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Management of Acute Overdose

Management of Acute Overdose . By: Peter Rempel March 27 th , 2013. Presentation Outline. Introduction and Statistics General management strategy Identification of Toxidromes Management of overdose for specific medications Role of pharmacist. Introduction - Overdose.

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Management of Acute Overdose

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  1. Management of Acute Overdose By: Peter Rempel March 27th, 2013

  2. Presentation Outline • Introduction and Statistics • General management strategy • Identification of Toxidromes • Management of overdose for specific medications • Role of pharmacist

  3. Introduction - Overdose • Definition: The use of a substance in quantities greater than recommended. • Accidental vs. Intentional misuse

  4. Epidemiology - Overdose • Approximately 2.3 million cases reported (US) • 50% caused by pharmaceutics • 41,592 deaths occurred in the US (2009) • 76%were unintentional • 91%caused by medications • Prevalence higher in males during the early years (0-12y) • Rates in females surpass males in older populations

  5. Epidemiology (Continued) Most common pharmaceutics: • Analgesics (Opioids) • Sedative/hypnotic/antipsychotics • Antidepressants • Antihistamines • Cardiovascular drugs • Vitamins, cough and cold products • Rates of unintentional overdose has been steadily increasing

  6. General Management Strategy • ABC management (vital signs) • Call Poison Control • Obtain best possible medical history • Order Labs • Prevent absorption of toxin • Enhance elimination (antidote)

  7. General management strategy • ABC management • Airway patency - head-tilt and chin-lift, removal of obstructions • Breathing -assisted ventilation • Circulation - colour change, sweating, decreased LOC - EKG, saline infusion, vasopressers

  8. General Management Strategy • Call Poison Control • Available 24/7 to provide poison treatment information • Help guide treatment strategy • Prevent unnecessary use of health care resources • http://www.capcc.ca/provcentres/on/on.html

  9. General Management Strategy • Obtain accurate history • Determine the causative agent • Dose • Time since exposure • Route • Demographics (age, weight) • Symptoms* • Physical Examination

  10. What if you don’t know what medication/poison was ingested?

  11. Identification of Toxidromes

  12. What is a Toxidrome? • Characteristic symptoms that are associated with a specific group of medications. • These group of symptoms are known as a “Toxidrome”

  13. Identification of Toxidromes Cholinergic Toxidrome • “SLUDGE” • Salivation, Lacrimation, Urination, Defecation, GI upset, Emesis • Miosis, diaphoresis, bradycardia • Causative Agents: Physostigmine, Organophosphates, Carbamate

  14. Identification of Toxidromes AnticholinergicToxidrome • Hot as a Hare - fever • Red as a Beet - flushing • Mad as a Hatter – confusion, delirium • Dry as a bone – dry skin/mucus membranes • Mydriasis, tachycardia, urinary retention • Causative Agents: Antihistamines, TCA`s, Anti-parkinsonmedications

  15. Identification of Toxidromes SympathomimeticToxidrome • Anxiety, Delusions, Sweating, Piloerrection, Seizures, Hyperreflexia, Mydriasis • Causative Agents: cocaine, salbutamol,, amphetamines, ephedrine, pseudoephedrine, methamphetamine

  16. Identification of Toxidromes Sedative/Hypnotic/Opiate Toxidrome • Slurred speech, confusion , stupor, coma, apnoea, respiratory depression • Hypotension, bradycardia, miosis • Causative agents: opioids,anticonvulsants, antipyschotics, barbiturates, benzodiazepines, ethanol

  17. Back to the Management Strategy

  18. General Management Strategy • Order lab tests • Confirm offending agent(s) • Predict prognosis • Direct therapy/monitoring Includes:Toxicology screen, anion gap, osmol gap, CBC, BUN, SCr, blood glucose, electrolytes, EKG monitoring

  19. General Management Strategy • Prevent absorption • *Activated Charcoal- first line therapy in most emergency departments • Whole Bowel Irrigations- clears the GI tract using high volumes of PEG • OrogastricLavage- No benefit over the use of activated charcoal • Syrup of Ipecac- NO LONGER RECOMMENDED http://www.freepatentsonline.com/7077825.html

  20. General Management Strategy Activated Charcoal • Ability to adsorb substances due to its high surface area • Offending agent(s) become trapped by the charcoal and are excreted in the feces Dosing: 1g/kg po OR by NG tube (usually given multiple times) AE: aspiration pneumonia, GI obstruction Contraindications: presence of ileus

  21. General Management Strategy Activated Charcoal • Does not adsorb the following compounds: • Iron • Lithium • Lead • Cyanide • Alcohol

  22. General Management Strategy • Enhance Elimination • Hemodialysis/Hemoperfusion • Administer Antidote

  23. General Management Strategy Administer Antidote: *See my website for a more exhaustive list www.ODmanagement.weebly.com

  24. Opioid Overdose Managment

  25. Opioid Overdose Management • Signs and Symptoms? • Hint: Remember the toxidrome!

  26. Opioid Overdose Management • Signs and Symptoms? • Hint: Remember the toxidrome! • Decreased LOC, RR, GI motility • Hypotension, bradycardia, miosis

  27. Naloxone • Reverses effects from opioid overdose • Pure opioid receptor antagonist • Duration of action 30-120 minutes • 0.4-2mg (IV,IM,SC); repeat q2-3 minutes until reversal of symptoms • Use continuous IV infusion for exposure to long-acting opioids or SR formulations

  28. Acetaminophen Overdose

  29. Hamm J. Acute acetaminophen overdose in adolescents and adults.CriticalCare Nurse; Jun 2000; 20(3) 69-74

  30. Hamm J. Acute acetaminophen overdose in adolescents and adults.CriticalCare Nurse; Jun 2000; 20(3) 69-74

  31. N-acetylcysteine • Indicated for the reversal of Acetaminophen toxicity • Hepatoprotective agent • Restores hepatic glutathione and acts as a glutathione substitute • Prevents the production of the toxic by-product of acetaminophen

  32. N-acetylcysteine Dosing • 21 hour IV dosing regimen (3 doses) • LD: 150 mg/kg (Max 15g) over 1 hour • 2nd dose: 50 mg/kg (max 5g) over 4 hours • 3rd dose: 100 mg/kg (max 10g) over 16 hours • Oral dosing regimen also available (72 hours) • Therapy is guided by the Matthew-RumackNomogram

  33. Matthew-RumackNomogram The Merck Manual for Health Professionals. Acetaminophen Poisoning. http://www.merckmanuals.com/professional/injuries_poisoning/poisoning/acetaminophen_poisoning.html

  34. Anaesthetic Overdose/Refractory Cases

  35. Lipids 20%- Intralipid® • Used in anaesthetic overdose and refractory cases (unlabelled use) • Mechanism unknown • Effective for lipophilic medication overdose • Suggested Dose: • 1.5 mL/kg bolus infused over 1 minute (may repeat up to 2 times) • Followed by 0.25 mL/kg/minute continuous infusion http://www.lipidrescue.org/

  36. Role of the Pharmacist • Role in both the community and hospital setting • Educating patients on the dangers of drug misuse • Identifying potential at risk patients • Identifying inappropriate medication regimens • Medication Reconciliation

  37. Highlights • Majority of overdoses are accidental • Rates of accidental overdose is steadily increasing • Identifying Toxidromes plays a vital role in the management of overdose • Activated charcoal and whole bowel irrigation are effective at lowering absorption • Pharmacists can play a role in both the prevention and treatment of an overdose

  38. References • Clinical Practice Guidelines. Management of Drug Overdose & Poisoning. Ministry of Health, Singapore. May 2000. • Green SL, Dargan PI, Jones AL. Acute poisoning: understanding 90% of cases in a nutshell. Postgrad Med J. 2005;81:204-216. • Tenenbein M et al. Efficacy of ipecac-induced emesis, orogastriclavage, and activated charcoal for acute drug overdose. Annals of Emergency Medicine; 16(8): 838-841  • Lab Tests Online. Emergency and Overdose Drug Tests. http://labtestsonline.org/understanding/analytes/emergency/tab/test: Accessed March 22, 2013 • Thim T, Niels HV, et al. Initial assessment and treatment with the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach. International Journal of General Medicine; 2012:5 117-121

  39. References 6) Centers for disease control and prevention. Home and Recreational Safety. Unintentional Poisoning Data and Statistics. Retrieved from http://www.cdc.gov/HomeandRecreationalSafety/Poisoning/data.html ; accessed March 3, 2013 7) HodgmanMJ et al. A review of Acetaminophen Toxicity.Crit Care Clin. 28 (2012) 499-516 8) G Cave et al. Intravenous Lipid Emulsion as Antidote Beyond Local Anesthetic Toxicity: A Systematic Review. Academic Emergency Medicine: 2009; 16:815-824 9) Boyer EW. Management of Opioid Analgesic Overdose.. N Engl J Med: 367;2 146-155

  40. Thank you for listening ANY QUESTIONS? www.odmanagement.weebly.com

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