Poisoning Approach

Question 1

Someone went to a pill party and ingested random pills. What’s your general approach to managing toxicologic ingestions?

Answer 1

Safety first!
A - Airway (intubate?)
B - Breathing
C - Circulation (effective blood pressure, do they need it brought up? IV Fluids or medications) 
D - Decontamination (get toxins out)
E - Enhanced Elimination
F - Find an Antidote
G - General management

Monitors, IV Access, Oxygen
Vitals
Focused history
Focused physical exam
ECG
Laboratory investigations

Question 2

What are the 4 ways of decontamination?

Answer 2

1. Don PPE (personal protection equipment), hose down, remove contaminated clothing (abosrb through skin), hair/skin can be contaminated so wash with mild soap (don’t want to break skin)
2. Gastric Lavage (pump stomach), intubate, big tube down esophagas with saline, they move side to side, suck out pills; only effective in first 20-30 min.
3. Activated Charcoal: binds in GI tract before drug is absorbed by body; within 4 hours, 50g for adults, 1g/kg for kids. LIMITATIONS: altered LOC, vomit and aspirate do not give, causes inflammation in lungs; doesn’t bind well with PHAILS: pesticides, hydrocarbons (gas), acids/alkalis/alcohol, Iron, Lead, Lithium, Solvents and aspirin-like complexes.
4. Whole-Bowel Irrigation: take lots of sustained release? missed 4 hour window? Induce pooping so its not absorbed, give 1-2L/hr until what comes out is completely clear. GoLYTELY

Question 3

What is considered for General management?

Answer 3

oxygen (supplemental)
IV fluids
electrolytes (correct)
normoglycemia (maintain normal blood sugar)
vasopressor agents for hypotension
foley catheter to monitor urine output

Question 4

Why are vital signs and physical exam findings important in a toxic ingestion?

Answer 4

Give you clues as to what type of agent was ingested.

Vital signs consists of:
Heart Rate - beta blockers
Blood Pressure
Temperature - super important to cool them down
Blood Glucose - insulin

Question 5

What are you looking for in a history (toxins)?

Answer 5

Agent
Time of exposure
Volume/dose
Any immediate clinical effects
Location of ingestion (for accidental ingestions)
Ask about commonly ingested agents
Intention of ingestion (certify them or let them leave)

Question 6

What compenents of a physical exam (toxins)?

Answer 6

Vitals
CNS: GCS, CN exam - pupils
CVS: Heart rate, Blood pressure
Resp: breathing pattern & rate
Abdo: tenderness, masses, emesis
Skin: temperature, dry, diahoretic, colour
General: excited vs. depressed state

Question 7

What do you look for in Altered Mental Status?

Answer 7

Rule out hypoglycemia, or hypoxia
Consider “coma cocktail” in patients with presentation of opioid toxicity (taking other substances too) or thiamine deficiency (alcoholics, not eating). Give narcan and some glucose see if that improves anything.
Don’t forget about occult trauma.

Question 8

When do you use enhanced elimination?

Answer 8

After substance has been absorbed into bloodstream how do you get it out? (typically needs to stay in bloodstream)

1. MDAC - multidose activated characoal. Keep giving multiple doses, sits in GI tract, creates concentration gradient that allows agent to flow down created gradient out of the blood and pooped out. Only works with some compounds.
2. Hemodialysis/Hemoperfusion - good for things you were already goign to pee out, like external kidney filtering blood; effective for:
   Low Molecular weight
   Low volume of distribution (stays more in blood vs tissues)
   Low protein binding and
   Water soluble.

Question 9

What therapy is most effective, antidotes or supportive therapy?

Answer 9

Antidotes! but there are only 20. Most toxins do not have a specific antitidote, so supportive therapy is often the most important treatment.