Management of Acute Intoxications

Question 1

Why does a poisoned patient die?

Answer 1

CNS depression - loss of airway protective reflexes, respiratory drive, airway obstruction (flaccid tongue), aspiration

cardiovascular failure - hypotension, hypovolemia, peripheral vascular collapse, arrhythmias

cellular hypoxia - interference with transport and utilization of oxygen

seizures - pulmonary aspiration, brain damage

behavioral effects - traumatic injury

Question 2

Basic assessment of a poisoned patient

Answer 2

Does not differ initially from other emergency situations - assess level of consciousness, ventilation, circulation

History (80% of poisoned pts are conscious at arrival to ED)

Physical

If a specific toxidrome is suspected, deploy the appropriate antidote and decontamination

Tox screens, electrolytes

Question 3

3 primary interventions to minimize a toxic response in a poisoned patient and provide a specific example for each intervention

Answer 3

decontamination

enhance elimination from the body

administration of antidote

Question 4

Define a toxidrome

Answer 4

Group of signs or sx that provide clues to the diagnosis of a poisoning

Question 5

Main signs and toxicants associated with anticholinergic toxidrome

Answer 5

toxicants: tricyclic antidepressents, antipsychotics, oxybutinin, ipratropium, ACh receptor antagonists, Jimson weed, deadly nightshade,

Sx: increased HR and BP, increased temp, dilated pupils, decreased bowel sounds, decreased sweating, confused, dry mouth and urinary retention, grabbing invisible objects, flushed skin

“blind as a bat, hot as a desert, dry as a bone, mad as a hatter, red as a beet”

tx: physostigmine

Question 6

Main signs and toxicants associated with sympathomimetic toxidrome

Answer 6

toxicants: epinephrine, cocaine, amphetamine, methylphenidate, caffeine, ephedrine

Sx: increased HR and BP, increased RR, increased temp, dilated pupils, increased bowel sounds, increased sweating

Tx: supportive care, manage agitation (chemical restraint), manage hypertension with beta blockers if unresponsive to sedation, monitor and manage core temperature

Question 7

Main signs and toxicants associated with cholinergic toxidrome

Answer 7

toxicants: Ach receptor agonists, AchEIs i.e. donepezil, organophosphate pesticides, poisonous mushrooms

Sx: constricted pupils, increased bowel sounds, increased diaphoresis (no cardiac, RR, or temp effects in contrast with sympathomimetic toxidrome)

other: very wet (salivation, crying, running noise, sweating, vomiting, urination, diarrhea)

Tx: atropine (deadly nightshade) and pralidoxime chloride

Question 8

Main signs and toxicants associated with opioid toxidrome

Answer 8

opiate (natural narcotic derived from poppy) vs opioid (synthetic)

toxicants: morphine, heroin, hydromorphone, oxycontin

Sx: decreased HR/BP, decreased RR, decreased temp, pupil constriction, decreased bowel sounds, decreased diaphoresis (exact opposite of sympathomimetic), rhabdomyolysis, compartment syndrome, myoglobinuric renal failure, hepatic injury from acetaminophen or hypoxemia

Tx: naloxone

Question 9

Main signs and toxicants associated with sedative-hypnotic toxidrome

Answer 9

toxicants: benzos and barbs, Z-drugs, antihistamines, alcohol, anticonvulsants

Sx: Decreased HR/BP, decreased RR, decreased temp, decreased bowel sounds, decreased diaphoresis (distinguish from opioid bc no pupil effects with sedative hypnotics), impaired consciousness

Tx: distinuguish from opioid od by administering naloxone and seeing what happens, general supportive care, flumanezil for bzd od? (controversial)