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An approach to acute poisoning in the Emergency Department
- 1. UKZN INSPIRING GREATNESS AnApproach to the Poisoned Patient Done By: Duncan Havenga EM Registrar Ngwelezane ED
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- 3. UKZN INSPIRING GREATNESS GeneralApproach • Mnemonic “Resus – RSI – DEAD” 1. Resuscitation 2. Risk Assessment 3. Supportive Care & Monitoring 4. Investigations 5. Decontamination 6. Enhanced Elimination 7. Antidotes 8. Disposition
- 4. UKZN INSPIRING GREATNESS Resuscitation •Airway • Breathing • Circulation • Disability – Seizure Control • Correct Hypoglycaemia • Correct Hypothermia • Recognise TOXIDROMES – Resuscitation specific antidotes http://www.andoverrec.com/adult/adultenrichment/CPR
- 5. UKZN INSPIRING GREATNESS Toxidromes •Sympathomimetic • Anticholinergic • Cholinergic • Sedative/Hypnotic • Opioid • Serotonin Syndrome • Neuroleptic Malignant Syndrome
- 6. UKZN INSPIRING GREATNESS SympathomimeticToxidrome https://www.emnote.org/emnotes/sympathomimetic-toxidrome
- 7. UKZN INSPIRING GREATNESS Anti-cholinergicToxidrome Mad as a Hatter - Confusion Red as a beet - Flushed Hot as a Hare - Hyperthermia Blind as a Bat - Mydiasis Dry as a Bone – Dry skin http://www.thegasmanhandbook.co.uk/toxidromes.html
- 8. UKZN INSPIRING GREATNESS CholinergicToxidrome https://lifeinthefastlane.com/cholinergic-toxidrome/ http://traumagency.blogspot.co.za/2015/09/organophosphate-poisoning.html
- 9. UKZN INSPIRING GREATNESS Sedative/HypnoticToxidrome http://klossandbruce.com/video-flashcard-clonidine-overdose/ CLINICAL FEATURES • sedation • coma • pupillary changes • respiratory and cardiovascular depression Consider Other Common Sedatives: • Ethanol • Benzodiazepines https://i2.wp.com/fayvivian.co.ke/wp-content/uploads/2018/0 3/flessen-van-geassorteerde-sterke-drankmerken-74935312 .jpg
- 10. UKZN INSPIRING GREATNESS OpioidToxidrome https://twitter.com/jackcfchong/status/828180278841528320
- 11. UKZN INSPIRING GREATNESS SerotoninSyndrome • Serotonin syndrome ensues when there is a drug interaction involving the selective serotonin reuptake inhibitors (SSRIs) or an overdose of an SSRI. • Can occur weeks after SSRI been stopped and drug interaction. • Drug interactions: • SSRI’s • SRI’s • MAOI • TCA • Tryptophan • Lithium http://klossandbruce.com/video-flashcard-serotonin-syndrome/
- 12. UKZN INSPIRING GREATNESS NeurolepticMalignant Syndrome NMS (tetrad) 1. Altered Mental Status 2. Hyperthermia 3. Autonomic Instability 4. Muscle Rigidity – lead Pipe Rigidity http://klossandbruce.com/video-flashcard-neuroleptic-malignant-syndrome/
- 13. UKZN INSPIRING GREATNESS GeneralApproach • Mnemonic “Resus – RSI – DEAD” 1. Resuscitation 2. Risk Assessment 3. Supportive Care & Monitoring 4. Investigations 5. Decontamination 6. Enhanced Elimination 7. Antidotes 8. Disposition
- 14. UKZN INSPIRING GREATNESS RiskAssessment • A distinct cognitive step that is quantitative in nature and takes into account: – Agent(s) – Dose(s) – Time since ingestion – Current clinical status – Patient factors https://www.cartoonstock.com/directory/d/dieting_pill.asp
- 15. UKZN INSPIRING GREATNESS GeneralApproach • Mnemonic “Resus – RSI – DEAD” 1. Resuscitation 2. Risk Assessment 3. Supportive Care & Monitoring 4. Investigations 5. Decontamination 6. Enhanced Elimination 7. Antidotes 8. Disposition
- 16. UKZN INSPIRING GREATNESS SupportiveCare & Monitoring • FAST HUGS IN BED Please • Fluid therapy and feeding • Analgesia, antiemetics • Sedation and Spontaneous breathing trial • Thromboprophylaxis • Head up position (30 degrees) if intubated • Ulcer prophylaxis • Glucose control • Skin/ eye care and suctioning
- 17. UKZN INSPIRING GREATNESS SupportiveCare & Monitoring • Indwelling catheter • Nasogastric tube • Bowel cares • Environment (e.g. temperature control, appropriate surroundings in delirium) • De-escalation (e.g. end of life issues, treatments no longer needed) • Psychosocial support (for patient, family and staff) http://www.movingbrands.com/work/red-cross
- 18. UKZN INSPIRING GREATNESS GeneralApproach • Mnemonic “Resus – RSI – DEAD” 1. Resuscitation 2. Risk Assessment 3. Supportive Care & Monitoring 4. Investigations 5. Decontamination 6. Enhanced Elimination 7. Antidotes 8. Disposition
- 19. UKZN INSPIRING GREATNESS Investigations •Diagnosis of intoxication is usually clinical. • Investigations Supportive • Recommended Test (Rosen’s EM 9th Edition) – FBC, U&e, LFT – Blood gas – Urinalysis & preg test – Urine toxicology – Serum alcohol level – Serum lactate – Bedside glucose – Specific Drug levels (if ingestion known or suspected) – ECG https://www.health.harvard.edu/blog/blood-test-results-not-qu ite-normal-201606029718
- 20. UKZN INSPIRING GREATNESS Investigations WallsR.M, Hockberger R.S, Gausche-Hill M (2018). Rosen’s Emergency Medicine Concepts and Clinical Practice (9th Edition). Philadelphia, PA: Elsevier. Section Two: Toxicology, Chapter 139 : Approach to the Poisoned Patient, pg 1817.
- 21. UKZN INSPIRING GREATNESS GeneralApproach • Mnemonic “Resus – RSI – DEAD” 1. Resuscitation 2. Risk Assessment 3. Supportive Care & Monitoring 4. Investigations 5. Decontamination 6. Enhanced Elimination 7. Antidotes 8. Disposition
- 22. UKZN INSPIRING GREATNESS Decontamination •Decontamination is the process of preventing systemic absorption into the body. – Ocular & Dermal exposure = irrigate with water. – Syrup of Ipecac – inducing emesis – Gastric Lavage – Whole Bowel Irrigation http://bryanking.net/syrup-of-ipecac/
- 23. UKZN INSPIRING GREATNESS Decontamination •Single Dose Activated Charcoal Walls R.M, Hockberger R.S, Gausche-Hill M (2018). Rosen’s Emergency Medicine Concepts and Clinical Practice (9th Edition). Philadelphia, PA: Elsevier. Section Two: Toxicology, Chapter 139 : Approach to the Poisoned Patient, pg 1819.
- 24. UKZN INSPIRING GREATNESS GeneralApproach • Mnemonic “Resus – RSI – DEAD” 1. Resuscitation 2. Risk Assessment 3. Supportive Care & Monitoring 4. Investigations 5. Decontamination 6. Enhanced Elimination 7. Antidotes 8. Disposition
- 25. UKZN INSPIRING GREATNESS EnhancedElimination • Increase rate of removal of an agent from the body to reduce severity & duration of toxicity. – Multiple Dose Activated Charcoal (MDAC) – Serum Alkalinisation – Extracorporeal Elimination – Intravenous Fat Emulsion (Intralipd) http://www.kidney-symptom.com/kidney-fail ure-treatment/kidney-failure-function-dialysi s-needed.html
- 26. UKZN INSPIRING GREATNESS EnhancedElimination • Multiple Dose Activated Charcoal – Interruption enterohepatic circulation – “Gastrointestinal Dialysis” (high to low conc) Walls R.M, Hockberger R.S, Gausche-Hill M (2018). Rosen’s Emergency Medicine Concepts and Clinical Practice (9th Edition). Philadelphia, PA: Elsevier. Section Two: Toxicology, Chapter 139 : Approach to the Poisoned Patient, pg 1820.
- 27. UKZN INSPIRING GREATNESS EnhancedElimination • Serum Alkalinisation – Salicylates – Methotrexate – Phenobarbital • Monitor for Hypokalaemia! https://www.healthline.com/health/urinalysis#after-urinalysi s
- 28. UKZN INSPIRING GREATNESS EnhancedElimination • Extracorporeal Elimination – (e.g. hemodialysis, hemofiltration, hemoperfusion, plasmapheresis and exchange transfusion) Walls R.M, Hockberger R.S, Gausche-Hill M (2018). Rosen’s Emergency Medicine Concepts and Clinical Practice (9th Edition). Philadelphia, PA: Elsevier. Section Two: Toxicology, Chapter 139 : Approach to the Poisoned Patient, pg 1820.
- 29. UKZN INSPIRING GREATNESS EnhancedElimination • Intravenous Fat Emulsion (Intralipid) – Therapy for poison induced cardiogenic shock – Lipid Sink Theory – Enhanced Cardiac Metabolism Theory http://ecatalog.baxter.com/ecatalog/loadproduct.html?cid=20016&lid=10001&hid=20001&pid=823334
- 30. UKZN INSPIRING GREATNESS GeneralApproach • Mnemonic “Resus – RSI – DEAD” 1. Resuscitation 2. Risk Assessment 3. Supportive Care & Monitoring 4. Investigations 5. Decontamination 6. Enhanced Elimination 7. Antidotes 8. Disposition
- 31. UKZN INSPIRING GREATNESS Antidotes PoisonAntidote Acetaminophen (Paracetamol) Opioids Organophosphates Iron Tricyclic Antidepressants Beta-Blockers What’s The Antidote? N-acetylcysteine Naloxone Atropine/pralidoxime Deferoxamine Sodium Bicarbonate Glucagon Walls R.M, Hockberger R.S, Gausche-Hill M (2018). Rosen’s Emergency Medicine Concepts and Clinical Practice (9th Edition). Philadelphia, PA: Elsevier. Section Two: Toxicology, Chapter 139 : Approach to the Poisoned Patient, pg 1821.
- 32. UKZN INSPIRING GREATNESS GeneralApproach • Mnemonic “Resus – RSI – DEAD” 1. Resuscitation 2. Risk Assessment 3. Supportive Care & Monitoring 4. Investigations 5. Decontamination 6. Enhanced Elimination 7. Antidotes 8. Disposition
- 33. UKZN INSPIRING GREATNESS Disposition •Severe Toxicity – ICU/High Care • Asymptomatic but toxic ingestion – admit inpatient setting or observation unit 24hrs. • Asymptomatic & minimally toxic substance – discharge from ED once psychiatric issues addressed. – SADPERSONS score
- 34. UKZN INSPIRING GREATNESS References •Walls R.M, Hockberger R.S, Gausche-Hill M (2018). Rosen’s Emergency Medicine Concepts and Clinical Practice (9th Edition). Philadelphia, PA: Elsevier. Section Two: Toxicology, Chapter 139 : Approach to the Poisoned Patient, pg 1813-1822. • Chris Nickson. Approach to Acute Poisoning. Life in the Fast Lane. May 2016. Available from URL: https://lifeinthefastlane.com/ccc/approach-to-acute-poisoning/ • Images Referenced on Slides
Editor's Notes
- #4 Personal and Protective equipment. Decontamination if on-going exposure to toxin.
- #6 Cocaine Amphetamines – speed, ectasy, ritalin MAO-inhibitors
- #7 Parkinson's medications. diphenhydramine (Benadryl) trihexyphenidyl benztropine mesylate biperiden (Akineton) antipsychotics. clomipramine chlorpromazine Atropine Other common manifestations include: urinary retention, sinus tachycardia, reduced GI motility, tremor, hypertension
- #8 Organophosphates carbamate insecticides Physostigmine Edrophonium Mushrooms sarin nerve gas
- #9 Opioids Benzodiazepines Barbiturates baclofen (may mimic brain death, suspect in MS patients) clonidine (mimics opioid toxidrome with marked bradycardia and hypotension)
- #11 Serotonin syndrome ensues when there is a drug interaction involving the selective serotonin reuptake inhibitors (SSRIs) or an overdose of an SSRI. Fluoxetine (Prozac), Sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), and citalopram (Celexa) are commonly used SSRIs.
- #19 Understand Limitations of Toxicology Screens Serum Toxicology screens can give false negatives, if drug short half life and blood not taken early enough. Urine toxicology screens more reliable – longer period detection – qualitative and not quantitative therefore can have false positives.
- #20 Blood gas can aid in the differential diagnosis, especially with calculating the anion gap.
- #22 Ocular & Dermal exposure = removal of contaminated clothes and irrigate with water. Syrup of Ipecac – inducing emesis – Not indicated in the treatment of the poisoned patient in the ED Gastric Lavage – only if within 1 hour of ingestion and only if no antidote exists for ingested drug, so poor prognosis if drug absorped. Whole Bowel Irrigation with Polyethylene Glycol indicated only in certain conditions, extended release preparations, illicit drug packets or metals (iron and lead)
- #23 Single dose activated charcoal Administer within 1 hour of ingestion toxin Awake and alert patient Toxin ingested – high toxicity or massive amounts ingested Not recommended use due to lack of evidence in clinical benefit (very few appropriate designed trials) Risk Aspiration – low risk but if occurs poor prognosis. Bowel Obstruction - Contraindicated Activated charcoal historically has most often been given in a dose of 25 to 100 grams (10 to 25 grams or 0.5 to 1.0 gram/kilogram in young children).
- #26 MDAC facilitates removal toxin that already absorbed – interruption of enterohepatic circulation & Gastrointestinal dialysis (High concentration of drug in the gut wall microcirculation and low concentration in gut lumen filled with charcoal and therefore drug moves down concentration gradient). When MDAC is indicated, the initial loading dose of an activated charcoal–to-xenobiotic ratio of 10 : 1, is followed by subsequent doses of 50% of the initial dose every 4 to 6 hours for up to 24 hours. MDAC may be discontinued when the patient’s measureable serum levels are no longer considered in the toxic range. MDAC caution aspiration and Bowel Obstruction.
- #27 Certain water-soluble ingestants such as salicylates, methotrexate, and phenobarbital will undergo ion-trapping and enhanced urinary elimination if the serum is sufficiently alkalinized. Salicylates alkalinisation will also prevent crossing of BBB. Goal serum pH 7.5 and urine pH 8 Combine 150 mEq (3amps) of 8.4% sodium bicarbonate into a litre of dextrose 5% in water (D5W) and add potassium @250ml/hr.
- #28 Hemodialysis effectively enhances elimination of any drug that: is a small molecule has a small volume of distribution rapid redistribution from tissues and plasma slow endogenous elimination.
- #29 The lipid sink theory posits that fat-soluble drugs are soaked up and removed from the site of toxicity, effectively increasing the volume of distribution for a fat-soluble drug. This is the predominant theory behind the use of IFE. A second theory involves optimization of cardiac metabolism. The heart under physiologic circumstances prefers free fatty acids; in times of stress, it switches to glucose metabolism for energy. A dose of IFE theoretically provides a large supply of free fatty acids to optimize energy use in the heart. In addition to providing supplemental energy for myocytes, IFE may also enhance activation of cardiac calcium channels.
- #31 Specific treatment for each poison.