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Emergency Medicine > Poisoning and Overdose > Flashcards

Poisoning and Overdose Flashcards

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1
Q

50% of poisonings are in ___

A

kids younger than 6 years

**Rare for poisoning to cause death in a child, but suicide attempts are more likely to cause death

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2
Q

Some patient factors for poisoning

A
  1. Age (bad to be very young or very old)
  2. Dose (the dose makes the poison)
  3. Timing (just took it or took it 3 days ago)
  4. Co-ingestion (additive effects)
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3
Q

Describe the systemic approach to poisoning

A
  1. Sick or not sick?
    - If they are sick start resuscitating them
  2. If they are not sick you have time
    - Treat symptoms
    - Try and figure out what is likely to happen
    - Try and prevent later complications
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4
Q

What is in tox. resuscitation

A
  1. manage airway early!
  2. Breathing
  3. Circulation-hypotension
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5
Q

The most common cause of poisoning death is ___

A

loss of airway or breathing

*Airway management will prevent most poisoning deaths

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6
Q

Many poisonings cause a ___

Patients compensate with a __

A

metabolic acidosis

respiratory alkalosis

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7
Q

If you are controlling ventilation, you need to maintain ____

A

metabolic compensation

*So hyperventilate the patient (a little) until you see their blood gas

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8
Q

Most poisoned patients circulatory status

A
  • hypovolemic
  • Decreased oral
  • Vomiting
  • Vasodilation
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9
Q

tx for circulation resuscitation

A
  1. Give fluids unless clear volume overload
    - Peds 20 ml/kg saline
    - Adults 2L
  2. If no response, begin adrenergic vasopressor
    - Dopamine, epinephrine, norepinephrine
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10
Q

Complication of poor circulation

A
  • arrhythmias (slow or fast and narrow)

* fixing rate does not fix BP

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11
Q

Tx of slow rhythm from poor circulation

A
  • Atropine, Pacing

- Digoxin Fab?

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12
Q

Tx of fast and narrow rhythm from poor circulation

A
  • Most commonly caused by hypovolemia or CNS stimulation

- Give fluids, sedation with benzodiazepines

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13
Q

tx of fast and wide rhythm from poor circulation

A
  1. Most common in medical cases due to heart disease
    - Amiodarone and shock
  2. Most common in poisoning due to sodium channel blocking
    - Hypertonic sodium bicarbonate (1-2 meq/kg) push
    * *Won’t improve by shocking
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14
Q

What most commonly causes:

  • fast and narrow rhythm:
  • fast and wide rhythm:
A
  • fast and narrow rhythm:hypovolemia or CNS stimulation

- fast and wide rhythm: Na channel blocking or heart dz (MI, electrolyte abnormality)

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15
Q

What drugs block potassium channels

A
  1. Antipsychotic medications
  2. Haloperidol
  3. Antidepressants- venlefaxine
  4. Cardiac drugs- Propafanone, quinidine, sotalol
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16
Q

What is the ECG manifestation of potassium channel blocking?

A

prolonged QT–> can lead to Torsades (polymorphic VT)

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17
Q

What is the ECG manifestation of Na channel blocking?

A

Wide QRS

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18
Q

When does Torsades typically happen

A
  1. uncommon w/ meds

2. usually only w/ bradycardia

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19
Q

TX of torsades

A
  1. Defib
  2. Magnesium 2g iv
  3. Cardiac pacing to rate >100 BPM
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20
Q

Complications of CNS depression and CNS excitation

A

CNS depression- manage airway

CNS excitation- agitation or seizure

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21
Q

TX of CNS deficits

A
  1. Benzodiazepines- 2-5 mg lorezepam repeated as needed
  2. If not responding consider paralysis and propofol or other general anesthetic
  3. Cool patients if hyperthermia develops*
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22
Q

How do you tx the sx of CNS effects, CV, and vomiting

A
  1. Monitor for CNS effects
    - Intubate for severe sedation
    - Sedate for severe agitation
  2. Monitor for CV effects
    - Fluids/pressors for hypotension
    - Treat dysrhythmias as discussed
  3. Antiemetics for vomiting
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23
Q

Most common manifestation of poisoning

A

vomiting

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24
Q

How can you predict what sx might happen?

A
  1. Extension of therapeutic effect
    - Hypotension after ingestion of a anti-hypertensive
    - Coma from a sedative overdose
  2. Extension of side effect
    - Sedation from antipsychotic
    - Seizure from ADD medication
  3. Other effect– Use your resources or call the PC
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25
Q

Treat the patient not the poison!!

Most of the time you don’t need to know the exact poison- just treat the __

A

symptoms

*However, sometimes you can figure out the poison from the symptoms

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26
Q

What are toxidromes

A

*Collection of symptoms that are caused by a specific exposure

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27
Q

Toxidromes are usually due to a xenobiotic that acts at a wide spread receptor type including

A
  • Opioid
  • Adrenergic
  • Anticholinergic
  • Muscarinic cholinergic
  • Serotonergic
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28
Q

Presentation of Opioid toxidrome (oxycodone, heroin)

A
  1. CNS depression
  2. Respiratory depression
  3. Miosis=small pupils
  4. Decreased bowel sound (ileus)
  5. Bradycardia
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29
Q

Presentation of Sympathomimetic toxidrome

A
  1. Agitation and extremely paranoid/Vigilant
  2. Tachycardia
  3. fever
  4. HTN
  5. Tachypnea
  6. Hyperactive bowel sounds
  7. Sweating
  8. Dilated pupils
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30
Q

Examples of Sympathomimetics

A
  1. Cocaine
  2. Methamphetamine
  3. “Bath Salts”
  4. Ecstasy
  5. Ephedrine
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31
Q

Presentation of Anticholinergic toxidrome (benadryl, atropine, jimsonweed)

A
  • *Red as a beet, dry as a bone, mad as a hatter, hot as a hare, blind as a bat
    1. Agitated and confused/delirium
    2. Fever
    3. Dry flushed skin
    4. huge pupils/dilated= mydraisis
    5. Urinary retention
    6. Dry mouth
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32
Q

Presentation of Cholinergic crisis / toxidrome (organophosphate, nerve gases)

A

SLUDGE

  1. Salivation
  2. Lacrimation
  3. Urination
  4. Defecation
  5. GI upset (diarrhea)
  6. Emesis
  7. pulm. edema wheezing/cough/rales
  8. miosis (constricted pupils)
  9. muscle fasciculations*
33
Q

Other managements of poisonings

A

resuscitation, sx managment

  1. Decontamination
  2. Antidotes
  3. Drug screens
  4. Poison Center
34
Q

presentation of Serotonin toxidrome

A

hx: PCP changed from paroxetine to venlafaxine 3 days ago
1. Hyperreflexia
2. Fever
3. Tachycardia
4. Flushed skin
5. confusion/mental status changes
6. seizure
7. Tremor/shakey

*Clinical Dx

35
Q

Tx of Serotonin toxidrome

A
  1. Benzos- to sedate
  2. Give Cyproheptadine
  3. admit
  4. +/- cool patiet
36
Q

Common after OD or adding new serotonergic med

  • Effects vary from mild-severe
  • mild-tremor anxiety
  • Severe- delirium hyperthermia rigididy
A

Serotonin toxicity

37
Q

Describe the use/concept of decontamination

A
  1. Concept- keeping the poison from being absorbed will prevent the toxicity

2 Reality-

  • Most poisons don’t cause severe symptoms
  • Many patients present with symptoms because the poison is already in their system
  • Decontamination methods are not very effective (decrease ~30-60% absorption)
  1. Used selectively (if ever!)
38
Q

What are ways to decontaminate

A
  • *never induce vomiting!!
    1. activated charcoal**
    2. Gastric lavage (pumping of the stomach- rarely used)
    3. Whole bowel irrigation (Huge doses of polyethylene glycol to push bowel contents through- rarely used)
39
Q

Complications of activated charcoal

A

Can cause severe pneumonitis if aspirated

*do not give if they are at risk of aspiration– very sleeping, vomiting,

40
Q

When are antidotes used

A

(Drugs that reverse or attenuate a specific poison)

  • Most poisoned patients do not need an antidote
  • Used WITH SUPPORTIVE CARE to treat a poisoned patients
41
Q

Most pharmaceutics are bound by charcoal but activate charcoal must be given __

A

BEFORE the drug is absorbed

42
Q

-Huge doses of polyethylene glycol to push bowel contents through- rarely used
Commonly done w/ drug smuggling or extended release med

A

Whole bowel irrigation

43
Q

How do drug screens affect management?

A
  • Drug screens rarely change management
  • If the drug screen is positive and the pt has no symptoms you don’t treat them
  • If the drug screen is negative and the patient has symptoms you still treat them

*Presence does not mean intoxication!

44
Q

When do you use urine or blood for drug screens

A
  1. For screening use urine**
    Drugs are concentrated for excretion- easier to detect
  2. For quantitative concentrations use blood
    Serum concentrations correlate best with effects
    *also use for renal failure with no urine production

*more likely to detect the drug in urine bc it concentrates there and blood also has more things in it– use urine to screen

45
Q

Most common drug screen is __

A

an immunoassay that looks for specific drugs

  • Cocaine, amphetamines, opioids, benzos, marijuana
  • Don’t order if you are interested in something else
46
Q

What are some common drugs that are missed on drug screen

A
  1. Methadone- can hide opioids
  2. Fentanyl
  3. Clonazepam

*And (rarely) false positives occur in general

47
Q

What are some other methods of drug screens that may detect more drugs

A

Gas chromatography/Mass spectrometry can detect >1000 drugs

  • These tests are generally done in reference labs and not rapidly available
  • For medical-legal cases (e.g. deliberate poisoning) you need to preserve chain of custody (contact your lab)
48
Q

What is the bottom line for drug screens

A
  • Bottom line- Order the test but understand the limits
    1. Treat the patient not the test
    2. You wont find what the immunoassay doesn’t look for
    3. If you really need to know you can order a reference test- but it will take a while
49
Q

___ overdoses are common but rarely serious

___ ingestions account for most deaths

A

Accidental pediatric

Deliberate adult

50
Q

Most common OD that results in hospitalization in US

A

acetaminophen

51
Q

Describe the management and tx of acetaminophen OD

A
  1. Calculate if exposure is potentially toxic (>150mg/kg)
  2. Need a tylenol level FOUR HRS after exposure
  3. Tx w/ acetylcysteine (NAC) 150 mg/kg –> repeat dosing until acetaminophen no longer detected in serum

*if the 4 hour tylenol level is greater than 150microgram/ml, treat

52
Q

NAC is most effective if given w/in ___

A

8 hrs, but even delayed administration is helpful

53
Q

27 year old ingests 3 gms amitriptyline
What are the expected symptoms?
What are the target organs?

A
  1. CV and neuro toxicitiy

Cardiac: wide complex tachy

54
Q

What is the primary tx for QRS prolongation or dysrhythmia

A
  1. 1-2 meq/kg IV bolus
  2. Infusion not really effective
  3. Hypertonic saline if alkalemia present
55
Q

what is the tx of adrenergic vasopreesors/ hypotension

A

Norepi considered pressor of choice for hypotension

56
Q

Describe the presentation and tx of TCA OD

A
  1. Sedation-seizure
  2. EKG: Prolonged QT (wide, fast)

Tx:

  1. Bicarbonate
  2. tx seizure w/ benzos
57
Q

Describe the evaluation ASA OD

A
  1. Confusion, pulmonary edema?
  2. BMP
    - Renal function
    - ? Acidosis and anion gap
  3. Blood gas (venous)
    - Mixed acid base disorder
    - ? Compensation
  4. Serum salicylate concentration
  5. Urine pH
58
Q

SX of ASA OD

A
  1. N/V
  2. Tinnitus
  3. Increase respiration (Respiratory alkalosis)
  4. +/- renal failure
  5. Mixed acid/base disturbance
    * anion gap acidosis causes a mixed A/B disorder
  6. Pulmonary edema
  7. Mental status change/Cerebral edema
59
Q

tx of ASA OD

A
  1. Calculate a potentially toxic ingestion (150-300mg/kg) or salicylate level of >30
  2. Tx w/ fluids, urine alkilinazation w/ bicarc
  3. dialysis prn
60
Q

Who needs dialysis for ASA OD

A
  1. NOT JUST A CONCENTRATION
  2. Failure of medical management
    - Metabolic
    - Increasing levels
  3. Fluid overloaded/Pulmonary edema
  4. Renal failure
  5. Altered mental status
61
Q

Enteric coating ASA overdose may not peak for __, which requires __

A

24 hours

*Intubation and standard ventilator settings may lead to respiratory acidosis so adjust their minute ventilation (increase)

*Anion gap not always as high as you think
Probably true in mild/early cases

62
Q

How do you calculate if an acetaminophen ingestion is a toxic dose?

A

Toxic dose is 150mg/kg

Do a calculation: 30 tablets x500mg – 1500 mcg/weight…; also talk about a serial tylenol level if concerned

63
Q

SX of carbon monoxide poisoning

A
  • Nonspecific Sx
    1. HA
    2. N/V
    3. Dizzy
    4. Mental status
    5. Consider it seasonally- spring and fall when heating system start to work
    6. Ataxia
64
Q

Describe the evaluation of CO poisoning

A
  1. Send a venous CO/ Carboxyhemoglobin
    * O2 sats are NOT helpful

Consider:

  • Brain injury- Syncope, mental status test, ataxia
  • Cardiac injury- CP, ecg, trops
65
Q

Describe the tx of CO posioning

A

** high flow o2 (all symptomatic patients)

-hyperbaric oxygen (no consensus on efficacy)

66
Q

clues to CO poisoning

A
  1. spring and fall when heating system start to work
  2. working w/ a generator in basement/garage
  3. N/V/HA but no fever

**Key is making dx to avoid reexposure

67
Q

SX of spice OD/ingestion (K2)

A
  1. N/V
  2. coma
  3. bradycardia
  4. hypotension

**not detected on drug screens

68
Q

TX of spice OD/ingestion

A
  1. Treat supportively

2. Some become agitated and may have seizures–Treat with benzodiazepines

69
Q

Substituted amphetamines

Sold as “not for consumption”

A

bath salts

70
Q

SX of Bath salt ingestion/smoked

A
  1. Moderate stimulant similar to MDMA
  2. sympathomimetic toxicity,
  3. psychosis and
  4. rhabdomyolysis
71
Q

SX of GHB intoxication

A
  1. Initial intoxication/euphoria
  2. May progress to profound coma
  3. Patients seen to wake up with airway management attempts
  4. Symptoms usually resolve over 4-6 hours
72
Q

Tx of the following toxidromes:

  1. Opioid:
  2. Sympathomimetics:
  3. Cholinergic:
  4. Anticholinergic:
A
  1. Opioid: Naloxone or supportive
  2. Sympathomimetics: benzo, hydration, cooling
  3. Cholinergic: atropine, airway
  4. Anticholinergic: benzo, cooling, Physostigmine prn
73
Q

Presentation of sedative/hypnotic OD (benzos, barbiturates)

A
  1. Decrease LOC
  2. slurry speech
  3. ataxia
  4. Bradycardia
  5. Bradypnea
74
Q

tx of sedative/hypnotic OD (benzos, barbiturates)

A

ventilatory support prn otherwise just time

75
Q

Presentation of EPS OD (haldol, phenergan, reglan)

A
  1. Dystonia
  2. Muscle rigidity
  3. restlessness
76
Q

Tx of EPS OD (haldol, phenergan, reglan)

A

Benadryl

benzo

77
Q

What can cause Methemoglobinemia

A
  1. pyridium

2. Oragel/benzocaine

78
Q

Describe the presentation and tx of Methemoglobinemia

A
  1. cyanosis
  2. cyanosis that is unresponsive to supplemental O2

Tx: Methylene blue

Emergency Medicine (22 decks)

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