Impossible to cover all tox emergencies in 90 minutes! Review
pharmacology, assessment & management Major players of illicit
& prescribed medications commonly causing toxicity
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Who: Group vs individual What: What & how much? Where: Is
the scene safe? Why: SI vs accidental How: Route of exposure
Ingestion, Inhalation, Absorbtion Social History Drugs, Alcohol,
Smoking Allergies Medications Prescribed & Illicit PMH ODs, SI,
HI, medical Hx Last Oral Intake Events W W W W W H
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Vitals are Vital Physical exam clues help with identifying
toxin In most cases, its not immediately important what toxin is,
rather treating effects of the exposure Always assume patient is
lying
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Focus on supportive therapy rather than toxin identification as
it is often complicated by a poor or creative historian 1. IV / O2
/ Monitor 2. Airway management 3. Altered mental status (AMS)
protocol including glucose check 4. Symptomatic management of
nausea, vomiting, seizures 5. Early & effective decontamination
For all toxins above steps are part of the general management
Alcohols Anticholinergics Cholinergics Heavy Metals Beta
Blockers CO Antidepressants Lithium Opiods PCP Antipsychotic
Salicylates Sedative-Hypnotics
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Based upon neurotransmitter stimulated or receptor triggered by
a chemical reaction Symptoms result from having too much or too
little of a neurotransmitter or chemical Most symptoms secondary to
nervous system effects
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Acetylcholine Dopamine Serotonin Norepinephrine
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Primary neurotransmitter in brain reward pathways Dopaminergic
drugs produce euphoria Over time neurons require more & more
dopamine stimulation to produce euphoria, or tolerance
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Dopamine stimulant fools neurons into releasing dopamine to
send a pleasure message Also stimulates serotonin &
norepinephrine Highly addictive, causing intense pleasurable rush
followed by a euphoric high lasting for 12+ hours User experiences
severe depression as euphoria dissipates Powder or clear chunky
crystal from an odorless, bitter-tasting, crystalline powder that
is ingested, snorted, injected or inhaled
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#2 illicit drug worldwide, #1 illicit drug in US 20%-30% labs
discovered after a fire or explosion Police & EMS most often
injured during explosions Previously prescribed to treat obesity,
sexual dysfunction, narcolepsy & ADHD Asian factories supply
workers with meth to maintain productivity in tedious &
repetitive tasks
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Children at >25% of labs Sustain physical, developmental
& psychological hazards 3x greater likelihood of physical &
/ or sexual abuse Likely to imitate parents' behaviors Hazard
Exposure: Weapons / Explosives Rodent & insect infestation
Rotten food & garbage Inoperative heater, air conditioner,
toilets & running water Drug paraphernalia Dangerous animals
You are a mandatory reporter, required to file a 51A
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ACh is an excitability, arousal & reward neurotransmitter
with effects on learning & memory Cholinergics produce mimic,
or release acetylcholine Think Organophosphate Insecticides
Bethanacol Edrophonium Physostigmine Pilocarpine Nicotine
Toxicologic hallmark is DUMBELS / SLUDGE
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Defecation / Diarrhea Urination Miosis Bronchorrhea/
Bradycardia Emesis / GI Distress Lacrimation Salivation Prehospital
Management: Airway Management Seizure Management Gastric
decontamination Atropine & Pralidoxime (2-PAM) - Mark I
Kit
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Substances that block or decrease ACh Antihistamines
Antipsychotics / Antidepressants Belladonna / Mushrooms Muscle
Relaxants & Antispasmodics Mydriatics Atropine Classified
according to receptors affected: Antimuscarinics &
Antinicotinics Considered least "fun" recreational drug Lack of
euphoria Low risk of dependence
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Hot as a Hare Fever Dry as a Bone Dry Skin / Xerostomia / Ileus
/ Urinary Retention Red as a Beet Flushed skin Mad as a Hatter
Psychosis / Hallucinations / Delirium / Agitation / Amnesia Other
Tachycardia Increased Intraocular Pressure / Mydriasis / Diplopia
Ataxia / Choreoathetosis / Seizures / Coma Respiratory
depression
GABA stimulating Widespread legal & illicit use Anxiety,
depression, pain Date rape drug Toxicity worsened if used with
alcohol or other sedatives SSX: AMS, amnesia, hallucinations
Dizziness, ataxia, weakness, slurred speech Drowsiness, paradoxical
agitation Blurred vision, nystagmus Respiratory depression
Hypotension Coma / Death Management Charcoal w/ little prehospital
utility & contraindicated if somnolent AMS Protocol &
aggressive airway support Hypotension rare Search for another cause
Never use benzodiazepine antagonist flumazenil
Disassociative amnestic / anesthetic structurally resembling
PCP CNS depressant, rapid-acting general anesthetic, sedative-
hypnotic, analgesic & hallucinogenic Symptoms Impaired motor
function Pulmonary edema Delirium, hallucinations, out of body
experiences, vivid Dreams Seizures, dystonia Vomiting Arrhythmias,
cardiac arrest Coma Treatment: Benadryl for dystonia
Benzodiazepines for sedation
GABAenergic anesthetic / sedative often used as a body-
building aid Clear liquid, white powder, tablet or capsule often
carried in a water bottle or eye dropper Used in combination with
alcohol to increase effect
Benzodiazepine, sedative-hypnotic, respiratory depressant,
amnestic Date rape drug often placed in alcoholic drinks for
ingestion Odorless, tasteless, dissolves easily Clonazepam often
used as a roofie alternative SSX: Sedation, amnesia, suggestiveness
Treatment: Supportive Often will not seek care until effects of
drug wear off Suspected ingestions treated as criminal cases
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Stress hormone & catecholamine synthesized from dopamine
Fight-or-flight response increases HR, triggering release of
glucose & increasing blood flow to muscle Increasing BP
triggers compensatory baroreceptor reflex resulting in paradoxical
bradycardia Typical Sympathomimetics Cocaine MDMA (Ecstasy)
Phencyclidine (PCP) Amphetamine / Methamphetamine Ephedrine / 2
-agonists Caffeine Nicotine Dextromethorphan (DMX)
Feel Good Drug suppresses need to eat, sleep or drink
Similarities to hallucinogens & amphetamines Ingested, inhaled,
injected Often mixed with PCP Blocks reuptake & release of
serotonin & dopamine Effects within 15 mins include euphoric
& energy rush followed by a 2-3 hour plateau then fatigue
Cough suppression via opiate agonist activity Effects related
to ketamine, PCP, opiates OTC Robitussin Maximum Strength (not DM)
cough syrup Disassociative anesthetic with a 2-4 hr duration
Effects at low dosage similar to alcohol Carefree clumsiness /
vertigo Vivid hallucinations (auditory, visual, tactile) AMS,
violent outbursts, seizures, coma Hyperthermia, HTN, tachycardia
Long Term ~ Olney's Lesions Brain vacuoles cause impaired memory
& schizophrenia-like syndrome
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Coricidin Cough & Cold Caps: 30 mg DXM + 4 mgs of
Chlorphineramine maleate Respiratory depression occurs at twice
recommended dose Treatment for suspected ingestion Benadryl for
dystonic reactions Be wary of acute agitation, violent outbursts
& psychotic outbursts
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Even a single tablet of a beta blocker, calcium channel
blocker, hypoglycemic agent or mood stabilizer can be fatal to a
child Although most of these medications are dose dependant, they
can have fatal effects with a single dose Many ODs are AMS + deadly
prescribed polypharmacy Dont forget OTCs & herbs.
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Prescribed for HTN, Angina, Hyperthyroid, Migraine, Glaucoma,
SVT MOI 1 Cardiac & 2 peripheral influence Selective &
non-selective agents Toxic Dose is 2-3 x therapeutic dose May still
have symptoms at non- toxic dosages
Gastric decontamination Never give calcium due to underlying
hyperkalemia Atropine & transcutaneous Pacemaker Arrhythmia
management Digibind: Life-threatening CV toxicity K + >5.5 mEq/L
Level >10 ng/mL or ingested >10 mg
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1 million ODs annually, 400 fatalities Increases norepinephrine
& serotonin, histamine & acetylcholine Most Common
Prescribed Amitriptyline (Elavil) Clomipramine (Anafranil)
Desipramine (Norpramin) Doxepin (Sinequan) Imipramine (Tofranil)
Nortryptyline (Pamelor)
Modulates anger, temp, aggression, mood, sleep, sexuality,
appetite, metabolism & stimulates vomiting Drugs targeting
serotonin used to treat psychiatric disorders Confusing name ~
Selective Serotonin Reuptake Inhibitors increase serotonin
(serotonergic)
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Most common prescribed anti-depressants Decrease serotonin
(5HT) reuptake to increase serotonin levels SSX of OD: N/V Lethargy
/ Sedation Arrythmias AMS / Decreased LOC
18 yo student admitted to the hospital with fever of 103.5,
agitation, AMS, jerking motions Taking phenelzine (MAOI
antidepressant), heroin & THC Given meperidine / demerol in the
hospital for agitation, which increased agitation eventually
leading to physical restraints 6 hrs later at a temp of 107 she
arrested & died
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Ms. Zion seen only by an intern & 2 nd year resident with
responsibility for 40 pts in their 36 hour shift Instead of
recognizing SSX of serotonin syndrome, treated pt for drug-related
agitation & psychosis Zions father (a reporter for the NY
Times) reported his daughters death in the NY Times, Newsweek,
Washington Post & 60 Minutes In 1989 NY adopted an 80 hr
resident work week w/ supervision guidelines All residencies adopt
guidelines by 2004
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Respiratory support Fever control Sedatives Muscle relaxants
Serotonin Syndrome: Benzodiazepines, hydration, cooling
Neuromuscular blockade Dantrolene (+/- as usually rx for
neuroleptic malignant syndrome)
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Serotoninergic stimulation Hallucinations Sweating Tachycardia
Mydriasis No true withdrawal state Effects last 4 grams / 24 hrs No
specific early symptoms or signs Treatment Gastric decontamination
N-acetylcysteine (N-AC) Liver t">
Toxic ingestion 140 uM/L >4 grams / 24 hrs No specific early
symptoms or signs Treatment Gastric decontamination
N-acetylcysteine (N-AC) Liver transplant
Most common poisoning death Vague symptoms related to exposure
/ dose: HA & flu-like symptoms Dizziness N/V Irritability,
seizures, coma Cardiovascular collapse Treatment: Remove from
affected area 100% O2 Hyberbaric O2 Treat for co-poisonings (i.e.
cyanide)
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Hydrogen cyanide ion halts cellular respiration by inhibiting
an mitochondrial cytochrome c oxidase Histotoxic hypoxia as cells
unable to use oxygen Seizures, apnea, pulmonary edema, cardiac
arrest & death in mins Lower dosages: LOC, general weakness,
giddiness, headaches, vertigo, confusion Skin color to turn pink
from cyanide-hemoglobin complexes
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Inhaled amyl nitrite, IV sodium nitrite, IV sodium thiosulfate
+/- methemoglobin Hydroxocobalamin / Cyanokit antidote kits Vitamin
B 12 binds cyanide to form harmless cyanocobalamin form of vitamin
B 12, then eliminated through urine Administration of sodium
thiosulfate improves ability of the hydroxocobalamin to detoxify
cyanide poisoning Relatively expensive, not universally available,
testing takes days
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Airway control, seizure treatment & supportive management
are key to toxicological emergencies Rely on physical examination
rather than history Often the exact toxin(s) not known for days, if
ever Poison Control (1-800-222-1222) & Medical Control are your
best resources