Poisoned Patient

Question 1

Components of initial assessment of poisoned ptn:

Answer 1

ABCs… plus:
D = Dextrostick / Details / Decontaminate

E = EKG / Evaluate Toxidrome

Question 2

What are the “details” you need in a poisoned ptn:

Answer 2

EMS report = pill bottles, odors, vomitus

medications, products in home, other people living in household and their medical problems?

hobbies, occupations which may give access to unique toxins

Question 3

What is going on:

Answer 3

Digitalis effect on ST segment

“Dali’s Mustache”

Question 4

What to think with right axis deviation in a poisoned ptn:

Answer 4

Type 1A Sodium channel antagonist drugs like cyclic antidepressants (tricyclics)

Question 5

Toxicities associated with QRS prolongation > 100ms

Answer 5

– type Ia cardiotoxicity
– TCA, quinidine, diphenhydramine, cocaine

Question 6

Drugs associated with QT prolongation and the potential sequelae of this effect:

Answer 6

antipsychotics

hypocalcemia

risk for torsade de pointe

Question 7

What is going on?

Answer 7

“wide complex tachycardia”

associated with Type1a toxicity

(TCA, quinidine, diphenhydramine, cocaine)

Question 8

Methods of Decomtamination:

Answer 8

Whole Bowel Irrigation

Question 9

Indications for whole bowel irrigation:

Answer 9

Sustained release drugs (CCB’s, lithium)

Drug packets (body packers)

Question 10

Patient with a hx of cancer presents somnolent with poor respirations….

Right before intubation, you notice the image:

What is going on?

Answer 10

Heroin OD

Question 11

Features of opiod toxidrome:

Answer 11

• pinpoint pupils
• respiratory depression
• lethargy to coma
• bradycardia, hypothermia, borderline hypotension

Question 12

Common opioids and “opioid like” drugs:

Answer 12

• common opioids
  
  • morphine
  • heroin
  • codeine
  • meperidine
  • propoxyphene – fentanyl
  • hydrocodone – methadone
• Opioid like drugs:
  
  • clonidine
  • imidazolidines
  • tramadol

Question 13

Young student altered after final exam

Found by roommate in dormitory BIBFR

Tachycardia 140/min

BP 150/90 mmHg

Agitated, restless

Most likely dx?

Answer 13

Anticholinergic Syndrome

Question 14

Features of fulminant anticholinergic syndrome

Answer 14

Mad as a hatter = AMS / Delirium

Blind as a bat = Mydriasis

Red as a beet = Flushing

Hot as a hare = increased temp

Dry as a bone = no sweat + dry mouth

Full as a tick = urinary retention

+ tachycardia

Question 15

Common drugs for anticholinergic toxidrome

Answer 15

– Diphenhydramine (OTC cold, sleep meds)

– Benztropine (antiparkinson meds)

– Misidentified or contaminated plant/herbal products

Question 16

Plant with anti-cholinergic properties

Answer 16

Jimonsweed

Question 17

ECG changes seen in anticholinergic syndrome:

Answer 17

Sinus tach

Question 18

Features of sympathomimetic toxidrome

Answer 18

tachycardia

elevated bp

hyperthermia

dilated pupils

hyperactive bowels

diaphoresis

Question 19

Common sympathomimetics

Answer 19

cocaine

amphetamines

anorectics (appetite suppressants)

otc stimulants

“herbal” stimulants

Question 20

cholinergic toxidrome =

Answer 20

excess acetylcholine at sites of ACH transmission in brain, ANS and NMJ

results in: AMS, excess secretions, fasciculations, and weakness

Question 21

Mneumonic for cholinergic toxidrome:

Answer 21

• DUMBBELS
• D diarrhea, diaphoresis
• U urination
• M miosis
• B bradycardia
• B bronchorrhea
• E emesis
• L lacrimation
• S salivation, seizures

Question 22

Common cholinergic agents

Answer 22

Organophosphates or carbamate pesticides

carbamate medicinals such as donepezil, physostigmine, pyridostigmine

Nerve gas agents

Question 23

• 28 yo male brought by FR after children called 911 “Dad went berzerk”

• agitated, grinding teeth kicking, flailing
• handcuffed to transport stretcher for safety

How should you approach this patient?

Answer 23

Initially check ABCs

Question 24

“Bezerk” patient from before now has vitals measured:

pulse 180, regular

what is your next step in management?

Answer 24

adequate sedation

physical examination

Question 25

“Bezerk” patient has the following exam findings:

• vital signs: hr 160, bp 180/100, rr 32
• diaphoretic, unresponsive but w/ eyes open
• pupils 8mm, reactive
• bs normal, no retention

** what next? **

Answer 25

Do a fingerstick

Get an ECG

Question 26

DDx for Berzerk patients:

Answer 26

sympathomimetic intoxication

environmental hyperthermia

sedative withdrawal

encephalitis/meningitis

neuroleptic malignant or serotonin syndrome