blocker </li></ul></ul><ul><ul><li>Sodium Channel Blockade </li></ul></ul>
  44. 44. TCA CLINICAL FEATURES <ul><li>Anticholinergic Symptoms </li></ul><ul><li>Tachycardia </li></ul><ul><li>CNS Toxicity </li></ul><ul><li>Coma </li></ul><ul><li>Hypotension </li></ul><ul><li>Arrhythmia </li></ul><ul><li>Seizures </li></ul>
  45. 45. TCA CLINICAL FEATURES <ul><li>ECG </li></ul><ul><ul><li>“ right axis deviation of the terminal 40ms of QRS greater than 120 0 “ </li></ul></ul><ul><ul><li>Sinus Tach-Wide QRS-Decreased Inotropy-Increased PRI-Bradycardia </li></ul></ul><ul><ul><li>Wide QRS=Life Threatening Toxicity </li></ul></ul>
  46. 46. TCA TREATMENT <ul><li>GI Decontamination </li></ul><ul><li>Sodium Bicarbonate-Indications </li></ul><ul><ul><li>QRS Widening </li></ul></ul><ul><ul><li>Hypotension </li></ul></ul><ul><ul><li>Ventricular Arrhythmias </li></ul></ul><ul><li>Sodium Bicarbonate-Mechanism </li></ul><ul><li>1 - 2 mEq/Kg To pH 7.50-7.55 </li></ul>
  47. 47. TCA TREATMENT <ul><li>Physostigmine </li></ul><ul><ul><li>Peripheral Anticholinergic Symptoms </li></ul></ul><ul><ul><li>Agitation/Seizures/Hypotension When Other Methods Fail </li></ul></ul><ul><ul><li>Side Effects </li></ul></ul><ul><li>Seizures </li></ul><ul><ul><li>Benzodiazepines/Barbiturates </li></ul></ul><ul><li>Hypotension </li></ul>
  48. 48. SALICYLATES <ul><li>Gastroenteritis </li></ul><ul><li>Mixed Respiratory And Metabolic Acidosis </li></ul><ul><li>CNS </li></ul><ul><li>Cardiac Toxicity </li></ul><ul><li>Pulmonary </li></ul><ul><ul><li>ARDS </li></ul></ul><ul><li>Tinnitus </li></ul>
  49. 49. SALICYLATES TOXIC DOSE <ul><li>Done Nomogram </li></ul><ul><li>Acute, Single Ingestion </li></ul><ul><li>Cannot Use For: </li></ul><ul><ul><li>Acute Ingestion With Salicylate Taken Within Last 24 Hours </li></ul></ul><ul><ul><li>Chronic Salicylate Poisoning </li></ul></ul><ul><ul><li>Ingestion Of Enteric Coated Tablets </li></ul></ul><ul><li>Treat Patient If Symptomatic </li></ul>
  50. 50. SALICYLATES TREATMENT <ul><li>Charcoal </li></ul><ul><li>IV Fluids </li></ul><ul><li>Urine Alkalinization </li></ul><ul><ul><li>Mechanism “Ion Trapping” </li></ul></ul><ul><ul><li>Un-ionized Salicylate Reabsorbed By Renal Tubules </li></ul></ul><ul><ul><li>Alkaline Urine Favors Ionized Salicylate Which Cannot Be Reabsorbed </li></ul></ul><ul><li>Dialysis </li></ul>
  51. 51. SALICYLATES DISPOSITION <ul><li>Asymptomatic Nomogram After 6 Hours </li></ul><ul><li>Patient Asymptomatic </li></ul><ul><li>Enteric Coated </li></ul><ul><ul><li>150 mg/kg </li></ul></ul><ul><li>Psychiatric Evaluation </li></ul><ul><li>Follow-up </li></ul>

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