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Poisoning/Overdose

Poisoning/Overdose. General Management. Poisoning. Exposure to substance that is toxic in any amount. Overdose. Exposure to substance in excess amount resulting in toxic effects. 1998 TESS Data. 2,241,082 reported human exposures 97.9 % at home

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Poisoning/Overdose

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  1. Poisoning/Overdose General Management

  2. Poisoning Exposure to substance that is toxic in anyamount

  3. Overdose Exposure to substance in excessamount resulting in toxic effects

  4. 1998 TESS Data • 2,241,082 reported human exposures • 97.9 % at home • Peak volume 4pm-10pm • 91% of calls 8am-midnight

  5. Exposures by Age • < 6 years old 52.7% • < 3 years old 39.6%

  6. Fatalities • 775 fatalities • 0.03% of total exposures • ages 20 - 49 years = 56% • >6 years = 2.1%

  7. Number of Substances • 92.8% of all cases--one substance • 44.7% of fatal cases-->2 substances

  8. Management Location • Managed on site 75.2% • Treated, released at ER 12.3% • Admitted to critical care 2.7% • Refused referral 2.0%

  9. Therapy • No therapy 11.9% • Observation only 12.7% • Decontamination only 59.6% • Activated charcoal 6.8% • Ipecac 1.2%

  10. Most Common Substances • Cleaning substances 10.2% • Analgesics 9.6% • Cosmetics 9.4% • Plants 5.5% • Foreign bodies 4.6% • Cough, cold 4.5% • Bites, stings 4.1%

  11. Most Common Substances • Insecticides, pesticides, rodenticides3.9% • Sedative, hypnotics, antipsychotics 3.2% • Antidepressants 3.0% • Hydrocarbons 3.0% • Alcohols 2.5%

  12. Largest Number of Deaths • Analgesics 264 • Antidepressants 152 • Stimulants, street drugs 118 • Cardiovascular medication 118 • Sedatives, hypnotics 89 • Alcohols 56

  13. Indicators • Sudden onset of CNS signs: • Seizures • Coma • Decreased LOC • Bizarre behavior

  14. Indicators • Sudden onset of: • Abdominal pain • Nausea • Vomiting

  15. Indicators • Sudden onset of unexplained illness • Bizarre, incomplete, evasive history • Trauma (>50% of adult trauma EtOH, drug-related) • Pediatric patient with arrhythmias

  16. History • What? • How much? • How long? • Multiple substances? • Treatment attempted? How? Whose advice? • Psychiatric history? • History of suicide?

  17. General Management • SupportABC’s • Secure airway, intubate as needed • Ensure adequate oxygenation, ventilation • Maintain adequate circulation • Monitor ECG • Obtain vascular access • Manage hypotension initially with volume • Use vasopressors cautiously

  18. General Management • Keep patient calm • Maintain normal body temperature • Evaluate nature/toxicity of poison • Check container, package insert, poison center information • Treat the patient, not the poison

  19. General Management • Rule out • Trauma • Neurological disease • Metabolic disease • Base general management on route of poison entry

  20. Ingestion Slow movement from injection site throughout body Poison Entry • Prevent absorption from GI tract • Inhalation • Remove from exposure; Support oxygenation, ventilation • Absorption • Remove from skin surface • Injection

  21. Ingested Poisons Objective Remove from GI tract before absorption occurs

  22. Ipecac • RARELY used anymore • If used, has to have been initiated within few minutes after ingestion • Vomiting in 20-30 minutes • Only removes about 32% of contaminate • Many contraindications

  23. Ipecac • Dose • 15 cc if 12 months to 12 years old • 30 cc if >12 years old • Follow with 2-3 glasses of water • Keep patient ambulatory if possible

  24. Ipecac • If no vomiting after 20 minutes, repeat • When emesis occurs, keep head down • Collect, save vomitus for analysis

  25. Ipecac • Contraindications • Comatose or no gag reflex • Seizing or has seized • Caustic (acid or alkali) ingestion • Low viscosity hydrocarbon ingestion • Late term pregnancy

  26. Ipecac • Contraindications • Severe hypertension, cardiovascular insufficiency, possible AMI • Ingestion of: • Strychnine • Phenothiazines (Thorazine, Stellazine, Compazine) • Tricyclic antidepressants • Iodides • Silver Nitrate

  27. Lavage • Commonly used in ED’s • Removes about 31% of substance • Helps get activated charcoal in patient, especially if patient is unconscious • Not helpful for sustained release tablets • Will not remove large tablets

  28. Activated Charcoal • Adsorbs compounds, prevents movement from GI tract • Very effective at adsorbing substances • Binds about 62% of toxin • Dose • 5 - 10X estimated weight of ingested chemical

  29. Activated Charcoal • Inactivates Ipecac • Do not give until vomiting stops • Do not give with • Cyanide • Methanol • Tylenol (+) • Containers must be kept airtight

  30. Inhaled Poisons Objective: Move to fresh air; optimize ventilation and protect personnel from exposure

  31. Absorbed Poisons Objective: Remove poison from skin Liquid: Wash with copious amounts of water Powder: Brush off as much as possible, then wash with copious amounts of water Protect personnel from exposure

  32. Dilute / Irrigate / Wash • Use soap, shampoo for hydrocarbons • No need for chemical neutralization - heat produced by reaction could be harmful

  33. Eye Irrigation • Wash for 15 minutes • Use only water or balanced salt solutions • Remove contact lenses • Wash from medial to lateral

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