Toxicology Intro
88
TO ICOLOGY INTRODUCTION TO A FRAMEWORK FOR EVIDENCE-BASED PRACTICE than J. Cleveland, MD, University Medical Center, Emergency Medicine Physicians, Decemb 2011
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Nathan Cleveland, MD, MS
Transcript of Toxicology Intro
TO ICOLOGYINTRODUCTION TO
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
Nathan J. Cleveland, MD, University Medical Center, Emergency Medicine Physicians, December 2011
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
DISCLAIMER
TRIVIA
GOALS
TOX MASTERJACK OF ALL TRADES
TITLE
E.B.M.
WHAT NOT TO DO
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
TRIVIA
DISCLAIMER
TRIVIA
GOALS
TOX MASTERJACK OF ALL
TRADES
TITLE
WHAT NOT TO DO
E.B.M.1. INTUBATION 2.
RESUSCITATION
3. COORDINATION 4. TOXICOLOGY
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
DISCLAIMER
TRIVIA
GOALS
TOX MASTERJACK OF ALL
TRADES
TITLE
4. TOXICOLOGY
TRIVIA
WHAT NOT TO DO
E.B.M.
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
EPIDEMIOLOGY
DISCLAIMER
TRIVIA
GOALS
TOX MASTERJACK OF ALL TRADES
GOALS
• ‘Whirlwind’ overview
• Principles for evidence-based diagnosis/management
• Few specifics
TRIVIA
WHAT NOT TO DO
E.B.M.
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
GOALS
TOX MASTERJACK OF ALL TRADES
GOALS
• New PPT style – feedback please!
EPIDEMIOLOGY
DISCLAIMER
TRIVIA
TRIVIA
WHAT NOT TO DO
E.B.M.
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
PRICIPLE #1
TRIVIA
GOALS
TRIVIA
• 6 Questions
• Famous Poisonings
• Beer
TOX MASTER
EPIDEMIOLOGY
DISCLAIMER
TRIVIA
WHAT NOT TO DO
E.B.M.
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
TRIVIA
PRINCIPLE #1
DISCLAIMER
TRIVIA
DISCLAIMERS
• I’m not a toxicologist
• This is an overview
• No eminence-based medicine!
GOALS
EPIDEMIOLOGY
TRIVIA
WHAT NOT TO DO
E.B.M.
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
EVALUATION
TRIVIA
PRINCIPLE #1
E.B.M.
DISCLAIMER
TRIVIA
EPIDEMIOLOGY
TRIVIA
WHAT NOT TO DO
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
HISTORY
EVALUATION
TRIVIA
PRINCIPLE #1
EPIDEMIOLOGY
TRIVIA
E.B.M.
WHAT NOT TO DO
DISCLAIMER
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
HISTORY
EVALUATION
TRIVIA
PRINCIPLE #1
EPIDEMIOLOGY
TRIVIA
E.B.M.
WHAT NOT TO DO
DISCLAIMER
P.A.C.E.D.F.A.S.T.C.O.O.L.S.N.A.S.A.C.R.A.S.H.E.D.C.T.S.C.A.N.S.L.O.W.P.A.N.T.O.T.I.S.C.A.M.P.B.E.L.
L.A.E.I.O.U.T.I.P.S.C.O.P.S.A.A.A.S.S.O.A.P.C.O.I.N.S.A.B.C.D.E.C.H.A.R.C.O.A.L.I.S.T.U.M.B.L.E.
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
PHYSICAL
HISTORY
EVALUATION
TRIVIA
PRINCIPLE #1
EPIDEMIOLOGY
TRIVIAWHAT NOT
TO DO
E.B.M.
THE DEATH OF SOCRATES 1787 – JACQUES-LOUIS DAVID
Name this poison
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
PHYSICAL
HISTORY
EVALUATION
TRIVIA
PRINCIPLE #1
EPIDEMIOLOGY
TRIVIAWHAT NOT
TO DO
DISCLAIMER
HEMLOCK• Cicutoxin• GABA-receptor antagonist• CNS stimulation, seizures,
death
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
PRINCIPLE #2
PHYSICAL
HISTORY
EVALUATION
TRIVIA
PRINCIPLE #1
EPIDEMIOLOGY
TRIVIA
POISON IN THE U.S.
WHAT NOT TO DO
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
PHYSICAL
HISTORY
EVALUATION
TRIVIA
EPIDEMIOLOGY
TRIVIA
POISON IN THE U.S.
• 2,384,825 encounters in NPDS
• 1,730 Deaths (pharma)• Deaths rising since 1985
1985 1997 2010
Deaths 328 786 1730
% Suicide 53 53 45
% Peds 6.1 3.2 3.2WHAT NOT TO DO
PRINCIPLE #1
PRINCIPLE #2
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
EPIDEMIOLOGY
TRIVIAWHAT NOT
TO DO
PHYSICAL
HISTORY
EVALUATION
TRIVIA
PRINCIPLE #1
PRINCIPLE #2
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
EPIDEMIOLOGY
TRIVIAWHAT NOT
TO DO
PHYSICAL
HISTORY
EVALUATION
TRIVIA
PRINCIPLE #1
PRINCIPLE #2
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
EPIDEMIOLOGY
TRIVIAWHAT NOT
TO DO
PHYSICAL
HISTORY
EVALUATION
TRIVIA
PRINCIPLE #1
PRINCIPLE #2
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
EPIDEMIOLOGY
TRIVIAWHAT NOT
TO DO
POISON IN THE U.S.
• Interesting facts:• 87% are ingestional• 20% are intentional• Intentional is more deadly• 50% are peds• 50% (at least) are mixed
PHYSICAL
HISTORY
EVALUATION
TRIVIA
PRINCIPLE #1
PRINCIPLE #2
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
TRIVIA
PRINCIPLE #1
EPIDEMIOLOGY
PRINCIPLE:
• Poisoning is common
• Poisoning is (rarely) deadly
TRIVIA
PHYSICAL
HISTORY
EVALUATION
TRIVIA
PRINCIPLE #2
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
WORK-UP
TRIVIA
PRINCIPLE #1
EPIDEMIOLOGY
Georgi Markov
PHYSICAL
HISTORY
EVALUATION
PRINCIPLE #2
TRIVIA
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
TRIVIA
RICIN• Inhibits protein synthesis• LD50 = 22mcg/kg!!• Organ failure, death over days
EPIDEMIOLOGY
PRINCIPLE #1
WORK-UP
PHYSICAL
HISTORY
EVALUATION
PRINCIPLE #2
TRIVIA
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
WORK-UP: EKG
EVALUATION
TRIVIA
EVALUATING THE POISONED
PATIENT
PRINCIPLE #1
WORK-UP
PHYSICAL
HISTORY
PRINCIPLE #2
TRIVIA
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
WORK-UP: EKG
EVALUATION
TRIVIA
PRINCIPLE #1
WORK-UP
PHYSICAL
HISTORY
PRINCIPLE #2
TRIVIA
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
COMMON DEADLY
SILENTWORK-UP: EKG
EVALUATION
TRIVIA
PRINCIPLE #1
WORK-UP
PHYSICAL
HISTORY
PRINCIPLE #2
TRIVIA
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
WORK-UP
HISTORY
EVALUATION
HISTORY
Is everything…
• Available meds/drugs• Missing meds/drugs• Time course• Intention
TRIVIA
WORK-UP: EKG
WORK-UP
PHYSICAL
PRINCIPLE #2
TRIVIA
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
HISTORY
…and nothing.
• Unobtainable• Unreliable• Misleading
WORK-UP
HISTORY
EVALUATION
TRIVIA
WORK-UP: EKG
WORK-UP
PHYSICAL
PRINCIPLE #2
TRIVIA
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
PHYSICAL
HISTORY
EVALUATION
PHYSICAL EXAM
Rule #2: Vitals are vital!!WORK-UP
WORK-UP: EKG
WORK-UP
PRINCIPLE #2
TRIVIA
WORK-UP: UDS
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
PHYSICAL EXAM
• Pupils – large/pinpoint/sluggish• Skin – dry/diaphoretic/piloerection• Reflexes – decreased/brisk/clonus• Tone – flaccid/fasciculations• Speech – slurred/pressuredPHYSICAL
HISTORY
EVALUATION
WORK-UP
WORK-UP: EKG
WORK-UP
PRINCIPLE #2
TRIVIA
WORK-UP: UDS
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
PHYSICAL EXAM
Toxidromes:• Cholinergic• Anticholinergic• Opiod• Sympathomimetic• Sedative/hypnotic• Salicylism
• Hallucinogenic• Serotonergic• Withdrawal• Neuroleptic• Etc., etc., etc…
PHYSICAL
HISTORY
EVALUATION
WORK-UP
WORK-UP: EKG
WORK-UP
PRINCIPLE #2
TRIVIA
WORK-UP: UDS
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
AGITATED /DELERIOUS /SEIZURE
SEDATED /COMATOSE /RESPIRATORY
SILENTPHYSICAL
HISTORY
EVALUATION
WORK-UP
WORK-UP: EKG
WORK-UP
PRINCIPLE #2
TRIVIA
WORK-UP: UDS
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
PRINCIPLE #2
PHYSICAL
HISTORY
PRINCIPLE:
A. We rarely know (for certain)what has been ingested
B. It will rarely matter
WORK-UP
WORK-UP: EKG
WORK-UP
TRIVIA
WORK-UP: UDS
WORK-UP: BAL
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
WORK-UP: OSM
TRIVIA
PRINCIPLE #2
PHYSICAL
Janis Joplin
WORK-UP
WORK-UP: EKG
WORK-UP
WORK-UP: UDS
WORK-UP: BAL
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
HEROIN• Derived from poppy• Diacetylmorphine• Morphine prodrug
WORK-UP: OSM
TRIVIA
PRINCIPLE #2
PHYSICAL
WORK-UP
WORK-UP: EKG
WORK-UP
WORK-UP: UDS
WORK-UP: BAL
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
WORK-UP: ASA
WORK-UP
TRIVIA
PRINCIPLE #2
Essential components:• Glucose• BMP• APAP• EKG
TOX TESTING
WORK-UP: OSM
WORK-UP
WORK-UP: EKG
WORK-UP: UDS
WORK-UP: BAL
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
PRINCIPLE #3
TOX EKG
WORK-UP: ASA
WORK-UP
TRIVIA
WORK-UP: OSM
WORK-UP
WORK-UP: EKG
WORK-UP: UDS
WORK-UP: BAL
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
DRUG LEVELS • Urine drug screen? • Serum ethanol? • Osmolality? • Salicylate?
TOX TESTING
PRINCIPLE #3
WORK-UP: ASA
WORK-UP
WORK-UP: OSM
WORK-UP
WORK-UP: EKG
WORK-UP: UDS
WORK-UP: BAL
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
PRINCIPLE #4 • Urine drug screen?
TOX TESTING
DRUG LEVELS
PRINCIPLE #3
WORK-UP: ASA
WORK-UP: OSM
WORK-UP
WORK-UP: EKG
WORK-UP: UDS
WORK-UP: BAL
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
• Urine drug screen?
TOX TESTINGPRINCIPLE #4
DRUG LEVELS
PRINCIPLE #3
WORK-UP: ASA
WORK-UP: OSM
WORK-UP
WORK-UP: EKG
WORK-UP: UDS
WORK-UP: BAL
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
• Can only tell you what it is designed to tell you…
…the SOCIAL HISTORY!!!
UDSPRINCIPLE #4
DRUG LEVELS
PRINCIPLE #3
WORK-UP: ASA
WORK-UP: OSM
WORK-UP
WORK-UP: EKG
WORK-UP: UDS
WORK-UP: BAL
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
• Urine drug screen? No
TOX TESTINGPRINCIPLE #4
DRUG LEVELS
PRINCIPLE #3
WORK-UP: ASA
WORK-UP: OSM
WORK-UP
WORK-UP: EKG
WORK-UP: UDS
WORK-UP: BAL
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
• Urine drug screen? No• Serum ethanol?
TOX TESTING
PRINCIPLE #4
DRUG LEVELS
PRINCIPLE #3
WORK-UP: ASA
WORK-UP: OSM
WORK-UP
WORK-UP: UDS
WORK-UP: BAL
TRIVIA
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
SERUM ETOH
PRINCIPLE #4
DRUG LEVELS
PRINCIPLE #3
WORK-UP: ASA
WORK-UP: OSM
WORK-UP
WORK-UP: UDS
WORK-UP: BAL
TRIVIA
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
SERUM ETOH• We should be able to
recognize “straight up” EtOH
• Cannot tell you if current AMS is due to alcohol.
PRINCIPLE #4
DRUG LEVELS
PRINCIPLE #3
WORK-UP: ASA
WORK-UP: OSM
WORK-UP
WORK-UP: UDS
WORK-UP: BAL
TRIVIA
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
• Urine drug screen? No• Serum ethanol? Maybe
TOX TESTING
PRINCIPLE #4
DRUG LEVELS
PRINCIPLE #3
WORK-UP: ASA
WORK-UP: OSM
WORK-UP
WORK-UP: UDS
WORK-UP: BAL
TRIVIA
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
• Urine drug screen? No• Serum ethanol? Maybe• Osmolality?
TOX TESTING
PRINCIPLE #4
DRUG LEVELS
PRINCIPLE #3
WORK-UP: ASA
WORK-UP: OSM
WORK-UP: UDS
WORK-UP: BAL
TRIVIA
MANAGEMENT
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
• Osmotically active small ions
2[Na+]+gluc/18+BUN/2.8+EtOH/4.6
Normal < 10 mOsm/kg
OSMOLALITY
PRINCIPLE #4
DRUG LEVELS
PRINCIPLE #3
WORK-UP: ASA
WORK-UP: OSM
WORK-UP: UDS
WORK-UP: BAL
TRIVIA
MANAGEMENT
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
OSMOLALITY
• Severe unexplained acidosis
• MetOH and EG unavailable
PRINCIPLE #4
DRUG LEVELS
PRINCIPLE #3
WORK-UP: ASA
WORK-UP: OSM
WORK-UP: UDS
WORK-UP: BAL
TRIVIA
MANAGEMENT
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
• Urine drug screen? No• Serum ethanol? Maybe• Osmolality? No
TOX TESTING
PRINCIPLE #4
DRUG LEVELS
PRINCIPLE #3
WORK-UP: ASA
WORK-UP: OSM
WORK-UP: UDS
WORK-UP: BAL
TRIVIA
MANAGEMENT
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
• Urine drug screen? No• Serum ethanol? Maybe• Osmolality? No• Salicylate?
TOX TESTINGABCs
PRINCIPLE #4
DRUG LEVELS
PRINCIPLE #3
WORK-UP: ASA
WORK-UP: OSM
WORK-UP: BAL
TRIVIA
MANAGEMENT
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
ABCs
SALICYLATE• Common• Deadly• Silent?PRINCIPLE #4
DRUG LEVELS
PRINCIPLE #3
WORK-UP: ASA
WORK-UP: OSM
WORK-UP: BAL
TRIVIA
MANAGEMENT
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
ABCs
SALICYLATE• Common• Deadly• Silent?• Resp alkalosis easy to miss• Acidosis could be anything• No tinnitus in acute ingestion• Test readily available
PRINCIPLE #4
DRUG LEVELS
PRINCIPLE #3
WORK-UP: ASA
WORK-UP: OSM
WORK-UP: BAL
TRIVIA
MANAGEMENT
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
• Urine drug screen? No• Serum ethanol? Maybe• Osmolarity? No• Salicylate? Yes
TOX TESTINGABCs
PRINCIPLE #4
DRUG LEVELS
PRINCIPLE #3
WORK-UP: ASA
WORK-UP: OSM
WORK-UP: BAL
TRIVIA
MANAGEMENT
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
PRINCIPLE:
A. A test can only tell you what it can tell you.
B. Resist the false reassurance of a test result.
ABCs
PRINCIPLE #4
DRUG LEVELS
PRINCIPLE #3WORK-UP: ASA
WORK-UP: OSM
TRIVIA
MANAGEMENT
PRINCIPLE #5
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
• APAP, ASA, Dilantin, Depakote, Li++, Dig, etc.
• Serum concentration
DRUG LEVELS
ABCs
PRINCIPLE #4
DRUG LEVELS
PRINCIPLE #3
WORK-UP: ASA
TRIVIA
MANAGEMENT
PRINCIPLE #5
ABSORPTION
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
PRINCIPLE:
• Drug level has different implications depending on chronic vs acute ingestion.ABCs
PRINCIPLE #4
DRUG LEVELS
PRINCIPLE #3
TRIVIA
MANAGEMENT
PRINCIPLE #5
ABSORPTION
CHARCOAL
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
Jonestown, Guyana 1978
ABCs
PRINCIPLE #4
DRUG LEVELS
TRIVIA
MANAGEMENT
PRINCIPLE #5
ABSORPTION
CHARCOAL
PRINCIPLE #6
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
• Valium• Chloralhydrate• Phenergan• Cyanide
ABCs
PRINCIPLE #4
DRUG LEVELS
TRIVIA
MANAGEMENT
PRINCIPLE #5
ABSORPTION
CHARCOAL
PRINCIPLE #6
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
MANAGING THE POISONED
PATIENTABCs
PRINCIPLE #4
TRIVIA
MANAGEMENT
PRINCIPLE #5
ABSORPTION
CHARCOAL
PRINCIPLE #6
ELIMINATION
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
MANAGMENT1.Supportive Care
ABCs
PRINCIPLE #4
TRIVIA
MANAGEMENT
PRINCIPLE #5
ABSORPTION
CHARCOAL
PRINCIPLE #6
ELIMINATION
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
SUPPORTIVE CARE
ABCs
TRIVIA
MANAGEMENT
PRINCIPLE #5
ABSORPTION
CHARCOAL
PRINCIPLE #6
ELIMINATION
DIALYSIS
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
TRIVIA
PRINCIPLE:• “…most poisoned patients require
only supportive therapy for recovery.”
ABCs
MANAGEMENT
PRINCIPLE #5
ABSORPTION
CHARCOAL
PRINCIPLE #6
ELIMINATION
DIALYSIS
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
MANAGMENT1.Supportive Care
2.Decrease Absorption
ANTIDOTES
TRIVIA
ABCs
PRINCIPLE #5
ABSORPTION
CHARCOAL
PRINCIPLE #6
ELIMINATION
DIALYSIS
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
ANTIDOTES
ABSORPTION
TRIVIA
ABCs
PRINCIPLE #5
ABSORPTION
CHARCOAL
PRINCIPLE #6
ELIMINATION
DIALYSIS
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
CHARCOAL• Goal – Adsorbtion• Dose = 10 : 1
50 tabs APAP =
ANTIDOTES
TRIVIA
PRINCIPLE #5
ABSORPTION
CHARCOAL
PRINCIPLE #6
ELIMINATION
DIALYSIS
PRINCIPLE #7
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
CHARCOAL• Goal – Adsorbtion• Dose = 10 : 1• Time – within 2 hours
ANTIDOTES
TRIVIA
PRINCIPLE #5
ABSORPTION
CHARCOAL
PRINCIPLE #6
ELIMINATION
DIALYSIS
PRINCIPLE #7
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
CHARCOAL• Risk – aspiration• Be extremely careful in
ingestions of sedating drugsANTIDOTES
TRIVIA
PRINCIPLE #5
ABSORPTION
CHARCOAL
PRINCIPLE #6
ELIMINATION
DIALYSIS
PRICIPLE #7
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
TRIVIA
PRINCIPLE:• Charcoal (and lavage) should be
reserved for recent ingestions of a lethal dose of a lethal substance for which there is no effective treatment.
ANTIDOTES
TRIVIA
ABSORPTION
CHARCOAL
PRINCIPLE #6
ELIMINATION
DIALYSIS
PRINCIPLE #7
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
SUMMARY
MANAGMENT1.Supportive Care
2.Decrease Absorption
3.Increase elimination
ANTIDOTES
TRIVIA
CHARCOAL
PRINCIPLE #6
ELIMINATION
DIALYSIS
PRINCIPLE #7
TRIVIA
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
ELIMINATION
1. RENAL
2. BINDERS
3. DIALYSIS
SUMMARY
ANTIDOTES
TRIVIA
CHARCOAL
PRINCIPLE #6
ELIMINATION
DIALYSIS
PRINCIPLE #7
TRIVIA
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
DIALYSIS
• Best for small, water-soluble• Inherent risks• Serial dialysis for large VD
SUMMARY
ANTIDOTES
TRIVIA
PRINCIPLE #6
ELIMINATION
DIALYSIS
PRINCIPLE #7
TRIVIA
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
Viktor Yushenko
SUMMARY
ANTIDOTES
TRIVIA
ELIMINATION
DIALYSIS
PRINCIPLE #7
TRIVIA
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
DIOXIN• Hepatotoxicity, heme metabolism• Chloracne• A compound in Agent Orange
SUMMARY
ANTIDOTES
TRIVIA
ELIMINATION
DIALYSIS
PRINCIPLE #7
TRIVIA
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
MANAGMENT1.Supportive Care
2.Decrease Absorption
3.Increase elimination
4.Antidotes
SUMMARY
ANTIDOTES
TRIVIA
DIALYSIS
PRINCIPLE #7
TRIVIA
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
ANTIDOTES1.Inhibitors
2.Antibodies
3.Reversal agentsANTIDOTE
STRIVIA
DIALYSIS
PRINCIPLE #7
TRIVIA
SUMMARY
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
FLUMAZENIL• BZD receptor antagonist
• Days of the ‘coma cocktail’ are over
ANTIDOTES
TRIVIA
DIALYSIS
PRINCIPLE #7
TRIVIA
SUMMARY
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
NARCAN• Opioid receptor antagonist
• Narcotic withdrawal not deadly
ANTIDOTES
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DIALYSIS
PRINCIPLE #7
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SUMMARY
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
TYLENOL OD• Common, deadly, silent
ANTIDOTES
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DIALYSIS
PRINCIPLE #7
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A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
TYLENOL OD
ANTIDOTES
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DIALYSIS
PRINCIPLE #7
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SUMMARY
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
NAC• Chronic (aka repeated
supratherapeutic):• Elevated LFTs OR• [APAP] > 20 mcg/mL
• Acute:ANTIDOTES
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DIALYSIS
PRINCIPLE #7
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A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
NAC
ANTIDOTES
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PRINCIPLE #7
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A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
NAC
ANTIDOTES
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DIALYSIS
PRINCIPLE #7
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A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
PRINCIPLE:A. The existence of an antidote
does not necessarily mean you should use it. They are for saving lives!
B. Know NAC, atropine, pyridoxine, bicarb, DigiBind and CyanoKit
ANTIDOTES
TRIVIA
PRINCIPLE #7
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SUMMARY
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
Tokyo Subway 1995ANTIDOTES
PRINCIPLE #7
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SUMMARY
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
SARIN• Odorless, colorless, tasteless• Organophosphate• Cholinesterase inhibitor
ANTIDOTES
PRINCIPLE #7
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A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
SUMMARY1. We should be the best at Tox2. Poisoning is common/deadly3. Tox = managing the
unknown4. A test can only tell you what
it tells you5. Toxic level depends on
ACUTE versus CHRONIC
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PRINCIPLE #7
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
SUMMARY6. Management = Support (usually)
7. Charcoal is rarely useful8. Know your emergent
antidotes, look everything else up
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SUMMARY
PRINCIPLE #7
A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TO ICOLOGYINTRODUCTION TO
THANKS!
QUESTIONS?TRIVIA
SUMMARY
PRINCIPLE #7
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