poison Flashcards
An unresponsive patient has lost his or her ________ and is at risk for airway obstruction as well as aspiration
airway reflexes
Coma Cocktail
(reversible causes of “coma”
- Opioids: Narcan 0.4 to 2mg IV
- Hypoxia–> 100% O2 nonrebreather
- Hypoglycemia: POC D stick
if these do not reverse the symptoms, then intubation should be performed.
Key Historical Data in poison
What was ingested?
How much was ingested?
When was ingested?
Why? (accidental or intentional)?
classic presentations of poison are called _________
Toxidromes
classic anticholinergic syndrome:
Mad as a hatter (AMS) Blind as a bat (big-mydriasis) Hot as Hades Red as a beat Dry as a bone
*Rx mostly supportive.
Possible toxins with anticholinergic properties include the following
TCA’s
Antihistamines
Overactive bladder medication
classic cholinergic syndrome
SLUDGE
- Salivation
- Lacrimation
- Urination
- Diaphoresis
- GI upset/ defecation
- Excessive bradycardia or tachycardia (muscarinic or nicotinic)
Cholinergic poisoning Treatment:
Atropine, pralidoxime, decontaminate
Sympathomimetic toxidrome
- Tachycardia
- Hypertension
- Mydriasis
- Diaphoresis
- Hyperthermia
- Agitation
Sympathomimetic toxidrome poisons
OTC cold agents (containing ephedrine)
cocaine, amphetamines, MDMA
dietary supplements (ephedra)
Sympathomimetic toxidrome treatment
- Sedation
- Hydration
- Rx complications–> rhabdomyalysis and hyperthermia
Opioid Classic signs:
Apnea
Hypoxia
Unresponsiveness
Flash pulmonary edema (rare)
May appear to require intubation. Administration of Nalaxone can reverse the apnea and obviate the need for intubation
Discharge after naloxone
Naloxone will wear off before the opiate so the patient can NOT be discharged without a period of observation.
Unlike other toxic ingestions, acute ______ overdose can present asymptomatic and can be missed/ fatal if not tested.
acetaminophen
some poisonings–> presence of an anion gap metabolic acidosis is key to diagnosis
Causes of Anion Gap Metabolic Acidosis
M = Methanol U = Uremia D = DKA P = Paraldehyde I = Iron, Isoniazid L = Lactate (many causes CO, sepsis, blood loss?) E = Ethylene Glycol S = Salicylates
Physical exam for poison
vitals
pupil size
skin color and moisture
overall mental status.
Decontamination Methods for poison
Activated Charcoal
Whole Bowel Irrigation
Gastric Lavage (rare)
Activated Charcoal
- PO to absorb toxins in GI tract (excreted without being digested.)
- Best in 1st hour but still works after that
- Avoid in pts w/ somnolence –> risk of aspiration
Charcoal does not bind ___________.
metals (such as iron)
alcohols
hydrocarbons
Whole bowel irrigation involves the administration of
osmotically balanced polyethylene glycol electrolyte solution
Flushes GI to prevent the absorption of toxins.
It is used in cases where charcoal is not effective, with certain sustained release products, and in cases of illicit drug packet ingestions (body packers).
Whole bowel irrigation used when
- cases where charcoal is not effective
- certain sustained release products
- cases of illicit drug packet ingestions (body packers).
Gastric Lavage
Rarely used/ significant risks
good for:
-recently ingest lethal substances
-intubated overdose following recent ingestion
Gastric Lavage involves the application of
large bore (36 – 40 French) orogastric tube flushing the stomach with aliquots of water to obtain pill fragments.
Ipecac
- should not be used anymore
- not effective in removing toxin
- reduces effectiveness of better decontamination methods
Many patients with potential ingestions may be observed for _______ and then dispositioned if clinically asymptomatic
six hours
dc home or psychiatric facility-provided the ingestion is not an extended release agent
it is imperative that an _________ level is checked on all overdose patients
acetaminophen
- measured on Rumak nomogram
- toxic plasma level at four hours is 150.
four main stages of an acute acetaminophen overdose.
symptoms usually involve nausea, vomiting in the first two stages.
In an acute overdose, acetaminophen is metabolized by
- metabolized into NAPQI which combines with glutathione –> excreted.
- When glutathione is gone, NAPQI–> hepatic toxicity.
In an acute overdose, treatment is
- decontamination with repeated doses of activated charcoal,
- antidote N-acetylcysteine (Mucomyst)
Unlike the Rumak nomogram of acetaminophen, the _______ is associated with aspirin ingestions
Done nomogram
it is typically not used to determine toxicity and treatment.
Patients with an acute overdose of aspirin are usually present
ill appearing breathing fast vomiting confused sometimes febrile.
The toxic effects of aspirin
involve an uncoupling of oxidative phosphorylation.
causes a profound anoin gap metabolic acidosis
The general approach to aspirin overdose is
airway managment
gastric decontamination
sodium bicarbonate
hemodialysis
In addition to their anticholinergic properties, TCAs cause :
- a direct a-adrenergic blockade
- inhibition of norepi/ 5HT reuptake
- blockade of fast Na channels in myocardial cells
Treatment of TCA overdose includes _________ in the asymptomatic patient.
close monitoring for a period of at least six to eight hours
Treatment of TCA with QRS widening
Sodium bicarbonate
Seizures -benzo
Newer recommendations for lipid therapy exist in the treatment of severe toxicity.
three major alcohols that are considered “toxic”.
metabolic acidosis:
- methanol
- ethylene glycol
no metabolic acidosis
-isopropanol
________ alcohol is usually not life threatening and can be managed by supportive care.
Isopropanol
rarely hemodialysis may be required.
All alcohols are metabolized by
alcohol dehydrogenase (ADH). Therefore, the initial treatment for methanol and ethylene glycol involves the blockade of ADH.
treatment of toxic methanol and ethylene
blockade of ADH w/ ethanol or fomepizole
hemodialysis
Sodium bicarbonate and glucose may also be necessary.
isopropanol, methanol, and ethylene glycol sources
Isopropyl- solvents, mouthwashes, rubbing alcohols.
Methanol - windshield fluid.
Ethylene Glycol - antifreeze.
