Post on 24-Dec-2015
Toxic Alcohols and OpioidsToxic Alcohols and Opioids
Jamil A. Alarafi, D.O.Jamil A. Alarafi, D.O. 02.01.200702.01.2007
Toxic AlcoholsToxic Alcohols
EthanolEthanol
Methyl AlcoholMethyl Alcohol
Ethylene GlycolEthylene Glycol
Isopropyl AlcoholIsopropyl Alcohol
EthanolEthanol
Everybody's favorite!Everybody's favorite!
Unique among abused drugsUnique among abused drugs
Most frequently used and abused in most societiesMost frequently used and abused in most societies
Estimated to contribute to 100,000 deaths/yrEstimated to contribute to 100,000 deaths/yr
40% of MVC’s are related to ETOH use40% of MVC’s are related to ETOH use
EthanolEthanol
PathophysiologyPathophysiology
CNS DepressantCNS Depressant
Absorption: mouth to small bowelAbsorption: mouth to small bowel
Elimination:Elimination:
2 – 10% from lungs, urine, and sweat2 – 10% from lungs, urine, and sweat
Primary metabolized in the liverPrimary metabolized in the liver
EthanolEthanol
Clinical FeaturesClinical Features
Slurred speech, nystagmus, disinhibited behavior, Slurred speech, nystagmus, disinhibited behavior, CNS depression ( a spectrum which my lead to CNS depression ( a spectrum which my lead to coma), and poor motor coordination and controlcoma), and poor motor coordination and control
HypotensionHypotension
ToleranceTolerance
EthanolEthanol
TreatmentTreatment
Mainstay of treatment is supportiveMainstay of treatment is supportive
Attention to ABC’s, associated injuries, or co-Attention to ABC’s, associated injuries, or co-morbid conditions. morbid conditions.
Bedside glucose checkBedside glucose check
Thiamine, Folate, Multivitamins, Magnesium, Thiamine, Folate, Multivitamins, Magnesium, Fluids (D5NS)Fluids (D5NS)
Ethanol Ethanol
TreatmentTreatment
Careful serial examines are crucialCareful serial examines are crucial
Respiratory depression may require intubationRespiratory depression may require intubation
Most eliminate ethanol at a rate of 0.20-0.25/hrMost eliminate ethanol at a rate of 0.20-0.25/hr
CocaethyleneCocaethyleneMetabolite formed by the combination of ETOH and CocaineMetabolite formed by the combination of ETOH and Cocaine
EthanolEthanol
DispositionDisposition
Most rarely require hospitalization and can be Most rarely require hospitalization and can be sent home as long as certain conditions are in sent home as long as certain conditions are in placeplace
State legal limits veryState legal limits veryOhio 0.08Ohio 0.08
MethanolMethanolOverviewOverview
Also called methyl alcohol or “wood alcohol”Also called methyl alcohol or “wood alcohol”
Colorless,volatile liquid, with a distinctive odorColorless,volatile liquid, with a distinctive odor
Common SourcesCommon Sources
Sterno, paint removers, varnishes, shellacs, windshield fluids, and Sterno, paint removers, varnishes, shellacs, windshield fluids, and antifreezeantifreeze
Toxic Metabolites Toxic Metabolites Formaldehyde & Formic acidFormaldehyde & Formic acid
MethanolMethanol
Pharmacology and MetabolismPharmacology and Metabolism
Rapidly absorbedRapidly absorbed
Transdermal and respiratory absorption has resulted Transdermal and respiratory absorption has resulted in toxicityin toxicity
As little as 1.5ml of 100% methanol can produce a toxic level As little as 1.5ml of 100% methanol can produce a toxic level in small childrenin small children
High risk for inhalation exposure: painting, glazing, High risk for inhalation exposure: painting, glazing, varnishing, lithography, and printingvarnishing, lithography, and printing
Methanol Methanol
Pharmacology and MetabolismPharmacology and Metabolism
Serum levels peak 30 to 60 minutesSerum levels peak 30 to 60 minutes
Half life is 24 to 30 hours Half life is 24 to 30 hours Prolonged by EthanolProlonged by Ethanol
Smallest lethal dose Smallest lethal dose 15 mL in adults and 1.5 mL in toddlers15 mL in adults and 1.5 mL in toddlers
MethanolMethanol
Pharmacology and MetabolismPharmacology and Metabolism
Methanol has little toxicity and produces less Methanol has little toxicity and produces less inebriation than ethanolinebriation than ethanol
Methanol Methanol Formaldehyde Formaldehyde Formic Acid Formic Acid CO2 CO2 and Waterand Water
Formic Acid responsible for much of Anion Gap and Formic Acid responsible for much of Anion Gap and Ocular toxicityOcular toxicity
Methanol Methanol
Pathophysiology/Clinical FeaturesPathophysiology/Clinical Features
Optic NeuropathyOptic Neuropathy““Snow blindness”: diplopia, photophobia, and blindnessSnow blindness”: diplopia, photophobia, and blindness
Putaminal InjuryPutaminal InjuryParkinsonian type motor dysfunction, hypokinesis, and rigidityParkinsonian type motor dysfunction, hypokinesis, and rigidity
MechanismMechanismFormic Acid has a high affinity for iron and inhibits mitochondrial Formic Acid has a high affinity for iron and inhibits mitochondrial cytochrome oxidase, halting cellular respirationcytochrome oxidase, halting cellular respiration
Metabolism in the cytosol and mitochondria account for a second Metabolism in the cytosol and mitochondria account for a second mechanism of ATP depletionmechanism of ATP depletion
MethanolMethanol
Clinical FeaturesClinical Features
Symptoms may not appear until 12 to 18 hours after the Symptoms may not appear until 12 to 18 hours after the ingestioningestion
““Cardinal” signs of toxicity:Cardinal” signs of toxicity:
CNS effects similar to ETOH intoxication with N/V, abdominal pain, CNS effects similar to ETOH intoxication with N/V, abdominal pain, visual disturbances, and a wide anion gap metabolic acidosisvisual disturbances, and a wide anion gap metabolic acidosis
Coma and seizures can develop in severe casesComa and seizures can develop in severe cases
Hypotension and bradycardia are late findings and suggests a poor Hypotension and bradycardia are late findings and suggests a poor outcomeoutcome
Methanol Methanol
PrognosisPrognosis
Correlates with the degree of acidosis, not with the serum Correlates with the degree of acidosis, not with the serum methanol level. methanol level.
Treatment initiation within 8 hours of exposureTreatment initiation within 8 hours of exposure
Poor prognosis associated with coma, hypotension, bradycardia, Poor prognosis associated with coma, hypotension, bradycardia, seizures, or arterial pH less than 7.0seizures, or arterial pH less than 7.0
Patients who survive may have permanent blindness or severe Patients who survive may have permanent blindness or severe neurologic deficitsneurologic deficits
Methanol Methanol Laboratory FeaturesLaboratory Features
Anion GapAnion Gapmay be delayed 12 to 24 hoursmay be delayed 12 to 24 hoursAbsence with concomitant ethanol, lithium, or bromide Absence with concomitant ethanol, lithium, or bromide ingestioningestion
Elevated “Osmolar Gap”Elevated “Osmolar Gap”OG = Meas. Serum Osm. - Cal. OsmolalityOG = Meas. Serum Osm. - Cal. Osmolality
Normal gap is (-14 to +10)Normal gap is (-14 to +10)
Calculated osmolality= 2Na + BUN/2.8 + Calculated osmolality= 2Na + BUN/2.8 + glucose/18 + ethanol/4.6glucose/18 + ethanol/4.6
Ethylene GlycolEthylene Glycol
OverviewOverview
Viscous, colorless, slightly sweet-tastingViscous, colorless, slightly sweet-tasting
Primarily used in antifreeze and coolantsPrimarily used in antifreeze and coolants
Also in airplane deicing solutions, hydraulic brake Also in airplane deicing solutions, hydraulic brake fluids, industrial solvents, paints, lacquers, and fluids, industrial solvents, paints, lacquers, and cosmeticscosmetics
Most poisonings involve AntifreezeMost poisonings involve Antifreeze
Ethylene GlycolEthylene Glycol
Epidemiology Epidemiology
In 2001, there were 4938 exposures with 16 fatalitiesIn 2001, there were 4938 exposures with 16 fatalities 90% unintentional90% unintentional Most were children or suicide attemptsMost were children or suicide attempts 12% moderate to severe effects12% moderate to severe effects
Rapid treatment is imperative!Rapid treatment is imperative!
If treated early and aggressively, death is unlikely, but If treated early and aggressively, death is unlikely, but delay will result in multiorgan failure in 24 to 36 hoursdelay will result in multiorgan failure in 24 to 36 hours
Ethylene GlycolEthylene Glycol
Pharmacology/MetabolismPharmacology/Metabolism
Rapid absorption after ingestionRapid absorption after ingestion
Distributes evenly in the tissues, with peaked levels at Distributes evenly in the tissues, with peaked levels at 1-4 hours1-4 hours
Nonvolatile and inhalation absorption is unlikelyNonvolatile and inhalation absorption is unlikely
Half life of 3 to 8.6 hoursHalf life of 3 to 8.6 hours
Toxic doses of 0.2 ml/kg - 1.4 ml/kgToxic doses of 0.2 ml/kg - 1.4 ml/kg
Ethylene GlycolEthylene Glycol
PathophysiologyPathophysiology
Metabolized in the liver (70%) and kidneys (30%) to toxic Metabolized in the liver (70%) and kidneys (30%) to toxic metabolites- aldehydes, glycolate, oxalate, and lactatemetabolites- aldehydes, glycolate, oxalate, and lactate
2.3% converted to Oxalic acid, of which a small portion 2.3% converted to Oxalic acid, of which a small portion complexes with calcium to form calcium oxalate crystalscomplexes with calcium to form calcium oxalate crystals
These precipitate in kidney, brain, and peripheral tissuesThese precipitate in kidney, brain, and peripheral tissues these are harmful but the generation of toxic metabolites appear to these are harmful but the generation of toxic metabolites appear to be most responsible for the lethal effects to target tissuesbe most responsible for the lethal effects to target tissues
Ethylene GlycolEthylene Glycol
Clinical FeaturesClinical Features
Four Stages of Ethylene Glycol toxicityFour Stages of Ethylene Glycol toxicity
Acute NeurologicAcute Neurologic
Cardiopulmonary Cardiopulmonary
Renal Renal
Delayed Neurologic InjuryDelayed Neurologic Injury
Ethylene Glycol Ethylene Glycol
DiagnosisDiagnosis
Crystalluria is the hallmarks of EG ingestion, however Crystalluria is the hallmarks of EG ingestion, however its absence does not exclude the diagnosisits absence does not exclude the diagnosis
Useful test include:Useful test include:Electrolytes, calcium, BUN, Creatinine, glucose, serum Electrolytes, calcium, BUN, Creatinine, glucose, serum osmolality, ethanol level, ABG, ethylene glycol level, EKG, osmolality, ethanol level, ABG, ethylene glycol level, EKG, UAUA
Wood’s lamp fluorescence on a freshly voided urine Wood’s lamp fluorescence on a freshly voided urine specimen may be helpful if EG is suspectedspecimen may be helpful if EG is suspected
Ethylene GlycolEthylene Glycol
Diagnostic TestDiagnostic Test
Leukocytosis is nonspecific and non-sensitiveLeukocytosis is nonspecific and non-sensitive
QT prolongation with hypocalcemia secondary to QT prolongation with hypocalcemia secondary to crystal formation crystal formation
CPK may be elevated CPK may be elevated
Anion gap acidosis seen secondary to metabolites Anion gap acidosis seen secondary to metabolites glycolic acid and glyoxylic acidglycolic acid and glyoxylic acid
Methanol and Ethylene GlycolMethanol and Ethylene Glycol
ManagementManagement
Treatment essentially the same Treatment essentially the same
As in the OD setting, resuscitation and stabilization are As in the OD setting, resuscitation and stabilization are paramountparamount
Gastric emptying is not effective due to rapid absorption Gastric emptying is not effective due to rapid absorption
Only if ingestion in last 30 to 60 minutesOnly if ingestion in last 30 to 60 minutes
Activated charcoal not effectiveActivated charcoal not effective
Methanol and Ethylene GlycolMethanol and Ethylene Glycol
ManagementManagement
Severely obtunded patients should receive attention Severely obtunded patients should receive attention to ABC’s and “DON’T” therapy to ABC’s and “DON’T” therapy (dextrose,oxygen,naloxone, and thiamine)(dextrose,oxygen,naloxone, and thiamine)
Forced diuresis is of no value and may cause Forced diuresis is of no value and may cause pulmonary edema or ARDSpulmonary edema or ARDS
Early intubation may be indicatedEarly intubation may be indicated
Methanol and Ethylene GlycolMethanol and Ethylene Glycol
ManagementManagement
Treatment goalsTreatment goals
Correction of Metabolic AcidosisCorrection of Metabolic Acidosis
ADH Blockade thereby inhibiting the generation of ADH Blockade thereby inhibiting the generation of toxic metabolitestoxic metabolites
Hemodialysis to remove alcoholHemodialysis to remove alcohol
Methanol and Ethylene GlycolMethanol and Ethylene Glycol
ManagementManagement
Metabolic AcidosisMetabolic Acidosis
Large doses of bicarbonate may be required to correct the Large doses of bicarbonate may be required to correct the acidosisacidosis
Early correction is imperative to reduce the chance of Early correction is imperative to reduce the chance of methanol induced visual lossmethanol induced visual loss
Target pH is 7.45 to 7.50Target pH is 7.45 to 7.50
Bicarbonate may worsen hypocalcemia with Ethylene GlycolBicarbonate may worsen hypocalcemia with Ethylene Glycol
Methanol and Ethylene GlycolMethanol and Ethylene Glycol
ManagementManagement
Blocking ADHBlocking ADH
Either Ethanol or Fomepizole may be usedEither Ethanol or Fomepizole may be used ETOHETOH
Target level of ethanol is 100 to 150 mg/dLTarget level of ethanol is 100 to 150 mg/dLETOH increases the half-life to 30 hours Methanol and 17 ETOH increases the half-life to 30 hours Methanol and 17 hours Ethylene Glycolhours Ethylene Glycol
Fomepizole Fomepizole blocks ADH and has more predictable pharmacokinetics blocks ADH and has more predictable pharmacokinetics and improved safety profileand improved safety profilemore expensive more expensive
Methanol and Ethylene GlycolMethanol and Ethylene Glycol
ManagementManagement
HemodialysisHemodialysis
Indications: triad of hx, clinical, and lab results confirm Indications: triad of hx, clinical, and lab results confirm toxic ingestion, EG > 20, ARF, metabolic acidosistoxic ingestion, EG > 20, ARF, metabolic acidosis
Removes preformed metabolitesRemoves preformed metabolites
Peritoneal dialysis is less effectivePeritoneal dialysis is less effective
Endpoint is undetectable serum ethylene glycol or Endpoint is undetectable serum ethylene glycol or methanol concentrationmethanol concentration
Isopropyl AlcoholIsopropyl Alcohol
OverviewOverview
Clear, colorless, slightly bitter Clear, colorless, slightly bitter
Second most commonly ingested alcoholSecond most commonly ingested alcohol
Found in nail polish removers, household disinfectants, Found in nail polish removers, household disinfectants, and window cleaners, and common rubbing alcoholand window cleaners, and common rubbing alcohol
Less toxic than methanol or ethylene glycolLess toxic than methanol or ethylene glycol
Isopropyl AlcoholIsopropyl Alcohol
EpidemiologyEpidemiology
In 2002In 2002
31,187 exposures31,187 exposures91% unintentional91% unintentional3% moderate to major effects3% moderate to major effects4 fatalities4 fatalities
Fatalities are usually associated with chronic Fatalities are usually associated with chronic alcoholics with mixed ingestionsalcoholics with mixed ingestions
Isopropyl AlcoholIsopropyl Alcohol
Phamacology/MetabolismPhamacology/Metabolism
Absorption is rapid and complete, with peak serum Absorption is rapid and complete, with peak serum levels in 30 min, with a half-life of 3-7 hourslevels in 30 min, with a half-life of 3-7 hours
Potentially lethal dose is 150 to 240 mL (2 to 4 Potentially lethal dose is 150 to 240 mL (2 to 4 mL/Kg) but adults have survived up to 1 LitermL/Kg) but adults have survived up to 1 Liter
80% undergoes hepatic metabolism to acetone80% undergoes hepatic metabolism to acetone
Remaining 20% undergoes renal elimination Remaining 20% undergoes renal elimination unchanged unchanged
Isopropyl AlcoholIsopropyl Alcohol
Clinical FeaturesClinical Features CNSCNS
Inebriation with acetone odorInebriation with acetone odor
Headache, dizzinessHeadache, dizziness
Neuromuscular dysfunction, confusion, nystagmusNeuromuscular dysfunction, confusion, nystagmus
Coma in severe ingestionsComa in severe ingestions
Respiratory depression or failure may occurRespiratory depression or failure may occur
Isopropyl AlcoholIsopropyl Alcohol
Clinical FeaturesClinical Features GIGI
Gastritis may occurGastritis may occur
Hematemesis associated with gastritis but not Hematemesis associated with gastritis but not commoncommon
Abdominal pain, nausea, vomiting commonAbdominal pain, nausea, vomiting common
Isopropyl AlcoholIsopropyl Alcohol
Clinical FeaturesClinical Features
Hypotension Hypotension Rare but associated with severe ingestions, mortality rate is 45%Rare but associated with severe ingestions, mortality rate is 45%
Caused by peripheral vasodilatation and direct myocardial Caused by peripheral vasodilatation and direct myocardial depressiondepression
Sinus tachycardia Sinus tachycardia common but other dysrythmias if found are usually associated with common but other dysrythmias if found are usually associated with hypoxia, acidosis, or shockhypoxia, acidosis, or shock
Myoglobinuria, ATN, or hemolytic anemias may be presentMyoglobinuria, ATN, or hemolytic anemias may be present
Isopropyl AlcoholIsopropyl Alcohol
Diagnostic Test:Diagnostic Test:
Isopropanol levelIsopropanol level
electrolytes, osmolality, serum and urine ketoneselectrolytes, osmolality, serum and urine ketones
KetosisKetosismost common lab abnormality (from acetone)most common lab abnormality (from acetone)
Increased osmolar gapIncreased osmolar gap
Isopropyl AlcoholIsopropyl Alcohol
Diagnostic StrategiesDiagnostic Strategies
““Pseudo-renal failure”Pseudo-renal failure”
Early diagnostic clue with elevated creatinine and normal Early diagnostic clue with elevated creatinine and normal BUNBUN
100mg/dL of Isopropanol falsely elevates the creatinine 100mg/dL of Isopropanol falsely elevates the creatinine 1mg/dL1mg/dL
CPK should be obtainedCPK should be obtained
Isopropyl AlcoholIsopropyl Alcohol
ManagementManagement
ABC’s, glucose check, thiamine, narcanABC’s, glucose check, thiamine, narcan
Gastric emptying or charcoal is not useful unless Gastric emptying or charcoal is not useful unless ingestion was large and recentingestion was large and recent
ADH blockade not indicatedADH blockade not indicated
Manage hypotension with fluids/vasopressorsManage hypotension with fluids/vasopressors
Isopropyl AlcoholIsopropyl Alcohol
ManagementManagement
Dialysis is indicated for refractory hypotension or Dialysis is indicated for refractory hypotension or patients vital signs deterioratepatients vital signs deteriorate
Coma not an indication for dialysisComa not an indication for dialysis
Hemodynamic stability without coma in first 6 hours Hemodynamic stability without coma in first 6 hours rarely develops significant sequelaerarely develops significant sequelae
Care can generally be supportive in this case Care can generally be supportive in this case
Toxic AlcoholsToxic Alcohols
Key ConceptsKey Concepts
Small doses can killSmall doses can kill Latent periods can fool you (EG & Methanol)Latent periods can fool you (EG & Methanol) Double gap acidosis, think: ethylene glycol or Double gap acidosis, think: ethylene glycol or
methanol ingestionsmethanol ingestions Early treatment improves outcomes, you must act Early treatment improves outcomes, you must act
quicklyquickly Toxicity can not be excluded based on “normal” Toxicity can not be excluded based on “normal”
osmolar gaposmolar gap
OpioidsOpioids
IIII
OpioidsOpioids
Historical perspectiveHistorical perspective
In use for over 5000 yearsIn use for over 5000 years
Term for Term for opium opium is derived from the Greek word for is derived from the Greek word for poppy juicepoppy juice
Receptors and endogenous opioids have been Receptors and endogenous opioids have been recognized and characterized only in the last 25 yearsrecognized and characterized only in the last 25 years
OpioidsOpioidsTerms/Definitions:Terms/Definitions:
OpioidsOpioids natural, synthetic, and semi synthetic agent with morphine like natural, synthetic, and semi synthetic agent with morphine like
propertiesproperties In the US, heroin and opioid derivatives are abused most often and In the US, heroin and opioid derivatives are abused most often and
the cause of most deathsthe cause of most deaths
OpiateOpiate only natural agentonly natural agent
NarcoticsNarcotics any agent that induces sleep and is nonspecificany agent that induces sleep and is nonspecific
EndorphinsEndorphins Any peptide in the three opioid family: enkephalins, B-endorphins, Any peptide in the three opioid family: enkephalins, B-endorphins,
and dynorphinsand dynorphins
OpioidsOpioids
Mechanism of Action:Mechanism of Action: Modulate nociception in the terminals of afferent Modulate nociception in the terminals of afferent
nerves in the CNS and PNSnerves in the CNS and PNS
Three endogenous receptorsThree endogenous receptors OPOP11 (delta) (delta)
OPOP22 (kappa) (kappa)
OPOP33 (mu) (mu)
Concentrated in pain pathways, periaqueductal grey matter, Concentrated in pain pathways, periaqueductal grey matter, locus ceruleus, limbic system, nucleus raphe locus ceruleus, limbic system, nucleus raphe
OpioidsOpioidsClinical FeaturesClinical Features Wide variety of signs and symptomsWide variety of signs and symptoms
Miosis is not universalMiosis is not universal
Respiratory effects are variableRespiratory effects are variableLook for shallow respirations, cyanosis, bradypnea, or Look for shallow respirations, cyanosis, bradypnea, or hypercarbiahypercarbia
Diagnostic triad:Diagnostic triad:CNS depression, miosis, and respiratory depressionCNS depression, miosis, and respiratory depression
strongly suggest opioid intoxicationstrongly suggest opioid intoxication
OpioidsOpioids
Differential DiagnosisDifferential Diagnosis
ClonidineClonidinePeriods of apnea that respond to tactile stimPeriods of apnea that respond to tactile stim
Organophosphates and CarbamatesOrganophosphates and CarbamatesMuscle fasciculations, profuse N/VMuscle fasciculations, profuse N/V
PhenothiazinesPhenothiazinesCNS depression and miosisCNS depression and miosis
Carbon Monoxide exposureCarbon Monoxide exposureProfound CNS depressionProfound CNS depression
OpioidsOpioidsManagementManagement::
ABC’s…Airway managementABC’s…Airway managementInterventions may include supplemental oxygen,BiPaP, or Interventions may include supplemental oxygen,BiPaP, or BVM leading to intubationBVM leading to intubation
GI DecontaminationGI Decontamination Usually not routine Usually not routine Consider whole bowel irrigation for “body packers”Consider whole bowel irrigation for “body packers”
Activated CharcoalActivated Charcoal 1 g/Kg1 g/Kg may be beneficial to promote motility with large may be beneficial to promote motility with large
ingestionsingestions
HypotensionHypotension Treat with IV fluids, pressor agents as neededTreat with IV fluids, pressor agents as needed
OpioidsOpioidsReversal AgentsReversal Agents
Narcan (Naloxone)Narcan (Naloxone) a pure opioid antagonist with rapid onset of actiona pure opioid antagonist with rapid onset of action IV, SC, down ETT, and IM…not effective PO!IV, SC, down ETT, and IM…not effective PO! Acts by competitive binding at the receptor siteActs by competitive binding at the receptor site
Revex (Nalmefene)Revex (Nalmefene) Opioid antagonist alternative with long half-life and Opioid antagonist alternative with long half-life and
rapid onsetrapid onset PO, IV, SC, IM routesPO, IV, SC, IM routes Initial IV dose is 0.5 to 1.5mgInitial IV dose is 0.5 to 1.5mg
OpioidsOpioids
WithdrawalWithdrawal Not life threateningNot life threatening
Heroin Half-life : 0.5 hoursHeroin Half-life : 0.5 hours
Signs and symptoms may include CNS excitation, tachypnea, Signs and symptoms may include CNS excitation, tachypnea, tachycardia, hypertension, and mydriasistachycardia, hypertension, and mydriasis
Care is supportive and focused at minimizing symtoms in Care is supportive and focused at minimizing symtoms in
tolerant individualstolerant individuals
Withdrawal can be managed in the outpatient settingWithdrawal can be managed in the outpatient setting
Patients who have refractory N/V, electrolyte abnormalities, or those Patients who have refractory N/V, electrolyte abnormalities, or those with an uncertain diagnosis should be admittedwith an uncertain diagnosis should be admitted
OpioidsOpioidsWithdrawal AgentsWithdrawal Agents
Methadone or l-a-acetylmethadol (LAAM)Methadone or l-a-acetylmethadol (LAAM)
Long and longer acting opioids Long and longer acting opioids Used to treat chronic herion addictionUsed to treat chronic herion addiction 20mg PO or 10mg IM20mg PO or 10mg IM Controls cravings with limited euphoric effectControls cravings with limited euphoric effect LAAM dose is 30mg POLAAM dose is 30mg PO
ClonidineClonidine
Central a2-agonistCentral a2-agonist Controls symptoms by suppressing sympathetic hyperactivityControls symptoms by suppressing sympathetic hyperactivity Dose is 0.1mg PO, patches are an optionDose is 0.1mg PO, patches are an option Hypotension may limit treatment but usually not common in withdraw Hypotension may limit treatment but usually not common in withdraw
treatmenttreatment
OpioidsOpioids
Key ConceptsKey Concepts Diagnosis is based on history& physical examDiagnosis is based on history& physical exam
Key triad: CNS depression, respiratory depression, and miosisKey triad: CNS depression, respiratory depression, and miosis
Supportive care is the mainstay, with attention to airwaySupportive care is the mainstay, with attention to airway
Duration of opioids is longer than narcanDuration of opioids is longer than narcanSo…don’t discharge your patient until your certain the opioid So…don’t discharge your patient until your certain the opioid properties are fully metabolizeproperties are fully metabolize
This depends on the agents involved!This depends on the agents involved!
Opioid withdrawal is supportive and focused at minimizng the Opioid withdrawal is supportive and focused at minimizng the symptoms of withdrawalsymptoms of withdrawal
THE END!!!THE END!!!
Questions?Questions?