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  • "9th International Conference on Biomarker” welcomes all the attendees, speakers, sponsor’s and other research expertise from all over the world which is going to be held during October 26 -28, 2017 in Osaka, Japan. We are very much honoured to invite you all to exchange and share your views and experience on the Biomarkers Congress 2017. Oncology & Cancer has evolved into one of the most dynamic specialties in medicine. Biomarkers Congress 2017, in the hands of clinical investigators, provide a dynamic and powerful approach to understanding the spectrum of diseases with obvious applications in analytic epidemiology, biomarkers and clinical research in disease prevention, diagnosis, and disease management. Cancer biomarkers have the additional potential to identify individuals susceptible to disease. For more details:
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  1. 1. Approaching the Poisoned Patient!!<br />
  2. 2. Objectives<br />Provide a general overview of toxicology<br />How to approach the poisoned patient<br />Understanding common toxidromes<br />
  3. 3. What is Toxicology<br />What is it not a poison? All things are poison and nothing is without poison. Solely the dose determines that a thing is not a poison.<br />-Paracelsus (1943-1541), the Renaissance Father of Toxicology, in his Third defence<br />
  4. 4. Why do people OD?<br />Significant portion intend to die at time of overdose<br />Most want to escape an intolerable situation or state of mind<br />Small minority of patients want to punish someone or make someone feel guilty<br />Mental health difficulties particularly, depression, ETOH or substance misuse, and personality disorders are frequently seen<br />Inability to tolerate life stressor or events, relationship breakdowns, anniversaries of bereavement, ect.<br />Mitchell, A. Dennis, M. Self harm and attempted suicide in adults: 10 practical questions and answers for emergency department staff. Emerg Med J, 2006: 26, 251-255<br />
  5. 5. What Drugs do they OD on?<br />ETOH<br />Paracetamol<br />Benzo’s<br />Antipsychotics<br />Antidepressants<br />Antiepileptic<br />Opiods<br />And many many more!!!<br />
  6. 6. Risk Assessment<br />RRSIDEAD Approach<br />Resuscitation<br />Risk Assessment<br />Supportive Care & Monitoring<br />Investigations<br />Decontamination<br />Enhanced Elimination<br />Antidotes<br />Disposition<br />
  7. 7. Resuscitation<br />Airway<br />Breathing<br />Circulation<br />Control seizures<br />Correct hypoglycaemia<br />Correct hyperthermia<br />Consider resuscitation antidotes<br />
  8. 8. Risk Assessment<br />Agent<br />Dose<br />Time since ingestion<br />Clinical features and course<br />Patient factors<br />Geographical location<br />
  9. 9. Supportive Care & Monitoring<br />Supportive Care<br />Airway: Intubation<br />Breathing: O2, Ventilation<br />Circulation: IVIH, Inotropes, Defib or pacing<br />Sedation: Titrate Benzo’s<br />Seizure control/prophylaxis: Titrate Benzo’s<br />Metabolic: control pH, normoglycaemia<br />Fluids & Electrolytes: Monitor<br />Renal function: hydrate, haemodialysis<br />General: Bladder care? IDC, Nutrition, DVT & Stress ulcerprophylaxis, PAC, Monitor mental state<br />
  10. 10. Can good supportive care can be done at home?<br />
  11. 11. Supportive Care & Monitoring<br />Monitoring & investigation:<br />12 lead ECG <br />Paracetamol Level<br />BSL below 4 correct with D50<br />Temp above 38.5 requires continuous monitoring<br />
  12. 12. Drug Levels<br />
  13. 13.
  14. 14. The ECG in TOX<br />Valuable inexpensive screening tool<br />QRS widening R/T sodium channel blockade, common with TCA overdose<br />QT prolongation is a potassium channel effect associated with TDP, common in some antidepressant, antiarrythmics, & antipsychotic overdoses.<br />
  15. 15. Urine Drug Screen<br />Why don’t we do it?<br />In general it rarely if ever changes management.<br />Expensive<br />Takes 1-2 days to get back<br />When would we consider it?<br />
  16. 16. Gastrointestinal Decontamination<br />Methods:<br /><ul><li>Induced Emesis (Syrup of ipecac)
  17. 17. Gastric Lavage
  18. 18. Activated Charcoal
  19. 19. Whole Bowel Irrigation</li></ul>Activated charcoal has most benefits in a limited number of poisoning, other methods have limited if any evidence to support their use.<br />
  20. 20. Enhanced Elimination<br />Multiple-dose activated charcoal<br />Urinary alkalinisation<br />Haemodialysis and haemofiltration<br />Charcoal haemoperfusion<br />
  21. 21. Antidotes<br />Limited number of antidotes available for limited number of poisonings.<br />Common Antidotes:<br />NAC<br />Naloxone<br />Sodium Bicarb<br />Digoxin Immune Fab<br />5. Octreotide<br />
  22. 22. Common Complications in the Critically Poisoned Patient<br />Aspiration Pneumonia<br />ARDS<br />ARF<br />DVT/PE<br />Rhabdomyolysis<br />Compartment Syndrome<br />Hepatotoxicity<br />
  23. 23. Disposition<br />The patients journey can be:<br />RESUS <br />ICU <br />Assessment<br />Obs ward<br />Psych<br />Or patients with DSP need Pysch R/V<br />
  24. 24. Poisoning in Children<br />Most paediatric poisoning are benign, as children generally ingest small quantities.<br />Always base your assessment on worse case scenario:<br />The time of ingestion is assumed to be the latest possible time<br />Assume all missing or unaccounted for agent(s) have been ingested<br />Do not attempt to account for spillage, which is difficult to estimate<br />If more than child involved, it is assumed that each child ingested all the missing or unaccounted for agent(s)<br />
  25. 25. 2 tablets that can KILL a 10kg toddler<br />
  26. 26. Management of child who ingest unidentified poison<br />Admit for minimum of 12-hour observation<br />Ensure health care facility can cope<br />Defer IV access until evidence of toxicity<br />Check BSL at presentation and on D/C <br />Monitor GCS & vital signs<br />Cardiac monitor if decreased GCS or abnormal vital signs<br />D/C during daylight hours<br />
  27. 27. Poisoning in Pregnancy<br />Need to assess risk to fetus or infant if lactating<br /> Management rarely differs from non pregnant patients<br />Agents that pose greater risk to fetus:<br />Carbon Monoxide<br />Methaemoglobin-inducing agents<br />Lead<br />Salicylates<br /><ul><li>Need to provide risk/benefit analysis if breastfeeding is to continue as the mother recovers</li></li></ul><li>Poisoning in the Elderly<br />Can be challenging to manage R/T co-morbidities, decreased physiological reserve, and multiple prescribed medications.<br />Higher complication rate and longer hospital admission:<br />Pharmacokinetic changes:<br />Delayed gastrointestinal absorption<br />Decreased protein binding ^ free drug levels<br />Reduced hepatic metabolic function<br />Decreased GFR which impairs elimination<br />
  28. 28. Common poisoning in the Elderly<br />Digoxin<br />Metformin<br />Lithium<br />Disposition= Generally elderly patients end up in Gen Med units for prolonged periods of care<br />
  29. 29. Toxidromes<br />
  30. 30. Coma<br />Patients presenting with coma have generally overdosed on a drug with CNS depressant effects.<br />Can be caused by secondary effects:<br />Hypoxaemia<br />Hypoglcaemia<br />Hyponatraemia<br />Hypotension<br />Seizures <br />Cerebral oedema<br />
  31. 31. Coma Management<br />RRSIDEAD<br />Good supportive care & airway management<br />Treat secondary effects<br />Look at what else can cause coma<br />Neurotrauma<br />Metabolic encepathopathy<br />Menigioencephalopathy<br />Space occupying lesion<br />Patients generally go to ICU, till conscious states improve<br />Look for complication’s (Asp Pneumonia)<br />
  32. 32. Why do we use Diazepam so much in TOX?<br />Good safety profile<br />Long half life<br />Controls agitation well<br />Used to treat toxic seizures<br />Generally drug of choice in managing withdrawals<br />Dose adult 5-10mg, child 0.1-0.3mg/kg/dose every 3-5mins<br />
  33. 33. Anticholinergic Syndrome<br />Results from the competitive, reversible blockade of central & peripheral cholinergic blockade.<br />Is potentially life threatening<br />Diagnosed clinically by agitated delirium and peripheral muscarinic blockade<br />History of ingestion of known anticholinergic agent<br />
  34. 34. Types of Anticholinergic Agents<br />Antipakinson drugs (benztropine, amantadine)<br />Antihistamines (prometazine, doxylamine)<br />Antitussives (dextromethorphan)<br />Antidepressants (TCA)<br />Antipsychotic agents including atypical (Haloperidol, olazapine, Quetiapine)<br />Anticonvulsant agents (carbamazapine)<br />Motion sickness agents (hyoscine-scopolamine)<br />Antimuscarinic agents (Atropine)<br />Topical ophthalmological agents<br />Bronchodilators (Ipratropium)<br />Urinary antispasmodic agents (oxybutynin)<br />Muscle relaxants<br />Plants & herbal remedies (Selected mushrooms)<br />
  35. 35. Clinical Features of Anticholinergic Syndrome<br />
  36. 36. Remember the saying!!!<br />Hyperthermia (HOT as a hare)<br />Flushed (RED as a beet)<br />Dry Skin (DRY as a bone)<br />Dilated pupils (Blind as a bat)<br />Delirium, hallucinations (Mad as a hatter)<br />Tachycardia<br />Urinary Retention<br />
  37. 37. Management <br />Good Supportive Care<br />IV fluids<br />IDC<br />Diazepam to control agitation<br />Avoid drugs with anticholinergic effects<br />Antidote:<br /><ul><li> Physostigimine
  38. 38. Reverse anticholinergic delirium in selected patients that don’t respond to benzo’s</li></li></ul><li>Serotonin Syndrome<br />Clinical diagnosis based on history of ingestion of one or more serotonergic agents, the presence of characteristic symptoms, & high index of suspicion<br />Clinical features fall into 3 categories<br />CNS<br />Autonomic<br />Neuromuscular<br />
  39. 39. Clinical features of serotonin syndrome<br />
  40. 40. Life threatening serotonin syndrome<br />Characterised by:<br /><ul><li>Generalised rigidity
  41. 41. Autonomic instability
  42. 42. Delirium
  43. 43. Coma
  44. 44. Hyperthermia
  45. 45. Secondary multiple-organ failure</li></li></ul><li>Agents implicated in serotonin syndrome<br />SSRIs (fluoxetine, setraline, paroxetine)<br />SNRIs (venlafaxine, citalopram, bupropion)<br />TCAs (amitriptyline, dothiep)<br />MAOIs (phenelzine, moclobemide)<br />Lithium<br />Analgesic (pethidine, tramadol, dextromethorphan)<br />Antiemetics (metaclopramide, ondansetron)<br />Anticonvulsants (valproic acid)<br />Drugs of abuse (amphetamine, MDMA)<br />
  46. 46. Managing Serotonin Syndrome<br />RRSIDEAD<br />Check BSL<br />Check temp >38.5 continuous core monitoring, temp > 39.5 paralysis and intubate<br />Give benzo’s to achieve gentle sedation<br />HT & tachycardia generally respond to benzo’s, if refractory trial of GTN infusion<br />Antidote: Cyproheptadine, given orally or via NG<br />
  47. 47. The Tox Bible<br />
  48. 48. THE END!!<br />