Published on March 16, 2014
Toxicology Transition to critical care
The Call Ambulance 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
Toxidrome A constellation of signs and symptoms that suggest a type of toxin
Ways to remember a toxidrome Toxidrome handout Google toxidrome and find a tool Word clues Symptom 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 Cocaine Amphetamines Meth LSD Over the counter cold agents Albuterol, dopamine, tricyclic antidepressants MOA inhibitors Pharmacologic agents to reduce temperature will be ineffective
Cholinergic Pesticides Organophosphorus warfare – Sarin Soman Tuban Pilocarpine Bethenechol Some mushrooms Control hypoxia Atropine Pralidoxime (2PAM) soon after exposure Benzo - seizures
Anti Cholinergics Atropine Scopolamine Atrovent Antiparkinson drugs Plants – Jimson weed, nightshade, leaves of potato plant Physostigmine – is the cholinergic agent Give slow IV push
Treatment GI decontamination Charcoal or binding agents Whole Bowel irrigation Lavage Dermal Decontamination Enhance Elimination Antidotes
Lavage To 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 Potassium Acids Alkaline Ethanol Cyanide Fe Lead Lithium
Whole Bowel Irrigation When not bound to charcoal For sustained release or enteric coated Toxic substances such as balloons etc Give PEG solution (goLytely or clolyte solution)
Dermal or optic decontamination Procedure – 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
Antidotes See hand out
Specific situations Toxicology Cases
Calcification Inhibitors in CKD and Dialysis Patients
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