APPROACH TO THE UNDIFFERENTIATED POISONED PATIENT

Question 1

Approach to the Critically Ill Poisoned Patient

Answer 1

INITIAL STEPS

ABC(MOVIE)DDDDDS

ABC (Primary Survey)
Monitor, Oxigen, Vitals, IV Access, ECG
Disability (GCS, Pupils)
Dextrose
Detailed Physical Exam (Secondary Survey)

Drugs: Consider Universal Antidotes
Decontamination
Draw Labs
Specific Antidotes

History and Collateral Information

Question 2

Additional Considerations for General Approach

Answer 2

Call Poison Control
Always consider a second poison
Brief Psychiatric Assessment in Conscious patients to assess for possibility fo suicide attempt

Question 3

HISTORY

Answer 3

Things to ask:

What was taken

When was it taken (TIME)

How much was taken (DOSE AND NUMBER OF TABLETS)

Type of preparation (IMMEDIATE OR SUSTAINED RELEASE)

How it was taken (ROUTE)

What else was taken (CO-INGESTIONS?)

Why was it taken (INTENTIONAL VS ACCIDENTAL)

COLLATERAL INFORMATION: medication containers, EMS

ONSET OF SYMPTOMS

Question 4

PHYSICAL EXAM (Secondary Survey)

Answer 4

Vitals
General Appearance
Neuro: GCS, Extremity Tone, Tremors, Fasiculations
Eyes: Pupil Size, Reactivity. Nystagmus, Excessive Lacrimation
Skin: Cyanosis, flushing, diaphoresis, dryness. Injury, trauma.
CVS: Rate, Rhythm, peripheral pulses
Lungs: Bronchorrhea, bronchoconstriction.
GI: Bowel sounds, bladder size, rigidity / tenderness

Question 5

Universal Antidotes: the coma cocktail

Answer 5

TONG

Thiamine (100 mg IV / IM / PO but make sure to give with the dextrose)
Oxygen (nasal, face mask)
Narcan (0.4 mg - 2 mg IV / IM) T1/2 30 min
Dextrose 1 ampule of D50W (or glucagon 1mg IM)

Question 6

Investigations

Answer 6

Accucheck (part of inital assessment)
CBC lytes, creatinine
LFT
INR / PTT
Serum Osolarity
Osmolar gap
VBG
Lactate
Quantitave drug levels: (acetaminophen, salicylates, ethanol)
Urine Tox Screen
Pregnancy test
ECG
CXR (aspiration and pulmonary edema)

Question 7

Principles of Decontamination

Answer 7

Activated Charcoal - only appropriate for within 1 hr
Orogastric Lavage - only appropriate for within 1 hr
Whole Bowel Irrigation
Urine Alkalinization

Question 8

Activated Charcoal: Indications, Dosing, C/I

Answer 8

Indications:
within 1 hr of ingestion
Airway protected

C/i:
GCS < 8
Known / suspected GI perforation
Known ingestion of substance charcoal does not absorb

Question 9

Drugs Charcoal Cannot Absorb

Answer 9

HAILL:
Hydrocarbons
Alcohols
Iron
Lithium
Lead

Question 10

Activated Charcoal: Dosing

Answer 10

Dosing:
1 g / kg OR 10:1 Charcoal:dose ingested
WITH
Sorbitol 70% 1g/kg
OR
Mg Citrate 10% Solution 250 mL adults or 4 ml/kg children

Question 11

Indications and dosing for multi-dose activated charcoal

Answer 11

Indications: Theophylline, Phenobarbitol, Quinine, Carbemazepine, Colchicine

50-100 g PO first dose
THEN
12.5 - 25 PO g q 4-5 hrs

Question 12

Orogastric Lavage: Indications, C/I

Answer 12

Indications:
Life-threatening ingestions
Pills able to fit through orogastric tube holes
Ingestion within 1 hr

Contraindications:
Non life-threatening ingestions
Pills unable to fit through orogastric tube holes
Caustic ingestion
No ability to intubate patient
Ingestions where lung toxicity&raquo_space;GI toxicity

Question 13

Orogastric Lavage: steps

Answer 13

Intubate patient
Place in left lateral decubitus position
Head tilted 20 degrees downward
Insert 40 F orogastric tube (24 F Peds)
Ideal length measured from chin to xiphoid
Adults: Instill 200 cc body temperature fluids repeatedly until fluid clear
Peds: Instill 10 ml / kg
Ensure amount instilled is the amount returned
Instill activated charcoal at end if indicated before pulling NG tube

Question 14

Whole Bowel Irrigation: Indications / C/I

Answer 14

Indications:
Ingestion of sustained release drugs
Ingestion of substances that charcoal cannot absorb (HAILL)
Drugs ingested by body packers / stuffers

Contraindications:
Known of suspected bowel obstruction
Inability to intubate patient
Ingested toxin known to cause diarrhea

Question 15

Whole Bowel Irrigation: Steps

Answer 15

Intubate patient
Insert NG tube
Infuse Polyethylene glycol in osmotically balanced solution through NG tube at 2L/h (adults), 1L/hr children > 6 yrs, 0.5 L/hr children < 6 yrs
Infuse until rectal fluid is clear

Question 16

Urinary Alkalinization: Indications, Contraindications, Risks

Answer 16

Indications:
ASA
TCA
Phenobarbitol
INH
Quinolone OD

Contraindications:

Question 17

Urinary Alkalinization: Dosing, , target

Answer 17

1-2 mEq/kg NaHC03 IV push
3 ampules NaHC03 in 850 cc of D5W at 1.5x maintenance fluid rate
Monitor electrolytes and blood gas q 2 hrs (re. hypokalemia), urinary pH q 30 min

Target Urine pH: 7.5 - 8.5