This document provides an overview of poisonings and toxicology for primary care providers. It discusses the basics of assessing and stabilizing a poisoned patient, including determining if they are stable or unstable based on vital signs and mental status. It covers various toxin categories like anticholinergics, cholinergics, opioids, sedatives, sympathomimetics, carbon monoxide, and toxic alcohols. For each category it describes signs and symptoms, mechanisms, and treatment approaches like supportive care, activated charcoal, antidotes, and specific reversal agents. The goal is to help primary care recognize poisoning presentations and provide initial stabilization before transfer if needed.

1. Poisoning
AKA: Stupid sailor/marine tricks.
Tina F. Edwards, MD FAAEM
LCDR MC USN

2. Toxicology, in a nutshell
O Supportive care
O Seizure, coma, death

3. Conclusion
OQuestions?
OJust Kidding!

4. Overview
O Basics of the poisoned patient
O Anticholinergics
O Cholinergics
O Sedatives
O Sympathomimetics
O Carbon Monoxide
O Toxic Alcohols

5. What is a poison?
O Too much of anything can be a bad thing.

6. Why primary care?
O Jus’ gonna send this patient to ED!
O RecognizeStabilize
O YOU might be the ED

7. Basics
O Stable or unstable?
O Abnormal Vital signs
O Respiratory distress
O Altered Mental Status

8. Basics
O Nature of the syndrome?
O Mental status
O Agitated vs. Sedated
O Pupils
O Skin
O Vitals
O Mucous membranes
O Odors

9. Basics
O Emetics. Don’t.
O Charcoal, maybe.
O Aggressive supportive care:
O IV, monitors, fluids
O If it’s fast, slow it.
O If it’s slow, speed it up.
O If it’s low, raise it
O If it’s high, lower it.

10. Common Causes of Seizures
O Bupropion
O Tricyclic Antidepressants*
O Tramadol
O Isoniazid*
O Cocaine, amphetamines
O Antihistamines
O Venlafaxine (Effexor)

11. Workup
O EKG
O Finger stick blood sugar
O Chemistry
O Blood Gas
O CBC
O Tylenol, Aspirin, EtOH
O UA
O CXR,KUB

12. Treatments
O Got Activated Charcoal?
O 1 hour +/-
O Cautions
O Ineffective
O Alcohols
O Metals
O Caustic agents

13. Treatments
O Decontamination
O Naloxone (Narcan)
O Benzodiazepines
O Dialysis
O Antidotes
O Sodium Bicarb

14. So there you are minding
your own business…
When...

15. 19 yr old AD Female
O Oriented x 1
O Agitated
O 140, 156/92, 20, 10
1.2, 98%
O Dry skin, MM’s
O Hypoactive BS

16. Anticholinergic Toxidrome
O Benadryl
O Cough syrup
O TCA’s
O Scopolamine
O DM

17. Anticholinergic Toxidrome
O Flushed, dry skin, dry mucous
membranes
O Mydriasis
O Delirium
O Hyper: -thermia, -tension
O Tachycardia
O Urinary retention
O Hypoactive BS

18. Anticholinergic Treatment
O Aggressive supportive care
O Physostigmine Why?
O Can’t use if any QRS widening
O Contraindicated in asthma
O Requires continuous cardiac monitoring
O Usually won’t outlast the anticholinergic

19. 24 yr old AD male
O C/O frequent
diarrhea, vomiting
O Fatigued, mildly confused
O Acrid garlic smell
O 112/62, 52, 18, 98.2, 95%
O Productive cough
O Tearing
O Frequent spitting
O Muscle twitches

20. Cholinergic Toxidrome
O Muscarinic
O Nicotinic
O Central
O Causes
O Insecticides
O Pilocarpine
O Carbachol
O Betel nuts
O Indian Tobacco
O Nicotine
O Black widow

21. Cholinergic Toxidrome
O Nicotinic
O Tachycardia
O Hypertension
O Fasciculation's
O WeaknessParalysi
s

22. Cholinergic Toxidrome
O Central
O Agitation
O Psychosis/confusion
O Seizure/coma/death

23. Cholinergic Poisoning
O Muscarinic
O Diarrhea
O Urination
O Miosis
O Bradycardia
O Bronchorrhea
O Emesis
O Lacrimation,
salivation

24. Cholinergic treatment
O Protect yourself!
O Stabilize, then decontaminate
O Atropine until dry
O Pralidoxime currently recommended
O Aggressive supportive care

25. 17 yr old boy
O Brought in by mom
O C/C “not himself”
O Sedated, barely
responsive
O Disheveled
O 90/58, 52, 10, 97.2, 94%
O Crackles
O Decreased BS
O Hypotonic reflexes

26. Opioid Toxidrome
O Classic Triad
O Coma
O Respiratory
Depression
O Pinpoint pupils

27. Opioid Toxidrome
O Causes
O All the usual, plus Lomotil
O Dextromethorphan
O But wait!
O Random fact:
O Not all opioids cause miosis
O Meperidine (Demerol)
O Propoxyphene (Darvon)

28. Opioid Treatment
O Naloxone
O Aggressive supportive care

29. 19 year old AD male
O Brought in by roommate,
“Seized”
O Moans, doesn’t open
eyes
O 88/52, 101, 10, 95.8,
93%
O PERRL, but slowed
O Nystagmus

30. Sedative Hypnotic Toxidrome
O Barbituates
O Benzodiazapines
O GHB
O Zolpidem (Ambien)
O Zaleplon (Sonata)
O Confusion/coma
O Respiratory
depression
O Hypotension
O Hypothermia
O Pupillary changes
O Vesicles or bullae
O Seizures

31. Sedative-hypnotic treatment
O Aggressive supportive care
O Airway management
O Multiple-dose activated charcoal
O Phenobarbital may require dialysis

32. A note about flumazenil
O Why?
O Can precipitate seizures
O Absolutely contraindicated in QRS
widening
O Doesn’t reverse Hypoventilation

33. What to do?

34. 23 yr old AD male
O Brought in by
command, “not acting
right”
O Anxious
O 180/110, 142, 18, 103.2, 1
00%
O Flushed, sweating
O A+O x 3

35. Sympathomimetic Toxidrome
O Cocaine
O Methamphetamine
O Other CNS Stimulants
O Withdrawal from sedative hypnotics

36. Sympathomimetic Toxidrome
O Hypertension
O Tachycardia
O Hyperpyrexia
O Mydriasis
O Anxiety or delirium

37. Sympathomimetic treatment
O Aggressive supportive care
O Benzodiazepines
O Active cooling if needed

38. What to do?

39. 34 yr old AD male
O Losing
balance, headache,
chest
pain, vomiting
O 100/72, 120, 32, 98.
7, 99%
O A+O x 2
O Accessory muscle
use

40. EKG

41. Carbon Monoxide Poisoning
O Signs/Sx highly variable, non-specific
O Headache
O Dizziness
O Nausea/Vomiting/Diarrhea
O Confusion
O Syncope
O SOB
O Chest pain
O Cerebellar ataxia

42. Mechanism CO Poisoning
O Running engine, closed space
O Mechanics
O Suicide attempt
O Generators
O Gas heaters
O Camp stoves/Charcoal grills

43. CO Poisoning Treatment
O Oxygen, more is better
O Aggressive supportive care
O Mild to moderate acidosis is helpful
O Moves curve to right

44. 23 yr old AD
O Sent “I want to die”
text
O A+O x 1
O 102/62, 110, 12,
97.3, 97%
O Covered in vomit
O Slurred speech
O Ataxic gait

45. Toxic Alcohols
O Ethanol!
O Ethylene Glycol
O Methanol
O Isopropanol/Aceton
e
O Other glycols

46. Toxic Alcohols
O Ethylene glycol – Ca oxalate monohydrate
crystals
O Methanol – Formic acid
O Isopropanol – Acetone

47. Toxic Alcohols
O All – Airway compromise
O Ethylene Glycol
O Dysrhythmias
O Nephrotoxicity
O Meningoencephalitis
O Cerebral/pulmonary edema

48. Toxic Alcohols
O Methanol
O Visual symptoms, “snowfields”
O Coma
O Respiratory and circulatory failure
O Parkinson-like syndrome

49. Toxic Alcohols
O Isopropanol
O Ketonemia
O CNS Depression (2 x EtOH)
O GI effects
O Increased Cr w/nl BUN suggests

50. Toxic Alcohols
O Other glycols
O Effects
O Neurologic toxicity
O Renal failure
O Hepatitis
O Pancreatitis
O Hemolysis
O ARDS

51. Toxic Alcohols
O Diethylene glycol
O Renal failure epidemics
O Propylene glycol
O “safer” antifreeze
O Iatrogenic, IV Benzos

52. Toxic Alcohol
O Aggressive supportive care!
O Fomepizole
O Plain ol’ ethanol
O Look for acidosis, ketones, other clues

53. Are you ready?

54. 24 year old male
O Found down
outside barracks
O 90/54, 48, 8, 92%, 9
6.2
O Non responsive
O PERRL

55. 18 year old AD female
O Witnessed seizure
O 160/102, 120, 22, 1
02.4, 99%
O Flushed, Dry
O Pupils
dilated, reactive
O Absent bowel
sounds

56. 22 year old AD male
O Working outside
O Vomiting
O 190/120, 130, 24,
104.2, 95%
O Diaphoretic
O Rigid, shaking
O Smells of stool
O Pupils pinpoint, reactive

57. Sources
O Harwood-Nuss, Clinical Practice of Emergency Medicine, 5th
Edition, Lippincott Williams & Wilkins, Philadelphia, PA, 2010
O Hamilton, Sanders, Strange, Trott. Emergency Medicine, An
Approach to Clinical Problem Solving, 2nd Edition. Saunders.
Philadelphia, PA. 2003.
O http://www.mrcophth.com/plants.html
O http://memorize.com/toxidromes-and-antidotes/erichf
O http://emedicine.medscape.com/article/812411-clinical
O Thundiyil JG, et. al, Evolving epidemiology of drug-induced
seizures reported to a Poison Control Center System. J Med
Toxicol, 2007, Mar, 3(1):15-9.

58. Questions