Approach to Poisonings

38
Approach to Poisonings Robert J. Vinci, MD

description

Approach to Poisonings. Robert J. Vinci, MD. Background. 2 – 5 Million exposures per year 4% require hospitalization 96% minor or no effects. Background. 93% involve a single substance 67 % patients < 20 years of age 53% children < 6 years of age 25% children < 2 years of age - PowerPoint PPT Presentation

Transcript of Approach to Poisonings

Page 1: Approach to Poisonings

Approach to Poisonings

Robert J. Vinci, MD

Page 2: Approach to Poisonings

Background

• 2 – 5 Million exposures per year

• 4% require hospitalization

• 96% minor or no effects

Page 3: Approach to Poisonings

Background

• 93% involve a single substance• 67 % patients < 20 years of age• 53% children < 6 years of age• 25% children < 2 years of age• Bimodal Pediatric age distribution• Household products vs. pharmaceuticals

Page 4: Approach to Poisonings

Fatalities

• Cleaning substances

• Analgesics

• Antidepressants

• Heavy metals, especially iron

• Street drugs

• Cardiovascular drugs

• Alcohols

Page 5: Approach to Poisonings

How do Children Present?• Vague History• Change in mental status• Suspicion of Ingestion

– Open bottles– Pills on floor– Missing medications

• Directly Observed

Page 6: Approach to Poisonings

Initial Evaluation

• History– When– How Much– Symptoms– Meds in the Home– Any other possible exposures– Observations from EMS personnel

Page 7: Approach to Poisonings

Initial Evaluation

• History– Seizures

– GI symptoms

– Hallucinations

– Toxidromes

Page 8: Approach to Poisonings

Initial Evaluation

• Physical Examination– ABC’s – Rapid deterioration– Review vital signs for clues– Mental Status– Pupils– Nystagmus– Skin Color/Skin Warmth

Page 9: Approach to Poisonings

Initial Evaluation

• Laboratory Studies– Pulse Oximetry– EKG– Electrolytes/Blood Sugar– ABG’s– Toxic Screen/Drug Levels– Serum osmolality/osmolal gap

Page 10: Approach to Poisonings

Increased Anion Gap Acidosis

• Methanol• Ethylene Glycol• Salicylates• Iron, INH, Ibuprofen• Drugs producing hypotension and lactic

acidosis (many serious ingestions)

Page 11: Approach to Poisonings

Increased Osmolal Gap• Osmolal Gap = Osm (calc) – Osm (meas.)• Osmolal Calc. = 2 x Na + Gluc + BUN

18 2.6• Increased Osmolal Gap

– Ethanol– Methanol– Ethylene Glycol– Acetone

Page 12: Approach to Poisonings

Radiographic Studies• CHIPES• C = Chloral Hydrate• H = Heavy Metals, especially Iron• I = Iodinated compounds (thyroxin)• P = Psychotropic, Packers• E = Enteric Coated Medications• S = Salicylates, Sustained Release

Page 13: Approach to Poisonings

Toxidromes• Hyperthermia, agitation,

mydriasis, hypertensive hyperthermic

• Coma, Seizures, arrhythmia• Coma, respiratory depression,

myosis• Hallucinations, mydriasis, hot

dry skin, urinary retention, tachycardia

• Sympathomimetics

• Tricyclics• Opiods

• Anticholinergics

Page 14: Approach to Poisonings

Serum Toxic Screens

• Aspirin

• Salicylates

• Alcohols

• Tricyclics

Page 15: Approach to Poisonings

Urine Toxic Screens

• Benzodiazepines

• Barbiturates

• Opiates

• PCP

• Marijuana

Page 16: Approach to Poisonings

General Management

• Supportive Care

• Oxygen

• Intravenous glucose

• Careful monitoring for potential side effects

Page 17: Approach to Poisonings

Specific Management

• Gastric Emptying

• Decrease Absorption

• Enhance Elimination

• Specific Antidotes

Page 18: Approach to Poisonings

Gastric Emptying

• Syrup of Ipecac– Stimulates Gastric Receptors linked to the CNS

vomiting center

– Emesis within 20 minutes

– 80% after a single dose

– 99% after two doses

– Vomiting persists for 1 – 2 hours and may delay use of oral antidotes and treatments

Page 19: Approach to Poisonings

Syrup of IpecacShould it be Used?

• Adverse Effects– Uncontrolled vomiting/ Mallory Weiss Tear– Sedation– Fatal aspiration

• 30% recovered < one hour of ingestion. Minimal toxin recovered after 90 minutes

• No true evidence it improves outcome• Not studied well with delayed gastric

emptying or decreased peristalsis

Page 20: Approach to Poisonings

When to Consider Ipecac

• Alert, conscious children > 6 months of age

• Ingestion of potentially toxic amount of poisoning

• Within 60 minutes of ingestion

• Perhaps at home or in pre-hospital setting

• Limited value in the hospital setting

Page 21: Approach to Poisonings

Syrup of IpecacContraindications to Use

• Substance that produces rapid change in mental status

• Calcium channel blocker, digitalis, beta-blocker (worsen bradycardia of vomiting)

• Corrosives• Mental Status changes/Decreased Gag• Coagulopathy• Infants less than 6 months of age

Page 22: Approach to Poisonings

IpecacAdverse Effects

• Protracted vomiting, sedation or diarrhea

• Forceful vomiting (Mallory-Weiss tears, pneumomediastinum, bradycardia)

• Sedation or seizures leading to aspiration

• Cardiomyopathy with chronic abuse

• May delay oral therapy, especially charcoal

Page 23: Approach to Poisonings

Gastric Lavage• Need Presence of gag – now and during the

procedure• Left Lateral Decubitus/Trendenburg• Large Bore Single Lumen tube• After confirming position of tube, 10 – 15

ml/kg aliquots of saline until clear• Removes < 30 % of what is ingested (similar

to ipecac)• Similar contraindications to ipecac

Page 24: Approach to Poisonings

Gastric LavageContraindications

• Corrosives

• Uncooperative child

• History of GI surgery/pathology

Page 25: Approach to Poisonings

Gastric LavageTechnique

• Confirm presence of gag reflex• Left lateral decubitus position with head

lower than feet• Largest possible tube• Lavage with aliquots of 10 ml/kg until

clear

Page 26: Approach to Poisonings

Charcoal - Adsorbent• Binding surface areas of 3000 m2/gm• Maintains attachment through covalent

bonding• If treatment occurs within one hour as much

as 75% of toxin is adsorbed• Dose is 10:1 ratio, however a fixed dose of 1 gram/kg is recommended• May mix with flavoring to hide taste• ?Use with NG tube????

Page 27: Approach to Poisonings

Use of Charcoal• 1 gm/kg of body weight• Often pre-mixed as aqueous solution or with a

cathartic such as sorbitol• May flavor with cola, chocolate syrup in order

to make it more palatable• More effective than ipecac or gastric lavage• Greatest benefit if used within one hour of

ingestion

Page 28: Approach to Poisonings

Charcoal “Contraindications”

• Hydrocarbons

• Alcohols

• Heavy Metals (Iron)

• Minerals

• Corrosives (makes endoscopy difficult)

• GI perforation

Page 29: Approach to Poisonings

Multiple Dose Activated Charcoal

• Drugs which decrease gastrointestinal mobility

• Enterohepatic circulation• Gastric Dialysis• Give 0.5 mg/kg of charcoal without

sorbitol every 4 – 6 hours

Page 30: Approach to Poisonings

Adverse Effects of Charcoal

• Aspiration

• Diarrhea, if used with sorbitol

• Fluid loss and electrolyte abnormality

Page 31: Approach to Poisonings

Cathartics

• Osmotic Agents used to treat ingestions

• Increase Gastric Motility

• In pediatric patients the use of cathartics should be limited to the first dose of charcoal

Page 32: Approach to Poisonings

Magnesium Citrate

• 4 ml/kg of 6% suspension

• Larger doses do not improve efficacy

• Magnesium does get absorbed

Page 33: Approach to Poisonings

Sorbitol

• The most efficient osmotic agent

• 1 – 2 grams/kg

• Not recommended in children < 1 year

• May cause hypernatremic dehydration and cardiovascular collapse

Page 34: Approach to Poisonings

Whole-Bowel Irrigation

• Polyethylene glycol-electrolyte solution• There is no absorption• Large volumes infused (500 – 1000 ml

per hour) until effluent is clear• Treatment of choice for agents which

are not well absorbed by charcoal

Page 35: Approach to Poisonings

Indications

• Enteric coated pills• Sustained release tablets• Illicit drug packets• Drug concretions• Ingestions of substances poorly bound

by charcoal

Page 36: Approach to Poisonings

Common Antidotes• Opiate Overdose• Acetominophen• Salicylates• Digoxin• Iron• INH• Ethylene Glycol• Tricyclics

• Narcan• N-acetylcysteine• Alkalinization• Fab Antibodies• Deferoxamine• Pyridoxine• Fomepazole• Sodium Bicarbonate

Page 37: Approach to Poisonings

Approach to Patients

• Avoid the use of ipecac

• Gastric lavage has not been shown to be effective

• In general, activated charcoal is the sole intervention necessary to treat serious poisonings. This may be used with or without a cathartic

Page 38: Approach to Poisonings

Poison Control Centers

• 1-800-222-1222

• 617-232-2120

• May be helpful in identification of toxins based on symptoms alone