- The ABC's always come first
- Dextrose, Oxygen, Naloxone, Thiamine for AMS ( "the coma cocktail") DONT
Supportive measures alone (Scandinavian method) including mechanical ventilation and circulatory support will permit survival of most patients who are alive upon arrival at the hospital.
History
- Unreliable, seek multiple sources
- Pill bottles, drug paraphernalia
- Establish time and size of ingestion
- vomiting
Physical Exam
- Vital signs
- Mental status, Muscle tone, reflexes
- Pupils, nystagmus
- Skin and mucous membranes
- Respiratory exam
- Bowel sounds
- Autonomic nervous system
Laboratory tests
Decontamination/ Elimination
- Ipecac, Gastric lavage, Activated Charcoal
- Forced diuresis and urinary pH manipulation
- Hemodialysis
Antidotes
TOXIDROMES
"A pattern of signs or symptoms that suggests a specific class of poisoning"
Opioids
- triad of respiratory depression, pinpoint pupils, decreased LOC
- bradycardia, hypotension, hypothermia
- needle tracks
Sedative / Hypnotics
benzodiazepines, alcohol, barbituates
- altered mental status, stupor, coma, slurred speech
- respiratory depression
- variable pupil changes
- hypotension
- hypothermia
- barbiturate blisters
Sympathemimetics / Withdrawal
- Cocaine, amphetamines, PCP, pseudoephedrine
- HTN, tachycardia,
- Mydriasis
- Anxiety, delirium
- Diaphoresis
- Increased temperature
Anticholinergics
- TCA, antihistamines, antipsychotics, Gravol
- Hot as a hare, Red as a beet, Dry as a bone, Blind as a bat, Mad as a hatter
- Hyperpyrexia, cutaneous vasodilation, decreased saliva, mydriasis, hallucinations
- tachycardia
- Urinary retention
- Decreased bowel sounds
- Seizures, dysrhythmias
Cholinergics
- insecticides,carbamate, organophosphates, nerve gas, physostigmine
- Salivation, Lacrimation, Urination, Defecation, Gastric cramping, Emesis SLUDGE
- Drowning in secretions, profuse sweating
- AMS, seizures, coma
- Muscle fasciculations
Salicylates
- fever
- tachypnea
- tinnitus, lethargy, altered mental status
- respiratory alkalosis
- metabolic acidosis, ketosis
- vomiting
Serotonin
- fluoxetine, trazadone, meperidine
- irritability
- hyperreflexia, tremor, myoclonus, trismus
- flushing,diaphoresis
- diarrhea
Extrapyramidal
- haloperidol, phenothiazines
- rigidity, tremor
- opisthotonus, trismus
- choreoathetosis
- hyperreflexia
Hallucinogenic
- amphetamines, cannabinoids, cocaine, LSD, PCP
- hallucinations, psychosis, panic
- fever
- mydriasis
Bradycardia
- Beta- blockers, calcium-channel blockers, Digoxin
- Clonidine
- Phenylpropanolamine
- Carbamates, organophosphates, physostigmine
- TCA's
- Antidysrhythmics ( Types 1A AND 1C)
- Opioids
- Hypoxemia, MI, hyperkalemia, hypothermia, hypothyroidism, ICP
Agitation/ Seizures
Temperature alterations
Toxicology laboratory
- Arterial Blood Gas with Co-oximetry
- CO, MetHgb, CN-
- Oxygen saturation gap
- Respiratory or metabolic acidosis
- Urinalysis
- FeCl3
- Ketones
- Calcium oxalate crystals
- Woods lamp
- Electrolytes, BUN, Cr
- Lactate
- Serum ketones
- Serum osmolarity
Anion gap metabolic acidosis AG = [Na+] - [Cl-] - [HCO3-]
Methanol
Uremia
Diabetic Ketoacidosiss ( AKA, SKA )
Phenformin, Paraldehyde
Iron, INH
Lactic acidosis
Ethylene Glycol
Salicylates
Osmol Gap
Calculated osmolality = 2[Na+] + [BUN] + [glucose] + [ ethanol]
- Abdominal X-Ray
- Choral hydrate, heavy metals, iron, phenothiazines, enteric coated
- ECG
Toxicology Screening
- provides direct evidence of ingestion
- rarely impacts initial management
- initial supportive measures should never await these results
- rules in the presence of a drug
- provides grounds for treatment with a specific antidote
- Acetaminophen
- ASA
- Digoxin
- Theophylline
- Phenobarb
- Iron
- Lithium
- Methanol, Ethylene glycol
Antidotes
- DON’T
- Naloxone ( Narcan)
- Flumazenil
- Digibind
- NaHCO3
- Physostigmine
- Atropine/ praladoxime
- NAC
- Ethanol
- Glucagon
- Calcium chloride
- Amyl nitrite, sodium nitrite, sodium thiosulfate, hydroxycobalamine
- Methylene blue
- BAL, EDTA, penicillamine
- pyridoxine
Gastric emptying
Risk/ Benefit ratio unfavorable for majority of poisonings
Risks
- Aspiration
- Upper airway, esophageal, gastric trauma ( perforations)
- Pneumothorax
- Dysrhythmias
Benefits
- 33% ( 13 - 70 %) recovery of ingested toxin
- ? improved clinical outcomes if performed within 1 hour
Indications (selective use)
- Toxic substance and toxic amount
- Less than one hour from presentation and AMS
- Airway protected
Contraindications
- Nontoxic substance or amount
- Vomiting
- Greater than 1 hour
- Toxin readily absorbed
- Caustics, sharps, petroleum
- Large pills or packets
Evidence
1)Kulig ( 1985) - Gastric emptying + charcoal vs charcoal alone
- No benefit to Ipecac vs AC alone
- No benefit to lavage if done > 1 hour after ingestion
2) Albertson ( 1989) - Ipecac + Ac vs AC alone
- Fewer complications without Ipecac
- No difference in outcomes
3) Merrigan ( 1990) - Observation vs AC vs Gastric empty+AC
- No benefit to gastric emptying vs AC alone
- Gastric emptying increases aspiration pneumonia
4) Pond ( 1995) - 495 Gastric empty + AC vs 417 Ac only
No benefit including < 1 hour and those with severe toxicity
"gastric emptying procedures can be omitted from the treatment regimen for adults after acute overdose, including those that present within one hour of overdose and those that manifest severe toxicity."