OVERDOSING AND POISONING Flashcards
What components of a physical exam should be emphasized for a Overdose/Poisoned patient?
1) Mental status
2) Pupil size and reactivity
3) Skin temp
4) Presence or absence of sweat
5) Muscular tone
6) GI motility
7) Mucus membrane moisture
What is a collection of signs and symptoms that are observed after an exposure to a substance “toxic fingerprint”?
Toxidrome
If the toxin that was ingested is unknown, what medications should always be considered “Co-Ingestants?”
Acetaminophen and Aspirin
Acetaminophen and Aspirin are common overdoses and serum levels are important in the management of the patient. It is also important to consider these as co- ingestants in any unknown ingestion
Resuscitation of the poisoned patient begins with:
A) Management of Airway, Breathing, Circulation
B) Administration of Antidotes
C) Obtaining Toxicological Screening Test of Blood
D) Obtaining Toxicological Screening Test of Urine
A) Management of Airway, Breathing, Circulation
What is the priority for treatment of a poisoned patient that has been contaminated?
Removal of clothing and irrigation of skin
Overdose/Poisoning:
A patient is found unconscious, after doing a quick physical exam you find the patients eyes are dilated. What is the next step in treatment?
Naloxone
Dosage 0.4-2.0mg IV/IM/SQ
every 2-4 minutes
What is the average half-life of Naloxone?
60 minutes
Overdose/Posioning:
How is hypotension first treated?
Fluid Bolus
Overdose/Poisoning
What is the first line treatment for seizures?
Benzodiazepines
Overdose/Poisoning
Treatment for ocular exposure?
Copious Irrigation
Overdose/Poisoning
What are the methods of GI Decontamination?
1) Orogastric lavage (following placement of an NG tube)
2) Activated Charcoal
What is the most commonly used method of GI Decontamination?
Activated Charcoal
All patients with intentional poisoning/overdoses should be referred for __________________ once stable.
Psychiatric Evaluation
Toxidrome:
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
The effects of the Anticholinergic are due to disturbances in the __________ and __________.
Parasympathetic Nervous System (PNS)
and
Brain
Antihistamines (primarily diphenhydramine), phenothiazines,muscle relaxers, antidepressants, and Jimson weed are examples of __________ substances
Anticholinergic
What medications are common examples of Anticholinergic substances?
1) Antihistamines (primarily diphenhydramine)
2) Phenothiazines
3) Muscle relaxers
4) Antidepressants
5) Jimson weed
What are findings associated with Anticholinergic substances?
1) Absent bowel sounds
2) Mydriasis
3) Hyperthermia
4) dry skin/mucus membranes
5) Urinary retention
6) Confusion/agitation (Agitated, NOT really VIOLENT)
7) Tachycardia
8) Flushed skin
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.
What is the most common EKG finding with Anticholinergic substances?
Sinus Tachycardia
What EKG findings can be seen with Anticholinergic substances?
1) Sinus Tachycardia
2) Wide Complex Tachycardia
3) Prolonged QT Intervals
What is the emergency care procedures for a patient that has taken an Anticholinergic Substance?
1) Mostly supportive
2) IV, O2, monitor
3) GI decontamination with Activated charcoal (may be useful even if greater than 1 hour due to delayed GI motility)
4) Treat hyperthermia and seizures (Benzodiazepines)
5) If acutely agitated - Benzodiazepines
6) MEDAVICE/MEDEVAC
What is the Dosage for Naloxone?
Dosage 0.4-2.0mg IV/IM/SQ
What is the treatment for seizure, hyperthermia and acute agitation in a patient that has taken Anticholinergic Substance?
Benzodiazepines
What type of medications are Fluoxetine, Sertraline, Paroxetine, Fluvoxamine, Citalopram and Escitalopram?
Selective Serotonin Reuptake Inhibitors (SSRI’s)
What is the most serious adverse effect of Selective Serotonin Reuptake Inhibitors (SSRI’s)?
Serotonin Syndrome
How do most patients with an acute overdose of SSRI’s present?
Asymptomatic
After the Acute Overdose phase, patients that took SSRI’s develop what symptoms?
1) Nausea and Vomiting
2) Sedation
3) Tachycardia
Life threatening complications are _________ in patients that are overdosing on SSRI’s.
Uncommon
What are the Emergency Care Procedures for an SSRI Overdose?
1) Supportive care (IV / O2 / Monitor)
2) MEDADVIE / MEDEVAC
3) If symptomatic gain IV access and place on monitors
4) Benzodiazapines for Seizure (MEDEVAC)
What is potentially fatal adverse drug reaction to serotonergic medication, characterized by autonomic and neuromuscular dysfunction?
Serotonin Syndrome
Serotonin Syndrome is a fatal adverse drug reaction to SSRIs that is characterized by what two dysfunctions?
Autonomic Dysfunction
Neuromuscular dysfunction
What are the Clinical Features of Serotonin Syndrome?
1) Cognitive and behavioral - Confusion, Agitation, Coma, Anxiety, Hypomania, Lethargy, Seizures
2) Autonomic - Hyperthermia, Diaphoresis, Tachycardia, Hyper/Hypotension, Dilated pupils, Salivation
3) Neuromuscular - Myoclonus (Muscle Jerks/Spasms) Hyperreflexia, Rigidity, Tremor, Ataxia, Shivering, Nystagmus
What are the Cognitive/Behavioral clinical features of Serotonin Syndrome? (7)
1) Confusion
2) Agitation
3) Coma
4) Anxiety
5) Hypomania
6) Lethargy
7) Seizures
What are the Autonomic clinical features of Serotonin Syndrome? (6)
1) Hyperthermia
2) Diaphoresis
3) Tachycardia
4) Hyper/Hypotension
5) Dilated Pupils
6) Salivation
What are the Neuromuscular clinical features of Serotonin Syndrome? (8)
1) Myoclonus (Muscle jerks/spasms)
2) Hyperreflexia
3) Rigidity
4) Tremor
5) Ataxia
6) Ataxia
7) Shivering
8) Nystagmus
How is Serotonin Syndrome diagnosed?
Clinically
What are the emergency care procedures for Serotonin Syndrome?
1) Discontinue Serotoninergic meds
2) Supportive Care (IV / O2 / MONITOR)
3) MEDEVAC
4) Benzodiazepines for Seizures
What signs/symptoms are concerning for Rhabdomyolysis in a patient with Serotonin Syndrome?
1) Muscle Rigidity
2) Seizures
3) Hyperthermia
What medications fall under Sedatives and Hypnotics?
1) Barbituates
2) Benzodiazepines
______________ depress CNS activity by enhancing the action of Gamma aminobutyric acid (GABA).
Barbiturates
How do Barbituates enhance the action of Gamma aminobutyric acid (GABA)?
By depressing CNS activity
What is the main inhibitory neurotransmitter in the CNS?
Gamma aminobutyric acid (GABA)
What is the most common vital sign abnormality in severe Sedative and Hypnotic overdose?
Respiratory Depression
What are the signs and symptoms for Sedative and Hynotic overdose?
1) Sedation
2) Dizziness
3) Slurred Speech
4) Confusion
5) Ataxia
6) Respiratory Depression
What are the emergency care procedures for Sedative and Hypnotic overdose?
1) ABCs
2) Airway Management (Ventilator if warranted)
3) Activated Charcoal if within 1 hour
4) Flumazenil/Romazicon
What are the contraindications for Flumazenil/Romazicon in the use for Benzodiazepine overdose?
1) Multi-Drug Ingestion
2) Benzodiazepine Dependence
3) Ingestion of seizure inducing agent
4) Known seizure disorder
What is the phone number for poison control?
1-800-222-1222
Who should be called in the event of Benzodiazepine/Barbiturate overdose?
Poison Control 1-800-222-1222
What is the most frequently ingested intoxicant in the US?
Ethanol (Alcohol)
How does Ethanol commonly cause death?
Respiratory Depression
Ethanol is a __________ and __________ depressant.
CNS and Respiratory Depressant
What is the diagnosis of Ethanol Poisoning based on?
1) Clinical Findings and CONFIRMED with Blood Alcohol Level (BAL)
How is Ethanol Poisoning confirmed?
Blood Alcohol Level (BAL)
What must be considered and ruled out in all ETOH ingestion?
Head Injury
Hypoglycemia
What are the emergency care procedures for Ethanol Poisoning?
1) Mainstay is Observation and Supportive Care
2) Check Glucose–If low administer glucose
3) IV is only beneficial if dehydrated
4) Exclude complicating injuries (Like head injury, so do a MACE)
How long are Ethanol Poisoning patients monitored?
Until they are sober
Opioids work on nerves in the ____, _____, and _____.
CNS
PNS
GI Tract
Opioids are agonists on what three primary receptors?
1) Mu
2) Kappa
3) Delta
What primary receptor is responsible for analgesia, sedation, respiratory depression and cough suppression?
Mu
What are the clinical features of opioid overdose?
1) CNS depression
2) Miosis
3) Respiratory depression
4) Bradycardia
5) Hypothermia
6) Death
When Opioids are combined with ____________ it increases the chance for death via respiratory depression.
Benzodiazepines
What diagnosis is clinically suspected by Coma, Miosis, and Respiratory Depression?
Opioid Overdose
What symptoms would make you assume opioid overdose?
Coma
Miosis
Respiratory Depression
What are the emergency care procedures for Opioid overdose?
1) Airway and Ventilator Support
2) Activated Charcoal (If INGESTED less than 1 hr ago)
3) Naloxone 0.4mg IV - 2mg IM every 2 - 4 minutes
4) MEDEVAC
How do you prevent acute withdrawal in an opioid overdose patient?
Opioid dependent patients should receive a smaller dose
What should be discussed with the patient transport team for an opioid overdose?
Ensure they have Naloxone because it has a shorter half life than the opioids
What type of substances are Sympathomimetic agents?
1) Cocaine
2) Amphetamines
3) Stimulants
What substance causes sympathetic nervous system activation which causes typical mydriasis, tachycardia, hypertension and diaphoresis?
Cocaine
Cocaine, Amphetamines, and Stimulants are what type of agents?
Sympathomimetic agents
What substance block re-uptake of catecholamines, also have effect on serotonin release which causes hallucinogenic effect?
Amphetamines
What are clinical features of Sympathomimetic agents?
1) Psychomotor Agitation
2) Mydriasis
3) Diaphoresis
4) Tachycardia
5) Tachypnea
6) Hypertension
7) Hyperthermia
8) Altered Mental Status
9) Seizures
10) Rhabdo
11) Chest Pain
12) Headache
13) Dyspnea
14) Focal Neuro Complaints
Cocaine even at low doses can produce coronary vasoconstriction leading to chest pain that is exacerbated by _________________.
Smoking Cigarettes
What are the emergency care procedures for a patient that took Sympathmimetic agents?
1) Sedation
2) Monitor vitals
3) Monitor for rhabdo
4) Monitor for cardiac complications (EKG)
5) Active Cooling
6) Treat Acute Agitation, Tachycardia, Seizures and Hypertension with Benzodiazepines
7) Treat cardiac chest pain with ASA (Aspirin), Nitro, and Benzos
8) MEDEVAC/MEDADVICE
What is the mainstay of treatment for a patient that took Sympathmimetic agents?
Sedation and Monitor vitals
What class of medication is contraindicated in cocaine use?
Beta Blockers
unopposed alpha stimulation
A 23 y/o homeless patient arrives to your ER with alterations in mental status and agitated. 101.0, P 120, BP 155/100, R 18. On exam the patient is diaphoretic and pupils react sluggishly to light. Is this consistent with an anticholinergic or sympathomimetic toxidrome?
Sympathomimetic
Anticholinergic exposure paralyzes pupillary constrictor muscles and causes dilated pupils that DO NOT REACT. Imagine going to the ophthalmologist, they put drops in your eye(atropine, homotriptine…) so that when they look with a slit lamp they can see the retina without interference.
Sympathomimetic drugs (cocaine) activates pupillary dilator muscles but constricting muscles are intact and pupils WILL REACT. This patient has reactive pupils and given clinical history likely has exposure to cocaine. Also sympathomimetic patients are diaphoretic vs dry in anticholinergic. Both have mental status changes however sympathomimetic usually is more agitated and potentially violent vs mild alterations and hallucinations in anticholinergic.
Salicylates (ASA/Aspirin) absorption can be erratic however peak levels are usually apparent within how many hours?
6 hours
Clinical diagnosis of Salicylates (ASA/Aspirin) is made in conjunction with
Acid/Base status
ASA toxicity causes respiratory alkalosis due to a direct effect on the
Medullary Respiratory Center
Clinical features of Salicylates (ASA/Aspirin) Toxicity
Ingestion less than:
1) 150 mg/kg =
2) 150-300 mg/kg
3) 3)> 300mg/kg
1) 150mg/kg - MILD - N/V GI irritation
2) 150-300mg/kg - MODERATE - Vomiting, Tachypnea, Tinnitus, Sweating
3) > 300mg/kg - SEVERE
What are the signs and symptoms of Salicylates (ASA/Aspirin) Toxicity?
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
What are the emergency care procedures for Salicylates (ASA/Aspirin) Toxicity?
1) ABC’s, Cardiac monitoring, IV access
2) Activated Charcoal 1GRAM/kg
3) IV fluids (NS/LR) for volume depletion
4) Check glucose and administer supplemental glucose if low (maintain above 80)
5) If available on specific platform administer SodiumBicarbonate 1- 2mEq/kg and arrange for MEDEVAC. This causes alkalization of urine and increase Salicylate elimination
6) Ask SMO for treatment regimen
7) Patients may ultimately require hemodialysis
8) Follow ACLS protocol for cardiac abnormalities
9) Call poison control 1-800-222- 1222
What is the dosage for Sodium Bicarbonate for the treatment of Salicylates (ASA/Aspirin) Toxicity?
1- 2mEq/kg
What is the dosage for Activated Charcoal?
1 GRAM/kg
What is the most popular analgesic in the US?
Acetaminophen (APAP)
What is the mortality rate of Acetaminophen (APAP) Toxicity if liver failure has developed?
28%
What is maximum recommended daily dose of Acetaminophen (APAP) in adults?
4 Grams
Acetaminophen (APAP) toxicity is possible to occur with a single ingestion of ______, or greater than _______ in 24 hours.
140mg/kg
7.5 Grams
Where is Acetaminophen (APAP) primarily metabolized?
Liver
What is the toxic metabolite that Acetaminophen (APAP) is converted into?
NAPQI
NAPQI causes direct damage to _______
Hepatocytes
What type of patient is at a higher risk of Acetaminophen (APAP) Toxicity?
Alcoholics
The hepatic substance called “glutathione” that detoxifies NAPQI is lower in alcoholics
What are the 4 stages of Acetaminophen (APAP) Toxicity?
(a) Stage 1 first 24 hours - nonspecific. N/V, malaise, anorexia
(b) Stage 2 - day 2-3 - N/V may improve and evidence of toxicity may develop. RUQ pain, elevated bilirubin/jaundice
(c) Stage 3 - day 3-4 - progression to hepatic failure. Lactic acidosis, coagulopathy, renal failure, encephalopathy, N/V
(d) Stage 4 - those who survive will begin to recover
Serum levels above ________ after 4 hours from ingestion are considered toxic in Acetaminophen (APAP) Toxicity Patients.
150mcg/dl
