Poisoned Patient Flashcards
Components of initial assessment of poisoned ptn:
ABCs… plus:
D = Dextrostick / Details / Decontaminate
E = EKG / Evaluate Toxidrome
What are the “details” you need in a poisoned ptn:
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
What is going on:
Digitalis effect on ST segment
“Dali’s Mustache”
What to think with right axis deviation in a poisoned ptn:
Type 1A Sodium channel antagonist drugs like cyclic antidepressants (tricyclics)
Toxicities associated with QRS prolongation > 100ms
– type Ia cardiotoxicity
– TCA, quinidine, diphenhydramine, cocaine
Drugs associated with QT prolongation and the potential sequelae of this effect:
antipsychotics
hypocalcemia
risk for torsade de pointe
What is going on?
“wide complex tachycardia”
associated with Type1a toxicity
(TCA, quinidine, diphenhydramine, cocaine)
Methods of Decomtamination:
Whole Bowel Irrigation
Indications for whole bowel irrigation:
Sustained release drugs (CCB’s, lithium)
Drug packets (body packers)
Patient with a hx of cancer presents somnolent with poor respirations….
Right before intubation, you notice the image:
What is going on?
Heroin OD
Features of opiod toxidrome:
- pinpoint pupils
- respiratory depression
- lethargy to coma
- bradycardia, hypothermia, borderline hypotension
Common opioids and “opioid like” drugs:
- common opioids
- morphine
- heroin
- codeine
- meperidine
- propoxyphene – fentanyl
- hydrocodone – methadone
- Opioid like drugs:
- clonidine
- imidazolidines
- tramadol
Young student altered after final exam
Found by roommate in dormitory BIBFR
Tachycardia 140/min
BP 150/90 mmHg
Agitated, restless
Most likely dx?
Anticholinergic Syndrome
Features of fulminant anticholinergic syndrome
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
Common drugs for anticholinergic toxidrome
– Diphenhydramine (OTC cold, sleep meds)
– Benztropine (antiparkinson meds)
– Misidentified or contaminated plant/herbal products
Plant with anti-cholinergic properties
Jimonsweed
ECG changes seen in anticholinergic syndrome:
Sinus tach
Features of sympathomimetic toxidrome
tachycardia
elevated bp
hyperthermia
dilated pupils
hyperactive bowels
diaphoresis
Common sympathomimetics
cocaine
amphetamines
anorectics (appetite suppressants)
otc stimulants
“herbal” stimulants
cholinergic toxidrome =
excess acetylcholine at sites of ACH transmission in brain, ANS and NMJ
results in: AMS, excess secretions, fasciculations, and weakness
Mneumonic for cholinergic toxidrome:
- DUMBBELS
- D diarrhea, diaphoresis
- U urination
- M miosis
- B bradycardia
- B bronchorrhea
- E emesis
- L lacrimation
- S salivation, seizures
Common cholinergic agents
Organophosphates or carbamate pesticides
carbamate medicinals such as donepezil, physostigmine, pyridostigmine
Nerve gas agents
• 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?
Initially check ABCs
“Bezerk” patient from before now has vitals measured:
pulse 180, regular
what is your next step in management?
adequate sedation
physical examination
“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? **
Do a fingerstick
Get an ECG
DDx for Berzerk patients:
sympathomimetic intoxication
environmental hyperthermia
sedative withdrawal
encephalitis/meningitis
neuroleptic malignant or serotonin syndrome
