Emergency Medicine management of Poisonings in the ED - Jordan Barnett MD

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Transcript of Emergency Medicine management of Poisonings in the ED - Jordan Barnett MD

  • 1. TOXICOLOGY An Overview Jordan B. Barnett, M.D., FACEP Interim Director, Department of Emergency Medicine Episcopal Hospital

2. POISONING

  • Estimated 4 Million Annual
  • Pediatric
    • Child Abuse
  • Adult
    • Recreational
    • Suicide

3. HISTORY

  • What Poison?
  • How Much?
  • How?
  • When?
  • Why?
  • What Else Taken?

4. PHYSICAL EXAM

  • Vital Signs
    • ABCs
    • Temperature
  • Toxic Syndrome
  • Respiratory
  • Cardiovascular
  • Neurologic

5. TREATMENT

  • ABCs
  • Treat Other Injuries
  • Decontamination
  • Supportive Care
  • Definitive Care
    • Antidotes
    • Elimination

6. DECONTAMINATION: IPECAC

  • Absorption Reduced By 30%
  • Interferes With Further Decontamination
  • Interferes With Further Treatment
  • Home Use
  • NO EMERGENCY DEPARTMENT USE!

7. DECONTAMINATION: GASTRIC LAVAGE

  • 250 - 300 cc Aliquots Of Fluid
  • 36 - 40F Tube
  • Advantages
    • Immediate Recovery Of Gastric Contents
    • Direct access For Charcoal Instillation
  • Left Lateral Decubitus With Trendelenburg
  • Intubation May Be Needed

8. DECONTAMINATION: GASTRIC LAVAGE

  • Disadvantages
    • Not Complete Gastric Emptying
    • 30% Recovery At 1 Hour
    • Labor Intensive
    • Complications
      • 3% Overall
      • Esophageal Rupture
      • Aspiration
      • Hypoxia

9. DECONTAMINATION: CHARCOAL

  • Not Absorbed From GI Tract
  • Binds Most Substances
  • Prevents Absorption
  • Enhance Excretion
    • Multiple Dose
    • Enterohepatic Circulation

10. DECONTAMINATION: CHARCOAL

  • Charcoal
  • Emesis
  • Lavage
  • 57%
  • 38%
  • 32%

Ampicillin Model Decreased Absorption 11. ACTIVATED CHARCOAL

  • Dose 1g/kg
  • Repeat Dose
  • Disadvantages
    • Messy
    • Aspiration

12. SUBSTANCES NOT BOUND BY CHARCOAL

  • Alcohols And Glycols
  • Corrosives
    • Alkalis
    • Acids
  • Cyanide
  • Saline Cathartics
  • Heavy Metals
    • Iron
    • Lead
    • Lithium
    • Mercury
  • Hydrocarbons

13. CATHARTICS

  • Mechanism
  • Types
  • Mixture With Charcoal
  • Disadvantages
  • Use In Children

14. OTHER MODALITIES

  • Whole Bowel Irrigation
    • Indications
    • Technique
  • Skin
  • Eye

15. RESPIRATORY COMPLICATIONS

  • Airway Protection
  • Ventilatory Insufficiency
  • Bronchospasm
  • Noncardiogenic Pulmonary Edema
  • Aspiration

16. CARDIOVASCULAR COMPLICATIONS

  • Tachycardia
  • Bradycardia
  • Hypotension
  • Hypertension

17. NEUROLOGIC COMPLICATIONS

  • Coma
  • Seizures
  • Behavioral Abnormalities

18. DIAGNOSTIC STUDIES

  • Drug Screens/Levels
  • Acetaminophen
  • ABG
  • Electrolytes
  • Organ Function
  • EKG
  • X-RAY

19. SERUM OSMOLARITY

  • Serum Osmolarity= 2 (Na + ) + BUN/2.8 + Glucose/18
  • Osmolar Gap10 mOsm or less
  • Methanol, Ethylene Glycol, Ethanol
  • Glycerol, Mannitol
  • +ETOH/4.6

20. ETHANOL C 2 H 5 OH Molecular Weight=________ 21. DEFINITIVE CARE

  • Decontamination
  • Supportive Care
  • Antidotes
    • Oxygen/Glucose/Narcan/?Flumazenil
  • Elimination
    • Alkalinization
    • Repeated Dose Charcoal
  • Dialysis

22. DISCHARGE

  • Stable In Emergency Department
  • Psychiatric Issues

23. TOXIDROME Toxic Syndromes 24. TOXIDROMES:CASE 1 25 Year Old PA Student Just Back From Spring Break In Mexico.He's Been Having Terrible Diarrhea Since Returning and Has Been Using Pills to Alleviate the Symptoms. 25. TOXIDROMES:CASE 1

  • Dry Skin And Mucous Membranes
  • Thirst
  • Blurred Vision
  • Fixed Dilated Pupils
  • Flushing
  • Urinary Urgency And Retention
  • Hallucinations

26. TOXIDROMES:CASE 1

  • Anticholinergic
    • Hot As Hades
    • Blind As A Bat
    • Dry As A Bone
    • Red As A Beet
    • Mad As A Hatter

27. TOXIDROMES:CASE 1

  • Belladonna Alkaloids
    • Atropine/Scopolamine
    • Scopolamine
  • Synthetic Anticholinergics
    • Dicyclomine
  • Other
    • Antihistamines/Phenothiazines/TCA

28. TOXIDROMES:CASE 2 A 50 Year Old Farmer Is Found Unresponsive at His Barn. 29. TOXIDROMES:CASE 2

  • Sweating
  • Constricted Pupils
  • Lacrimation
  • Excessive Salivation
  • Wheezing
  • Vomiting/Diarrhea
  • Fasiculations

30. TOXIDROMES:CASE 2

  • Acetylcholinesterase Inhibitors
  • Pesticides
    • Organophosphate
    • Carbamates
  • Mechanism
  • Treatment
    • Atropine
    • Pralidoxime (2-PAM)

31. TOXIDROMES:CASE 3 An 8 Year Old Child Is Brought to the Emergency Department After Being Given a Compazine Suppository for Vomiting. 32. TOXIDROMES:CASE 3

  • Dysphonia
  • Oculogyric Crises
  • Rigidity
  • Torticollis/Opisthotonos

33. TOXIDROMES:CASE 3

  • Extrapyramidal Effects
  • Medications
    • Antipsychotic
    • Antiemetic
  • Treatment

34. TOXIDROMES:CASE 4 During a Visit to Grandma in the Nursing Home, You Find That You Can Not Wake Her Up. 35. TOXIDROMES:CASE 4

  • CNS Depression
  • Pinpoint Pupils
  • Slowed Respirations
  • Hypotension

36. TOXIDROMES:CASE 4

  • Narcotic
  • Medications
    • Prescribed
    • Illicit
  • Treatment

37. TOXIDROMES:CASE 5 A Movie Star Presents to Your Hospital. 38. TOXIDROMES:CASE 5

  • CNS Excitation
  • Seizures
  • Hypertension
  • Tachycardia

39. TOXIDROMES:CASE 5

  • Sympathomimetic
  • Medication
    • Prescribed
    • Illicit
  • Treatment

40. TOXIDROMES:CASE 6 A Family of 6 Presents to Your Office in the Middle of Winter and All Complain of the Flu. 41. TOXIDROMES:CASE 6

  • Headache
  • Flu Symptoms
  • Nausea, Vomiting, Dizziness
  • Dyspnea
  • Seizures
  • Death
  • Cyanosis
  • Chocolate Blood

42. TOXIDROMES:CASE 6

  • Hemoglobinopathies
  • Carbon Monoxide
  • Methemoglobin
  • Treatment

43. TRICYCLIC ANTIDEPRESSANTS

  • Mortality 2 - 5 Percent
  • Low Therapeutic/Toxic Ratio
  • Mechanism