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Emergency Med Exam 4 > Approach to poisonings and ingestions > Flashcards

Approach to poisonings and ingestions Flashcards

1
Q

Types of exposure

A

● Ingestion
● Inhalation/ Insufflation
● Skin or mucous membrane
● Injection

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2
Q

Priorities in managing the poisoned patient

A

● Resuscitation
○ Cardiac Arrhythmias
○ Mechanical Airway Support
○ Fluids
○ Seizures (Tx w/ Benzodiazepine)
● Elimination techniques (eg. Activated
Charcoal)
● Decontamination (eg.Chemical spills,
Organophosphates)

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3
Q

Complications in the poisoned patient

A

● Antidote- substance is known
● Hypoglycemia (Tx w/ IV Dextrose)
● Hyperthermia (eg. Sympathomimetics)
● Hypothermia (eg. Opioids)
● Keep your differential diagnosis broad

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4
Q

Toxicology- History

A

● Poor Historian
○ Children, altered mental status, elderly, confusion, agitation
● Family, EMS, medical records
● Ask about suicidal ideation
● Medication history
● Ask about when, what, route, amount, intent

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5
Q

Decontamination procedure

A
  • Use PPE
  • Decontamination areas, Remove clothing
  • Eyes- copious irrigation, Alkali worse than acids
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6
Q

Gastric Decontamination

A
  • Emesis- ipecac syrup has a limited role
  • Orogastric Lavage- limited role, first hour or massive dose
  • Activated Charcoal
  • Whole bowel Irrigation- use Polyethylene glycol
  • Urinary Alkalinization
  • Hemodialysis- very specific criteria
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7
Q

Activated Charcoal use:

A
  • < 1 hour from ingestion
  • Substances known to be absorbed by the charcoal
  • 1-2 gm/kg (max 100 gm)
  • Vomiting and aspiration is a concern
  • Patients don’t like it
  • Charcoal binds to toxins, limiting absorption
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8
Q

Urinary Alkalinization

A
  • Prevents resorption of acidotic drugs
  • Salicylate toxicity, Phenobarbital, Herbicides
  • Correct hypokalemia
  • Sodium Bicarbonate bolus, monitor urine pH
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9
Q

Discharge consideration

A
  • Poison control
  • Substance, Amount, Timing, Extended release
    medication?
  • Admit observation?
  • Abuse or neglect?
  • Mental health evaluation?
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10
Q

MUDPILES

A

M- Methanol
M- Metformin
U- Uremia
D- Diabetic (or Alcoholic) Ketoacidosis
P- Paraldehyde
P- Propylene Glycol
I- Isoniazid
I- Iron
L- Lactic Acidosis
E- Ethylene Glycol
S- Salicylates

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11
Q

What is a Toxidrome?

A

Substances belonging to a particular
pharmaceutical/chemical class often
produce a cluster of symptoms and signs,
or “toxidrome”,enabling the identification
of potential toxins when a clear history is
unavailable

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12
Q

Anticholinergic toxidrome class substances

A
  • Diphenhydramine is the most common for overdose
    Atropine, Tricyclic antidepressants, Phenothiazines,
    Antihistamines, Antiparkinsonian drugs, Jimsonweed (Abused for
    hallucinogenic effects), Belladonna (Taiwan)
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13
Q

Anticholinergic toxicity

A
  • Dry, flushed skin, dry mucous membranes, mydriasis, urinary retention, decreased bowel sounds, altered mental status
  • Confused, agitated, hyperthermia, wide-complex tachyarrhythmias secondary to sodium channel blocking.
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14
Q

Anticholinergic fatalities

A

secondary to severe agitation, status epilepticus,
hyperthermia, wide-complex tachyarrhythmias, and cardiovascular
collapse

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15
Q

Anticholinergic toxicology treatment

A

● Observation
● Monitor temperature
● Activated charcoal is < 1 hour
● Pharmacologic sedation w/ Benzodiazepine
● Sodium Bicarbonate for wide complex tachycardia.
● Consider Physostigmine when purely anticholinergic

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16
Q

Sympathomimetics substances

A

Cocaine, Amphetamines, Cathinones “Bath Salts” , MDMA
● Inhaled, ingested, IV

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17
Q

Cocaine mechanism

A
  • Blockade of the presynaptic reuptake of
    norepinephrine, dopamine and serotonin
  • Excess neurotransmitter results in sympathetic
    activation.
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18
Q

Sympathomimetic clinical featuers

A

● Agitation, Mydriasis, Tachycardia, Hypertension,
Diaphoresis, Seizures, Hyperthermia
Vasoconstrictive
● Hypertension
● Ischemia bowel. Miscarriages
Psychoactive
Pulmonary

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19
Q

Amphetamines

A

Several prescription drugs in this category.
Methamphetamine
Methylphenidate (Ritalin)
Dextroamphetamine (Dexedrine)
Ephedrine (Ephedra)
● Enhance the release and block reuptake of catecholamines.
Drugs of abuse
● Down regulation of dopamine receptors over long-term use.

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20
Q

Amphetamines clinical features

A

● Agitation, Mydriasis, Tachycardia, Hypertension,
Diaphoresis, Seizures, Hyperthermia,
Rhabdomyolysis
● Intracranial hemorrhage, infarction,
encephalopathy,
● Seizures
● Paranoid psychosis
● Advanced tooth decay

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21
Q

Sympathomimetics management

A
  • CBC, CMP, Creatine kinase, EKG, cardiac marker,
    PT, PTT, Head CT
  • Urine Drug Screen- Some Rx meds can be
    positive
  • IV access
  • Monitor Vitals
  • Supportive care, O2 prn
  • Treat hyperthermia- Cool mist fans, sedation
  • Seizures and sedation ( Tx w/ Benzo)
  • CCB and nitroglycerin for ST segment changes
    and SVT
  • Body packers at risk for large dose toxicity and
    death
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22
Q

Cholinergic substances

A
  • Organophosphates
  • Nerve Agents
  • Acetylcholinesterase inhibitors- Pyridostigmine
  • Wild mushrooms
  • GI irritation
  • CNS effects
  • Muscarinic symptoms
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23
Q

Organophosphates

A

Group of Insecticides - Varying brand names - Neurotoxicity- Inhibits Acetylcholinesterase - Irreversibly (aging) - Chemical spills
Nerve agents are organophosphate based - Sarin, VX

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24
Q

Organophosphates exposure

A
  • Inhaled
  • Skin, Mucus membrane, Eyes
  • GI exposure
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25
Organophosphates clinical features
- Dose dependant - Route of exposure - Chronic Exposure does occur - Cholinergic effects - Nicotinic effects - Miosis, muscle fasciculations, paralysis Sx range from mild to severe - HA, nausea, lacrimation, rhinorrhea, salivation - Confusion, coma, seizures, respiratory failure, death
26
Organophosphates diagnosis
- History and toxidrome - Cholinesterase levels take time - Don’t delay care
27
Organophosphates treatment
- PPE and protect the caregivers - Decontamination - Respiratory support, Oxygen - Atropine repeat q5 min until dry secretions - Pralidoxime given prior to “aging” reactivates enzyme
28
Opioid clinical features
- Respiratory and mental depression - Miosis - not always - Orthostatic hypotension - Nausea vomiting - Urticaria- Histamine release - Bronchospasm - Decreased GI motility and urinary retention - Seizures with tramadol - Acute Lung Injury
29
Opioids management
- Drug Screen- - Not specific - Beware of tylenol combos - Protect the airway - Naloxone an Opioid competitive antagonist - Given IV, SC, IM - Dose of 0.1mg - 2.0 mg IV depending on status - Activated Charcoal - Observe in the ED for 4-6 hours after last naloxone dose - Admit for continuous monitoring (eg. Buprenorphine) - Continuous infusion for long acting opioids (eg. Methadone)
30
Alcohol Withdrawal
- Alcoholic Ketoacidosis- - Tremors/ Hallucination - Withdrawal seizures- Tx w/ benzodiazepine (GABAergic) - Delirium Tremens: Confusion, tachycardia, hypertension
31
Benzodiazepine Withdrawal
- Occur after abrupt discontinuation (Sx up to 7-10 days later) - Similar to Alcohol - Anxiety, insomnia, tremors, anorexia, confusion, seizures - Long taper with D/C
32
Cocaine withdrawl
- Irritability, paranoid ideation, depression
33
Methamphetamine withdrawl
- Drowsiness, lethargy, hunger, tremor, chills, depression, suicide
34
Opioid withdrawl
- Typically not life threatening - Diaphoresis, tremors, irritability, insomnia - Clonidine, antiemetics - Methadone, Buprenorphine once withdrawal symptoms appear
35
Toxic alcohols
Methanol and Ethylene Glycol
36
Twice as potent as Ethanol and thus considered highly toxic
Isopropanol
37
Ethanol
● Clinical inebriation ● Legally intoxicated at 80 mg/dL ● Death can occur 400-500 mg/dL in non-habitual users ○ Respiratory depression and coma ● Broken down by alcohol dehydrogenase
38
Work-up Ethanol
● Keep your DDx broad for altered mental status ● Bedside glucose ● Check Ethanol levels ● Drugs of abuse ● CBC, CMP - gapping metabolic acidosis likely not from ethanol
39
Treatment for ethanol exposure
● Observation ● Activated charcoal doesn’t work ● Hypoglycemia ● Supportive
40
Isopropanol
more toxic than ethanol ● CNS depression ● Gastric irritation ● Respiratory depression, hypotension, and coma ● Also metabolized by alcohol dehydrogenase ● Toxic dose at 1 mL/kg ● Children are highly susceptible to toxic doses
41
Dx of isopropanol exposure
- Ketonuria without acidosis, smell of rubbing alcohol on breath
42
Tx for isopropanol
Supportive, watch for GI bleed, and consider hemodialysis
43
Methanol
- Highly toxic metabolites - Windshield fluid, automotive cleaning products, solvents, fuel for stoves, and contaminated alcohol beverages. - Lethal dose at 1.25 mL/kg - Permanent visual changes at 30mL - Metabolized by alcohol dehydrogenase → Formic acid - Formic acid is the toxic metabolite→ Metabolic acidosis & End Organ damage - Seizures, respiratory failure, pancreatitis, visual damage, tachypnea
44
Ethylene Glycol
- Highly toxic metabolites - Hydraulic fluid, antifreeze. Contaminated alcohol beverages - Has a sweet taste, so kids or pets may accidentally ingest - Lethal dose in adults is 1.0 - 1.5 mL/kg - Metabolized by alcohol dehydrogenase → Glycolic acid - Glycolic acid is the toxic metabolite→ Metabolic acidosis & End Organ damage - CNS depressant, metabolic acidosis, renal failure - Urine check may show calcium oxalate crystals
45
Methanol and Ethylene Glycol
- Blood ethanol level - Measure methanol and ethylene glycol levels - Calculate osmolar gap - ABG - CMP - Creatinine kinase - Ketone levels - Lactate levels - Consider acetaminophen and salicylate levels
46
Methanol and Ethylene Glycol Treatment
- Cardiovascular support - Correct acidosis - Sodium Bicarbonate to maintain pH - Block metabolism - IV Fomepizole, IV Ethanol - Increase clearance - Hemodialysis (Used when severe of refractory) - Vitamin Therapy Disposition - Patient likely will need admission
47
Benzodiazepine exposure presentation
- Gamma- aminobutyric acid (GABA) receptor - Given IV, IM, PO, PR (Diazepam rectal gel) - Half life varys - Often occurs as a mixed overdose - Sedation - Dizziness, somnolence - Slurred speech, ataxia, coma - Urine drug screen
48
Benzodiazepine exposure treatment
- Death is rare - Activated charcoal if early - Respiratory support - Flumazenil - Benzodiazepine antagonist - Caution w/ chronic user of benzodiazepine - Contraindicated in intracranial pressure increase eg. Head Trauma, Mass effect
49
Salicylate substances
- Aspirin - Can be enteric coated - Pepto Bismol - Aspercreme- topical - Oil of Wintergreen
50
Salicylate toxicity
Toxicity is complex - As pH ↑more salicylate crosses cell membrane - ↑ brain salicylate concentration - Respiratory alkalosis followed by anion gap metabolic acidosis - Corrosive injury to the GI tract
51
Salicylate clinical features
- Dose, Age dependent - Chronic exposures often worse - Tachypnea, tinnitus, hearing loss, fever - Confusion, coma, seizures, cerebral edema
52
Salicylate work up
- Labs with salicylate level - Level is unreliable indication of toxicity
53
Salicylate management
- Supportive - Activated Charcoal - Reducing salicylate concentration - Urinary alkalinization- Target urine pH 7.5 - IV Fluids with Sodium Bicarbonate - K is added to prevent hypokalemia - Also keeps salicylate away from the brain - Hemodialysis for severe toxicity or refractory
54
Antipsychotics substances
- Risperidone (Risperdal) - Haloperidol (Haldol) - Phenothiazines - Prochlorperazine (Compazine) - Promethazine (Phenergan)
55
Antipsychotics toxicity
- D2 receptor blockade - Blockade in the nigrostriatal region → extrapyramidal Sx - Worse with typical high potency
56
Neuroleptic Malignant Syndrome
- New drug or dosage change- Often acute - Tetrad - Fever - Altered - Muscle rigidity - Autonomic dysfunction
57
Neuroleptic Malignant Syndrome management
Discontinue the drug Supportive- Temp control, sedation, intubation Bromocriptine- dopamine agonist Dantrolene- muscle relaxant
58
Iron toxicity
- GI vs systemic toxicity is dose dependant - GI irritant - Widespread organ injury - toxic free radicals - Metabolic Acidosis - increased lactate
59
Iron clinical features
- Vomiting - Correlates to toxicity, also hematemesis - Lactic Acidosis - Coagulopathy - Hepatic failure
60
Iron toxicity treatment
- Activated Charcoal doesn’t work - Whole bowel irrigation - Endoscopy can remove tablets - Deferoxamine- binds to iron and allows renal excretion
61
Lead toxicity treatment
- Chelation therapy - Dimercaprol (caution with peanut allergy) and Edetate Calcium Disodium
62
Acetaminophen toxicity
- Glutathione is maxed out - Increased NAPQI which is toxic - Worse with ETOH
63
Acetaminophen treatment
- N-Acetylcysteine substitutes for glutathione - Activated Charcoal

Emergency Med Exam 4 (5 decks)

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