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OVERDOSE: THE BAND

OVERDOSE: THE BAND. Mr. RR, 36yo Male. Brought in by EMS/CPS Found in appt building foyer asleep with friend who “escaped” Not arousable, no I.D. Smells “fruity” GCS “3” but non-purposefull movements of all limbs present No signs of trauma, OPA accepted. TOXICOLOGY I.

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OVERDOSE: THE BAND

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  1. OVERDOSE: THE BAND

  2. Mr. RR, 36yo Male • Brought in by EMS/CPS • Found in appt building foyer asleep with friend who “escaped” • Not arousable, no I.D. • Smells “fruity” • GCS “3” but non-purposefull movements of all limbs present • No signs of trauma, OPA accepted

  3. TOXICOLOGY I MANAGEMENT OF O.D. AND DECONTAMINATION ISSUES KEVIN HANRAHAN DR. DAVID JOHNSON

  4. GENERAL CONCEPTS RESUSCITATION HISTORY TOXICOLOGY PHYSICAL TOXIDROMES INVESTIGATIONS GENERAL DECONTAMINATION G.I. DECONTAMINATION -ORAL REMOVAL -BINDING -MECHANICAL FLUSHING ENHANCED ELIMINATION ANTIDOTES DISPOSITION OUTLINE

  5. Nontoxic Ingestions • Only one substance in exposure • Substance absolutely defined • No hazards on product label • Unintentional • Route known • Approximate amount known • Asymptomatic with easy follow-up

  6. Setting • Occupational-eg. xylene • Recreational • Medical • environmental I wonder what this xylene would taste like

  7. Portals of Entry • Ingestion,most common historically(76%) • Inhalation(8%) • Cutaneous/mucous membrane(6%) • Injection-meds -drugs of abuse • Insufflation

  8. PADIS 03/04

  9. PREVALENCE • 2 Million toxic exposure in U.S.-2000 • 3rd leading cause of death • Mortality from acute poisoning <1% • Peds account for 80% • 10% admitted, usually accidental • Adults-20%,rarely accidental,90% admitted to hospital • Accounts for 1% admission,10% ICU

  10. PADIS APRIL 04/MAR 05 AGE DISTRIBUTION

  11. CIRCUMSTANCES- PADIS 03/04

  12. PADIS O3/04 OUTCOMES

  13. PADIS 03/04

  14. RESUSCITATION • Occurs simultaneously with Dx • Important as support may be only Tx for most overdoses • Vitals, all 6 critical in toxicology • T/BP/HR/RR/SAT/BS • Airway-patent & protected? -intubate for GCS<9 • Breathing-vitals and auscultate • Circulation-vitals,establish IV,EKG

  15. RESUSCITATION cont’d • Decide:stable/unstable :?heavy hitter eg TCA, Bblocker etc • Antidote-rarely takes precedence over ABC (cyanide toxicity) • Coma Cocktail-hypoxia -wernicke’s -opioid intox. -hypoglycemia

  16. “HEAVY HITTERS” • Largest number of deaths in 2000 in U.S. -analgesics -antidepressants -sedative/hypnotics/antipsychotics -stimulants -street drugs -CV drugs -alcohols

  17. RESUSCITATION cont’d • Seizures -BZD.,phenobarb, not dilantin • Hypotension -isotonic fluids,bicarb,hi dose levo/dop • Vent. Arhythmia -bicarb bolus,lidocaine,BB in chloral hydrate -see ACLS for specific toxins

  18. Cheap Minimal risk Simple Oxygen as per need D50W,50g,adult 4ml/k D25W or 10ml/k D10W Pediatrics COMA COCKTAIL

  19. THIAMINE • Not necessary in kids • 100mg IV/IM qdaily • ?before D50W? • Previously thought to prevent Wernicke’s encephalopathy

  20. WHERE’S THE EVIDENCE ?

  21. Thiamine/Glucose • Originally came from 5 case reports of Wernicke’s precipitated or made worse by glucose before thiamine • All 5 had severe nutritional deficiencies, several comorbid illnesses and received glucose for several days before thiamine was administered • Therefore don’t delay glucose in ED for thiamine Hack,JB,JAMA 1988

  22. NALOXONE (NARCAN) • 0.1-2.0MG IV/IM, +/- restraints • 20-60 min. response time • 2nd dose 2/3 of first • Observe 2-3h • Triad of dec. LOC,miosis,resp dep. • Resp status only reliable way to determine effect of narcan. • Other drugs affect LOC and some opioids can cause mydriasis

  23. NALOXONE • 730 pts prehospital tapes/sheets reviewed in AMS pts. for response to Narcan and clinical presentation. • RR<12,pinpoint pupils,circumstantial evidence of opiate abuse all predictive of response • Use of these criteria would decrease Narcan use by75-90% without missing any responders Hoffman,JR,Annals of Emergency Med., 1991

  24. FLUMAZENIL AS PART OF THE COMA COCKTAIL? • Retrospective analysis of 35 consecutive comatose pts • Divided into low and non-low risk for sz. based on clinical and ECG(proconvulsive OD’s) • Only 4 were assessed as low risk • High risk of sz. In non-low risk group • Low risk might benefit but very small minority of pts. Gueye,PN,Annals of Emergency Medicine, 1996 • Flum. May also precip. Arrythmia in TCA

  25. TOXICOLOGICAL HISTORY • MOST IMPORTANT DIAGNOSTIC TEST • # of pts/type of exp/ amounts,dose/route/intent • “all OD’s are liars” • Corroborate with MD/pharmacist/EMS/witnesses • Info on environment:empty bottles, odours,material,hobbies,notes • AMPLE

  26. Toxic Features • History -suicide, prev. O.D. or abuse -psychiatric or polypharmacy • Physical -arrest,bronchospasm,dysrythm nyd - thermia/tension -AMS,sz.,rigidity,dsytonia,rotary nystagmus • Investigation -anion/osmolar gap, K-Na-gluc -renal/hepatic failure,rhabdo,aspiration

  27. TOXICOLOGICAL PHYSICAL • Expose, look for hidden substances • Waist bands,skin folds,groin • Watch for sharps

  28. NEEDLE COLLECTION Bright yellow disposal boxes in easily accessible locations encourage IV drug users to safely discard used syringes. The project collected 22,245 needles in 2001.

  29. GENERAL APPEARANCE • LOC;agitation,obtundation,confus. • Skin;cyanosis,flushing,diaphoresis dryness, • Injuries,injections,bullae,bruising (may be from trauma,dec LOC longterm or coagulopathy)

  30. Almonds Eggs Fish Garlic Fresh hay Geraniums Swimming pool Mothball Violets Wintergreeen peanuts Cyanide Hydrogen sulf Sinc sulfide Org phosporous Phosgene Lewisite Chlorine gas Camphor,naptha Turpentine Methyl salicylate vacor ODOURS

  31. SKIN FINDINGS

  32. CNS • LOC/cognition • Tone • Reflexes • Coordination • Ambulation

  33. Amphetamines Antihistamines/ anticholinergics Caffeine/theoph Antipsychotics Carbamates CO Cocaine Hypoglycemics Chlorambucil Propranolol salicylates Cyclic antidepress Ethylene glycol Isoniazid Lead Lidocaine Lithium Methanol Organophosphates Phencyclidine Withdrawal from ETOH/sedatives Toxins Causing Seizures

  34. Toxins Affecting Tone

  35. Toxins Causing AMS

  36. EYES • Pupils: size, reactivity,equality • Dysconjugate gaze • lacrimation

  37. Toxins Affecting Pupil Size

  38. MOUTH (with suction) • Retained contents or pills • Gag • Dryness/salivation

  39. Lungs • Air entry • oxygenation • wheezing • bronchorhea

  40. Alcohols Barbs Botulinum Cyclic antidepress Neuromuscular blockade Opioids Sedative/hypnot Snake bite Strychnine tetanus TOXINS CAUSING HYPOVENTILLATION

  41. HEART/PULSES • Rate • Rhythm • Regularity • Peripheral pulses/perfusion

  42. Tachycardia Common -TCA -CO -anticholinerg eg. Gravol -adrenergic eg. cocaine Bradycardia Common -opioids -cholinergics -BBlockers TOXINS AFFECTING PULSE

  43. ABDOMEN • Bowel sounds • Rigidity • Urinary retention • tenderness

  44. TOXIDROMES • Physiological groups • Based on VS,general appearance, skin,eyes,mm,etc. • Also basic labs

  45. DO THE BASIC FINDINGS MATCH WITH A POISON ? • Basis for toxidrome • Eg. Autonomic syndromes sympathetic parasympathetic Adrenergic symptoms,eg. cocaine Cholinergic,eg organophospates Anticholinergic,eg. gravol No bowel sounds,dry skin,blurry vis,fever etc Tahycardia,htn, diaphoresis, mydriasis,etc S.L.U.D.G.E

  46. Autonomic Nervous System NIC NIC NIC NE MUSC NMJ S PS

  47. Hypothermia -TCA,Li,Phenothiazin -alcohol,barbs,opium -hypoglycemics colchicine,akee fruit -AMS in winter Hyperthermia -LSD,cocaine,PCP, amphetamines -antichol,antihist -TCA,MAOI,SSRI phenothiazines -ASA -malign hyper/NMS Toxins Affecting Temperature

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