Emergency Therapeutics: Mgmt of pt with Acute drug overdose Flashcards
What are the 6 steps in evaluating a patient with a drug overdose / toxic ingestion
- Stabilize the patient in the ER
- Evaluate patient, use all available clues, make a tentative Dx
- Prevent further absorption of toxin (if indicated and if safe to do so)
- Administer an antidote when indicated
- Enhance clearance of toxin if indicated (depends on time of ingestion)
- Plan what to follow, monitor, prevent, etc
Work through this step in evaluating a patient with a drug overdose / toxic ingestion: Stabilize the patient in the ER
- Begin with A,B,C’s –> esp. need arterial BG
- Coma: don’t forget trauma, hypoglycemia, avoid stimulants, EEG in presence of hypothermia or ? Brain death
- Seizures: don’t forget stimulants, hypoglycemia
- Respiratory depression: hard to assess clinically, but pulse oximetry is helpful (not definitive!!)
- Shock: perfusion is key, more important than P, BP per se; may be multifactorial (myocardial depression, vasodilatation, hypovolemia)
- “Cocktail” for all comatose patients: thiamine (100 mg), glucose (50 gm), naloxone (0.4 mg), flumazenil (1 mg).
Work through this step in evaluating a patient with a drug overdose / toxic ingestion: Evaluate patient, use all available clues, make a tentative Dx
- History is often the key: location, situation, bottles, meds in the cabinet, etc (timing)
- PE: need to focus on features likely to give most info, like VS, MS, pupils, bowel sounds, skin, mouth (odor)
- Concept of “toxidromes”: ability to recognize common poisons through common yet somewhat distinctive syndromes on presentation
- Lab tests:
- General and quick for “screening”: CBC, lytes (esp. for metabolic acidosis), BUN, creatinine
- More specific but quick: salicylate level, ACAM, ECG, Fe/TIBC, Osm
- Specific but slower: urine screen for DAU, methanol, Ethylene glycol
Work through this step in evaluating a patient with a drug overdose / toxic ingestion: Prevent further absorption of toxin (when benefits > risks)
-Sometimes on skin: wash profusely
-Usually GI tract, which is harder than it appears; PROTECT THE AIRWAY!!!
Pros and cons of Syrup of Ipecac
Pros and cons of gastric lavage
Pros and cons of activated charcoal
Pros and cons of cathartic (Mag citrate, mag sulfate, sorbitol, PEG)
Pros and cons of tracheal intubation
what drugs can cause seizures
CNS stimulants
- amphetamines
- cocaine
also: hypoglycemia (sulfonyurea)
-“Cocktail” for all comatose patients
- thiamine (100 mg) = for EtOH-induced
- glucose (50 gm) = for hypoglycemia
- naloxone (0.4 mg) = for opioid overdose; ADR: intractable seizures
- flumazenil (1 mg) = for benzodiazepine overdose
Pt found on the side of the Connecticut river next to his car, with an empty quart of vodka next to him. He was completely comatose.
Blood alcohol = 0.5 (intoxicated is 0.08)
Blood glucose nml
Blood sugar nml
Very well perfused
What is the cause?
How to manage?
He was found next to his car exhaust – so he drank enough to fall asleep and made sure next to be the exhause
== carbon monoxide poisoning
Tx =
Very large pupils: what drug?
stimulants = phenylephrine; alpha-1 anticholinergics = TCAs
Pros and cons of:
- Syrup of Ipecac
- gastric lavage
- activated charcoal
- cathartic (Mag citrate, mag sulfate, sorbitol, PEG)
- tracheal intubation
- Syrup of Ipecac
PROS: + movement == induce vomiting
CONS: arrhythmias - gastric lavage with warm water / saline
PROS: induce vomiting
CONS: esp. bad if caustic/facial/esophgeal trauma to push a tube down an inflamed esophagus (ADR: perforation) - activated charcoal
PROS: to absorb the drug [if can make sure to prevent them from aspirating it]
CONS: certain drugs can go into coma –> not protect airway –> then seize – aspirated slurry of activated charcoal can coat the respiratory tract - cathartic (Mag citrate, mag sulfate, sorbitol, PEG)
PROS: if drug is likely now in the small bowel; iatrogenic osmotic diarrhea
CONS: besides PEG - can cause severe electrolyte disturbances - tracheal intubation
PROS: protect the airway
CONS: if caustic drug / facial/esophgeal trauma – can perforate
Work through this step in evaluating a patient with a drug overdose / toxic ingestion: Prevent further absorption of toxin (when benefits > risks)
Few drugs have antidotes, and they are not always indicated
Drugs with antidotes CO ==> 2 ATM of hyperbaric O2 Iron ==> desferoxamine Acetaminophen ==> anacetylcysteine Mercury ==> chelating agent (2 arms ==> one side to grab the metal, other water-soluble side to excrete in urine) Pb ==> Cyanide ==> donating sulfur group Digoxin ==> anti-digoxin Ab Hydromorphone ==> naloxone Diazepam ==> flumazenil
Name the antidote for the following
CO
CO ==> 2 ATM of hyperbaric O2
Work through this step in evaluating a patient with a drug overdose / toxic ingestion: Enhance clearance of toxin (if benefits > risks)
For most toxins, these will not work
Salicylate ==> dialyzable b/c small, water-soluble; alkalinize the urine (trap in urine)
Methanol ==> dialyzable b/c small, water-soluble
Ethylene glycol ==> dialyzable b/c small, water-soluble
Lithium ==> dialyzable b/c small, water-soluble; saline diuresis
Amitriptyline ==> larger ==> percolate blood over charcoal cannister (ADR: hypoglycemia, thrombocytopenia)
Theophylline
Carbon monoxide hyperbaric O2
Digoxin
Name the antidote for the following
Iron
Iron ==> desferoxamine
Name the antidote for the following
Acetaminophen
Acetaminophen ==> anacetylcysteine
Name the antidote for the following
Mercury
Mercury ==> DMSA or DMPS- chelating agent (2 arms ==> one side to grab the metal, other water-soluble side to excrete in urine)
Pb ==>DMSA
