Drug Overdose and Poisoning #2 Flashcards
Describe carbon monoxide.
colorless, odorless gas that has a 200x more affinity for hemoglobin than oxygen.
What are some sources of exposure to carbon monoxide?
car exhaust
natural gas
propane furnace emissions
cigarette smoke
wood stove emissions
pollution
kerosene
charcoal
What are some signs of carbon monoxide posioning?
flu-like symptoms - HA dizziness, n/v
Increased exposure: dyspnea, AMS, coma, seizures, respiratory arrest
cv: chest pain (ischemia), dysrhythmias, hypotension, cardiac arrest
Renal: renal failure from rhabdo due to to prolonged unconsciousness has occured
How do you diagnose carbon monoxide poisoning?
Carboxyhemoglobin levels (COHb)
What is the fetal COHb in comparison to maternal?
10-15% greater
What level diagnoses carbon monoxide poisoning in a smoker and non-smoking patient?
> 10% in smoker and > 5% in non-smoker
Obviously to prevent further absorption you remove the patient from the source of the gas, how is it further treated after this is done?
ABCs
100% oxygen
If severe (decreased LOC, cerebellar dysfunction, COHb >25%: HBO therapy
What are some examples of prescribed and recreational opioids?
Prescribed: norco, lortab, oxycodone, oxycontin
Recreational: abuse of prescribed, heroin, morphine
What are the most common signs and symptoms of an opioid/benzo overdose?
CNS depression
miosis (pupil constriction)
respiratory depression
hypothermia
bradycardia
respiratory arrest = death
pulmonary edema
What are the proper interventions for an opioid overdose?
ventilation and nalaxone
for the client that requires multiple doses, an infusion should be administered because of its short action
what are the proper interventions for a benzodiazepine overdose?
ventilation and flumazenil
when is flumazenil indicated?
in a client who is benzo naive, quick reversal may cause seizures or status epilepticus in benzo dependent clients
What are some signs and symptoms of a cocaine overdose? What about crack cocaine (smokable)?
cocaine: wide QRS and prolonged QT intervals, can be myocardial toxic in large doses, dysrhythmias, myocarditis, cardiomyopathy, myocardial ischemia and infarct, aortic rupture, aortic and coronary artery dissection.
RHABDO
Crack cocaine: pulmonary hemorrhage, pneumonitis, asthma, pulmonary edema, pneumomediastinum, pneumothorax, pneumopericardium
What are some signs and symptoms of a methamphetamine overdose?
hyperthermia, dysrhythmias, seizures, HTN, intracranial hemorrhage or infarction, rhabdo
How do you treat cocaine, amphetamine, and other stimulant overdose?
sedations and vitals assessment, ECG
Cardiac enzymes to rule out MI
active cooling
treat seizures with benzos, phenobarbital if not effective
treat cardiac ischemia with chest pain protocols
people who pack the drugs in their system but are asymptomatic should be treated with activated charcoal
What are the signs and symptoms of ASA toxicity?
Neuro: tinnitus, lethargy, confusion, seizures, cerebral edema
Respiratory: tachypnea, pulmonary edema, respiratory alkalosis coupled with metabolic acidosis
GI: n/v, GI hemorrhage, hypothrombinemia, platelet dysfunction
Renal: dehydration, hypokalemia
How do you treat ASA poisoning?
prevention of absorption: syrup of ipecac, gastric lavage, activated charcoal
IV hydration
sodium bicarb if needed
potassium replacement if needed
hemodialysis if in renal failure
supportive care
monitor for cerebral edema
What lab tests would be assessed in ASA poisoning?
salicylate level, serial electrolytes, ABGs, coagulation studies
Describe what would be seen in an acetaminophen toxicity day by day starting day 1 going through day 4.
day 1 - may be asymptomatic, anorexia, nausea, malaise
day 2-3 - n/v, abdominal pain with elevated liver function tests and bilirubin possible, PT increase
day 3-4 - fulminant hepatic failure with lactic acidosis, coagulopathy, renal failure, and encephalopathy, jaundice present
How long after ingestion and how long after first level should serum acetaminophen levels be drawn?
4 hours - first draw or later if patient present to facility at later time
draw every 4 hours for 24 hour
What is the treatment for acetaminophen overdose?
activated charcoal. acetylcysteine (mucomyst), liver transplant center
What are the protocols for oral and IV acetycysteine?>
Oral: NAC, mucomyst
- 140mg/kg loading dose
- 70 mg/kg every 4 hours for total of 17 maintenance doses
- dilute NAC (20% solution) with soft drink or juice
- repeat any dose not tolerated after 1 hour, antiemetics may be needed to control vomiting
IV: acetadote
- 150 mg/kg in 200ml of D5W loading dose over 60 minutes
- first maintenance dose of 50 mg/kg in 500ml of D5W over 4 hours
- second maintenance dose of 100mg/kg in 1000 ml of D5W over 16 hours
describe the three phases of antifreeze/ethylene glycol overdose and the time frame of each phase.
1 - within 12 hours of ingestion - dominate CNS effects, client may appear intoxicated minus the smell of ETOH on the breath.
2 - 12-24 hours of ingestion - cardiopulmonary effects dominate - increased HR, increase RR, increase BP, CHF, respiratory distress, circulatory collapse
3 - within 24-72 hours of ingestion - renal effects predominate - flank pain, acute tubular necrosis, renal failure
How do you treat an ethylene glycol/antifreeze overdose?
fomepizole - inhibits alcohol dehydrogenase
ethanol drip - inhibits formation of toxic metabolites becuase it has a 10-20 times greater affinity for alcohol dehydrogenase than methanol and a 100 times greater affinity than ethylene glycol
even using oral commercial alcoholic beverages may be indicated
monitor serum glucose - energy is used in metabolism of toxin, reduces BG
possible dialysis
What does MUDPILES stand for, and what exactly is it?
Methanol Uremia DKA Paraldehyde Iron, Isoniazid, Inhalants Lactic acidosis Ethanol, Ethylene glycol Salicylates
This is a ddx for high anion gap metabolic acidosis
What are some examples of anticholinergic substances?
antihistamines anti-parkisonian agents antipsychotics antispasmodics TCAs OTC meds: excedrin PM, corocidin skeletal muscle relaxants mushrooms/plants
What are some signs and symptoms of anticholinergic toxicity?
mydriasis HTN hypoactive or absent bowel sounds tachycardia flushed skin disorientation urinary retention hyperthermia dry skin and mucous membranes confusion and agitation auditory and visual hallucinations
How would you diagnose an anticholinergic overdose?
CLINICAL S/S
Labs are usually normal and toxicology screens are of little to no value
How do you treat an anticholinergic overdose?
Monitor for tachycardia and dysrhythmias
gastric lavage if within 1 hour of ingestion
activated charcoal
monitor for hyperthermia
monitor for seizures
When does serotonin syndrome most commonly occur?
THERAPEUTIC DRUG LEVELS
What is serotonin syndrome?
Rare, idoiosyncratic compilation of antidepressant therapy characterized by cognitive impairment and autonomic neuromuscular dysfunctions
How is serotonin syndrome caused?
May be caused by any drug combination that increases central serotonin transmission
What are some cognitive and behavioral findings associated with serotonin sickness?
confusion agitation coma anxiety hypomania lethargy seizures insomnia hallucinations dizziness
What are some autonomic signs of serotonin syndrome?
hyperthermia diaphoresis flushed skin sinus tach HTN tachypnea dilated or unresponsive pupils hypotension diarrhea abdominal cramps
What are some neuromuscular findings associated with serotonin syndrome?
myoclonus hyperreflexia tremors muscle rigidity babinski sign nystagmus trismus (lockjaw)
How do you treat serotonin syndrome?
discontinue serotoninergic agents
benzo to relieve muscle cramping and rigidity
monitor for rhabdo and/or metabolic acidosis
ADMIT THE PATIENT
What are some examples of TCAs?
Amitriptyline (Elavil) Amoxapine (Asendin) Clomipramine (Anafranil) Cyclobenzaprine (Flexeril) Doxepin (Adapin/Sinequan)
What are TCAs used for? Has the popularity increased or decreased over the years?
depression
decreased
What age do most TCA exposures occur? What percentage is intentional?
young adults
60%
What are some signs and symptoms of mild TCA toxicity?
Drowsiness confusion slurred speech ataxia dry mucous membranes and axcillae sinus tachy decreased bowel tones and ileus mild HTN (doesnt usually require treatment) hypotension
What are the S/S of severe TCA toxicity? What time frame is this usually seen after ingestion?
Usually seen within 6 hours of ingestion?
coma cardiac conduction delays SVT VT seizures
What are some secondary isues that can be caused by TCA toxicity?
pulmonary edema
anoxic encephalopathy
hyperthermia
rhabdo
How do you treat TCA toxicity?
secure airway if needed
IV, IVF hydration
continuous cardiac monitoring
seizure precautions’
urinary catheter for antimuscarinic symptoms (unrinary retention)
if early ingestion activated charcoal is indicated
What triage level would some with TCA toxicity be?
Level 2 (RED)
What labs would you mintor with TCA toxicity?
electrolytes
CK
ABG
TCA drug screen (toxicology screen)
If the TCA ingestion was intentional and toxic what also may be needed as far as assessment?
psychiatric admission and assessment
If the clients toxicity was unintentional and becomes asymptomatic for 6 hours is it okay to discharge them?
YES
Who is always contacted in TCA overdose?
POISON CONTROL
