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Identifying Poisoning

Identifying Poisoning. Is This Patient Poisoned, And If So, With What?. The Dose Makes The Poison. “What is there that is not poison? All things are poison and nothing [is] without poison. Solely the dose determines that a thing is not a poison”. Philip Theophrastus Bombast von Hohenheim

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Identifying Poisoning

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  1. Identifying Poisoning Is This Patient Poisoned, And If So, With What?

  2. The Dose Makes The Poison “What is there that is not poison? All things are poison and nothing [is] without poison. Solely the dose determines that a thing is not a poison” Philip Theophrastus Bombast von Hohenheim aka PARACELSUS (1493-1541)

  3. Goal of Clinical Management To proceed from undifferentiated signs and symptoms in a patient [without a dependable history] to a reasonable diagnosis ....... in order to initiate appropriate therapy. • Rapid • Organized • Efficient • Safe • Effective

  4. Is This Patient Poisoned • A 37 year old female with a history of a seizure disorder presents with: • Fever (38.5oC) • A rash (shown) • Only medication, phenytoin 300 mg/day for years • No occupational exposures • No significant hobbies

  5. Is This Patient Poisoned • Laboratories • 21% Eosinophils • An AST of 300 IU/L • Diagnosis: • Anticonvulsant hypersensitivity syndrome

  6. The History • The toxin • Medications, Hobbies, Occupation • The form and route • Amount • Elapsed time • Symptoms • Current or resolved symptoms • Timing of symptom onset • Prior therapy administered

  7. Is This Person Poisoned • A 28 year old female is brought to the hospital because of “lethargy” • No past medical or surgical history • No medications • No hobbies • Full time student

  8. Vital signs normal • Slight nystagmus • Slight lethargy easily arousable • Dull expression • Flat affect • Not bothered by her condition • Slightly unsteady gait

  9. Basic laboratory studies normal • ECG normal • CT scan normal • Lumbar puncture normal • Urine positive for benzodiazepines • Flumazenil given • Mental status normal • Police investigation results

  10. How Are Poisoned Patients Different • Suicide note • Empty bottles • Occupational or environmental cluster • Psychiatric history • Substance abuse / misuse • Inconsistencies • Cardiac findings in young people • Vital signs not consistent with mental status

  11. Toxidrome = Toxicologic Syndrome • Toxidrome recognition allows rapid clinical diagnosis and targeted therapy. • Patient history • Vital signs • Targeted physical examination • Rapid, bedside laboratory testing • Metabolic • Glucose • Acid-base • ECG

  12. Toxicologic Physical Examination • Vital signs • Including temperature and pulse oximetry • Key organ system • Mental status • Pupils • Skin • Bowels • Bladder

  13. Toxidrome Symptoms & Signs History Vital signs Simple labs

  14. We Do This Will All Patients • Headache • Fever • Altered mental status • Rash • = Meningococcal meningitis

  15. Opioids • CNS depression • Miosis • Respiratory depression • Gastrointestinal Stasis • Relative bradycardia • Relative hypothermia

  16. Sympathomimetic • Hypertension, tachycardia, hyperthermia, tachypnea • Mydriasis • Diaphoresis • Psychomotor agitation

  17. AnticholinergicAntimuscarinic • Hypertension, tachycardia, hyperthermia, tachypnea • Mydriasis • Psychomotor agitation or somnolence • Dry flushed skin • Absent bowel sounds • Urinary retention

  18. Remember • Hot as a Hare: warm skin • Dry as a bone: dry skin and mouth • Blind as a Bat: cycloplegia, mydriasis • Red as a Pepper: flushed skin • Full as a flask: urinary retention • Mad as a Hatter: altered mental status, hallucinations

  19. Differentiation • Anticholinergic vs Sympathomimetic • Pupils? • Skin • Bowels • Bladder

  20. Muscarinic Salivation Lacrimation Urination Defecation Bronchorrhea Bradycardia Miosis Nicotinic Muscle weakness Fasciculations Paralysis Hypertension Tachycardia Mydriasis Cholinergic

  21. Salicylates • Nausea and vomiting • Tinnitus • Tachypnea and hyperpnea, rarely hyperthermia • Diaphoresis • Respiratory alkalosis • Metabolic acidosis • Ketonuria

  22. Tricyclic Antidepressant • Somnolence, lethargy, or coma • Tachycardia and hypotension • Seizures • Abnormal ECG • Anticholinergic findings

  23. Hypoglycemia • Tachycardia • Diaphoresis • Tremor • Altered mental status • Decerebrate posturing • Decorticate posturing • Fixed and dilated pupils

  24. Incidence of Hypoglycemia • True incidence probably unknown • In 12 months 125 patients were diagnosed at the Harlem Hospital ED • Malouf and Brust: Ann Neurol 1985;17:421-430 • 29/340 (8.5%) consecutive EMS runs for AMS, were identified with hypoglycemia • Hoffman: Ann Emerg Med 1992;21:20-24.

  25. Hypoglycemia • Using the classic findings hypoglycemia • Altered mental status • Tachycardia • Diaphoresis • And/or a history of diabetes • to predict a response to D50W, 25% of hypoglycemic patients would be missed • Hoffman: Ann Emerg Med 1992;21:20-24

  26. Hypoglycemia With A Normal Glucose • Poorly controlled diabetics had symptoms at glucose levels significantly higher than well controlled diabetics: • 4.3 vs 2.9 mmol/L • Boyle: N Engl J Med 1988;318:1487-1492

  27. Tackling Toxidromes • Good history • Directed physical examination • Vital signs, pupils, skin, bowel bladder • Simple tests • Rapid glucose, ECG, ABG, UA, etc • Simple interventions

  28. Think about… • Ethanol • Paracetamol (acetaminophen) • About 1 out of 500 suicidal patients has an unexpected, treatable level Ashbourne J. Ann Emerg Med 1989;18:1035 • Assessment of other potential exposures • Assessment of pregnancy

  29. Provide Life-Saving Care • Treat the Patient Before the Poison: • Airway • Breathing • Circulation • Rare immediate Antidotes • Cyanide kit

  30. Poisoning Includes Deficiencies • Withdrawal syndromes • Alcohol • Sedatives • Opioids • Etc • Metabolic • Thiamine (Wernicke’s encephalopathy)

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