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Noon conference: Intro to Toxicology
- 1. IM BoardIM Board Prep FunPrep Fun ToxicologyToxicology Kurt Kleinschmidt, MD,Kurt Kleinschmidt, MD, FACEP, FACMTFACEP, FACMT Professor ofProfessor of Emergency MedicineEmergency Medicine Division Chief &Division Chief & Program DirectorProgram Director Medical ToxicologyMedical Toxicology UTSW Medical CenterUTSW Medical Center
- 2. • Drug overdoseDrug overdose • Hazardous exposure to chemical productsHazardous exposure to chemical products – Pesticides; heavy metalsPesticides; heavy metals – Household productsHousehold products – Toxic gasesToxic gases – Toxic alcoholsToxic alcohols – Other industrial chemicalsOther industrial chemicals • Drug Abuse management & MRODrug Abuse management & MRO • EnvenomationsEnvenomations • Food-borne toxins, such as botulism; marine toxinsFood-borne toxins, such as botulism; marine toxins (e.g. paralytic shellfish toxin; ciguatoxin).(e.g. paralytic shellfish toxin; ciguatoxin). • Plants and mushrooms.Plants and mushrooms. • Independent medical examinationsIndependent medical examinations Problems Evaluated By ToxicologistsProblems Evaluated By Toxicologists
- 3. Board CertificationBoard Certification • American Board Medical Specialties RecognizedAmerican Board Medical Specialties Recognized • First ABMS exam 2000First ABMS exam 2000 • Toxicology is a Dependent “Sub-Board”Toxicology is a Dependent “Sub-Board” – Emergency Medicine (Administrative)Emergency Medicine (Administrative) – Preventive MedicinePreventive Medicine – PediatricsPediatrics • Approximately 50 examinees everyApproximately 50 examinees every otherother yearyear • Total Boarded < 400Total Boarded < 400
- 4. Which physicians can becomeWhich physicians can become medical toxicologists?medical toxicologists? • Emergency MedicineEmergency Medicine • Preventive andPreventive and Occupational MedicineOccupational Medicine • PediatricsPediatrics • Internal MedicineInternal Medicine • Family MedicineFamily Medicine • PsychiatryPsychiatry • NeurologyNeurology > 50%> 50% > 95%> 95%
- 5. North Texas Poison CenterNorth Texas Poison Center Division of Toxicology ≠ Poison Center (But we do share much)
- 6. ToxidromesToxidromes • Collection of symptoms characteristic forCollection of symptoms characteristic for specific agent groupsspecific agent groups • Many different agents can cause “a”Many different agents can cause “a” toxidrometoxidrome • Management of any one toxidrome…Management of any one toxidrome… – Is the sameIs the same – No matter the agentNo matter the agent
- 7. ToxidromesToxidromes SympathomimeticSympathomimetic Cocaine, Amphetamines,Cocaine, Amphetamines, Decongestants, CaffeineDecongestants, Caffeine AnticholinergicAnticholinergic 11stst -Generation antihistamines,-Generation antihistamines, Neuroleptics, TricyclicsNeuroleptics, Tricyclics CholinergicCholinergic Carbamates,Carbamates, OrganophosphatesOrganophosphates OpioidOpioid Codeine, Morphine,Codeine, Morphine, HydrocodoneHydrocodone Sedative-HypnoticSedative-Hypnotic Benzos, Barbs, EthanolBenzos, Barbs, Ethanol SerotonergicSerotonergic Too many to list…Too many to list…
- 8. Adrenal Medulla EpiEpi NENE NN VasoconstrictionVasoconstriction ↑↑ UrethralUrethral Sphincter ToneSphincter Tone MydriasisMydriasis DiaphoresisDiaphoresis MM αα TachycardiaTachycardia VasodilationVasodilation BronchodilationBronchodilation MetabolicMetabolic ↓↓ K+K+ ↓↓ PO4PO4 ↓↓ pHpH ↑↑ GlucoseGlucose ↑↑ WBCWBC ββ NENE NENE NN NN AChACh DDiarrheaiarrhea UUrinationrination MMiosisiosis BBronchospasmronchospasm BBronchorrhearonchorrhea EEmesismesis LLacrimationacrimation SSalivationalivation NN MM AChACh AChACh AChACh AChACh AChACh ANSANS ParsympatheticParsympatheticSympatheticSympathetic
- 9. AnticholinergicsAnticholinergics Hot as a hareHot as a hare HyperthermiaHyperthermia Mad as a hatterMad as a hatter Delirium / AgitationDelirium / Agitation Dry as a boneDry as a bone Skin; Muc Membranes DrySkin; Muc Membranes Dry Red as a beetRed as a beet Skin flushedSkin flushed TachycardiaTachycardia Hypoactive Bowel SoundsHypoactive Bowel Sounds Bladder Urine RetentionBladder Urine Retention But which are the most Sensitive?
- 10. Anticholinergic vs. SympathomimeticAnticholinergic vs. Sympathomimetic SympathoSympatho Anti-CholAnti-Chol HRHR ↑ ↑↑ ↑ BPBP ↑ ↑↑ ↑ PupilsPupils ↑ ↑↑ ↑ MentalMental AgitatedAgitated AgitatedAgitated BladderBladder NmlNml Nml orNml or ↑↑ Bowel SoundsBowel Sounds NmlNml Nml orNml or ↓↓ SkinSkin WetWet Dry**Dry**
- 11. CholinergicsCholinergics MuscarinicMuscarinic ““DUMBELS”DUMBELS” • DiarrheaDiarrhea • UrinationUrination • MiosisMiosis • BronchorrheaBronchorrhea • BronchospasmBronchospasm • EmesisEmesis • LacrimationLacrimation • SalivationSalivation NicotinicNicotinic ““M, T, W, tH, F”M, T, W, tH, F” • MydriasisMydriasis • TremorTremor • WeakWeak • HypertensionHypertension • FasciculationsFasciculations What agents affect these receptors?What agents affect these receptors?Organophosphates (Insecticides)Organophosphates (Insecticides) Carbamates (Insecticides)Carbamates (Insecticides) Nerve agentsNerve agents
- 12. OpioidOpioid The ToxidromeThe Toxidrome • Mental status depressedMental status depressed • MiosisMiosis • Respirations depressedRespirations depressed Not always clear…Coingestants…Not always clear…Coingestants… Hypoxic Brain damage may already be presentHypoxic Brain damage may already be present Narcan is a poor diagnostic toolNarcan is a poor diagnostic tool
- 13. Serotonergic ExcessSerotonergic Excess Class Drugs Antidepressants Monoamine oxidase inhibitors (MAOIs), TCAs, SSRIs, SNRIs, bupropion, nefazodone, trazodone mirtazapine Opioids tramadol, meperidine, dextromethorphan CNS stimulants MDMA, MDA, phentermine, methamphetamine, cocaine 5-HT1 agonists triptans Psychedelics 5-Methoxy-diisopropyltryptamine, LSD
- 14. Serotonergic ExcessSerotonergic Excess • ClinicalClinical – TremorTremor – ↑↑ DTRs / ClonusDTRs / Clonus – TachycardiaTachycardia – Agitation orAgitation or diaphoresisdiaphoresis • Differential DxDifferential Dx – NMSNMS – LithiumLithium – SympathomimeticsSympathomimetics – Malignant HyperthermiaMalignant Hyperthermia
- 15. 6 Acetaminophen Cases6 Acetaminophen Cases All are 40 y/o Males who took 15 grams…All are 40 y/o Males who took 15 grams… • 2 hrs before arrival2 hrs before arrival – One vomitingOne vomiting – One notOne not • 8 hrs before arrival8 hrs before arrival – One vomitingOne vomiting – One notOne not • 15 hrs before arrival15 hrs before arrival – One vomitingOne vomiting – One notOne not Start antidote before getting a level?Start antidote before getting a level? PO or IV?PO or IV? Duration of therapy?Duration of therapy? Role of repeat levels?Role of repeat levels?
- 16. Acetaminophen Case ContinuedAcetaminophen Case Continued • 2 hrs before arrival2 hrs before arrival – One vomitingOne vomiting – One notOne not • 8 hrs before arrival8 hrs before arrival – One vomitingOne vomiting – One notOne not • 15 hrs before arrival15 hrs before arrival – One vomitingOne vomiting – One notOne not Start antidote before getting a level? No PO or IV? If toxic level, go IV Duration of therapy? If IV, Bolus + 20 hours Role of repeat levels? None Start antidote before getting a level?Start antidote before getting a level? PO or IV?PO or IV? Duration of therapy?Duration of therapy? Role of repeat levels?Role of repeat levels?
- 17. Acetaminophen Case ContinuedAcetaminophen Case Continued • 2 hrs before arrival2 hrs before arrival – One vomitingOne vomiting – One notOne not • 8 hrs before arrival8 hrs before arrival – One vomitingOne vomiting – One notOne not • 15 hrs before arrival15 hrs before arrival – One vomitingOne vomiting – One notOne not Start antidote before getting a level? Yes PO or IV? If Vomiting, go IV If Not Vomiting, go PO (?) Duration of therapy? If IV, Bolus + 20 hours If PO, typically 24-36 hrs Role of repeat levels? None Start antidote before getting a level?Start antidote before getting a level? PO or IV?PO or IV? Duration of therapy?Duration of therapy? Role of repeat levels?Role of repeat levels?
- 18. • If treated within 8 hrsIf treated within 8 hrs – No pts → Liver FailureNo pts → Liver Failure – Some patients → HepatitisSome patients → Hepatitis • Toxicity Defined – AST > 1000Toxicity Defined – AST > 1000
- 19. Acetaminophen Case ContinuedAcetaminophen Case Continued • 2 hrs before arrival2 hrs before arrival – One vomitingOne vomiting – One notOne not • 8 hrs before arrival8 hrs before arrival – One vomitingOne vomiting – One notOne not • 15 hrs before arrival15 hrs before arrival – One vomitingOne vomiting – One notOne not Start antidote before getting a level? Yes (?) PO or IV? If Vomiting, go IV If Not Vomiting, go PO (?) Duration of therapy? If IV, typically 36 hrs** If PO, typically 36 hrs Role of repeat levels? None Start antidote before getting a level?Start antidote before getting a level? PO or IV?PO or IV? Duration of therapy?Duration of therapy? Role of repeat levels?Role of repeat levels? Duration based upon LFTs. Note that Acetadote use is likely BEYOND 21 hours
- 20. Besides vomiting, conditionsBesides vomiting, conditions where IV route is preferred?where IV route is preferred? PregnancyPregnancy Liver FailureLiver Failure Lets talk…BioavailabilityLets talk…Bioavailability
- 21. LithiumLithium • Your body thinks it is sodium…and treats it as suchYour body thinks it is sodium…and treats it as such • ClinicalClinical – NeuromuscularNeuromuscular – tremor; ↑ DTRs (very sensitive)– tremor; ↑ DTRs (very sensitive) – Chronic Neuro Sequelae #1 Concern.Chronic Neuro Sequelae #1 Concern. • Include cerebellar issues; memory deficits, NM weak, personalityInclude cerebellar issues; memory deficits, NM weak, personality change, tremors.change, tremors. • DecontaminationDecontamination – Charcoal – No role (like all monovalent cations)Charcoal – No role (like all monovalent cations) – Whole Bowel IrrigationWhole Bowel Irrigation • Fluids and Electrolytes - Key - Restore volume if there is depletion,Fluids and Electrolytes - Key - Restore volume if there is depletion, otherwise Lithium elimination is slowedotherwise Lithium elimination is slowed • Dialysis -Dialysis - Ideal for dialysis - (1) small, (2) not protein bound, and (3) smallIdeal for dialysis - (1) small, (2) not protein bound, and (3) small volume of distributionvolume of distribution; BUT…Li; BUT…Li++ is mainly intracellular and it diffuses slowlyis mainly intracellular and it diffuses slowly across cell membranes (needs serial HD treatments)across cell membranes (needs serial HD treatments) – Indication - Severe neurotoxicity i.e. AMS, those with ARF, Level > 4.0Indication - Severe neurotoxicity i.e. AMS, those with ARF, Level > 4.0 mEq/L (Acute) or 2.5 mEq/L (Chronic).mEq/L (Acute) or 2.5 mEq/L (Chronic).
- 22. Distribution Clinical MomentsDistribution Clinical Moments LithiumLithium • Normal Level: 0.6-1.2 mEq/LNormal Level: 0.6-1.2 mEq/L • Which is clinically worse for a patient?Which is clinically worse for a patient? – Level 4.2 mEq/LLevel 4.2 mEq/L – Level 2.2 mEq/LLevel 2.2 mEq/L It all depends…It all depends… Acute vs Chronic ExposureAcute vs Chronic Exposure Agent with slow distributionAgent with slow distribution
- 23. Distribution Clinical MomentsDistribution Clinical Moments - Lithium- Lithium FastFast SlowSlow Stomach and IntestinesStomach and Intestines Blood andBlood and some organs (Liver)some organs (Liver) BrainBrain AcuteAcute ChronicChronic 4.24.2 2.22.2 0.20.2 2.22.2 AbsorptionAbsorption DistributionDistribution
- 24. Common SalicylatesCommon Salicylates Alka-Seltzer Alka-Seltzer AnacinAnacin Excedrin Excedrin Bismuth subsalicylateBismuth subsalicylate (Pepto Bismol)(Pepto Bismol) ColdCold PreparationsPreparations AspirinAspirin KeratolyticKeratolytic AgentsAgents Oil ofOil of WintergreenWintergreen
- 25. Clinical Signs and SymptomsClinical Signs and Symptoms Salicylate Toxidrome (Acute)Salicylate Toxidrome (Acute) • Shortness of Breath (Hyperpnea, Tachypnea)Shortness of Breath (Hyperpnea, Tachypnea) • N/V & stomach upsetN/V & stomach upset • Tinnitus and/or Hearing changeTinnitus and/or Hearing change • DizzyDizzy • DiaphoresisDiaphoresis My great clinical moment…My great clinical moment… Can be easy to miss
- 26. More Clinical Signs and SymptomsMore Clinical Signs and Symptoms • CNSCNS – AMS (Cerebral edema, Hypoglycemia)AMS (Cerebral edema, Hypoglycemia) – SeizuresSeizures • HyperthermiaHyperthermia • Non-Cardiogenic Pulmonary EdemaNon-Cardiogenic Pulmonary Edema • Metabolic Acidosis & Resp AlkalosisMetabolic Acidosis & Resp Alkalosis • CoagulopathyCoagulopathy • Liver failureLiver failure • Renal failureRenal failure Multiorgan!Multiorgan! Often confused with SepsisOften confused with Sepsis and/or other conditionsand/or other conditions
- 27. LaboratoryLaboratory • Anion-Gap Metabolic AcidosisAnion-Gap Metabolic Acidosis • Plasma Salicylate LevelsPlasma Salicylate Levels – Serial levelsSerial levels – Useless without clinical courseUseless without clinical course
- 28. Significance of Salicylate LevelSignificance of Salicylate Level Urine EliminationUrine Elimination BloodBlood BrainBrain Level willLevel will ↓↓ Clinically -Clinically - GoodGood Level willLevel will ↓↓ Clinically -Clinically - BadBad Assessment: Assessment: Level + Clinical Level + Clinical ““Well, Mrs. Johnson…”Well, Mrs. Johnson…”
- 29. TreatmentTreatment • Absorption:Absorption: CharcoalCharcoal → ↓→ ↓ AbsorptionAbsorption • Distribution:Distribution: Not a targetNot a target • Metabolism and EliminationMetabolism and Elimination – Multidose Activated CharcoalMultidose Activated Charcoal – Ion Trapping (Sodium Bicarbonate)Ion Trapping (Sodium Bicarbonate) – HemodialysisHemodialysis
- 30. Ion TrappingIon Trapping Brain Blood Renal Tubule HAHA ↑ ↓↑ ↓ HH++ + A+ A-- Diurese it outDiurese it out HAHA ↑ ↓↑ ↓ HH++ + A+ A-- HAHA ↑ ↓↑ ↓ HH++ + A+ A--
- 31. Ion TrappingIon Trapping Brain Blood Renal Tubule HAHA ↑↑ ↓↓ HH++ + A+ A-- Diurese it outDiurese it out HAHA ↑↑ ↓↓ HH++ + A+ A-- HAHA ↑↑ ↓↓ HH++ + A+ A-- A weak acid in an alkaline environmentA weak acid in an alkaline environment Alkalinize the urineAlkalinize the urine
- 32. HemodialysisHemodialysis Items amendable to dialysisItems amendable to dialysis • SmallSmall • Non-chargedNon-charged • Low Volume of DistributionLow Volume of Distribution (Agent mostly in the blood)(Agent mostly in the blood) Indications with SalicylatesIndications with Salicylates • Renal failure (the # 1 indication)Renal failure (the # 1 indication) • Metabolic acidosis (persistent)Metabolic acidosis (persistent) • Cerebral or Pulmonary edemaCerebral or Pulmonary edema • Really nasty, horrid, ugly high levelsReally nasty, horrid, ugly high levels
- 33. Pitfalls in Salicylate ManagementPitfalls in Salicylate Management • Failure to be scaredFailure to be scared • Failure to know that symptomsFailure to know that symptoms can be delayedcan be delayed • Ruling out toxicity usingRuling out toxicity using serum level aloneserum level alone • Failure to alkalinize the urine dueFailure to alkalinize the urine due to inadequate K+ levelto inadequate K+ level • Failure to Dialyze in the reallyFailure to Dialyze in the really sick ones!!!!!!!!!!!!!!!!!!!!!!!!!sick ones!!!!!!!!!!!!!!!!!!!!!!!!! Continue therapy untilContinue therapy until symptoms are gonesymptoms are gone • Sodium BicarbSodium Bicarb for Ion Trappingfor Ion Trapping • Multiple DoseMultiple Dose ActivatedActivated CharcoalCharcoal
- 34. CyanideCyanide • Cyanide Salts: IngestCyanide Salts: Ingest →→ CN-salt + stomach AcidCN-salt + stomach Acid →→ HCNHCN →→ AbsorbedAbsorbed →→ DieDie • HCN Gas:HCN Gas: InhaleInhale →→ Mucosal absorptionMucosal absorption →→ DieDie Burn...Burn... Plastics (Polyacrylonitriles, Polyacrylamides)Plastics (Polyacrylonitriles, Polyacrylamides) Foam (Polyurethane)Foam (Polyurethane) Varnishes and Paints (Polyurethane)Varnishes and Paints (Polyurethane) Wool and SilkWool and Silk FireFire SmokeSmoke withwith HCNHCN Formed when combine an acid with the salt; thus keep pH high, no gas will be created
- 35. Cyanide PathophysiologyCyanide Pathophysiology Binds ferric ion inBinds ferric ion in CytochromeCytochrome OxidaseOxidase CNCN Cyt a3++Cyt a3++Cyt a3+++Cyt a3+++ OO22 2H2H22OO OxidativeOxidative PhosphorylationPhosphorylation X X Can NOT use OCan NOT use O22 CNSCNS LOCLOC SeizuresSeizures Body IschemiaBody Ischemia Severe Met acidosisSevere Met acidosis
- 36. Cyanide DiagnosisCyanide Diagnosis HistoryHistory LaboratoryLaboratory • Cyanide LevelCyanide Level:: Back next weekBack next week • Lactate:Lactate: Back next hourBack next hour
- 37. Cyanide DiagnosisCyanide Diagnosis Blood GasBlood Gas • Supporting CNSupporting CN – Severe metabolic acidosis*****Severe metabolic acidosis***** – Arterial-venous OArterial-venous O22 gradientgradient ↓↓ (?)(?) – Venous OVenous O22 ↑↑ (?)(?) • Smoke “clouds” the pictureSmoke “clouds” the picture – Hypoxia…Hypoxia… AsphyxiantsAsphyxiants Pulmonary irritantsPulmonary irritants COCO CNCN – Lactate…Lactate… HypoxiaHypoxia HypoperfusionHypoperfusion Severe Met Acidosis (Tox Related) Inhibitors / Uncouples Oxid Phosph Toxic Alcohols
- 38. Detoxification – The OldDetoxification – The Old CNCN HH22SS COCO NitriteNitrite Thiosulfate (S)Thiosulfate (S) Lilly Cyanide KitLilly Cyanide Kit Amyl Nitrite PearlsAmyl Nitrite Pearls Sodium Nitrite (300 mg)Sodium Nitrite (300 mg) Sodium Thiosulfate (12.5 g)Sodium Thiosulfate (12.5 g) Cyt a3++Cyt a3++ Cyt a3+++Cyt a3+++ OO22 2H2H22OO OxidativeOxidative PhosphorylationPhosphorylation Oxy-HgOxy-Hg Met-HgMet-Hg CyanoMet-HgCyanoMet-Hg CNCN RhodaneseRhodanese + S+ S SCN (Thiocyanate)SCN (Thiocyanate) Eliminated ATP
- 39. NitritesNitrites Side EffectsSide Effects – VasodilationVasodilation →→ HypotensionHypotension – MethemoglobinemiaMethemoglobinemia →→ ↓↓OO22 Carrying CapacityCarrying Capacity • Create a “toxicity” to cure another “toxicity”Create a “toxicity” to cure another “toxicity” • Another issue in smoke inhalation settingAnother issue in smoke inhalation setting Carbon Monoxide alsoCarbon Monoxide also →→ “Dys-hemoglobinemia”“Dys-hemoglobinemia” →→ ↓↓OO22 Carrying CapacityCarrying Capacity Sodium ThiosulfateSodium Thiosulfate is quite benignis quite benign Normal Hemoglobin
- 41. Recycling of HydroxycobalaminRecycling of Hydroxycobalamin CobalaminCobalamin OHOH CNCN CNCN CobalaminCobalamin OHOH-- ++ ++ (Vitamin B(Vitamin B1212)) HH++ CNCN CobalaminCobalamin ThiosulfateThiosulfate CobalaminCobalamin OHOH ThiocyanateThiocyanate RhodanaseRhodanaseHH22OO ++ ++ ++++ (Vitamin B(Vitamin B1212))
- 42. Alcohols that in significant amountsAlcohols that in significant amounts typically cause specific end organtypically cause specific end organ damage if not managed appropriatelydamage if not managed appropriately Toxic AlcoholsToxic Alcohols DefinedDefined These include:These include: • Ethylene GlycolEthylene Glycol • MethanolMethanol Do NOT include:Do NOT include: • IsopropanolIsopropanol • EthanolEthanol
- 43. Alcohol DehydrogenaseAlcohol Dehydrogenase Aldehyde DehydrogenaseAldehyde Dehydrogenase Metabolism of Ethylene GlycolMetabolism of Ethylene Glycol Pyridoxine Pyridoxine ThiamineThiamine GlycineGlycine OxalateOxalate FormateFormate αα-Hydroxy--Hydroxy- ββ-Ketoadipate-Ketoadipate GlyoxylateGlyoxylate Ethylene glycolEthylene glycol GlycoaldehydeGlycoaldehyde GlycolateGlycolate
- 44. FolateFolate AlcoholAlcohol DehydrogenaseDehydrogenase Metabolism ofMetabolism of MethanolMethanolMethanolMethanol FormaldehydeFormaldehyde FormateFormate COCO22 + H+ H22OO
- 45. The IssuesThe Issues • Ethylene GlycolEthylene Glycol ARFARF • MethanolMethanol BlindnessBlindness • IsopropanolIsopropanol Tummy upsetTummy upset
- 46. OsmolesOsmoles What is Normal?What is Normal? 65%65% -2-2 300 “Normal” people300 “Normal” people -2-2 ±± 66 95%95% 1010-14-14 2.5%2.5% 97.5%97.5% 97.5%97.5% populationpopulation gap < 10gap < 10
- 47. ManagementManagement Ethylene GlycolEthylene Glycol GlycoaldehydeGlycoaldehyde MethanolMethanol FormaldehydeFormaldehyde Alcohol DehydrogenaseAlcohol Dehydrogenase Ethanol Fomepizole
- 48. ManagementManagement HemodialysisHemodialysis • SymptomaticSymptomatic • Significant metabolic acidosis (?)Significant metabolic acidosis (?) – pH < 7.1pH < 7.1 – One that can’t easily correctOne that can’t easily correct • Ethylene glycol or methanol levelsEthylene glycol or methanol levels – > 25 mg/dL> 25 mg/dL – > 50 mg/dL> 50 mg/dL • Renal compromiseRenal compromise ? Indications: Symptoms present Often doneOften done after symptomsafter symptoms have begunhave begun
- 49. Sodium BicarbonateSodium Bicarbonate For TCAs and OtherFor TCAs and Other Sodium Channel BlockersSodium Channel Blockers •It’s theIt’s the sodiumsodium that countsthat counts •Boluses (Boli?) – the way to goBoluses (Boli?) – the way to go •You follow your “efficacy” thru – QRS!!!You follow your “efficacy” thru – QRS!!! •QRS corrects rapidly (minutes)QRS corrects rapidly (minutes)
- 50. • The big questions – Is there a correlation between…The big questions – Is there a correlation between… – QRS ≥ 100 ms & TCA concentration > 1000 ng/mLQRS ≥ 100 ms & TCA concentration > 1000 ng/mL – Development of seizures orDevelopment of seizures or ventricular dysrhythmias andventricular dysrhythmias and • QRS ≥ 100 msQRS ≥ 100 ms • TCA concentration > 1000 ng/mLTCA concentration > 1000 ng/mL NEJM 1985 313:474-9
- 51. Figure 1Figure 1 Correlation between theCorrelation between the max Limb Lead QRSmax Limb Lead QRS Duration and theDuration and the Occurrence of Seizures ofOccurrence of Seizures of Ventricular Arrhythmias.Ventricular Arrhythmias. Each circle denotes 1 of theEach circle denotes 1 of the 49 study patients.49 study patients.
- 52. Vs. Sodium BicarbonateVs. Sodium Bicarbonate with Salicylateswith Salicylates • It’s the bicarbonate that countsIt’s the bicarbonate that counts • Done as an infusion.Done as an infusion. • You will cause hypokalemiaYou will cause hypokalemia • You monitor “efficacy” via – urine pHYou monitor “efficacy” via – urine pH (want it high to trap)(want it high to trap)