The Approach to the Poisoned Patient

1. The Approach to the Poisoned Patient Toxicology Skills Workshop Regions Hospital Emergency Medicine Program

2. Initial Approach to the Patient with a Toxic Ingestion • Develop a Systematic Approach • Look for Toxidromes (“Talkingdromes”) • Attention to ABCs and need for Antidote • Know the Indications for Decontamination Procedures • Enhance when possible and appropriate

3. Initial Management of Severe OD - ABCDE • A – Antidote • B – Basics ; ABCs • C – Change catabolism • D – Distribute differently; Decontamination • E – Enhance elimination

4. Initial ManagementA = Antidote

5. A = Antidote

6. Basics - ABCs • Airway • Breathing • Circulation • Do the DONT • Dextrose • Oxygen • Naloxone • Thiamine

7. Reduce Adsorption • Vomiting (Ipecac) • Generally not indicated or used in an ED setting • Contraindicated in patients < 6 mos old, caustic ingestions, actual or potential loss of airway reflexes, need to give oral antidote • Activated Charcoal • Most effective if given within one hour • Caution in the patient with altered mental status (need a protected airway) • Not effective for hydrocarbons, metals (Lead, Iron, Lithium) • Gastric Lavage • Rarely used • Consider in large, potentially life threatening ingestions not amenable to activated charcoal

8. E = Enhance Elimination • Hemodialysis • STUMBLE(D) - Dialysis • Salicylates • Theophylline • Uremia • Methanol • Barbiturates, Bromide • Lithium • Ethylene Glycol • Depakote (high levels)

9. The Patient with a Toxic Ingestion – H & P • Focused History and Brief Tox Exam • History: what-when-how much • Reliability factor, relatives, paramedics • Exam • Vital signs • Mental status • Pupillary response • Skin changes, Odors/other prominent features. M A T T E R S

10. History & Mini Tox Exam • Exam • Vital signs • Pulse up or down or normal • BP up or down or normal • Temp up or down or normal • Resp up or down or normal

11. Vital Signs Toxicity – Pulse • Bradycardia (PACED) • Propranolol or other Beta blockers, Poppies (opiates) • Anticholinesterase drugs • Clonidine, CCBs, Ciguatera • Ethanol or other alcohols, Ergotamine • Digoxin

12. Vital Signs Toxicity – Pulse • Tachycardia (FAST) • Free base or other forms of cocaine • Anticholinergics, antihistamines, amphetamines • Sympathomimetics (ephedrine, amphetamines), Solvent abuse • Theophylline, Thyroid hormone

13. Vital Signs Toxicity – Temperature • Hypothermia (COOLS) • Carbon monoxide, Clonidine • Opiates • Oral hypoglycemics, Insulin • Liquor • Sedative-hypnotics

14. Vital Signs Toxicity – Temperature • Hyperthermia (NASA) • Nicotine, Neuroleptic malignant syndrome • Antihistamines • Salicylates, Sympathomimetics • Anticholinergics, Antidepressants

15. Vital Signs Toxicity – BP • Hypotension (CRASH) • Clonidine, CCBs (and B-blockers) • Reserpine or other antihypertensives • Antidepressants, Aminophylline, Alcohol • Sedative-hypnotics • Heroin or other opiates

16. Vital Signs Toxicity - BP • Hypertension (CT SCAN) • Cocaine • Thyroid supplements • Sympathomimetics • Caffeine • Anticholinergics, Amphetamines • Nicotine

17. Vital Signs Toxicity - Respirations • Rapid Respiration (PANT) • PCP, Paraquat, Pneumonitis (chemical) • ASA and other salicylates, Amphetamines • Non-cardiogenic pulmonary edema • Toxin-induced metabolic acidosis

18. Vital Signs Toxicity - Respirations • Slow Respirations (SLOW) • Sedative-hypnoptics, Strychnine, Snakes • Liquor • Opiates, OPs • Weed (marijuana) • Other causes: Nicotine, Clonidine, Chlorinated HC

19. Exam – Mental Status • Seizures? • Hallucinations? • CNS depressed?

20. Agents that Cause Seizures • WITH LA COPS • Withdrawals (alcohol, benzos) • INH, Insulin, Inderal • Tricyclics, theophylline • Hypoglycemics; Hemlock, water; Haldol • Lithium, Lidocaine, Lead, Lindane • Anticholinergics, Antiseizure

21. Agents that Cause Seizures • WITH LA COPS • Cocaine, Camphor, CN, CO, Cholinergics • Organophosphates • PCP, PPA, propoxyphene • Sympathomimetics, Salicylates, Strychnine

22. Agents that Affect Pupil Size • Miosis (COPS) • Cholinergics, Clonidine • Opiates, organophosphates • Phenothiazines, pilocarpine • Sedative-hypnotics, SAH • MydriASis (A3S) • Antihistamines, Antidepressants, Atropine • Sympathomimetics

23. Skin Changes • Diaphoretic (SOAP) • Sympathomimetics • Organophosphates • ASA or salicylates • Phencyclidine (PCP)

24. Dry Skin • Antihistamines, Anticholinergics • Bullous Lesions • Barbiturates and other sedative-hypnotics • Carbon monoxide • Tricyclics (personal case series) www.acponline.org/graphics/bioterro/bullous.jpg

25. Skin Changes • Flushed • CO (rare) • Anticholinergics • Boric acid • CN (rare)

26. Skin Changes • Cyanosis • Phenazopyridine • Aniline dyes • Nitrates • Nitrites • Ergotamine • Dapsone • Any agent hypoxia, hypotension • MetHb

27. Exam - Diagnostic Odors • Bitter Almonds • Carrots • Fruity • Garlic • Gasoline -Cyanide -Cicutoxin (water hemlock) -DKA, Isopropanol -OP, As, DMSO, selenium, thallium, phosphorus -Petroleum distillates

28. Diagnostic Odors • Mothballs • Pears • Pungent aromatic • Oil of wintergreen • Rotten eggs -Naphthlene, camphor -Chloral hydrate -Ethchlorvynol -Methylsalicylate -Sulfur dioxide, hydrogen sulfide

29. Laboratory Evaluation of the Tox Patient • Toxicology Screens • Urine Stat • Urine vs Serum • Acetaminophen level • Routine Tests • CBC • SMA-7 • Anion Gap • ABGs

30. Levels - Timing *Clinical Symptoms may dictate treatment, not level.

31. Suggestive Findings in the Poisoned Patient: Anion Gap • A MUD PILE CAT • ASA • Methanol • Uremia • DKA • Paraldehyde, Phenformin • INH, Iron, Ibuprofen • Lactic acidosis • Ethylene Glycol

32. Suggestive Findings in the Poisoned Patient: Anion Gap • A MUD PILE CAT • CO, CN, Caffeine • AKA • Theophylline, Toluene • Others • Benzyl alcohol • Metaldehyde • Formaldehyde • H2S

33. Suggestive Findings in the Poisoned Patient: Anion Gap • Decreased Anion Gap • Bromide • Lithium • Hypermagnesemia • Hypercalcemia

34. Osmolar Gap • Calculated • 2(Na)+[Glu/18] + [BUN/2.8] + EtOH(mg/dL)/4.6 Osm Gap = measured - calculated • Significant if >10 • Really significant if >19

35. Suggestive Findings in the Poisoned Patient: Osmolar Gap • Increased Osmolar Gap • MAD GAS • Mannitol • Alcohols (met, EG, Iso, eth) • Dyes, Diuretics, DMSO • Glycerol • Acetone • Sorbitol

36. Toxidromes: Case #1 • A 40 year old man collapsed at work while moving his car. He has a hx of depression. He had recently attended his mother’s funeral the day before. • He was found slumped over the steering wheel of his car, lethargic and incoherent. A co-worker left the patient and went to call medics. He was intubated and transferred to Regions Hospital.

37. Toxidromes: Case #1 • Examination • BP 130/88, P90, R-vent, T 1012 • Pupils 6mm unreactive but equal. • Skin warm, red, dry • Absent bowel sounds • Labs were unremarkable • ABG:pH 7.50, 32, 140 • EKG - QRS 102, occasional PVC

38. Toxidromes: Case #1 Is there a Toxidrome? • A. Opioid • B. Anticholinergic • C. Delayed Exercise Syndrome • D. Cholinergic poisoning Is there an antidote?

39. The Talkingdromes • Anticholinergic (antihistamines, cyclic antidepressants, Jimson weed) • Hot as a hare (hyperthermia) • Red as a beet (flushed) • Dry as a bone (dry skin, urinary retention) • Blind as a bat (mydriasis) • Mad as a hatter (hallucinations, delirium, myoclonic jerking)

40. The Talkingdromes • Also with anticholinergic • Mydriasis • Tachycardia • Hypertension • Hyperthermia • Seizures • How do you treat it? • Supportive care • TCAs – Sodium Bicarb for widened QRS • Benzodiazepenes for agitation, seizures • Consider physostigmine for pure anticholinergic overdoses (contraindicated in TCA overdose or with dysrhythmias)

41. Toxidromes: Case #2 • A 19 year old male presents after from a party after his friends noted he was “acting funny.” He was “out of control” and not making sense, so they decided to bring him into the Emergency Room. • The patient is agitated on arrival

42. Toxidromes: Case #2 • Examination • BP 180/114, P120, R20, T 101 • The patient is agitated and appears to be hallucinating • Pupils 6mm sluggish but equal. • Skin warm, red, very diaphoretic • Labs were unremarkable • EKG – sinus tachycardia

43. Toxidromes: Case #2 Is there a Toxidrome? • Opioid • Anticholinergic • Sympathomimetic • Cholinergic

44. Talkingdromes (Toxidromes) • Sympathomimetics (cocaine, amphetamines, ephedrine) • Mydriasis • Tachycardia • Hypertension • Hyperthermia • Seizures • Diaphoresis • Treatment • Supportive care • Benzodiazepines as needed

45. Toxidromes: Case #3 • A 40 y/o female is brought by medics. A family member called after a suicide note was found and the patient was found unresponsive. • On medic arrival the patient was noted to be very somnolent. She was transported to Regions Hospital.

46. Toxidromes: Case #3 • Examination • BP 100/65, P50, R6, T 98.6 • The patient is arousable only to sternal rub. • Pupils 2mm sluggish but equal. • Skin cool, dry • Labs were unremarkable • EKG – sinus bradycardia

47. Toxidromes: Case #3 Is there a Toxidrome? • Opioid • Anticholinergic • Sympathomimetic • Cholinergic Is there an antidote?

48. Talkingdromes (Toxidromes) • Narcotic (heroin, methadone, other opioids) • Miosis • Bradycardia • Hypotension • Hypoventilation • Coma/CNS depression • Treatment • Naloxone

49. The Imitators – Opioid-like • Clonidine • Hypotension usually more profound • May require HIGH dose naloxone to see any effect • Tetrahydrozaline • Periodic apnea in kids • Kids should be admitted if symptomatic in ED

50. Toxidromes: Case #4 • A 50 y/o male is brought in after being found in his garage. According to paramedics, there were several containers of liquids in glass jars near the patient. They also noted a large amount of emesis. He was noted to have altered mental status and some respiratory distress prior to arrival. He was intubated prior to arrival and transported to Regions Hospital.