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RESUSCITATION OF THE POISONED PATIENT. Dr Andy McClelland Dept. of Emergency Medicine Auckland Hospital. COMMON POISONINGS. Substance abuse - ‘recreational’ Alcohol's, narcotics, sedatives, stimulants, hallucinogens Intentional overdose Suicide / Parasuicide Accidental
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RESUSCITATION OF THE POISONED PATIENT Dr Andy McClelland Dept. of Emergency Medicine Auckland Hospital
COMMON POISONINGS • Substance abuse - ‘recreational’ Alcohol's, narcotics, sedatives, stimulants, hallucinogens • Intentional overdose Suicide / Parasuicide • Accidental Mislabelled containers / paediatric age group • Toxic exposures Gases , sprays, house fires 5 YR TOXICOLOGY 2003
A journey into the unknown? 5 YR TOXICOLOGY 2003
EVALUATION • Recognition of poisoning • Identification of the poison • Prediction of toxicity • Assessment of severity 5 YR TOXICOLOGY 2003
MANAGEMENT • Supportive care • Prevention of poison absorption • Administration of antidotes • Enhancement of elimination • Prevention of re-exposure • Treat associated conditions/injuries • Disposition of the patient 5 YR TOXICOLOGY 2003
“ The surest poison is time.” Ralph Waldo Emerson (1803-1882)
Suspectoverdose / poisoning in any patient with • altered level of consciousness • unexplained signs & symptoms 5 YR TOXICOLOGY 2003
CLINICAL COURSE • Non-toxic ingestion • Acute toxicity • Delayed toxicity 5 YR TOXICOLOGY 2003
INITIAL PATIENT MANAGEMENT • Condition upon arrival • Likely course of the poisoning • Other injuries / medical conditions • Patient compliance 5 YR TOXICOLOGY 2003
INITIAL PATIENT MANAGEMENT- if unwell ‘Team approach’ 5 YR TOXICOLOGY 2003
INITIAL PATIENT MANAGEMENT- if unwell Initial stabilisation • Triage • Position patient • A, B, C, D • Blood glucose, Temperature • Monitor – SaO2, ECG, BP, LOC 5 YR TOXICOLOGY 2003
INITIAL PATIENT MANAGEMENT- if unwell Airway • Adequacy, protection Breathing • Always 0XYGEN; intubation/ventilation Circulation • Large bore IV’s • Low BP due to decreased vascular tone will respond to IV fluids /inotropes 5 YR TOXICOLOGY 2003
INITIAL PATIENT MANAGEMENT- if unwell • Correct • Hypoxia • Fluid balance • Electrolyte abnormalities • Acid / base abnormalities 5 YR TOXICOLOGY 2003
INITIAL PATIENT MANAGEMENT- if unwell ‘Coma cocktail’ 50 mls 50% dextrose naloxone 2 mg thiamine 100 mg 5 YR TOXICOLOGY 2003
POISONS INFORMATION Ask a senior colleague! 5 YR TOXICOLOGY 2003
POISONS INFORMATION • Text books • Ellenhorn • Haddad • Goldfrank • On-line resources • Substance database (National Poisons Centre) • Poisindex • Toxindex 5 YR TOXICOLOGY 2003
AVOID INJURY TO STAFF • Barrier precautions where applicable • External decontamination • Adequate ventilation • Avert / control violent behaviour • Exclude at risk staff 5 YR TOXICOLOGY 2003
EVALUATION 1 • History • Toxidromes 5 YR TOXICOLOGY 2003
EVALUATION 2- History • Circumstances of discovery • Mental illness / suicide attempts • Reason for overdose • Recreational • Self harm • Depression • Additional injuries • Past medical history • Social history / family history 5 YR TOXICOLOGY 2003
EVALUATION 3- prediction of toxicity • The substances ingested • The quantities ingested • The time since ingestion • Any treatment to date • Concurrent medical conditions 5 YR TOXICOLOGY 2003
EVALUATION 4 - History • Intoxicated patients can be unreliable historians • 70% of intentional overdoses involve more than 1 substance • Always consider substances which patients may not think are harmful examples: aspirin, paracetamol, antihistamines 5 YR TOXICOLOGY 2003
EVALUATION 5- assessment of severity • Vital signs • Physical examination • Eyes • Pupillary size, nystagmus • Neurological • Focal deficit is rare in overdose patients • Skin • Odors • Toxidromes 5 YR TOXICOLOGY 2003
EVALUATION 6- toxidromes • Anticholingeric • Cholingeric • Sympathomimetic • Narcotic • Sympatholytic • Extrapyramidal movement disorders • Haemoglobinopathies • Metal fume fever 5 YR TOXICOLOGY 2003
EVALUATION 7- Diagnostic testing 1 • ECG • Blood tests • Paracetamol level for all patients • Arterial blood gas if unwell • U + E, glucose, anion gap, osmolar gap • FBE • Drug levels • Urine drug screens 5 YR TOXICOLOGY 2003
EVALUATION 7-Diagnostic testing 2: • Harrisons text 5 YR TOXICOLOGY 2003
EVALUATION 8- Diagnostic testing 3 Consider specific tests • CXR for pulmonary aspiration / oedema • LFT’s / coagulation for liver damage • Creatinine kinase for rhabdomyolysis • Cervical spine XR / CT head for injury • AXR for radio-opaque substances 5 YR TOXICOLOGY 2003
PREVENTION OF POISON ABSORPTION ‘Decontamination’ Note - staff may be at risk
DECONTAMINATION 1 • Skin • Remove contaminated clothing / wash skin • Gastrointestinal • Activated charcoal (in 1st hour post ingestion) x Emesis(‘ipecac’ ) – rarely used x Gastric lavage – rarely used • Cathartics / whole bowel irrigation • Eyes 5 YR TOXICOLOGY 2003
DECONTAMINATION 2- activated charcoal • 1 gram / kg • Does not absorb • Lithium • Heavy metals - iron • Alcohols/Solvents/hydrocarbons • Caustics/strong acids • Cyanide • Pesticides • Recovers 60% of poison if administered within the first hour 5 YR TOXICOLOGY 2003
DECONTAMINATION 3- cathartics • Reduced gastrointestinal transit time => reduced time for drug absorption • Osmotic agents – sorbitol, mannitol, MgSO4 • Contraindications • ileus / bowel obstruction • electrolyte imbalance • Indication = debatible 5 YR TOXICOLOGY 2003
DECONTAMINATION 4-whole bowel irrigation • May be useful for concretions & sustained-release preparations • Polyethylene-glycol solution • Administer at 1000 mls/hour until effluent is clear • Rarely donebut may be life saving if SR overdose 5 YR TOXICOLOGY 2003
ANTIDOTES • Useful in < 5% of overdoses • Know which antidotes are stocked • Know how to get advice 5 YR TOXICOLOGY 2003
ANTIDOTES – some examples 5 YR TOXICOLOGY 2003
ENHANCEMENT OF ELIMINATION • Diuresis • Multiple-dose activated charcoal • Urinary pH manipulation - salicylate • Haemodialysis - small molecules, low protein binding - e.g. salicylate, Lithium • Charcoal haemoperfusion - theophylline/barbiturates/carbamazepine 5 YR TOXICOLOGY 2003
TREAT ASSOCIATED CONDITIONS • Trauma • Chronic illness • Environmental 5 YR TOXICOLOGY 2003
MONITORING • Clinical observation • i.e. neurological assessments • Pulse oximetry • ECG monitoring • Minimum 6 hours if cardio-active drug • >24 hours if delayed release preparation 5 YR TOXICOLOGY 2003
DISPOSAL 1 • Discharge • Admission 5 YR TOXICOLOGY 2003
DISPOSAL 2 • Discharge Prerequisites: • Medical fitness • ‘Safety check’ Formal assessment of suicide and self-harm risk 5 YR TOXICOLOGY 2003
DISPOSAL • Admission 4 • Critical Care unit 5 YR TOXICOLOGY 2003
DISPOSAL 5 • Admission • Psychiatric unit 5 YR TOXICOLOGY 2003
DISPOSAL 6 • Admission • General Medical unit 5 YR TOXICOLOGY 2003
DISCHARGE ADVICE • COUNSELLING • Community and alcohol counselling contacts for recreational drug abuse • EDUCATION • Care-giver education for accidental ingestion's • LEGAL • OSH contact for work-related toxic exposures 5 YR TOXICOLOGY 2003
SUMMARY 1 • Consider poisoning in any patient with • ALOC • Unexplained signs and symptoms of any nature • Supportive care is the primary objective • TSS ‘Think simple stupid’ • A • B • C 5 YR TOXICOLOGY 2003
SUMMARY 2 • Evaluation of the patient • Is thorough history taking from all sources • Is occasionally aided by ‘toxidrome’ recognition • Do not rely on toxicology screening tests 5 YR TOXICOLOGY 2003
SUMMARY 3 • Management of the patient • Depends on your assessment of A B C D • Treating the patient not the poison • Initiating clinically indicated treatment early • Asking advice early 5 YR TOXICOLOGY 2003
Any questions? 5 YR TOXICOLOGY 2003