Post on 19-Jul-2015
The PCC, Toxidromes, and “Deadly in a Dose”
Peds IngestionsJohn Dayton, MD FACEP
Emergency Physician, Assistant ProfessorBoard Member, Utah ACEP
Legislative Committee Member, UMA
Disclosure
Most of these slides are mine, but I also included information from the Poison Control Center’s (PCC) 2012 review book and a toxidrome presentation.
I did this for two reasons: the data goes with their Toxidrome booklets I’m handing out and their data is really good.
Goals
• Discuss scope of poisonings in Utah
• Discuss common toxidromes and common prescriptions, OTCs and supplements from each category
• Discuss initial evaluation and stabilization
• Discuss use of PCC resources and EMS resources
• Quiz time (with prizes)
Utah Poisonings from 2012 Report
Why?•Kids – 99% accidental•Teens – 42% accidental•Adults – 61% accidental
Where?•Own home – 88%•Other home – 5%•Work – 2%•Other – 5%
Utah Poisonings from 2012 Report
•Unintentional – 84%•Intentional – 11%•Adverse Reaction – 2.5%•Other (tampering, poisoning, etc) – 1%•Unknown – 0.6%
Utah Poisonings from 2012 Report
Call outcome:
• 76% of calls handled over the phone
• 90% of Peds cases managed over the phone
• 20% required treatment in health care facility
Most Common Substances
Less than 6
years
6-19 years 20+ Years
Cosmetics/
personal care
Analgesics Analgesics
Analgesics Cough and Cold Sedative/hypnotic
Cleaning
substances
Sedative/hypnotic Antidepressants
Vitamins &
Minerals
Antidepressants Bites/envenomations
Topicals Foreign bodies Cleaning substances
Utah 2008
“Deadly in a Dose”
Beta-blockers
Calcium channel blockers
Clonidine
Opioids (narcotics)
Oral hypoglycemics
Toxic alcohols
Tricyclic antidepressants
“olols”: carvedilol (coreg), labetalol, metoprolol
(toprol),timolol (timoptic eye drop)
“pines”: amlodipine (norvasc), nifedipine (procardia),
nicardipine (cardene), verapamil, diltiazem (cardizem)
Clonidine (kapvay or nexiclon) for HTND or ADHD
Lortab, percocet, tylenol 3, fentanyl, oxcodone,
oxycontin, hydrocodone, methadone, suboxone
Sulfonylurea (glyburide, blipizide), acarbose, glucovance
(glyburide/metformin)
Methanol (wood alcohol blindness and death),
isopropyl alcohol (solvent), ethylene glycol (antifreeze)
Amitriptyline (elavil), imipramine (tofranil)
“Deadly in a Dose”
Ingestions are possibly deadly for Ped patients in homes where any family members (especially grandparents) are taking meds for:
• Hypertension – beta Ca blockers (-olos)
• Diabetes – sulfonylureas (glipizide)
• Pain - narcotics
• Parkinsons – selegiline (MAO-B inhibitor), benztropine (cogentin – anticholinergic/antihistamine)
• Psychiatric problems – TCAs (elavil, Imipramine)
Poisoning Fatalities• Sedative/Hypnotics/Antipsychotics
– benzodiazepines (Valium, Xanax, Klonipin)– antipsychotics (Seroquel)
• Opioids (Oxycontin, methadone)• Antidepressants (amitriptyline, Prozac)• Cardiovascular drugs (beta blockers, calcium channel
blockers, clonidine)• Acetaminophen alone and combinations (pain and
cold meds)• Alcohols• Stimulants and street drugs
Toxidrome
• A constellation of signs and symptoms that characterize a particular toxin or a category of toxins
• Helps in “unknown” situations to narrow down possible toxins
• Vital signs and toxicology assessment essential to identify possible toxidromes
Toxicology Assessment
• Signs and Symptoms– vital signs (HR, BP, R, Temp)– neurologic status– pupils– skin color/temp
• Allergies• Medications in home• Past medical history
• Circumstances Leading to Event
Toxidrome #1
• A 16-year-old girl found by parents to be confused, agitated and actively hallucinating (picking bugs off skin)
• Vital signs: HR 124 bpm, BP 135/88 mm Hg, T 100.8°F
• Pupils: 5 mm bilaterally (mydriasis)
• Skin: flushed, dry skin
• Physical exam: dry mouth, diminished bowel sounds
Anticholinergic Toxidrome
• Blind as a bat
• Dry as a bone
• Red as a beet
• Hot as a hare
• Mad as a hatter
Exam: mydriasis, dry flushed skin, hyperthermia, altered mental status, seizure, tachycardia, hypotension, urinary retention
Antidote: PhysostigmineOther Treatment: fluids
Anticholinergics
OTC: antihistamine (benadryl)
Prescriptions:
• TCAs (amatriptyline/elavil, imipramine)
• Antipsychotics (chorpromazine,
fluphenazine/prolixin, haldol)
• Parkinson meds (benztropine)
• Muscle relaxants
• Scopolamine
• Atropine
Natural: Jimson weed, deadly nightshade
Toxidrome Case #2
• 32-year-old woman found delirious and very agitated; extremely paranoid; appears to be hallucinating
• Vital signs: HR 130 bpm; BP 170/100 mm Hg; R 16/min; T 100.4°F
• Pupils 7mm (mydriasis)
• Skin: moist, diaphoretic
Stimulant (Sympathomimetic) Toxidrome
Vitals: elevated BP, HR and hyperthermia
HEENT: mydriasis
Derm: diaphoresis
Cardiac: tachycardia, SVT, Afib, Aflutter, heart blocks, chest pain
Neuro: seizures, stroke
Psych: psychosis, delirium,
bruxism (teeth grinding)
Stimulants
OTC: decongestants (pseudoephedrine), phenylephrine
Prescription: Adderall, Ritalin, Thyroid Supplements (synthroid)
Natural: ma huangIllegal: PCP, cocaine, meth
• Treatment: Benzodiazepines
Toxidrome Case #3
A 15-year-old boy found unresponsive, snoring in bed.
Vital signs: HR 50 bpm, BP 90/60 mm Hg, RR 5/min, Temp 97°F
Pupils 1-2 mm (miosis)
Neurologic: unresponsive to painful stimuli
Physical exam: decreased bowel sounds
Opioids (“Narcotics”)
Signs and Symptoms
• CNS and respiratory depression
• Miosis
• Hypotension, bradycardia, hypothermia
Antidote
• Naloxone 0.4-2 mg
Examples: heroin, morphine, oxycodone, fentanyl, hydrocodone, hydromorphone, buprenorphine (Suboxone), methadone
Toxidrome Case #4
• A 45-year-old female found unresponsive at home. She was last seen approximately 20 hours prior. She does not respond to painful stimuli.
• Vital signs: HR 60 bpm, BP 100/50 mm Hg, T 96°F, RR 10/min
• HEENT: 4 mm bilaterally, reactive to light• Skin: pressure sores• Physical exam: poor gag reflex,
decreased muscle tone and depressed reflexes
Sedative-Hypnotic Agents• Central nervous system depression
– ataxia, slurred speech, drowsiness, confusion → coma– loss of reflexes, respiratory depression, myocardial
depression• Barbiturates like phenobarbitol, pentobarbital
(nembutal) • Benzodiazepines like chordiazepoxide (librium),
diazepam (valium), alprazolam (xanax)• Combo drugs: fioricet/fiorinal (contains
butalbital), donnatol• Alcohol and narcotics• Additive/synergistic effects in combination
Sedative-Hypnotic Agents:Alcohol Derivatives
Methanol:• Found in windshield wiper fluid, anifreeze, solid fuels (sterno)• Conversion to formic acid anion gap acidosis - intoxicated, headache, CNS
depression, visual change “looking through snow field” blindess, tachycardia/ypnea, abd pain, N/V
• Hallmark: blind drunk with anion gap metabolic acidosisEthylene glycol • Found in coolants (antifreeze) • oxalic acid renal toxicity• Sx include intoxication, HA, CNS depression,
N/V, Acute Renal Failure• Oxalate crystals in urine can be seen with woods lampsIsopropyl alcohol• Found in rubbing alcohol and hand sanitizers• CNS depression, coma, N/V, hemorrhagic gastritis• Hallmark: drunk without +serum alcohol
Toxidrome #5
• A 14-year-old girl found acting strangely with complaints of nausea and vomiting and ringing in ears
• Vital signs: HR 110 bpm; BP 120/60 mm Hg; R 30/min; T 100.2°F
• Pupils 4 mm
• Skin: diaphoretic
Salicylates
Exam
• Neuro: confusion, agitation, seizures, lethargy coma
• Vitals: increased respiratory rate, HR and temp
• Skin: normal to sweaty
• GI: nausea and vomiting
• Hallmarks: tinnitis (ringing ears) or other hearing changes
OTCs, prescriptions – aspirin, shampoos, pepto-bismol, oil of wintergreen, muscle rubs
Treatment – supportive care +/- intubation, charcoal, HD
Toxidrome #6
• A 56-year-old woman with confusion, shortness of breath, vomiting and diarrhea
• Vital signs: HR 50 bpm; BP 90/palp mm Hg; R 32/min; T 98.6°F
• Pupils 2 mm
• Skin: profuse sweating, tearing and rhinorrhea
• Physical exam: hyperactive bowel sounds, muscle fasciculations
Cholinergic ToxidromeMnemonics:• DUMBELLS:
• Diarrhea
• Urination
• Miosis, muscle fasciculations & weakness
• Bronchorrhea, Bradycardia, Bronchospasm
• Emesis
• Lacrimation, Loss of muscle strength
• Salivation, Sweating
• SLUDGE: Salivation/sweating, Lacrimation, Urination, Defecation, GI distress, Emesis
• Killer Bs: Bradycardia/Bronchorhea/Bronchospasm)
Cholinergic Meds
Medications: Alzehimers meds (donepizil), Myasthenia Gravis meds (pyridostimine, edrophonium), Carbamates like soma, felbatol for seizures
Chemicals: organophosphates (farming), carbamatesinsecticides, sarin, cytocybe and inocybe mushrooms
Other Drugs to be Aware of
Tylenol – 140 mg/kg can kill the liver. Presents in 4 stages. RUQ pain with elevated LFTs and bili. Antidote is NAC.
SSRIs - fluoxetine (prozac), citalpram (celexa), paroxetine (paxil) can cause N/V, abd pain, tachycardia, CNS sedation, hyperthemia, diaphoresis, AMS, nystagmus, myoclonus, hyper-relfexia. Give supportive care, benzos for sz, cyproheptadine is the antidote for seratoninsyndrome.
Other Drugs to be Aware of
• MAOIs – Depression meds like phenlzine (nardil), trancylcypromaine (parnate), MAO blockers for Parkinsons (selegiline, rasagiline), and St John’s Wart. Will inhibit monoamine oxidase decreased inactivation of biogenic amines like epineph, norepi, seratonin excess catecholaminessympathomimetic reaction. Treat with benzos and antipyretics for agitation/rigidity/sz
• Isoniazid (INH) – Tuberculosis med causes lupus-like syndrome, reduces Vitamin B6 and can lead to seizures. Treatment is supportive, pyridoxine (Vit B6).
Drugs of Abuse
Drug Symptoms/Toxidrome Treatment
Cocaine Sympathomimetic Supportive, benzos
Amphetamines (extacy, ADD and narcolepsy meds, weight loss supplements)
sympathomimetic Supportive, benzos
Opiates Opiate Nalaxone, support respiration
PCP Sympathomimetic, rotary or vertical nystagmus, hyperthermia
Supportive, benzos, cooling, sedation as needed
GHB (used as date rape drug, ravers, body builders)
Coma with episodes of agitation, hypothermia, sudden awakening
supportive
Poison Control Centers
• Available 24-hours/day
• Specialists in poison information
• pharmacists and nurses
• extensive toxicology knowledge and resources
• Medical toxicologist available 24/7
• Outreach education materials
Role of the PCCThey take history of exposureThey make assessment based on history, circumstances, health
statusThey recommend treatment They recommend management site
• manage on site• refer to Health Care Facility
• private vehicle • EMS
They follow up on exposuresCommunication bridge during disasters
• PCC has 800 mHz radio
Tox Management
Emergency stabilization• Airway, Breathing, Circulation
“Coma cocktail”• Naloxone (0.01 mg/kg)• Amp D50• some include thiamine (100 mg IV before D50)
Activated charcoal• best if used within 1-2 hours of ingestion• Do not use if you have concern for aspiration• Does not work for metals, alcohols, hydrocarbons and
caustics
Tox Management: ABC’s
Airway: check for flaccid tongue, gag reflex, clear secretions, nasal trumpet/oral airway, position to avoid aspiration
Breathing: check sats and RR – give Os, give albuterol for brochospasm, atropine for bronchorrhea, BVM and intubate as needed to protect airway (low sats, AMS, caustic burn)
Circulation: IV access, draw labs, fluids for hypotension, EKG monitoring (bicarb for long QT)
EKG abnormalities by Drugs
Bradycardia – beta and calcium blockers, digitalis, clonidine
Tachycardia – anticholinergics, stimulants
QRS widening –TCAs, sympathomimetics
Ischemic changes – stimualnts(cocaine)
Digoxin – Salvidor Dali mustache
From Rapid Interpretation of EKG's copyright © 2013 COVER Publishing Co. Inc.
Quiz Time
What toxidrome will these cause?• Percocet• Jack Daniels• Soma (hint – has barbiturate)• Pepto-Bismol• PCP• Crystal Meth• Organophosphate fertilizer• Jimson Weed
Quiz Time
You pick up a lethargic child who was staying with his grandma who has diabetes. What medication do you worry about?
You pick up some ravers from SaltAir who have pacifiers in their mouth? What drug and toxidrome are you concerned about?
You are called to the home a depressed teenager who just broke up with her boyfriend. She has ringing in her ear. What med did she OD on what toxidrome does she have?
Quiz Time
You are called to an orchard where some workers are foaming at the mouth and having difficulty breathing. What was their likely exposure and what toxidrome do you see? How do you treat it?
You pick up a patient who admits a soma overdose. What kind of symptoms do you expect to see and what will his tox screen look like?
Picture Sources
Peds Ingestion – www.emsworld.comXanax pill - psychiatrist-blog.blogspot.comPCP hallucination – www.defense.govMydriasis - webeye.ophth.uiowa.eduMad Hatter - http://www.alice-in-wonderland.net/pictures/mad-hatter-pictures.htmlJimson Weed – www.commons.wikimedia.org , sowandhoe.blogspot.comPeter Pan Hallucination - theosophical.wordpress.comEcstasy Pacifier - www.michaelallenblair.comMa Huang – www.eagleherbs.comMiosis – www.tumblr.com/tagged/miosisNaloxone - http://www.tumblr.com/tagged/naloxonePressure Sore - www.snjourney.comSterno – www.zenstoves.netPesticides – animalpetdoctor.homestead.comSarin gas newspaper - www.sciencemuseum.org.ukAtropine and 2PAM - www.atsdr.cdc.govAntidote, Activated Charcoal, and Hemodialysis Charts – www.ebmedicine.netDali Mustache - From Rapid Interpretation of EKG's copyright © 2013 COVER Publishing Co. Inc