EMERGENCY MEDICINE

POISONING
Dr.Mohd Rusydan B Alias
Pegawai Perubatan Jabatan Perubatan HRPZII

Overview
-Question statement
-Answer slide / Discussion

Topics covered

Poisoning and drug overdoses

Mx medical emergencies

A 25 year old make presents with a history of ingestion of unknown quantity of digoxin. His
blood pressure is 105/65 mmHg,
His investigations reveal :
Serum creatinine 99mmol/L
Serum digoxin 8.5nmol/L (0.5-2nmol/L)
ECG revealed sinus rhythm and multiple premature ventricular beats.
The patient is administered charcoal and digoxin-spesific Fab fragment. After 10 minutes the
ECG monitor shows VT. The patient is dizzy and sweaty and his BP drops to 85/55mmHg.
What is the most appropriate further treatment for this patient?
A. Synchronized direct current (DC) cardioversion
B. Asynchronized DC cardioversion
C. IV procainamide
D. IV amiodaraone
E. IV lidocaine

Answer : E
In digoxin toxicity DC cardioversion is not used unless all other
measures have been exhausted because it is usually unsuccessful
and can precipitate VF. If no choice give at low energy (10-25 J).
Amiodarone and procainamide may increase digoxin levels and
should be avoided.
In digoxin toxicity the best choice for ventricular arrhythmias is
lidocaine / phenytoin.
Forced diuresis / HD does not help due to large extensive tissue
binding and large volume distribution.

Digoxin toxicity symptoms include GI upset, CNS manifestations

and also visual disturbance (xanthopsia-objects appear yellow ;
green to yellow haloes and blurring vision) + cardiac arrhythmias
(except RBBB, LBBB, hemiblocks and parasystole).
Activated Charcoal-usually within 1st hour to reduce GI
absorption of many drugs
Digoxin specific Fab fragment-indications include :
VT / VF
severe brady-arrhytmia
haemodynamically unstable
altered sensorium due to digoxin toxicity.

A 34 y.o male is admitted to the Emergency Department after having

been found by his ex-wife having drunk a unknown quantity of
paraquat together with an unknown quantity of codeine tablets. It is
though that the overdose occurred 3 hours previously. On examination
he is drowsy with a BP of 112/74,HR 76 bpm and regular.
Which one of the following is the most important step in the
management of paraquat overdose?
A.
B.
C.
D.
E.

Gastric lavage with Fullers Earth within first 6 hours

Dexamethasone IV bolus
Cyclophosphamide IV
Repeated installation of activated charcoal
High flow oxygen

Answer : A

Paraquat is herbicidal and forms oxygen radicals, thus the

over riding side effect is pulmonary toxicity.

Paraquat is principally excreted by the kidney. ATN can

occur in 1st 24 hours thereby enhancing overall toxicity.
Often oliguric renal failure develops 12 hours post
ingestion and resolves by 2nd week of ingestion.

Gastric lavage is indicated with patients who present within 6 hours

of overdose provided there is no evidence of corrosive injury.
Plasma levels of paraquat above 0.1mg/L at 24 hours are a/w poor
prognosis.
Ingestion of more than 10g is mortality 100%. (Death a/w as little
as 3g )
High volume ingestion death from multi organ failure and
cardiovascular collapse 1 week after ingestion.
Cause of death is usually progressive pulmonary fibrosis which
begins at 2nd week post ingestion.

A 32 y.o. farmer presents to the ED after becoming increasingly confused over the
last 5 hours. He had been well before going to the farm but now complained of
N&V and feeling generally weak. He had profuse diarrhea with abdominal cramps.
Examination revealed him to be diaphoretic and salivating profusely and not
orientated to T/P/P. His pupils were equal and constricted. Afebrile. HR was
54bpm, JVP not seen and BP 102/54 mm. Respiratory examination revealed
bilateral expiratory wheeze but no crepitation. Oxygen saturation was 92% on
room air. Abdomen soft and diffusely tender but no rebound/guarding. Power 4/5
all limbs with slightly reduced reflexes. Fasciculation's noted over legs.
What is the likely diagnosis?
A.
B.
C.
D.
E.

Botulism
Gullian Barre
Tetanus
Organophosphate poisoning
Paraquat poisoning

Answer : D

OPs block AchE enzyme and cause prolonged stimulation of

muscarinic and nicotinic pathways.

Nicotinic receptors location mostly muscle end plates causing

muscle fasciculation's, tremor and weakness. Death by
respiratory paralysis.

Muscarinic receptors are found in both CNS & peripheral

nervous system, in heart, lungs, upper GI tract and sweat
glands.

Effects

include :V & D, abdominal cramp, bronchospasm,

miosis, bradycardia, excessive salivation and sweating.

Severe poisoning conduction block, low BP & pulmonary oedema

with CNS effects including agitation, seizure and coma.
Tx supportive..IV atropine to counter muscaranic effects.
Pralidoxime spesific antidote that regenerate enzyme activity at all
affected sites but mostly nicotinic.
SLUDGEM (Salivation, Lacrimation, Urination, Defecation, GI
motility, Emesis, Misosis)
Measure Ache activity in RBC / plasma (usually < 50% of normal)
Gastric lavage if 1st 1 hour then charcoal. Continue lavage till odour
free. IV atropine is key in tx ;Keep at least 5-7 days.

A 21 yo man is admitted unconcious. No history is available.

Examination revealed evidence of previous self harm. He is intubated
and sent to ICU. A toxic screen is sent and reveals high serum
paracetomol levels and IV N-acetylcysteine is commenced.
Which of following is the most important determinant of liver transplant?
A.ALT
B.pH
C.Biliruin
D.AST
E.Albumin
Answer : B

PCM is converted to toxic metabolite N-acetyl-p-benzoquinonimine,

which is deactivated by conjugation by reduced glutathione.
Hepatic enzymes rise after 24 hours and peak at D3-D4. Recovery
after 4 days. Symptoms / signs of hepatic failure include RUQ pain,
jaundice, coagulopathy, confusion, somnolence and coma.
Kings College criteria for liver transplant in PCM induced acute
liver failure :
-Arterial pH < 7.3 or lactate > 3.0 after adequate fluid resuscitation
-Any of following 3 in a 24 hour period :
i) Cr > 300 umol/L
ii) PT > 100 (INR > 6.5)
iii) Grade III / IV encephalopathy

A 21 year old man is brought to the ED via ambulance after being found by his
girlfriend semi-conscious and hyper-ventilating, surrounded by a number of
empty packets of aspirins. Apparently there had been a fight that morning.
Blood tests reveal:
K 3.0 mmol/L
Salicylate 110mg/dl
Which of the following issues regarding treatment best fit with aspirin OD?
A. Pulmonary edema is not an indication for HD
B. Urine should acidified
C. Activated charcoal should be given even after 6-8 hours after OD
D. Serum salicylate of 15 mg/dL 24 hours after ingestion indicates severe OD
E. K should not be replaced
Answer : C

Treatment of salicylate poisoning involves initial dose of activated

charcoal. Some levels show good evidence of late use as levels
sometimes peak 12 hours after ingestion.
Dehydration addressed to maintain urine output at 2-3ml/kg/hour.
Low K should also be addressed. NaHCO3 should be given to
alkalinize urine but no value of forced diuresis.
Indications for HD include : coma, renal, hepatic or pulmonary
edema or severe acid-base imbalance.
A salicylate level after 6 hours of OD is of predictive value is
stratifying the severity of OD (asymptomatic to severe).

Salicylates stimulate respiratory center causing hyperpnoea,

hypocarbia thus leading to respiratory alkalosis. To compensate
kidney excretes HCO3,K and Na and maintain Cl hypokalemia
and dehydration.
Salicylates interfere with carbohydrate metabolism and lead to
accumulation of lactic acid, ketones, inorganic acid thus causing
high anion gap metabolic acidosis. Low K in mild poisoning but high
K in severe poisoning.
Glucose supplement for patient with altered consciousness as aspirin
reduces CNS glucose despite normal peripheral blood glucose.

A 28 year old patient on methadone has newly moved into the area.
He has run out of his methadone. 2 days later he admitted to the ED
after being found fitting in the street. On arrival he is hypertensive,
soiled with diarrhea and appears to have been vomiting.
Which of the following represents the best treatment for him?
A. Fluoxetine

Recommencement of methadone with specialist advice

C. Diazepam
D. Diamorphine PRN IV
E. Dihydrocodeine
B.

Answer : B

Opiate withdrawal syndromepeak on the 2nd or 3rd day

after opiate abstinence.
Characterized by fitting or muscular twitching, aches and
pains, abdominal cramps, vomiting, high BP, insomnia,
anorexia and profuse sweating.
Fluoxetine should not be used in this case, as it would
reduce for further seizures.

OPIATE OD TRIAD : COMA + PIN-POINT PUPILS + DEPRESSED

RESPIRATION
Other features include : Low HR , Low BP , Low Temperature, Fits,
Arrhythmias. ARF, APO.
Diagnosis based on clinical scenario + rapid response to naloxone.
Urine qualitative to confirm recent use.
Tx:
Secure airway
Treat coma, fits, low BP and non-cardiogenic PO.
Activated charcoal or gastric lavage useful up to 12 hours.
IV naloxone 0.4mg to 2mg repeated at 3-5 minutes until RR > 15/min.

A 52 y/o woman is brought in unconscious by ambulance. On

admission she has a GCS of 6. Her airway appears to be compromised.
Her sister follows by car and claims that she had taken a large overdose
of lorazepam tablets. She had also taken a few tablets amitriptyline.
ABG suggest respiratory depression with both raised CO2 and reduced
O2 levels.
What is the most appropriate management step?
A. Observation

in ICU
B. Consideration for intubation
C. Repeated dose of IV flumazenil
D. Repeated dose of IV naloxone
E. Continuous flumazenil infusion
Answer : B

Flumazenil is a benzodiazepine receptor antagonist and

can reverse CNS and respiratory depression and obviate
need for intubation.
However this is a case of mixed OD. Patient had taken an
OD of TCA tablets also and giving flumazenil might
cause fits.

As patient unable to protect airway KIV for intubation.

Benzodiazepines enhance the effect of the neurotransmitter GABA at

the GABA receptor.
Short- and intermediate-acting benzodiazepines are preferred for the
treatment of insomnia.
Longer-acting benzodiazepines are recommended for the treatment of
anxiety.
Examples of :
Ultra short acting benzo midazolam
Short acting benzo-alprazolam / lorazepam
Long acting : diazepam / clonazepam
Clinical features more CNS weakness, hyporeflex, ataxia, dysartrhia,
nystagmus, drowsy, coma.

A 26 year old patient admitted drowsy and confused. History revealed

a history of depression and multiple suicide attempts. She was found
with an empty bottle of phenobarbitol. Examination revealed slurred
speech, ataxia and nystagmus.
Which therapy will best aid elimination of the toxin?
A. Sodium

bicarbonate
B. Ammonium chloride
C. Gelofusin
D. Dicobalt adetate
E. Mannitol
Answer : A

Barbiturates still used for anesthesia and anti-epileptics.

Hepatic enzyme inducers.
OD leads to respiratory depression, impaired coordination and coma
(more CNS depression).
Others : low temp , low BP , Low RR,non-cardiogenic PO,cardiac arrest,
barbiturate blisters
Acidic in nature and elimination via kidney with forced alkaline diuresis with
sodium bicarbonate. Other options : charcoal and HD (long acting
barbiturates)
Short acting : pentobarbital / thiopental
Long acting : phenobarbital
(short acting toxicity with lower doses but fatality more with long acting agents)

A 25 year old man presented in a agitated state. The ED MO after consult with
the psychiatry on-call prescribed chlorpromazine and arranged an out-patients
clinic review.
He now presented again with a temperature of 38.6 degrees, muscle rigidity,
tachycardia and hypertension. Blood testing revealed a CK of 345 and ALT of
115.
Which of the following is the most appropriate treatment for this man?
A.
B.
C.
D.
E.

Diazepam
Methadone
Bromocriptine
Paroxetine
Fluoxetine

Answer :C

Neuroleptic malignant syndrome occurs in 0.2% of patients taking

dopamine D2-receptor antagonist drugs, particular the more potent
ones such as haloperidol and chlorpromazine.
Symptoms include hyperthermia, muscle rigidity, autonomic
instability and fluctuating level of consciousness.
Abnormal investigations include raised CK,TWC and abnormal
liver biochemistry.
Bromocriptine(dopamine agonist) is the treatment of choice.

Otherwise phenothiazines used for psychosis and agitation.

Features of OD include : Convulsion, reduced consciousness, Low BP, Low temp.
Low RR, constricted pupils,Torsades.
Extrapyramidal reactions : Tremor, rigidity, bradykinesia, oculogyric crisis
& dystonia.
Anti-cholinergic effects : Dry mouth, absence sweating, high HR and urine
retention.
Protect airway-lavage(can give after few hours also)-cardiac monitoring-acute
dystonia (procyclidine)-look out for hypotension & fits (tx with diazepam and
phenytoin)
HD not useful as very lipid soluble and high volume distribution.

THANK YOU