1 / 40

Diagnosis of Poisoning

Diagnosis of Poisoning. Kent R. Olson, MD, FACEP Medical Director California Poison Control System, San Francisco Division University of California, San Francisco. Lessons from history. A young princess ate part of an apple given to her by a wicked witch

oshin
Download Presentation

Diagnosis of Poisoning

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Diagnosis of Poisoning • Kent R. Olson, MD, FACEP • Medical Director • California Poison Control System, • San Francisco Division • University of California, San Francisco

  2. Lessons from history • A young princess ate part of an apple given to her by a wicked witch • She presented comatose and unresponsive (as if she was in a deep sleep) • Airway positioning and mouth to mouth ventilations were performed, and she recovered

  3. Diagnosis of Poisoning • Rule #1: Take good care of the patient • ABCD’s: • Airway • Breathing • Circulation • Dextrose, Drugs & Decontamination • Rule out: • Head trauma, Meningitis, Sepsis • Metabolic disorders

  4. Diagnosis of Poisoning • Rule #2: Get a good history • Check multiple sources: • Patient • Family, Friends • Paramedics, Pharmacy • Circumstances: • What was taken? • How much? • When?

  5. Diagnosis of Poisoning • Rule #3: Do a good physical exam • Toxicologic physical exam: • Mental status • Vital signs (all of them) • Pupils • Bowel sounds • Muscle tone and activity • Skin: dry or diaphoretic? • Look for an autonomic syndrome

  6. Autonomic Syndromes SympatheticCholinergic • Blood Pressure +++/-- • Pulse Rate + +/-- • Pupils dilated pinpoint • Peristalsis -++ • Skin sweatysweaty

  7. Autonomic Syndromes SympatheticSympatholytic • Blood Pressure ++-- • Pulse Rate + -- • Pupils dilated small • Peristalsis -- • Skin sweaty-

  8. Autonomic Syndromes AnticholinergicCholinergic • Blood Pressure ++/-- • Pulse Rate ++ +/-- • Pupils dilated pinpoint • Peristalsis --++ • Skin dry sweaty

  9. Autonomic Syndromes SympatheticAnticholinergic • Blood Pressure +++ • Pulse Rate +++ • Pupils dilateddilated • Peristalsis --- • Skin sweatydry

  10. Case Study • Two adolescents are brought to the ED by their parents because of agitation. • #1: BP 150/100, HR 120, pupils dilated, jumpy, diaphoretic. • #2: BP 130/90, HR 130, pupils dilated, distended bladder, dry flushed skin.

  11. Sympathomimetic Syndrome • Common features: • Agitation, psychosis • Hypertension, tachycardia • Dilated pupils • Diaphoresis • Hyperthermia • Common causes: • Cocaine • Amphetamines (including MDMA - Ecstasy) • Phencyclidine (PCP) • Phenylpropanolamine (PPA): often causes severe hypertension with reflex bradycardia

  12. Anticholinergic Syndrome • Common features: • Dilated pupils • Dry, flushed skin • Sinus tachycardia • Ileus, urinary retention • Confusion, delirium • Common causes: • Atropine & related drugs • Plants (eg, jimson weed)& mushrooms (eg, A. muscaria) • OTC & Rx antihistamines • Tricyclic antidepressants Mad as a Hatter Red as a Beet Blind as a Bat Dry as a Bone

  13. Case Study • A 28 year old woman presents groggy and confused. Pupils 7-8 mm. Skin dry and flushed. Bowel sounds diminished. • 130/90 120/min 14/min 37.8 C • Shortly after arrival she has a grand-mal seizure. • ECG monitor: QRS 0.16 sec, wide complex tachycardia

  14. Tricyclic Antidepressant Overdose • Anticholinergic syndrome • The three “Cs”: • Coma • Convulsions • Cardiac conduction abnormalities • QRS >0.12 sec is a better predictor of toxicity than the serum drug level

  15. Common Causes of Seizures • Tricyclic antidepressants • Newer antidepressants – esp. Wellbutrin • Cocaine, Amphetamines • Diphenhydramine • Isoniazid

  16. Case Study • A 2 year old child is found unresponsive. The parents are suspected heroin users. • BP 80/50 HR 70 RR 6, shallow • Pupils 1 mm. Peristalsis decreased. Muscle tone flaccid. No sweating. • There is no response to 0.4 mg naloxone.

  17. Case (cont.) • Common causes of miosis: • Opioids • Other sympatholytic drugs • Phenothiazines • Cholinergic agents • CNS structural lesions

  18. Case (cont.) • There was no response to repeated doses of naloxone to a total of 4 mg. • There was no response to flumazenil (total dose 1.2 mg). • The parents found an opened bottle of clonidine 0.1 mg on the kitchen floor.

  19. Common Sympatholytic Agents: • Opioids • Clonidine • Benzodiazepines • Barbiturates • Ethanol

  20. Case Study • A 34 year old man drank an unidentified liquid. He vomited several times, and became weak and pale. In the ED: • BP: 150/100 HR 110 • Pupils pinpoint. Profuse diaphoresis. Vomit has a chemical odor. • He develops muscle fasciculations and has a respiratory arrest.

  21. Cholinergic Syndrome • “SLUD” • Salivation, Sweating • Lacrimation • Urination • Diarrhea, Vomiting • also:muscle weakness paralysis

  22. Diagnosis of Poisoning • Rule #4: Use the laboratory appropriately • Routine labs • Arterial blood gases • Electrolytes & anion gap • Osmolality • Toxicology testing • Tox screening • Specific stat quantitative tests

  23. Case Study • A 44 year old man was found unconscious, with a suicide note and a half-empty bottle of whiskey. • BP 110/80 HR 110 RR 32 • pH 7.47 pCO2 18 pO2 88 • Na 140 K 3.8 Cl 106 HCO3 18 • Ethanol 0.18 gm/dL

  24. Anion Gap • Na - Cl - HCO3= 8-12 mEq/L • Causes of increased gap: “SALAD” • Salicylates • Alcohols • Lactic Acidosis • Anuria • DKA

  25. Salicylate Intoxication • Typical mixed acid-base abnormality: • Respiratory alkalosis • Metabolic acidosis • Treatment: • Alkalinize urine, restore serum pH • Hemodialysis

  26. Radiopaque Drugs & Poisons • Unreliable - useful only if positive • Commonly radiopaque: • Iron • Potassium • Calcium • Sometimes visible: • Chloral hydrate • Phenothiazines • Sustained-release preparations

  27. Case • A 16 year old was brought to the ED by paramedics after an overdose of Tylenol with codeine • She had small pupils, and was very sleepy/poorly responsive • Naloxone 2 mg increased pupil size and she became combative but not fully awake

  28. Case, continued • Her mother was questioned: “. . . I didn’t say she overdosed. . . I told them I was worried about all the pain pills she was using for her headache. . .” • Rectal Temp: 102.5 F • LP: pneumococcal meningitis!

  29. Important “Rule-Outs” • “ATOMIC” • Alcohol: check ETOH; consider alcoholism • Trauma: consider CT scan • Overdose: other drugs involved? • Metabolic: Na, glucose, O2, Thyroid, etc. • Infection: consider LP • Carbon Monoxide: obtain COHgb

  30. Case Study • A 27 year old woman found obtunded with pinpoint pupils, awoke with IV naloxone, and admitted to ingestion of a few pain pills. • Does this patient need a Tox Screen? • She was treated with oral activated charcoal, observed for 4 hours, and released to psychiatry.

  31. Case (cont.) • Three days later, she returned because of nausea, abdominal pain, and lethargy. She appeared jaundiced. • AST 8,000 PT 28 sec Bilirubin 3.6 • Toxicology screen from the original visit revealed acetaminophen.

  32. Acetaminophen • Pitfalls in Diagnosis: • History: • Not volunteered by patient • Hidden ingredient in many products • No initial specific symptoms • Physical exam & laboratory: • No initial specific findings • Only reliable test: STAT acetaminophen

  33. Comprehensive Toxicology Screening • Problems: • Slow, expensive • Many drugs not included • Potential uses: • Forensic questions • Possible brain death • Quick “drugs of abuse” screens • ? Useful - for JGP • Many drugs not included – know your hosp’s limits • Should not use (+) test forensically unless confirmed

  34. Toxicology Laboratory • Quantitative testing may be useful if: • results will return quickly, and . . . • results will affect clinical management • Examples of specific useful levels: • Acetaminophen • Carbon monoxide • Digoxin • Salicylate • Valproic acid

  35. Diagnosis of Poisoning - Summary • Take good care of the patient • Get a good history • Do a good physical exam • Use the laboratory appropriately • Consult with the Poison Control Center: • 1-800-411-8080 or 1-800-222-1222

More Related