Overdose or Poisoning Flashcards
The term _______ refers to the collection of signs and symptoms that are observed after an exposure to a substance “toxic fingerprint
“toxidrome”
True/False
In the emergency setting toxicological screening test of blood and urine does not contribute significantly to the evaluation, management, or outcome for most patients.
True
_______are common overdoses and serum levels are important in the management of the patient.
Acetaminophen and Aspirin
Thorough physical examination is essential - with a special emphasis on:
(a) Mental status
(b) Pupil size and reactivity
(c) Skin temp
(d) Presence or absence of sweat
(e) Muscular tone
(f) GI motility and mucus membrane moisture
For the majority of patients resuscitation of the poisoned patient begins with assessment and management of…
airway, breathing and circulation rather than administration of antidotes
If the pt is contaminated what is priority?
removal of clothing and copious irrigation of the skin
_____ should be worn at all times for decontamination
PPE
If altered mental status, obtunded, or coma is present then administer what?
-Naloxone 0.2-2.0mg IV/IM/SQ
-Glucose (dextrose)
-Thiamine (if available)
Why does naloxone often require re-dosing?
has a duration 30-60 minutes which is a shorter half-life than most opioids
Hypotension is first treated with..
fluid bolus
_______ are first line treatment for seizures
Benzodiazepines
Ocular exposure tx
copious irrigation
GI decontamination - various methods including
(a) Orogastric lavage
(b) Activated charcoal - most commonly used
What is the dosing for Activated Charcoal?
1gm/kg
What is an alternate route of administration of Activated Charcoal?
NG tube
observation for patients is variable and should be done in consultation with ____ and _______
supervising MO and poison control
All patients with intentional poisoning/overdoses should be referred for _____ when stable
psychiatric evaluation
What are the symptoms for Anticholinergic
Dry as a bone, red as a beet, hot as a hare, blind as a bat, mad as a hatter and stuffed as a pipe.
Anticholinergic Toxidrome is commonly seen in the ED due to high use of what medications
-Antihistamines (primarily diphenhydramine),
-phenothiazines,
-muscle relaxers,
-tricyclic antidepressant (TCA),
-Jimson weed
Anticholinergic Emergency Care
(a) Mostly supportive
(b) IV, O2, monitor
(c) GI decontamination with Activated charcoal (may be useful even if greater than 1 hour due to delayed GI motility)
(d) Treat hyperthermia and seizures (Benzodiazepines)
(e) If acutely agitated - benzodiazepines
(f) MEDAVICE/MEDEVAC
These are what type of medication?
Fluoxetine, Sertraline,
Paroxetine, Fluvoxamine, Citalopram and Escitalopram.
SSRI’s
What is the most adverse effect of SSRI’s?
Serotonin syndrome
What would you suspect? how would you treat?
Hx of depression tx
(a) Cognitive and behavioral - confusion, agitation, coma, anxiety, hypomania, lethargy, seizures
(b) Autonomic - hyperthermia, diaphoresis, tachycardia, hyper/hypo tension, dilated pupils, salivation
(c) Neuromuscular - myoclonus, hyperreflexia, rigidity, tremor, ataxia, shivering, nystagmus
Serotonin Syndrome
(a) D/C all serotoninergic agents and provide supportive care
(b) MEDEVAC to closest Emergency Department or facility with a higher level of care.
(c) Monitor all patients with muscle rigidity, seizures or hyperthermia for rhabdomyolysis.
(d) For muscle rigidity or seizures administer benzodiazepines.
Sedative and Hypnotics include what?
barbiturates and benzodiazepines
_____ depress CNS activity by enhancing the action of Gamma aminobutyric acid (GABA)
Barbiturates
Ingestion of _____ and/or ______ lead to sedation, dizziness, slurred speech, confusion,
ataxia.
-Respiratory depression is the most common vital sign abnormality in severe
overdoses.
Sedative and Hypnotics
-barbiturates and benzodiazepines
Sedative and Hypnotics overdoes emergency care
(a) Assess and stabilize ABC’s
(b) Airways management and ventilator support may be required in the obtunded patient
(c) Activated charcoal may decrease absorption and should be administered to the cooperative patient presenting within 1 hour of ingestion
(d) Flumazenil/Romazicon - limited role
_______ may decrease absorption and should be administered to the cooperative patient presenting within 1 hour of ingestion
Activated charcoal
What is a is a benzodiazepine antagonist
Flumazenil
What would you suspect?
Hx of tx with pain meds
(a) CNS depression
(b) Miosis
(c) Respiratory depression
(d) Bradycardia
(e) Hypothermia
Opioid overdose
Opioid overdose tx
(a) Airway and ventilator support are most important considerations
(b) Activated charcoal - considered if ingestion is less than 1 hour
(c) Naloxone (Narcan) - competitive agonist at all opioid receptors
what are the most important considerations when managing an opiod overdose
Airway and ventilator support
What should be considered when treating Opioid dependent patients with overdose
should receive a smaller dose to prevent acute withdrawal
_____ causes sympathetic nervous system activation which causes typical mydriasis, tachycardia, hypertension and diaphoresis
Cocaine
______ - similar effect to cocaine. Block re-uptake of catecholamines, also have effect on serotonin release which causes hallucinogenic effect
Amphetamines
What would you suspect?
(a) May demonstrate psychomotor agitation
(b) mydriasis
(c) diaphoresis
(d) tachycardia
(e) tachypnea
(f) hypertension
(g)hyperthermia
(h)AMS
(i) Watch for seizures and rhabdo
(j) May have chest pain, headache, dyspnea or focal neuro complaints
Cocaine, Amphetamines, Stimulants overdose
Cocaine, Amphetamines, Stimulants overdose
Mainstay of treatment is…..
adequate sedation and continuous monitoring of vital signs
Cocaine, Amphetamines, Stimulants overdose
-Emergency Care
(a) Mainstay of treatment is _______________.
(b) Monitor for signs of rhabdo, cardiac complications and manage acute agitation.
(c) Obtain ____
(d) ________ will often improve tachycardia, hypertension and agitation
(e) Active cooling
(f) Treat seizures with _______
(g) Treat cardiac chest pain with __________
(h) Call for _______
a) adequate sedation and continuous monitoring of vital signs
c) EKG
d) Benzodiazepines
f) benzodiazepines
g) ASA, Nitro, Benzo
h) MEDEVAC/MEDAVICE
True/False
Beta Blockers are INDICATED in cocaine use induced chest pain
False
CONTRAINDICATED
(unopposed alpha
stimulation)
ASA toxicity causes what?
respiratory alkalosis due to a direct effect on the medullary
respiratory center
ASA
Clinical diagnosis made in conjunction with acid base status. Ingestion less than:
1) _____ - mild - N/V GI irritation
2) ______moderate - vomiting, tachypnea, tinnitus, sweating
3)______ - severe
1) 150mg/kg - mild - N/V GI irritation
2) 150-300mg/kg moderate - vomiting, tachypnea, tinnitus, sweating
3) > 300mg/kg - severe
What issue?
1) tachypnea
2) tinnitus
3) N/V
4) acid base abnormalities
5) AMS
6) pulmonary edema
7) arrhythmia
8) hypovolemia
9) thrombocytopenia
10) hepatic effects
ASA Toxicity
What medication can be administered for ASA Toxicity, that causes alkalization of urine and increase Salicylate elimination
Sodium Bicarbonate 1- 2mEq/kg
ASA Toxicity Patients may ultimately require what?
hemodialysis
What is the most popular over the counter analgesic in US.
Acetaminophen (APAP)
APAP is rapidly absorbed from the ____ and metabalized in the ____
-GI tract
- liver
What stage of APAP Toxicity?
first 24 hours - nonspecific. N/V, malaise, anorexia
Stage 1
What stage of APAP Toxicity?
day 2-3 - N/V may improve and evidence of toxicity may develop. RUQ pain, elevated bilirubin/jaundice
Stage 2
What stage of APAP Toxicity?
day 3-4 - progression to hepatic failure. Lactic acidosis, coagulopathy, renal failure, encephalopathy, N/V
Stage 3 -
what stage of APAP Toxicity?
those who survive will begin to recover
Stage 4 -
Toxicity may occur with acute ingestion
______ or ____over 24 hours.
> 140mg/kg
or
7.5 gm
What is the specific antidote for APAP toxicity
NAC (N-acetylcysteine)
NAC (N-acetylcysteine) Can prevent
toxicity in administered within how long of ingestion?
8 hours
1) Serum levels should be drawn on all patients with APAP ingestion and levels at ___ hours evaluated.
2) Levels above _______ at 4 hours are considered toxic.
1) 4
2) 150mcg/dl
Toxidrome/clinical features of Insecticides (malathion, parathion) and Nerve agents (VX, sarin)
1) Salivation
2) Lacrimation
3) Urinary incontinence
4) Defecation
5) GI pain/dismotility
6) Emesis
insecticides and Nerve agents
Pt usually symptomatic within ____ of dermal exposure to organophosphates. Nerve agents ___
-8 hours
- Immediate effect
insecticides and Nerve agents emergency care
(a) Decontamination
(b) Monitoring
(c) Atropine
(d) Pralidoxime -2-PAM.
(e) MEDEVAC
(f) Seizures - Benzo’s
(h) Support airway and breathing
Atropine** 1mg in adult. Repeat Q___ min until _____
-Q5m
- respiratory secretions improve
True/False
Pralidoxime -2-PAM. Can be administered without concurrent Atropine.
False
Should NOT
NAC dosage Oral:
NG tube 140mg/kg loading dose, followed by 70mg/kg Q4 hours for 17 additional doses
NAC dosage IV:
150mg/kg loading dose, followed by 50mg/kg over the next 4 hours, then 100mg/kg
over next 16 hours.
-Ideally initiate loading dose and medevac to higher echelon under consultation with poison control and MO
Naloxone (Narcan) doseage and freq
20-90 minutes
0.4-2 mg
