Toxidromes 1 Flashcards
Viscous Lidocaine Poisoning
In 2014, FDA reviewed 22 case reports of serious adverse reactions, including deaths, in infants and young children 5 months to 3.5 years of age who were given oral viscous lidocaine 2 percent solution for the treatment of mouth pain, including teething and stomatitis, or who had accidental ingestions.
Caution: do not have patients go home on viscous lidocaine; can cause massive seizures and overdose
Most often Reported 6-12 years old
- Foreign bodies, toys, and misc: 8.78%
* Foreign bodies is number 1 - Cosmetics, personal care: 7.11%
- Analgesics 6.64%
- Antihistamine 5.43%
- Vitamins 5.21%
Very Toxic Agents (8)
- Prenatal vitamin supplements
- Sulfonylureas
- Calcium channel antagonist
- Toxic alcohols
- Clonidine
- Salicylates
- Tricyclic Antidepressants; Asystoles and ventricular arrythmias
- Hydrocarbons
Fatal Sip (3)
- Camphor
* Vicks Vapor Rub: Eat 5 ml and get CNS effects - Methyl Salicylate 1/2 tsp. (Salonpas patches)
- Benzocaine 2 ml
a. Methemoglobinemia – Seizure
b. Benzocaine is found in teething medicine
Malignant Swallow (5)
- Chloroquine (20 mg/kg) 500mg
- Theophylline (8.4 mg/kg) 500mg
- Imipramine (15 mg/kg)150 mg
- Chlorpromazine (25 mg/kg) 200mg
- Clonidine 0.3 mg tablet
Clinical Clues suggestive of Poisoning (6)
- Child is pica prone age 1-5 years
- Acute onset of symptoms
- Change in caretakers
- Multi-organ system dysfunction
- Significantly altered mental status
- Family history:
a. Recent illnesses medications such as Elavil, antidiarrheal medications
b. Accidental overdose at holiday parties
Clinical Clues suggestive of Poisoning: Adolescents (9)
a. Clinically acute intoxication
b. Intentional ingestion of toxic drug
c. Experimentation with abuse substance
d. Depression
e. School deterioration
f. Personality change
g. Specific suicidal ideation
h. Psychotropic medication in family
i. Prior substance abuse
ABCD of Poison Management (6)
- Airway
- Breathing
- Circulation
- Disability LOC, GCS
- Drugs:
a. Rapid dextrose
b. Naloxone
c. Oxygen - Decontamination
a. Skin: Water then soap and water
b. GI: Consider options
c. Eye: Copious water
Airway for toxidromes (4 w/ info)
- Airway obstruction can cause death after poisoning
a. flaccid tongue
b. Aspiration
c. Respiratory arrest
i. Count respiratory rate
ii. Aspirin causes acidosis, leading to compensatory respiratory alkalosis because the patient is trying to blow out the acid
d. If someone ingests lye it can cause airway obstruction - Evaluate mental status and gag/cough reflex
- Airway interventions
a. Head-down, left-sided position
b. Examine the oropharynx
c. Clear secretions
d. Airway devices: nasal trumpet, oral airway
e. Atropine should be used if the patient has rales and increased respiratory secretions
f. Melaxone should be used if the patient isn’t breathing fast enough - Intubation?
a. Consider naloxone first
Breathing for Toxidromes (5)
- Determine if respirations are adequate
- Give supplemental oxygen
- Assist with bag-valve-mask
- Check oxygen saturation, ABG
- Auscultate lung fields
a. Bronchospasm: Albuterol nebulizer
b. Bronchorrhea/rales: Atropine
c. Stridor: Determine need for immediate intubation
Circulation for toxidromes (6 w/ info)
- IV access
- Obtain bloodwork
- Measure blood pressure, pulse
- Hypotension treatment:
a. Normal saline fluid challenge, 20 mL/kg
b. Vasopressors if still hypotensive
c. PRBC’s if bleeding or anemic - Hypertension treatment:
a. Nitroprusside, beta blocker, or nitroglycerin - Continuous ECG monitoring
a. Assess for arrhythmias, treat accordingly
b. Check QRS and QT interval
i. This is critical
Physical exam findings to assess (8)
- Some physical findings are of particular importance to toxicology
- Vital signs including temperature
- LOC
- Pupillary size: Reactivity nystagmus – Mouth: Corrosive lesions/odor
- Skin – Dry or moist? Color?
- GI: Motility? Corrosive effects – Track marks?
- Pressure sores or compartment syndrome?
- Odors
Miosis causes (4)
(COPS) – small pupils
1. Cholinergics, Clonidine
- Opiates, Organophosphates
- Phenothiazine, Pilocarpine
- Sedatives (Barbiturates)
Mydriasis causes (4)
(AAAS) – large pupils
- Antihistamine
- Antidepressant
- Anticholinergics (atropine)
- Sympathomimetics –
Amphetamine, Cocaine, PCP
Autonomic Nervous System Vital Signs – Hypothermia
Sedative-hypnotic exposure such as baclofen or barbiturate
Autonomic Nervous System Vital Signs – RR
Depression due to opioids
Autonomic Nervous System Vital Signs – Tachypnea and hyperapnea
Respiratory compensation for metabolic acidosis or direct medullary stimulation from salicylate
Autonomic Nervous System Vital Signs – Fever
Excessive neuromuscular agitation from sympathomimetics or anticholinergic agent or uncoupling or oxidative phosphorylation due to salicylate or dinitrophenol ingestions
Hypotension possible xenobiotics (9)
- BB
- CaCB
- Antipsychotics
- Tricyclics
- Barbiturates
- Iron
- Theophylline
- Clonidine
- Opioids
Hypertension possible xenobiotics (5)
- Amphetamines/sympathomimetics
- Phencyclidine
- MAOI Inhibiotrs
- Anticholinergics
- Clonidine (early)
Coma possible xenobiotics (6)
- Opioids
- Sedative hypnotics
- anticholinergics
- OTC Sleep preparations
- Carbon monoxide
- Clonidine
Delirium/psychosis possible xenobiotics (7)
- Alcohol
- Phenothiazines
- Drugs of abuse
- Sympathomimetics
- OTC cold meds
- steroids
- heavy metals dextromorphan
Diagnostics: Essential Lab Tests (8)
- Complete metabolic profile → Calculate Anion Gap
- LFT’s, CK (rhabdomyolysis)
- Urinalysis, urine drug screen
- ETOH, alcohol screen
- Serum osmolality
- Acetaminophen, salicylates; ordering specific drug levels
- Specific drug levels
- Pregnancy test
Anion Gap (4)
- Means amount of sodium and potassium in the serum equals the amount of bicarbonate and chloride
* Anion Gap: Na+ – (HCO3- + Cl-)
* Normal: 8-16 mEq/L when K is not included - 12 to 20 when formula includes Potassium
* Anion Gap = (Na+ + K+) - (HCO3- + Cl-) - Can be normal (but actually low) in the face of a low protein
- Anion gap is different when you calculate potassium
Know how to calculate anion gap +/- potassium
Causes of abnormal anion gaps (8)
MUD PILES
- Methanol
- Uremia
- DKA
- Paraldehyde, metformin
- Iron, isoniazid, ibuprofen
- Lithium, lactic acidosis
- Ethylene glycol
- Strychnine, starvation, salicylates
Osmolar Gap (5)
- Calculated osmolality–measured osmolality
- 2(Na)+glucose/18+BUN/2.8
- Normal=285-290mOsm/L
- Gap>10mOsm/L suggests the presence of extra solutes:
a. Ethanol, methanol
b. Ethylene glycol, isopropyl alcohol – Mannitol, glycerol - Clinical Pearl: Anion gap acidosis with an osmolar gap should suggest methanol or ethylene glycol poisoning
Diagnostics - special drug levels (2)
- Acetaminophen level is indicated on ALL overdose patients
a. Ubiquitous toxin with significant toxicity
b. Asymptomatic presentation
c. Easily treatable with time sensitive antidote
d. Best done at 4 hours post ingestion - Specific drug levels may be indicated for some toxins
a. Iron, theophylline, aspirin, phenytoin, digoxin for example
Diagnostic Electrocardiogram: Prolonged QRS (3)
a. Tricyclics (TCA)
b. Phenothiazines
c. Calcium channel blockers
Diagnostic Electrocardiogram: Sinus bradycardia/AV block (3)
- Beta-blockers, calcium channel blockers
- TCAs
- Digoxin
Diagnostic Electrocardiogram: Ventricular tachycardia (5)
a. Cocaine, amphetamines
b. Chloral hydrate
c. Theophylline
d. Digoxin
e. TCAs
General Info about Diagnostics for Toxidromes (5)
- ECGs
a. ECG should be done on every single poisoning
b. Looking at QRS rate and the QT interval
c. Prolonged QRS → TCAs
d. Sinus brady cardia → beta blockers, dig, TCAs - Always get glucose
a. Fear of hypoglycemia - In comatose patient where you have no history, naloxone should be considered
a. When in doubt give naloxone - Toxic screens may be helpful but usually street drugs have other substances
- Fentanyl and cocaine is latest mixture
Poisonings Management (6)
- GI decontamination
a. Simple dilution
b. Gastric emptying
c. Activated charcoal
d. Whole bowel irrigation - Antidote Therapy
- Supportive care
- Toxic screen
a. May not be at all helpful - Contact poison control center
- Psychiatric evaluation
