Identifying Poisoning

Is This Patient Poisoned, And If So, With What?

The Dose Makes The Poison

What is there that is not poison? All things are poison and nothing [is] without poison. Solely the dose determines that a thing is not a poison

Philip Theophrastus Bombast von Hohenheim aka PARACELSUS (1493-1541)

Goal of Clinical Management

To proceed from undifferentiated signs and symptoms in a patient [without a dependable history] to a reasonable diagnosis ....... in order to initiate appropriate therapy. Rapid Organized Efficient Safe Effective

Is This Patient Poisoned

A 37 year old female with a history of a

seizure disorder presents with:

Fever (38.5oC) A rash (shown)

Only medication, phenytoin 300 mg/day for

years No occupational exposures No significant hobbies

Is This Patient Poisoned

Laboratories 21% Eosinophils An AST of 300 IU/L
Diagnosis: Anticonvulsant hypersensitivity syndrome

The History
The toxin Medications, Hobbies, Occupation The form and route Amount Elapsed time
Symptoms Current or resolved symptoms Timing of symptom onset Prior therapy administered

Is This Person Poisoned

A 28 year old female is brought to the

hospital because of lethargy No past medical or surgical history No medications No hobbies Full time student

 Vital signs normal

Slight nystagmus Slight lethargy easily arousable

Dull expression
Flat affect Not bothered by her condition

Slightly unsteady gait

 Basic laboratory studies normal

ECG normal CT scan normal

Lumbar puncture normal

Urine positive for benzodiazepines Flumazenil given Mental status normal Police investigation results

How Are Poisoned Patients Different

Suicide note
Empty bottles Occupational or environmental cluster

Psychiatric history
Substance abuse / misuse Inconsistencies Cardiac findings in young people Vital signs not consistent with mental status

Toxidrome = Toxicologic Syndrome

Toxidrome recognition allows rapid clinical diagnosis

and targeted therapy.

Patient history Vital signs Targeted physical examination Rapid, bedside laboratory testing Metabolic Glucose Acid-base

ECG

Toxicologic Physical Examination

Vital signs

temperature and pulse oximetry Key organ system Mental status Pupils Skin Bowels Bladder

Including

Toxidrome
History Symptoms & Signs

Vital signs

Simple labs

We Do This Will All Patients

Headache
Fever Altered mental status

Rash
= Meningococcal meningitis

Opioids
CNS depression Miosis Respiratory

depression Gastrointestinal Stasis Relative bradycardia Relative hypothermia

Sympathomimetic
Hypertension,

tachycardia, hyperthermia, tachypnea Mydriasis Diaphoresis Psychomotor agitation

Anticholinergic Antimuscarinic
Hypertension,

tachycardia, hyperthermia, tachypnea Mydriasis Psychomotor agitation or somnolence Dry flushed skin Absent bowel sounds Urinary retention

Remember
Hot as a Hare: warm skin
Dry as a bone: dry skin and mouth Blind as a Bat: cycloplegia,

mydriasis Red as a Pepper: flushed skin Full as a flask: urinary retention Mad as a Hatter: altered mental status, hallucinations

Differentiation
Anticholinergic vs Sympathomimetic
Pupils? Skin

Bowels
Bladder

Cholinergic
Muscarinic Salivation Lacrimation Urination Defecation Bronchorrhea Bradycardia Miosis Nicotinic Muscle weakness Fasciculations Paralysis Hypertension Tachycardia Mydriasis

Salicylates
Nausea and vomiting Tinnitus Tachypnea and hyperpnea, rarely

hyperthermia Diaphoresis Respiratory alkalosis Metabolic acidosis Ketonuria

Tricyclic Antidepressant
Somnolence,

lethargy, or coma Tachycardia and hypotension Seizures Abnormal ECG Anticholinergic findings

Hypoglycemia
Tachycardia Diaphoresis Tremor Altered mental status
Decerebrate

posturing Decorticate posturing Fixed and dilated pupils

Incidence of Hypoglycemia
True incidence probably unknown
In 12 months 125 patients were diagnosed at

the Harlem Hospital ED

Malouf and Brust: Ann Neurol 1985;17:421-430

29/340 (8.5%) consecutive EMS runs for

AMS, were identified with hypoglycemia

Hoffman: Ann Emerg Med 1992;21:20-24.

Hypoglycemia
Using the classic findings hypoglycemia
Altered

mental status Tachycardia Diaphoresis And/or a history of diabetes

to predict a response to D50W, 25% of

hypoglycemic patients would be missed

Hoffman: Ann Emerg Med 1992;21:20-24

Hypoglycemia With A Normal Glucose

Poorly controlled diabetics had

symptoms at glucose levels significantly higher than well controlled diabetics: 4.3 vs 2.9 mmol/L

Boyle: N Engl J Med 1988;318:1487-1492

Tackling Toxidromes
Good history Directed physical examination
Vital

signs, pupils, skin, bowel bladder glucose, ECG, ABG, UA, etc

Simple tests
Rapid

Simple interventions

Think about
Ethanol
Paracetamol (acetaminophen) About 1 out of 500 suicidal patients has an unexpected, treatable level
Ashbourne J. Ann Emerg Med 1989;18:1035

Assessment of other potential

exposures Assessment of pregnancy

Provide Life-Saving Care

Treat the Patient Before the Poison:
Airway Breathing

Circulation

Rare immediate Antidotes

Cyanide

kit

Poisoning Includes Deficiencies

Withdrawal syndromes Alcohol Sedatives Opioids Etc
Metabolic Thiamine (Wernickes encephalopathy)