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850 > Poisoning Management > Flashcards

Poisoning Management Flashcards

1
Q

Poisoning Assessment

A
  1. History - who, what, how, how much, why, when
  2. Physical Examination (toxidrome)
  3. Laboratory Findings
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2
Q

History Pearls

A
  1. Directed approach
  2. 50% history is accurate
  3. Verify with friends, family, EMS, etc
  4. Etiology (dose, timing, formulation)
  5. Acuity
  6. HPI, PMHx, PSHx, Allergies
  7. Whose meds were these?
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3
Q

Tox Screen - ALWAYS Need

A
  1. Serum APAP level
  2. Serum salicylate level
  3. +/- blood ethanol level
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4
Q

Urine Tox Screens

A
  • General: performed on urine using EMIT technique, usually available in 6 hours
  • Do not change medical management
  • Know what meds are being screened: negative could mean not detected, below detectable range, or not included in the screen

-Non-drug specific: osmolality (not useful), radiographs for radio opaque poisons

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5
Q

X-ray

A

-KUB, CXR, US, CT
-Remember CHIPES
C - Chloral hydrate
H - heavy metals
I - Iron/Iodine
P - Phenothiazindes
E - Enterics
S - Solvents

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6
Q

Quantitative Tests

A
  • Guide patient management
  • For use of dialysis/hemoperfusion, ethylene glycol, methanol, lithium, salicylates, and theophylline
  • Use of antidote APAP, carboxyhemoglobin, methemoglobin, digoxin, heavy metals, iron
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7
Q

Poison Treatment Strategies

A
  1. Supportive Care/Stabilization**
  2. Prevent Absorption**
  3. Enhance Elimination**
  4. Provide Antidote
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8
Q

Monitoring

A
  • Part of stabilization
  • Cardiac monitoring
  • 12 lead ECG
  • Pulse Oximetry
  • Non-invasive BP
  • Core Temperature
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9
Q

Temperature + Causers

A

Hyperthermia: sympathomimetics, salicylates, and other uncouplers

Hypothermia: barbiturates. sedative-hypnotics

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10
Q

Preventing Absorption Methods

A
  • Inhalation => fresh air/oxygen
  • Dermal => irrigation/soap, remove contaminated clothing
  • Ocular => irrigation
  • Ingestion => gastric lavage, activated charcoal/cathartic, whole bowel irrigation
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11
Q

Syrup of Ipecac

A
  • Limited supporting literature
  • Average removal of 30% of bowel contents
  • May push contents through pylorus and enhance absorption
  • No indications, not available, MANY CI
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12
Q

General GI Decontamination Indications

A
  • Substantial risk of serious toxicity associated with exposure
  • Recent ingestion (Liquids =< 1 hour, Solids =< 2 hours)
  • GI decontamination procedure can be performed safely
  • GI decontamination procedure will work
  • No alternate that is safer or more effective is available
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13
Q

General GI Decontamination CI

A
  • Rapid onset of seizures
  • Rapid onset of CNS depression
  • Alkaline corrosives (acids = controversial)
  • Loss of gag reflex
  • Recent bariatric surgery (Roux en Y pouch = 15-30 mL)
  • Hemorrhagic diathesis
  • Ingestion of sharp objects
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14
Q

Lavage

A
  • 18-28 F - kids, 28-36F - adults
  • Orogastric or nasogastric
  • Saline used for kids (10 cc/kg aliquots)
  • Water used from adults (300 cc aliquots)
  • Endpoint: clear returns
  • SE: aspiration, esophageal/gastric bruising, fluid/electrolyte imbalance, EKG changes, esophageal rupture, hypoxia
  • Efficacy: 30% reduction in bioavailability
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15
Q

Lavage Indications/CI

A

Indications
-Minimal: rare, lethal, recent, and not bound to charcoal

CI

  • CNS depressed patients can only be lavaged if they are intubated with cuffed endotracheal tube first
  • Epileptic patients only lavaged with controlled seizures and when intubated
  • Cannot lavage preps that are too large to fit through lavage tube
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16
Q

Single-Dose Activated Charcoal

A
  • Adcorbent
  • Dose: 1 gm/kg or 10:1 ratio (kids: 15-30g, adults: 30-60g)
  • Preps: powdered, pre-mixed aqueous or sorbitol solutions
  • No evidence for specific indications to utilize, potentially toxic, “within 1 hour” (might be changing)
17
Q

Activated Charcoal AE

A
  • Vomiting
  • Constipation
  • Aspiration
  • Charcoal empyema
  • GI obstruction
  • GI perforation
  • Efficacy: 40% reduction in bioavailability
18
Q

Poorly Charcoal Adsorbed Substances

A
  • Low molecular weight, charged compounds: cyanide, bromide, potassium, ethanol, methanol, iron, lithium, alkaline corrosives, and mineral acids
  • Highly lipophilic substances: hydrocarbons (gasoline, kerosene)
19
Q

Commonly Used Cathartics

A

Saline

  • Magnesium citrate (4cc/kg to 300 cc)
  • Magnesium sulfate (240 mg/kg to 30 mg)
  • Sodium sulfate (250 mg/kg to 30 mg)

Hyperosmotic
-Sorbitol (0.5-0.9 gm/kg to 50 g)

20
Q

Cathartic Use in Poisoning

A

-Rationale: prevent de-adsorption
-Dose: No more than 1 dose per 24 hours
-Efficacy is questionable
Precautions
-May cause hypovolemia and electrolyte imbalance
-Magnesium containing cathartics should not be used in patients with renal impairment

21
Q

Whole Body Irrigation

A
  • Products: Polyethylene glycol electrolyte solution (GoLYTELY)
  • Better efficacy than lavage or ipecac
  • Procedure varies based on age
  • Endpoint is to clear rectal effluent
  • Efficacy: 67% reduction of bioavailability
22
Q

Whole Body Irrigation Indications/Outcomes

A

Indications

  • Toxic doses of modified released products (Wellbutrin XL)
  • Fe, Li, K
  • Body packers

Outcomes
-No studies showing improvement

23
Q

Whole Body Irrigation CI

A
  • Bowel perforation
  • Adynamic ileus
  • Intestinal obstruction
  • Hemodynamic instability
24
Q

Enhancing Poison Elimination Indications

A
  • Impaired normal route of elimination
  • Severe presentation
  • Progressive deterioration despite full supportive care
  • Significant toxicity expected**
  • Exists a method that works
25
Q

Methods to Enhance Poison Elimination

A
  • Multiple dose activated charcoal (MDAC)
  • Ion trapping with sodium bicarbonate
  • Hemodialysis
  • Hemoperfusion (not readily available)
  • Plasmapheresis
  • Exchange transfusions
26
Q

Ideal PK Characteristics for Hemodialysis

A
  • Low Vd (<1 L/kg)
  • Single compartment kinetics
  • Low endogenous clearing (<4 mL/min/kg)
  • MW < 500 daltons
  • Water soluble
  • Not bound to plasma proteins
27
Q

MDAC Mechanism

A
  • Interrupts entero-enteric and entero-hepatic recirculation of poison or metabolite
  • “Gut dialysis”
28
Q

Possible MDAC Indications

A
  • Limited number of substances with no effect on clinical outcomes
  • Reduce elimination rates

“Some of These Patients Drink Charcoal Quickly”

  • Salicylate
  • Theophylline/caffeine
  • Phenobarbital
  • Dapsone
  • Carbamazepine
  • Quinine/quinidine
  • Valproate and phenytoin?
29
Q

MDAC

A
  • 0.5-1 g/kg every 2-6 hours

- Possible complications: pulmonary aspiration, constipation, and fluid/electrolyte imbalance

30
Q

Altering Urine pH

A
  • “Trap” drug in tubule by adjusting tubular filtrate pH so poison is in ionized form
  • Creates a [gradient] favoring elimination
31
Q

Urine Alkalinization

A
  • Agent: Sodium bicarbonate
  • Dose: 1-2 mEq/kg every 3-4 hours
  • Goal: Urine pH > 7.5
  • Indications: phenobarbital, salicylates
  • Agents not Used: Acetazolamide, THAM

850 (23 decks)

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