THE MOST COMMON AND THE MOST DANGEROUS INGESTIONS

Russell E. Berger, MDCo-Director of Medical Toxicology

Emergency Physician

Cambridge Health Alliance

Instructor in Medicine

Harvard Medical School

Brief Outline-Toxidromes

-The “Tox” EKG

-Guidance on some of the most common ingestions

-Agents of Concern

-Agents of little or no concern

-Q &A

Toxidromes

A way that we can group symptoms together which helps us formulate a treatment plan.

Vital Signs

Mental Status

Pupils

Skin Findings

Neurologic Exam

Opiate Toxidrome

Vitals signs: Down

- low heart rate, low blood pressure

Mental Status: Down (asleep)

Pupils: Down(small)

Skin Finding:

- Needle tracks, usually cool and dry

Sympathomimetic

Vital signs: up:

-high heart rate, hypertensive

Mental Status: up

-agitated-VIOLENT

Pupils(up)

Skin findings(sweaty)

Anticholinergic

Vital Signs: Up

Mental Status:

-Agitated, DELIRIOUS

Pupils: Up

Skin: DRY

Serotonergic

AMS

Hyper-reflexia (clonus is most important feature.

Dysautonomia(Vital sign abnormalities, usually activated)

Sympathomimetic versus Anticholinergic

Freddy Kruger

Versus

The Cookie Monster

Tox EKG

QRS duration

QTC duration

Terminal R in aVR

If you block Sodium channels…

You prolong the QRS complex

>100ms is significant

Just read from the top of the cardiogram

If you block Potassium Channels… You prolong the QTC

>450ms is significant

Just go by what’s reported on the top of the cardiogram

Some Na Channel Blockers besides TCA’s Carbamazepine Benadryl Flecainide, Procainamide Chloroquine Propranolol Quinine Bupivicaine

Some QTC prolonging Agents

Seroquel Zofran Methadone Trazodone Citalopram Erythromycin

DRUGS

Tylenol

It is in everything.

It produces early symptoms that are easy to overlook.

Have a low threshold to test for it and a low threshold to treat in overdose.

Tylenol

We have NAC to treat this overdose.

The dosing of NAC is very confusing for people so needs to be checked carefully for accuracy.

NAC may produce a scary appearing reaction during loading. Still give it!

Opiates

One of the most worrisome emerging epidemics.

RESPIRATORY RATE is the most important reason to give Narcan.

Remember Narcan has a short half life compared with the agents it is reversing. Observe, Observe, Admit, Observe.

Give Narcan sparingly to avoid precipitating patient distress.

Don’t forget to check a tylenol level.

Detectable tylenol levels should = NAC treatment and admission (in the setting of combined opiate preps, eg percocet)

Aspirin

One of the most dangerous agents we see.

30, 60, 90 rule; chronic levels are worse than acute levels so get treated earlier.

Single levels are not adequate to medically clear a patient

Aspirin

Any change in mental status = dialysis

Seizures = death

If you are at a facility without reliable renal coverage, push to transfer the patient.

Carbon Monoxide Exposures

Flu like symptoms

Is the dog sick or not?

Duration of exposure is as important as level

While level is cooking, NRB based 100% oxygen.

Carbon Monoxide If your patient is pregnant, worry about them.

Patients will have a functional anemia.Chest painSOBDizzinessHeadache.

If in doubt, talk to a dive chamber for guidance.

Lithium

Check the level.

Is the level post-distribution---was the blood drawn >6 hours after the last dose of medication. If yes, it is reliable. If not, it may not be reliable.

Is the patient neurotoxic? Can they walk?

Substantial alteration in mental status is always a reason to dialyze (esp with co-ingestants).

Early dialysis is associated with better patient outcomes. Level is NOT everything.

Give sodium to trick the kidneys into eliminating lithium as early as you can.

Benadryl

In everything

Patient can get SUPER sick

Don’t forget your NAC (eg tylenol PM).

May act like a TCA overdose

Benadryl

Patient will be dry, delirious, and tachycardic.

They may have prolongation of their QRS complex on EKG.

They may seize and develop ventricular dysrhythmias.

Sympathomimetic Agents

Cocaine LSD Ecstacy Bath Salts PCP Ketamine

Crazy and aggressive.

Wide eyed and pouring sweat

Control with benzodiazepines/Avoid Haldol.

Keep the patient cool. Intubate and paralyze PRN.

Clonidine Very common in both pediatric and adult

populations(ADHD or withdrawal)

Sedation

Produces hypotension, bradycardia with normal potassium and glucose.

Looks like opiate---pinpoint pupils---may respond to narcan

Digoxin Hypotension, bradycardia, hyperkalemia.

More common in the elderly or in cardiac kids.

Can reverse with digibind.

Labs for digoxin will be off when you check the level again. Don’t freak out about this---go by the clinical picture.

Digoxin Consider treating the potassium itself

Avoid calcium (for now)

Concentration x Wt in Kg/100 gives you reversal dose of digibind (round up)

Pt is 80 kg, dig level is 4.0. [80]x[4]/100 = 3.2Give 4 vials

Calcium Channel BlockersHypotension, bradycardia, HYPERglycermia

The worst of the worst ingestions

High Dose insulin therapy

Intralipid

ECMO/Intra-aortic balloon pump.

Seroquel

“I take seroquel for sleep.”

Ataxia

Prolongation of the QT.

May need to be tubed 2/2 decreased mental status.

Sleeping Pills

Ambien Lyrica Gabapentin Lunesta

A lot of worry

Little true concern

Agents to not worry about Motrin(unless > 400mg/kg) Most Antibiotics SSRI’s Thyroid Hormone Laxatives Most diuretics Ace inhibitors ARBS Vitamins(except prenatals) Sleep aids Benzodiazepines

Household Items(bedroom and bathroom)

I don’t care:MakeupHousehold bleachDish soapBath soapDish detergent (Pods are different)ShampooRat poisonRaidVitamins

Household items(garage) Emergency:

-Gasoline/Kerosone

-Oil of wintergreen(salicylate)

-Antifreeze(EG)

-De-icer(Methanol)

-Button Batteries

-Wheel Cleaners(HF)

-Essential Oils(citronella)

Admit these kids

Oral sulfonylureas(glipizide, glimeperide, etc)

Long acting opiates, suboxone and methadone

TCA’s Calcium Channel Blockers Most beta blockers MAOi exposures Wellbutrin

Specific Agents: Questions

Contact: rberger@challiance.org

Thank you