Toxidromes 4 Flashcards
Tricyclics overdose presentation (6)
- Initially similar to anticholinergic toxidrome
- Occurs early: usually within 4 hours
- Mortality related to Life threatening events
- Cardiac: Ventricular arrhythmias
- CNS toxicity: Seizures, coma
* Seizures are worse than cardiac arrythmias b/c they can kill you instantly - MUST DO AN ECG!!!!!!!!!!!!!!
* Very toxic, only needs a small dose to be bad for you → could lead to death
What do you see on ECG with tricyclic overdose? (4)
i. Prolonged QT
ii. Large QRS wave
iii. Sinus tachycardia with tall R in R
iv. QRS wave is tall and wide
TCA Overdose: General Info (6)
- Leading cause of death by intentional overdose
- Blocks sodium channels
- Death by cardiovascular dysrhythmias and cardiovascular collapse
- Most TCA’s have anticholinergic effects – Dry skin, blurry vision, hot
- Severe OD: hypotension, seizures, respiratory depression
- In severe cases: ARDS, rhabdomyolisis, DIC
TCA Overdose: Management (4)
- Management: Multiple charcoal doses
- Assess risk in well appearing patient
Normal vital signs and LOC:
- Traditional dose of concern is >l0 mg/kg
- Rule of thumb: concern is greater if greater than 5 therapeutic doses are ingested
TCA Evaluation of Well-Appearing Patient (6)
- Assess vital signs and LOC
- Cardiac monitor for rhythm and QRS duration
- IV placement
- Gut decontamination
- Observe 6 hours after ingestion
- Can discharge if psychiatric clearance and VS, LOC, and ECG are normal throughout the observation period
Ill-Appearing Patient with TCA Poisoning (4)
- Assess and stabilize if needed
- Monitor vital signs and LOC
- Venous access, ABG and cardiac monitor playing attention to QRS
- Correct acidosis with NaHCO3
Treatment of TCA Overdose (4)
- Sodium Bicarbonate
a. Titrate for serum pH of 7.45-7.5
b. Because TCA is alkaline - IV fluids
- Lidocaine for persistent arrhythmias
- AVOID Class IA drugs (procainamide quinidine)
What is Alkalization Effect? (4)
- Alkalization of serum may help with specific toxins
- Salicylates – facilitates elimination and keeps toxin out of the tissues
- Tricyclic antidepressants
- Methanol intoxication
Iron overdose: general info (4)
- Most common cause of poisoning death in children over 6
- MOST DIFFICULT TO TREAT
Mechanism of Toxicity
- Potent oxidizer and catalyst of free radical formation
- Saturation of metabolic pathways results in the production of excess toxic metabolite that is hepatoxic and nephrotoxic
Iron overdose signs and symptoms (5)
- Stage 1: GI symptoms: abd. pain, vomiting hematochezia and hematemesis within two hours of ingestion
- Stage 2: Stable but evidence of hypoperfusion and acidosis
- Stage 3: Acidosis, shock
- Stage 4: Hepatotoxicity with 48 hours of ingestion
- Stage 5: Bowel obstruction from inflammation and stricture formation occurring 2-4 weeks following ingestion
- Will get acidotic, hepatotoxic and bowel obstruction
- Will have stricutres
- There are long-term effects even if they survive the
Iron overdose assessment (3)
Doses of concern:
- Child >40 mg/kg
- Adolescent: Any dose over l.5 grams
- If there is a lack of gut symptoms within 6 hours, likely to be a nontoxic ingestion
Iron overdose management (3)
- Get Abdominal x-ray: central
i. If normal and well, likely non-toxic ingestion
ii. If abnormal, perform gut decontamination –> Go LYTLEY works well - Gut decontamination
i. Whole bowel irrigation
ii. No bicarbonate or phosphate or oral deforoxamine - Volume support
what shows up on x-ray with iron overdose? (5)
- Chloral hydrate and cocaine packets
- Opiate packets
- Iron and other heavy metal such as lead arsenic and mercury
- Neuroleptics
- Sustained release or enteric coated tablets
* Can see lead and iron on X-Ray! Including the pills – you’ll know how many pills they ingested
Iron overdose plan of care for w/ info (4)
- Obtain serum iron concentration
a. Likely serial needed
b. Not TIBC - Indication for chelation therapy –> Clinical symptoms of GI, altered mental status, metabolic acidosis and hypotension
* Serum iron >400 ug/dL; Monitor
* IV Deferoxamine is iron chelator - Shock and acidosis
a. Multifactorial nature of shock
b. Hypovolemia: from GI loss
c. Distributive: iron mediated vasodilation
d. Cardiogenic: Cardiac suppression - Acidosis
a. Can be profound
b. Etiology is hydration of nonbound plasma iron lactic acidosis
c. Requires large amount of bicarbonate
Iron overdose: other effects (8)
- Patient will be acidotic with slight hyperglycemia
- Leukocytosis
- Metabolic acidosis
- Iron pills in stomach may be visible on KUB
- Order CBC, glucose serum iron, blood gas, chem screen (include LFT’s)
- IRON does not bind to charcoal
- If there within l5-30 minutes, syrup of ipecac
- If in first one-2 hours, can lavage Whole bowel irrigation: GoLYTELY
Iron: Serious Overdose (4)
- Deferoxamine: chelation
- If significant metabolic acidosis, or iron pills on x-ray
- If iron level > 500 micrograms/dL
- Given by continuous infusion then taper usually 24 hours
Caustic Alkali (2)
- Household cleaning products most common exposure
a. Children < 6 years
b. Start talking to parents about this at 4-6 months – safety precautions - Most common cause of morbidity
a. Alkali Drain Cleaners
b. Acid toilet bowl cleaners
Acid and Alkali Toxicity: What follows initial injury with ingestion? (5)
a. Thrombosis of vessels
b. Heat production through neutralization
c. Bacterial invasion
d. Inflammatory response with granulation tissue formation
e. Scar retraction at 3 weeks to months with subsequent stricture formation
Affected sites with acid and alkali toxicity (5)
a. Oropharynx, Esophagus, stomach are most common
b. Alkali more often cause esophageal lesion
c. Acids more often cause gastric lesions
d. Many exceptions since usually multiple sites
e. Must open up the mouth, look in the back of the throat, look at the pharynx, etc, if you can’t see anything then the patient needs to get scoped
* If you need a scope, call GI rather than ENT because it’s an ingestion
Clinical presentation of acid and alkali toxicity (5)
- Absence of respiratory distress does not preclude the existence of airway burns
- The absence of oropharyngeal burns does not preclude the presence of esophageal burns
- Pain: oral, retrosternal abdominal
- Dysphagia, drooling, vomiting, stridor
- Oropharyngeal and laryngeal burns
Acid and Alkali Ingestion Evaluation (4)
- History: identity, concentration, volume, time, circumstance
- Physical: AIRWAY, oropharyngeal
- Lab: depends on severity
- Fiberoptic endoscopy for all symptomatic or in asymptomatic child with a strong history
Acid and Alkali Ingestion Management (6)
a. Airway stable
b. Vascular access
c. Poison control center
d. Decontamination
e. Supportive care
f. Psychiatric evaluation
