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IN THE NAME OF GOD

IN THE NAME OF GOD. AN APPROACH TO A POISONED PATIENT DR. FAZEL GOUDARZI;TRAUMATO PATHOLOGIST AND CLINICAL TOXICOLOGIST SHIRAZ UNIVERCITY OF MEDICAL SCIENCES. Introduction. What is a poison? In common usage - poisons are chemicals or chemical products that are distinctly harmful to human

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IN THE NAME OF GOD

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  1. IN THE NAME OF GOD

  2. AN APPROACH TO A POISONED PATIENT DR. FAZEL GOUDARZI;TRAUMATO PATHOLOGIST AND CLINICAL TOXICOLOGIST SHIRAZ UNIVERCITY OF MEDICAL SCIENCES

  3. Introduction • What is a poison? • In common usage - poisons are chemicals or chemical products that are distinctly harmful to human • More precisely - a poison is a foreign chemical (xenobiotic) that is capable of producing a harmful effect on a biologic system

  4. Other terminology • What is a toxin? • It originally referred to a poison of animal or plant origin • Toxicant is the currently preferred scientific term for all poisons.

  5. Epidemiology • Ingestion of a potentially poisonous substance by a young child is common. • American Association of Poison Control Centers reported 1.2 million ingestions in children < 6 years of age in 2001. • Death is uncommon in this age group. • Decline in death rate from 500 mortalities per year in the 1940s to 25 mortalities in 1997

  6. Epidemiology Decline in mortality attributed to: • child resistant containers • safer medications • anticipatory guidance • public education • legislation • establishment of poison control centers • sophisticated medical care • antidotes

  7. Clinical assessment

  8. Approach to the Poisoned PatientHistory • Time of ingestion • Medications in the household • Amount ingested • Onset of symptoms • Intentionality • Underlying medical conditions

  9. Approach to the Poisoned PatientPhysical Examination • Vital Signs • Pupillary exam (miosis, mydriasis) • Skin (dry, cyanotic) • Lungs (crackles, wheezing) • Cardiac (tachycardia, bradycardia) • Abdomen (decreased bowel sounds, tenderness) • Neurologic (altered mental status, seizure)

  10. Approach to the Poisoned Patient Initial Management • Airway • Breathing • Circulation • Disability • Exposure

  11. Clinical assessment • Airway - ensure clear airway, clear secretions, check for cough/gag • Breathing - check oxygenation, supplemental O2, breathing pattern & adequacy • Circulation - heart rate, rhythm, blood pressure

  12. Clinical assessment • Neurologic - GCS, seizures, agitation, spasms, pupils, autonomic dysfunction • Miscellaneous - odour, temperature, pallor, cyanosis, jaundice • Abdomen - rigidity, bleeding, urine output

  13. Laboratory and imaging(paraclinical) assessment

  14. CBCD Electrolytes ABG LFTs CXR ECG AXR Serum Tox Urine Tox ASA level Tylenol level Serum OSM Cholinstrase Approach to the Poisoned PatientDiagnostic Evaluation

  15. Laboratory assessment • Electrolytes • Hypokalemia • Oduvanthalai poisoning (Clistanthis collinis) • Diuretics, Methyl xanthine, Toluene • Hyperkalemia • Digoxin • Beta-blocker • Liver function tests • Acetaminophen, Ethanol, Carbon tetrachloride • Renal function tests • Ethylene glycol, NSAIDS

  16. Anion Gap (AG) Anion Gap = Na+ - [Cl- + HCO3 -] Normal AG: 8-16

  17. Methanol Paraldehyde INH Fe Ethylene glycol Salicylates CO Cyanide Hydrogen Sulfide ETOH (ketones) Metformin Phenformin Sulfur Theophylline Toluene Toxins associated with increased AG

  18. Toxins associated with decreased AG • Lithium • Bromide

  19. Osmolal Gap (OG) Serum OSM: 2[Na] + [Glc]/18 + [BUN]/2.6 OG: Measured OSM-Calculated OSM Normal OG: -3 to 10 mOSM/kg H2O

  20. Toxins associated with increased OG • Methanol • Ethanol • Ethylene glycol • Acetone • Isopropanol

  21. Acetaminophen Carbon Monoxide Ethanol Ethylene glycol Heavy metals Iron Methanol Methemoglobin Salicylates Carbamazepine Digoxin lithium Phenobarbital Phenytoin Theophylline Valproate Useful Toxin Levels Set time point Serial levels

  22. ECG and Imaging Assessment • ECG • Digoxin toxicity • TCA overdose - sinus tachycardia, QT prolongation, increased QRS • Beta-blockers - conduction abnormalities • Imaging • Chest x-ray • Abdominal x-ray • Cervical x-ray (lateral) • C.T scan or MRI in decrease L.O.C.

  23. Radiopaque drugs • Bezoars/Bags • Calcium carbonate • Chloral hydrate • Enteric-coated tablets • Heavy metals • Iodine • Fe • Phenothiazines • Potassium compounds

  24. Other terminology • What is a toxidrome?(TOXICOLOGIC SYNDROME)? • It is the association of several clinically recognizable features, signs, symptoms, phenomena or characteristics which often occurtogether, so that the presence of one feature alerts the physician to the presence of the others.

  25. Common toxidromes

  26. Opiate toxidrome

  27. Opiate toxidrome

  28. Opiate toxidrome

  29. Toxidromes Opiates • Miosis • Respiratory depression • Cns depression • Hypotension • Sedation • Decreased GI motility • Urinary retention

  30. ToxidromesOpiates • Seizures-Meperidine; occur secondary to the metabolite normeperidine • Dysrhythmias-Propoxyphene; occur from the metabolite norpropoxyphene • Rigid Chest-Fentanyl

  31. Common toxidromes

  32. The cholinergic toxidrome

  33. The cholinergic toxidrome

  34. The cholinergic toxidrome

  35. ToxidromesCholinergics-Muscarinic Effects • Salivation • Lacrimation • Urination • Defecation • Gastrointestinal Distress • Emesis

  36. TOXIDROMECHOLINERGIC CNS EFFECT • RESTLESSNESS • AGITATION • CONFUSION • CONVULSION • COMA • DEATH

  37. ToxidromesCholinergics-Nicotinic Effects • Muscle Fasciculations • Weakness • Paralysis • Sympathomimetic effect

  38. What toxidrome?

  39. The anticholinergic toxidrome Hot as a hare Dry as a bone Red as a beet Mad as a hatter Blind as a bat

  40. The anticholinergic toxidrome Hot as a hare Dry as a bone Red as a beet Mad as a hatter Blind as a bat

  41. The anticholinergic toxidrome Hot as a hare Dry as a bone Red as a beet Mad as a hatter Blind as a bat

  42. ToxidromesAnticholinergics • “Red as a beet”- Flushed skin • “Hot as a hare”-Hyperthermia • “Mad as a hatter”-Psychosis • “Dry as a bone”-Dry skin, urinary retention • Tachycardia • Mydriasis

  43. What toxidrome? disorientation Amphetamine hallucinations Cocaine Hallucinogenic hyperactive bowel Pseudoephedrine panic Phencyclidine Benzodiazepenes seizure Ephedrine Toxidrome Hypertension Tachycardia Tachypnea

  44. HallucinogenicSympathomimetic toxidrome disorientation Amphetamine hallucinations Cocaine Hallucinogenic and stimulants hyperactive bowel Pseudoephedrine panic Phencyclidine Benzodiazepenes seizure Ephedrine Toxidrome Hypertension Tachycardia Tachypnea

  45. HallucinogenicSympathomimetic toxidrome disorientation Amphetamine hallucinations Cocaine Hallucinogenic hyperactive bowel Pseudoephedrine panic Phencyclidine Benzodiazepenes seizure Ephedrine Toxidrome Hypertension Tachycardia Tachypnea

  46. HallucinogenicSympathomimetic toxidrome disorientation Amphetamine hallucinations Cocaine Hallucinogenic hyperactive bowel Pseudoephedrine panic Phencyclidine Benzodiazepenes seizure Ephedrine Toxidrome Hypertension Tachycardia Tachypnea

  47. HallucinogenicSympathomimetic toxidrome disorientation Amphetamine hallucinations Cocaine Hallucinogenic hyperactive bowel Pseudoephedrine panic Phencyclidine Benzodiazepenes seizure Ephedrine Toxidrome Hypertension Tachycardia Tachypnea

  48. Common toxidromes

  49. Sedative/hypnotic toxidrome

  50. Sedative/hypnotic toxidrome

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