toXXX Flashcards
Poison control #
1-800-222-1222
What information to collect when a patient calls or presents with substance poisoning
- Age, weight
- PMH
- Time of exposure and route
- Present s/s
- Exact name of product, formulation, strength
- How much has been ingested
- Occupation
- Were there suicide notes?
General management to a patient with substance poisoning
ABCDE
- Airway
- Breathing
- Cirulaation
- Dextrose/Decontamination
- EKG/Elimination
Non-pharm for substance poisoning
- If the agent was inhaled: remove pt from the exposure area
- If agent is topical/derm: irrigate with soap and water
- If agent is ingested: can consider orgogastric (“stomach pumping”)
- hemodialysis can also be considered for specific situations
When to use orgogastric methods in substance poisoning
stomach pumping
- Ingestant has potential for serious toxicities
- No antidotes exist
- Time window gives reason to believe agent may still be in stomach
When to use hemodialysis in substance poisoning
- Other elimination strategies not effective or are contraindicated
- Ingestant has potential to produce serious ADR
- Agent is able to be removed through filtration
- EXTRIP is a good source to find out if hemodialysis would work
ex: ASA and tox alcohols
GI decontamination methods (pharm-ish) for substance poisoning
- do NOT use Ipecac
- Can consider activated charcoal: enhances gastric dialysis of certain drugs and prevents prolonged absorption or enterhepatic recirculation
- Can consider PEG3350 with electrolytes (whole bowel irrigation)
- golytely, nulytely, colyte, NOT miralax
When to use activated charcoal in substance poisoning
- Most benefit if used within an hour of ingestion (doesn’t mean you can’t use it if it’s been mmore than an hour)
- It helps prevent absorption
- No benefit if the ingested substance is
- Ionized metals: lithium, iron
- Alcohols
- Gasoline
Activated charcoal dosing
- sometimes the first dose is formualted with sorbitol to improve palatability tho no big evidence for benefit of sorbitol
- 1g/kg
- pediatric dosing
- 0.5-1g/kg OR
- multiple dose: loading dose of 1g/kg followed by 0.5g/kg Q4-6H up to 24 hrs
Activated charcoal AE
vomitting, black tarry stools
- Do NOT want pt to vomit this up and have it in their airways
When to use whole bowel irrigation in substance poisoning and dose
- Goal is to minimize time that ingestant is in GI tract for absormption
- Beneficial for XR products, metals (Fe), and body packers (people who store packets of illicit drugs in their GI system to smuggle across borders)
- 1-2 L/hr or until rectal effluent is clear
- peds: NG is easier to use
- 0.5L/hr in small children Q4-h H
- 1.2-2L/hr in older chilren/adolescants Q4-6 H
Toxidrome defininiotn
s/s that point to a class of toxin based on understanding of pharmacology
Drug(s) that have adrenergic/sympathomimetic toxidrome
- Cocaine
- Amphetamines
- Bathsalts
- Pseudoephedrine
- Nootropics
- Bupropion
Drug(s) that have cholinergic toxidrome
Organophosphates
Pesticides
Drug(s) that have anticholinergic toxidrome
- TCAs
- antihistamines (like benadryl)
Drug(s) that have sedative/hypnotic toxidrome
- Benzos
- EtOH
Drug(s) that have opioid toxidrome
- opioids
- heroin
- morphine
- loperamide (need 30-200mg → cross BBB and PGP can’t kick it out)
Adrenergic/sympathomimetic toxidrome S/S
- Enlarged pupils
- Increased BP
- Increased HR
- Increased RR
- Increased temp
- Bowel sounds
- Tremor
- Seizures
Cholinergic toxidrome S/S
- Salivation
- Lacrimation
- Urination
- Defecation
- Gastric cramps
- Emesis
- Bradycardia
- Bronchorrhea
- Bronchospasm
- Pinpoint pupils
- Bowel sounds
Anticholinergic toxidroe S/S
- Blind as a bag
- Hot as a hare
- Dry as a bone
- Red as a beet
- Mad as a hatter (agitated)
- Enlarged pupils
- Increased BP
- Increased HR
- Increased RR
- Increased temp
- Urinary retention
- Tremor
- Seizures
Sedative/hypnotic toxidrome S/S
Sleepy with normal vitals
- bp, hr, rr may be a little decreased
Opioid toxidrome S/S
- Unresponsive to painful stimuli
- Pinpoint pupils
- Low RR
- Low BP
- Low HR
- Low temp
- Hyporeflexia
- Decreased mental status
Loperamide can cause arrhythmias
Treatment for pts with cholinergic toxidrome
Atropine: inhibits muscarinc actions of ACh
- 1mg IV titrated to effect, no MDD
Pralidoxime: reactivates cholinesterase
- 30mg/kg IV load
- 8-10mg/kg/hr continuous infusion
Treatment for pts with anticholinergic toxidrome d/t antihistamine overdose
Physostigmine: ACh inhibitor
- 0.5 - 2 mg IV
Treatment for pts with benzo overdose
Benzos alone aren’t that bad, can be handled with monitoring, supportive care; intuation if needed
- NOT LETHAL
The problem with flumazenil and when to use it
Can send someone who is benzo overdosed (not lethal) into withdrawal (lethal)
_
So when to use flumazenil?
- procedural sedation
- in peds accidental overdose who are not benzo dependent
- Z-drug overdose (not really tho)
Flumazenil dosing
competitivte antag at benzo receptor site
- 0.2mg IV over 15 seconds
- peds: 0.01 mg/kg IV
- onset: 1-2 min
idk if this is just for benzo overdose or in general
Opioid overdose treatment
IV naloxone dose
- 0.4mg for non-opioid dependent
- 0.04mg for opioid dependent pt
- titrate to effect (ideally)
- continuous inf: 1/2 of initial effective dose as bolus then 2/3 of effective dose/hr
Protect airway or breath for them
Naloxone IV vs. nasal
- IV: quick onset, quick wear off
- IN: longer onset and duration
- IM: somewhere inbetween
Naloxone AE
- flash pulmonary edema: treat with nitroglycerin, diuretic, and positive pressure ventilation
- runny nose
Loperamide overdose treatment
- Naloxone
- IF CARDIAC DISTURBANCE
- IV Mg
- Sodium bicarb
- IV isoproteronol or transcutaneous pacer
What drug levels do we like to draw in patients who present with overdose/substance poisoning?
- Digoxin
- Vanco
- Phenytoin
- Lithium
- APAP - no toxidrome
- ASA - unique toxidrome
Polysubstance overdose approach
- Eliminate: activated charcoal
- Admin antidotes: naloxone, NAC
- Supportive care: benzos
Benzo withdrawal s/s
- Severe sleep disturbance
- Irritability
- Increased tension and anxiety
- Panic attacks
- Sweating
- Difficulty in concentration
- Dry retching and nausea
- Palpitations
- Headache
- Psychotic reaction
- Seizures
- Death
Which is deadlier? benzo overdose or benzo withdrawal
WITHDRAWAL
OTC that can cause asa/ salicylates overdose
- Peptobismol
- Alkaselzter
- Oil of wintergreen: 98% methyl salicyalte (98g/100ml)
- Icy hot
- Bengay
- ASA
ASA/salicylate toxic levels (adults)
- Toxic at >150mg/kg
- Life threatening at >500mg/kg
ASA/salicylate mechanism of tox
metabolic acidosis and uncoupled oxidative phosphorylation (can’t produce ATP and excess H+)
ASA/salicylate overdose S/S
- Resp: tachypnea/hyperpnea
- GI: disrupt nucosal barrier, N/V, hemorrhagic gastritis, bezoar formation
- CNS: neuoronal energy depletion, hypoglycorrachia (hypoclycemia in brain only), AMS, tinnitus, hyperpyresxia, tachycardia, fever, coma, seizures
- Non-cardiogenic pulmonary edmea
- Renal and hepatic injury
ASA/salicylate overdose acid/base labs
- Early on in overdose: resp alkalosis
- Middle of overdose: mixed metabolic acidosis and resp alkalosis
- Late/preterminal overdose: metabolic and resp acidosis
- Body can no longer compensate and you can’t even compensate by breathing hard
What is a bezoar formation
concrete ball of salicylate in stomach that can break off and release more drug into system
ASA/salicylate overdose electroytes presentation
- Hypo or hyperglycemia
- Increased fluid and electrolyte losses
- Increased anion gap
- Urine: ketones in urine
ASA/salicylate overdose treatment
- Airway, breathing, circulation (do NOT ventilate)
- Enhance elimination
- Multiple doses of activated charcoal (1g/kg)
- Urine alkalization (we want a pH >7.5)
- Can consider hemodialysis
- Dextrose (even if normal glucose levels): 0.5-1g/kg
- Fluid maintenance
- Serum pH 7.45-7.55
- 150 mEq of sodium bicarb in D5W at twice maintenance rate (alkalinize urine)
- Treat spefic AE too (seizures, edema, etc.)
ASA/salicylate overdose monitorng
Monitor Q2H
- Mental status
- Urine and blood pH
- Salicylate levels
- Fluid and electrolytes
- Maintain K (often low)
ASA/salycylate overdose: if pt is on hemodilaysis for the overdose, when to stop
Stay on hemodilaysis until clear inprovement in pt AND salicylate level <19mg/dL
- Or 4-6 hrs if you can’t get labs
ASA/salicylate overdse: who qualifies for hemodialysis
- Serum level >100mg/dL in pts with acute
- Serum level >60mg/dL in pts with chronic
- Neurologic deterioration
- Seizures
- Intractable acidosis (pH <7.2)
- Renal failure
- Pulmonary edema
Purpose of urine alkalinzation in asa/salicylate overdose
shift salicylate into un-ionized form → move across barriers → more excretion
If you overdose on an antidepressant, will it present as serotonin syndrome?
Very unlikely, usually only see serotonin syndrome if polypharmarcy with multiple serotenergic agents or with drug specific for 5HT2A or 5HT1A
Serotonin syndrome presentation
- Spontaneous clonus
- Agitation
- Diaphoresis
- Hyperthermia
- Tremor
- Hyperreflexia
- Diarrhea
- AMS
- Incoordination
SSRI overdose presentation
Seroternergic features
- AMS
- Tachycardia
- Myoclonus
- Tremors
- Diarrhea
Serotonin syndrome antidone
cyproheptadine but it is very anticholinergic, so not used often
- Can use benzos and propranolol for symptom treatment
Serotoin overdose treatment
- Supportive care
- Monitoring
- Escitalopram and citalopram are most likely to cause seizures and QTc prolongation
List the TCAs
- amitriptyline
- nortriptyline
- doxepin
- imipramine
- desipramine
TCAs MOA and related overdose S/S
- Catechol reuptake inhibitior: hypotension
- Alpha adrenergic blocker: hypotension
- GABA antag: seizure
- Sodium channel blocker: dysarrythmias → lethal
initial increase in BP and HR and then quick drop; anticholinergic toxidrome
TCA and EKG/ECG
- If there’s an R wave in aVR: there was some exposure to TCA (not necessarily a TCA overdose, but it is present)
- Elevated QRS → increased risk of seizure
- Bigger R wave amplitude → higher incidence of seizure
TCA overdose treatment
don’t worry about the treatments for specific s/s for this card
- If pt came in early enough; can consider
- orogastric lavage (GI flush) or activated charcoal - hypertonic sodium bicarb 1-2 mEq/kg bolus and then 150 mEq in 1L D5W at twice maintenance rate (150-200 ml/hr); give until
- Do this until QRS narrows
- We would also like to see blood pH go back to normal (<7.5) but fixing QRS is more important
Hypertonic sodium bicarb MOA in TCA overdose
- Sodium (hypertonic sodium like 3% NaCl) → prevents lethal sodium channel blockade
- Alkalinzation (via hyperventiliation) may also be effective
TCA overdose: additional treatment if pt is experiencing seizures
- Benzos
- Barbituates
- do NOT give phenytoin: can increase frequency and duration of VT
- do NOT give flumazenil: prevents benzo protection against seizure and can worsen seizures
TCA overdose: addition treatment if dysrhythmias aren’t going away
- Mg
- Lidocaine (replace TCA with a more benign sodium channel blocker)
TCA overdose: additional treatment if pt is hypotensive
- Ne, E, vasopressin, phenylephrine
- Methylene blue, lipid emulsion, high dose insulin
Bupropion overdose S/S
- May be asymptomatic until like 24 hrs later when they suddenly have a seizure -> hold pt until certain no seizures
- Widening of QRS complex but does NOT respond to sodium bicarb
- Sympathomimetic crisis
- Cardiogenic shock
- Status epilepticus
- Lazarus effect (pronouced dead but then randomly wakes up later)
- Death
Bupropion overdsoe treatment
- Supportive care
- Maybe lipid emulsion and ECMO
- Maybe orogastric lavage or activated charcoal or whole bowel irrigation
- IF HTN, can try benzos
Antihypertensive overdose general presentation
Toxidrome: bradycardia, hypotension
- Cardiac: AV blocks and CHF
- Sotalol can cause torsades
- CNS: depressed LOC
- Propranolol can cause seizures
Differentiation dx between CCB and BB overdose
CCB has elevated glucose
CCB specific overdose presentaiton
- Alert initially
- Elevated blood sugar
- Hypotension (d/t vasodilation)
-
non-DHP CCBs:
- decreased ventricular contratility
- sinus node depression
- AV node depression -> various blocks
CCB and BB overdose treatment
- GI decontamination if applicable
- fluids: isotonic crystalloids (0.9 NaCl, LR)
- atropine: 0.5-1mg Q5min 3x
- calcium
- CaCl (can cause sclerosing): 1-3g IV
- Ca gluconate: 3-9g IV - high dose insulin (HIET)
- 1 U/kg bolus then 1-10 U/kg/hhr
- give glucose to counteract insulin
- maintain glucose >100 mg/dL
- 30-60 min onset - potassium prn to maintain 2.8-3.5 mg/dL
Same as BB
Other than the normal treatment steps, what other agents might you use in the setting of CCB and BB overdose?
- vasopressors: NE and E
- can be used as monotherapy in mild overdose
- can also be used as bridge insulin - inotropes: dobutaminne (CCB), milrinone (BB)
- cardiac pacing
- intralipid:
- pull toxin off of site
- modulate myocardial energy - ECMO
- BB ONLY: glucagon 3-5mg bolus then 3-5mg/hr + zofran (n/v)
Why can glucagon be considered in BB overdose but not CCB?
it’s like a beta agonist that bypasses the beta receptor
Glucagon AE
vomiting (zofran ppx)
- avoid use in pts wtih AMS
Alpha agonist specific overdose s/s
- Decreased mental status
- Small pupils
- No delay in onset
-
CLONIDINE SPECIFIC
- transient HTN and tachycardia before suddenly going to bradycardia and hypotension
- CNS depression
- Respiratory depression
Alpha agonist overdose treatment
- Suportive care
-
Clondine: naloxone for respiratory depression
- 5-10mg bolus
- can start an infusion if response
Acute digoxin toxicity s/s
- Predistribution
- N/V
- Hyperkalemia: guaranteed death if K >5.5
- Post distribution (6 hrs)
- Hypotension
- Bradycardia
- Dysrhythmias
- Death
Chronic digoxin toxicity S/S
less typical and K level is unhelpful
Digifab indication in chronic digoxin tox
- Post-distribution (>6 hrs after ingestion) level of >6 mcg/L
- Progressing or severe signs of tox
Digifab dosing in practice
2 vials and then titrate to effect
- Give every hr if no response is seen
Acute digoxin tox treatment
- GI decontamination: activated charcoal, repeat doses needed in renal failure
- Digifab if appropriate
- K >5
- Digoxin level >20 mg/dL
- Progresing signs of tox
- Temporizing measures: Ca if patient is looking bad (high K+)
But too much calcium induces “stone heart” = irreversible contraction of heart
Data says still give calcium too
MUDPILES
- M - Methanol
- U – Uremia
- D – DKA, SKA, AKA
- P – Phenformin (metformin), Paraldehyde
- I – Isoniazid, INH
- L – Lactate, CO, CN, MetHb
- E – Ethylene Glycol
- S – Salicylates
Causes of anion gap metabolic acidosis
Anion gap calculation
Calculating anion gap: gap = Na - (Cl + HCO3)
normal = 4-12
Clinical presentation after ingestion of toxic alcohols
- Early:
- AMS - like they’re drunk
- GI distress
- Late:
- High anion gap metabolic acidosis
- Specific differences between EtOHs
- Methanol: visual changes “blind”
- Ethylene glycol: nephrotox, hypocalcemia
Toxic alcohols
- Methanol: high volatility - in gasline antifreeze and windshield washer fluid
- Ethylene glycol: low volatility - in engine fluid
What labs to look at in pts who present for ingestion of toxic alcohol
- Electrolytes - and treat where needed
- Arterial blood gas
- Ethanol level
- Methanol and ethylene glycol levels
- The labs won’t return until the next day, so for the first day that they present, you don’t really know which they have
- Measured osmolality
Management/treatment of ingestion of toxic alcohols
- GI decontamination: useless
- alcohol dehydrogenase (ADH) inhibitor: ethanol OR 4-methylpyrazole-fomepizole (4-MP, Antiol: preferred agent)
- Supplementation
- ethylene glycol
- B6 pyroxidone IV 100mg QD
- B1 thiamine IV 100mg QD
- methanol
- folic acid: 1mg/kg Q4-6H for 24hrs
- Mg
- ethylene glycol
- Sodium bicarb: to correct acidosis
supplement doses are from peds lecture, idk what adult doses are
Ethanol dosing in ingestion of toxic alcohols
- adults:1g/kg to maintain a BAC of ~100 mg/dL
- peds: loading dose of 8 ml/kg over 1 hr → 0.8 ml/kg/hr IV
- Goal serum [ ]: 100-150 mg/dL
- Goal [ ] of toxic alcohols: <25 mg/dL
Ethanol formulations
- IV 10% soln
- PO: shots x 4
Ethanol AE
- CNS inebriation
- thrombophlebitis (IV)
- GI symptoms
4-MP (fomepizaole) AE
- HA
- Dizziness
- Minor allergic reactions
4-MP (fomepizaole) dosing in ingestion of toxic alcohols
- 15 mg/kg load, then 10mg/kg Q12h x4, then 15mg/kg Q12H
- Dilute in NS or D5W and infuse over 30 min
- Lower then re-up dose d/t autoinduction
- Dose increased during hemodialys
- peds: same dosing as adults
- goal toxic alcohol [ ]: <25 mg/dL
Who needs hemodilaysis in pts who have ingested toxic alcolhols
- Methanol or ethylene glycol level 25-50 mg/dL
- High osmal gap (>10) without aother cause
- A normal gap could mean pt is doing well or tthat pt is doing trash, not super specific or helpful
- End organ manifestations of tox (renal, vision)
- Severe metabolic acidosis
CB1 receptors
- CNS
- GPCRs
- Motor activity
- Thinking
- Pain perception
CB2 receptors
- Periphery
- GPCRs
- Immune modulation
- Anti-inflammatory
Unwanted effects form phytocannabinoids
- Short term memory difficulties
- Agitaion
- Feeling intense
- Anx
- Dizziness
- Lightheadedness
- Confusion
- Loss of coordination
Phytocannabioids
- natural cannabis
- THC parital agonism at CB1 receptor
Sythetic cannabinoids
- Full agonist (act on CB1 AND CB2)
- Higher receptor affinity
- Longer half lives
Synthetic cannabinoids tox clincal presentation
- CNS depression
- Disorientation
- Restlessness/agitation
- Hallucinations
- Seizures
- Comativeness
- Anx
- Mydriasis
- Tachycardia
- Vomitting
Synthetic cannabinoids tox labs
- Hypokalemia
- Increased blood glucose
- Increased SCr
- Increased WBC
- Increased Creatinine kinase
synthetic cannabinoids tox treatment
- Agitation: treat with benzos
- Seizures: treat with benzos
- Dehydration: treat with IV crystalloids
- HTN/tachycardia: treat with benzos ad if benzos don’t work, IV antihypertensives
synthetic cannabinoids n/v moa and dx
- excessive vomitting d/t dysregulation of endocannabinoid system and alteration in TRPV2 receptor
- dx
- Hx of regluar cannabis use
- Cyclic N/V
- Generalized diffuse abdominal pain
- Compulsive hot showers with symptom improvement
synthetic cannabinoid n/v presentation: pre-emetic phase
- months-years
- diffuse abdominal dyscomfort
- feelings of agitaiton or stress
- morning nausea
- fear of vomiting
- Often pts will self treat with more marijuana
synthetic cannabinoid n/v presentaito: hyperemetic phase
- 24-48 hrs
- Cyclic episodes of N/V
- Diffuse, severe abdominal pain
Synthetic cannabinoid n/v presentation: recovery phsase
- Only upon cessation of cannabis (may take a month for full resolution)
- Bowel regimens
- Fluids
- Electrolyte replacement
synthetic canabinod n/v treatment
- Activate TRPV1
- Hot showers
- Caapsaicin topical cream
- Anti-nausea
- Haloperidol - better opiton
- Ondansetron
- Benzos: inhibitory effect on medullary and vestibular nuclei associated with n/v
- Supportive care
- Fluids
- Electrolytes
Cocaine specific tox s/s
- euphoria
- seizures
- dysrhythmias
- HTN
- coronary artery spasm MI
cocaine speific tox treatment
- benzos
- supportive care
amphetamines specfic tox s/s
- agitation
- seizures
- hyperthermia
- HTN
- delirium
longer acting than cocaine
Amphetamine specific tox treatment
- benzos or barbituates
- anti-htn
- supportice care
Bath salts specific tox s/s
- agitation
- tachycardia
- insomnia
- paranoia
- seizures
- violent unpredictable behavior
Bath salts specific tox treatment
supportive care
sympathomimetic (general) treatment
- Elimination strategies (charcoal)
- Clinical effects: Benzos
- Airway protection: intubation
- Hyperthermia: Ice baths, benzos, antipyretics
- Dysrrthmias: Sodim bicarb, lidocaine
- Rhabdo: Fliuds
- Antihypertensives
- Anti-psych
- Electrolyte management
Peds poisoning labs to get
- Lab evals as is relevant to the H&P and pt presentation
- but almost always at least serum chemistries and acid-base
- strong consideration for serum APAP (also salicylates, ethanol, iron) d/t easy access/OTC status
toxic APAP doses in peds
> 200mg/kg PO or >60mg/kg IV
Peds apap overdose treatment
- GI contamination with activated charcoal if it has been less than an hr
- NAC dosing
- PO: 140mg/kg x1 → 70mg/kg Q4H x17
- IV (more often used): 150mg/kg over 1 hr → 50mg/kg over 4 hrs → 100mg/kg over 16 hrs
- To prevent hypoNa, product should be diluted to a [ ] of 40mg/dL
household cleaners/caustic exposures: possible causes and treatment
- Cleaners: bleaches, detergents, soaps
- Caustics: toilet cleanere, drain cleaner, oven cleaner
- JUST SUSPPORTIVE CARE
- If GI injury can consider PPIs
- do NOT use GI decontamination
Foreign body ingestion treatment
GI decontamination: manual removal if esophagaeal impact suspected
Peds cough and cold: overdose/tox treatment
- Products should be avoided in pts < 6 per FDA 2017
- Use activated charcoal
- Symptomatic management
- HTN: labeatol, nicardipine
- Arrhythmias: amiodarone
- Seizures: benzos
Fatalities due to pseudoephedrine
