ABCs of Poisoning Care 2006.ppt
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Transcript of ABCs of Poisoning Care 2006.ppt
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MANAGEMENT OF ACUTEPOISONING
Kent R. Olson, MD
Medical Director
California Poison Control System
San Francisco Division
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Lessons from history
A young princess ate part of an apple
given to her by a wicked witchShe was found comatose and
unresponsive, as if in a deep sleep
Airway positioning and mouth tomouth ventilation were performed, and
she recovered fully
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Lesson:
Best antidote is good supportive care
(Loves first kiss)
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Case 1:
Young woman found unconscious,
several empty pill bottles nearbyUnresponsive to painful stimuli
Shallow breathing
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Initial management: ABCDs
Airway
Breathing
Circulation
Dextrose, drugs, decontamination
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Airway issues
Risks:
Floppy tongue can obstruct airway
Loss of protective reflexes may permit
pulmonary aspiration of gastric contents
Major cause of morbidity in poisonedpatients
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Assessing the airway
Gag reflex
Indirect measure
May be misleading
Can stimulate vomiting
Alternatives
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Breathing
Assess visually
pCO2 reflects ventilation - ABG useful
pulse oximetry provides convenient,
noninvasive evaluation of O2
saturation
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Pitfalls
pO2 measures dissolved oxygen
can be normal despite abnormalhemoglobin states, eg COHgb, MetHgb
Pulse oximetry also fails to detect COpoisoning
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Interventions
Endotracheal intubation
Protects airway
Allows for mechanical ventilation
Reverse coma?
Naloxone: note T = 60 min
Flumazenil?
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Dont forget GLUCOSE
A stroke is never a stroke until its
had 50 of D50 Dr. Larry Tierney , 1976
Give Thiamine 100 mg IM or in IV
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Case 2
47 year old man calls 911, suicidal
BP 70/50, HR 50/min
Junctional rhythm
Hx: uses an antihypertensive
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Circulation = plumbing
Pump working?
Enough volume (is it primed)?
Adequate resistance (no leaks)?
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Management of Hypotension
Hypovolemia?
IV f luid chal lenge
Pump?
Dopamine
Inadequate vascular resistance? Norepinephr ine, phenylephr ine
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Antihypertensives
Diuretics
Beta blockersCalcium channel blockers
ACE Inhibitors
Centrally acting agents
Vasodilators
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Calcium channel blockers
Bad ODs!!
Low Toxic:Therapeutic ratioHigh mortality
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Negative
Inotropic
Effects
Decreased
Automaticity
& Conduction
Dilated Vascular
Smooth Muscle
SVRCOHR
AV Block
SHOCK
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Calcium antagonists - treatment
Calcium: most effective
High doses may be needed
Glucagonvariable results
Insulin plus glucose? (experimental)
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Case 3:
An 18 month old takes some of his
grandmothers sleeping pillsBrought to the ER after a seizure
HR 150/min
Pupils dilated, skin flushed, mucousmembranes dry
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Common causes of seizures
Amphetamines/cocaine
Tricyclic and other antidepressants
Isoniazid (INH)
Diphenhydramine
Alcohol withdrawal
Many others . . .
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30 minutes later, the ECG shows:
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Tricyclic antidepressants
Anticholinergic syndrome
Seizures
Cardiotoxicity
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TCA overdose treatment(similar tox possible w/ massive diphenhydramine)
Stop the seizures
Benzodiazepines, phenobarb i tal
Treat cardiotoxicity
Sodium bicarbonate 1 mEq/kg IV
IV f luids
Dopam ine and/or NE
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Case 4: now were cookin
24 year old man with Hx depression
Agitated, confused
BP 110/70 HR 120 RR 20 T 40.4 C
Muscle tone increased, LE clonus
Tox screen negative for cocaine,
amphetamines
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Drug-induced Hyperthermia
Heat StrokeMalignant Hyperthermia
Neuroleptic Malignant Syndrome
Serotonin Syndrome
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Drug-induced heat stoke
Altered judgment leads to excessive
sun/heat exposureAnticholinergic drugs prevent
sweating
Excessive muscle hyperactivity fromseizures, or from extreme agitation
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Malignant hyperthermia
Rare, familial myopathy
Triggered by general anesthesia Succinylcholine
Inhalational agents (eg, Halothane)
Muscle rigidity, hypermetabolic state
Treatment: dantrolene
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Neuroleptic Malignant Syndrome
Patient on dopamine-blocking drugs
Haloperidol classic cause Also with newer agents (eg, clozapine)
Rigidity (lead-pipe)
Autonomic instability
Hyperthermia
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Serotonin Syndrome
Current hot diagnosis
Serotonin-enhancing Rx SSRIs in OD or multiple combos
MAOI + serotonin-ergic drug
Hypertonicity/clonus (esp. lower extr.)
Autonomic instability
Hyperthermia
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Hyperthermia treatment
Act quickly!
Remove cloth ing sp ray and fan Sedat ion and ant iconvulsants PRN
Neuromuscu lar paralys is i f T >40 C
Dantroleneif NM paralys is ineffect ive
Consider bromoc ript ine, cyproheptadine
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Gut decontamination after OD
Goal: reduce systemic absorption
Induce vomiting? Pump the stomach?
Activated charcoal
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Ipecac-induced emesis
Easy to perform, but
not very effectiveContraindicated:
Comatose/convulsing
Ingested corrosive or hydrocarbon
Bottom line: nobody uses it anymore
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Pumping the stomach
Cooperation not required
MD sense ofcontrol
Punitive value?
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Gastric lavage
May stimulate gagging, vomiting
Risky if airway reflexes dulledLack of proven efficacy
Bottom line: used only rarely
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Activated charcoal
Finely divided powdered material
Huge surface area
Binds most drugs/poisons
Exceptions:
Lithium Iron
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Activated charcoal
More effective than SI, GL
First choice for most ODs
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Whole bowel irrigation
Mechanical flush
Balanced salt solution with PEG No net fluid gain/loss
Good for:
Iron Lithium
Sustained-release pills,foreign bodies
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Call the Poison Center
1-800-222-1222 - 24 hours
Immediate consultation byclinical pharmacists
Back-up by MD toxicologists
Identify pills, discuss diagnosis & Rx
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I dont think we should go up there, especially without a paddle