ToxicologyTransition to critical care

The CallAmbulance is transporting a 16 year old girl found unresponsive at home. Moans to light pain stimuli.

Color pink. HR 60 RR12 BP 110 / 50 spo2 93% on room air.

Parents saw her last night at 2400 when she came home after going out with friends

ETA – 10 min

"All substances are poisons; there is none that is not a poison. The right dose differentiates a poison from a remedy." Paracelsus (1493–1541)

Toxic exposures are a common cause of ED visits

2008 – ED saw 2,000 people / day from poisoning

Estimated annual poisonings or drug overdoses = 4.5 million

2/3 of toxic exposures reported involve children

ENO

Management

Provide continuous respiratory and hemodynamic support

Patient safety

Evaluate the potential for toxicosis

Intervene to reduce toxin absorption and promote its excretion

Provide substance-specific therapy, including antidote administration

What Questions do you need to ask?

Discuss with neighbor and determine at least 4 important questions

Poison Control

Initial

Follow - up

LAB?

Toxidrome

A constellation of signs and symptoms that suggest a type of toxin

Ways to remember a toxidrome

Toxidrome handoutGoogle toxidrome and find a toolWord cluesSymptom Clues

Google toxidrome to find one you like

Toxidrome Clues Anticholinergic: Blind as a bat, mad as a hatter, red as a

beet and dry as a bone

Cholinergic: DUMBELS- defication, urination, miosis, bronchospasm, emesis, lacrimation, sedation

Alcohol: hypothermia

Barbiturates: barb blisters

Pulmonary edema: aspirated hydrocarbon, ethyl glycol, ASA,

Gum discoloration: lead arsenic, Vitamin A

Sympathomimetic

Illegal street drug

CocaineAmphetaminesMeth

LSDOver the counter cold agentsAlbuterol, dopamine, tricyclic antidepressants MOA

inhibitors

Pharmacologic agents to reduce temperature will be ineffective

Cholinergic

PesticidesOrganophosphorus warfare – Sarin Soman Tuban

PilocarpineBethenecholSome mushrooms

Control hypoxiaAtropinePralidoxime (2PAM) soon after exposureBenzo - seizures

Anti Cholinergics

AtropineScopolamineAtroventAntiparkinson drugs Plants – Jimson weed, nightshade, leaves of potato plant

Physostigmine – is the cholinergic agent Give slow IV push

Treatment

Treatment

GI decontaminationCharcoal or binding agentsWhole Bowel irrigationLavage

Dermal DecontaminationEnhance EliminationAntidotes

LavageTo lavage or not – That is the question

Syrup of ipecac

Yes or No?

Activated Charcoal

GI decontamination is the preferred treatment

Prevents entry into enterohepatic circulation

Effective alone or in combination with other therapy

Thoughts on administration?

Charcoal

Complications

Absolute contraindication

Repeated dose therapy

Charcoal doesn’t work PotassiumAcidsAlkalineEthanolCyanideFeLeadLithium

Whole Bowel Irrigation

When not bound to charcoalFor sustained release or enteric

coated Toxic substances such as balloons etc

Give PEG solution (goLytely or clolyte solution)

Dermal or optic decontaminationProcedure – lets practice

Enhance Elimination

Alkalinization – goal of urine pH 7.5 – 8

Hemodialysis

CAVH – hemofiltration

Cathartics - Mag Citrate or Sorbitol– electrolyte imbalance, GI discomfort, cramping

AntidotesSee hand out

Specific situations

Toxicology Cases