GENERAL APPROACH TO

ACUTELY POISONED
PATIENTS
AYA KHATER
SEPTEMBER, 2007
Faculty of Medicine,
Ain Shams University.
 Objectives
• To provide a systematic approach to
the resuscitation, work-up, diagnosis
and treatment of the acutely
poisoned patients.
 Outline
• Case based approach to:
– Initial stabilization
– History
– Evaluation of the poisoned patient
– Techniques to prevent absorption
– Techniques to enhance elimination
 Immediate Stabilization
• Airway with cervical spine control
– Intubate…what do you want to use?
• Breathing
– 100% O2 , ventilation
• Circulation
– Insert new IVs
– Draw bloods with IV start
– Bolus 1-2L NS
– Cardiac monitor
• Some toxicological emergencies require specific
interventions during the primary survey (eg.
cyanide)
 “Coma Cocktail”
Current – DON’T

• Dextrose
• Oxygen
• Naloxone
• Thiamine
 Dextrose
• Rationale: Hypoglycemia common cause of LOC

• D50W ( 50 -100cc IV ) or D25W 2-4cc/kg in peds

• DDx – hypoglycemia
– Tox – insulin, oral hypoglycemic, EtOH, salicylates
– Non-tox – sepsis, hyperthermia, hepatic failure,
myxedema
• Cautions – diabetic or hyperosmolar pts, cerebral
infarct
 Thiamine
• Co-factor for pyruvate dehydrogenase, and -
ketoglutarate dehydrogenase.(Vit B1)
• Decreased levels in:
– chronic liver ds, folate deficiency, malabsorption,
malnutrition, EtOH intake
• Deficiency - Wernicke’s encephalopathy
– Ophthalmoplegia,Nystagmus.
– Ataxia
– Altered mental status
• Dose: 100 mg IV
• Little evidence to support its use, but safe,
inexpensive, cost-effective
 Naloxone
• Narcan® - Pure opioid antagonist used for
reversal of acute intoxication
• Diagnostic and therapeutic
• 0.4- 2 mg (max 10mg) IV, IM, SC, ETT or
intralingual
• Cautions - Associated with life threatening
complications:
– seizures, arrhythmias, cardiac arrest and
precipitation of violence
 Vital Signs
• Hypoventilation/hyperventilation
• Bradycardia – PACED
• Tachycardia – FAST
• Hypotension – CRASH
• Hypertension – CT SCAN
• Hyperthermia – NASA
• Hypothermia – COOLS
• Seizures – OTIS CAMPBELL
 Toxicologic Physical Exam
• CNS – level of arousal, GCS, pupils,
behaviour, neurologic exam
• CVS – rate, rhythm
• Resp – pattern, depth, wheezing
• GI – bowel sounds, distention
• Skin – color, temp, signs of trauma
• Odors
 Toxidromes
• Sympathomimetic
• Cholinergic
• Anticholinergic
• Opiate
• Sedative hypnotic
• Withdrawal (EtOH, BDZ, opiates)
 Toxicological History
• Often incomplete, unreliable or
unobtainable

• Sources – Patient, friends, family, empty

dosettes or pill containers

• MHx, liver/renal disease, concurrent

medications, previous overdoses,
substance abuse
 The 5W’s of toxicology
• Who – pt’s age, weight, relation to others
• What – name and dose of medication,
coingestants and amount ingested
• When – time of ingestion, single vs.
multiple ingestions
• Where – route of ingestion, geographical
location
• Why – intentional vs. unintentional
 Laboratory
Investigations

• What lab tests should we order?

• What special tests are available?

Laboratory investigations (cont’d)

• General labs(routine): CBC,ECG,LFT,

Electrolytes, BUN, Cr, glucose, ABG.
• Special laboratory investigation
indicated in following cases
– Intentional ingestion
– Substance unknown
– Potential for mod to severe toxicity
Laboratory investigations (cont’d)

• Labs considered essential and

available :
– EtOH, acetaminophen, salicylate,
digoxin, Carbamazepine, phenobarb,
phenytoin, Valproate, theophylline
– Methanol, Ethylene glycol, Isopropanol,
Iron, Lithium
• Tox screen – does not contribute to
patient management
 Additional Tests
• ECG – TCA or other cardiotoxic drugs,
arrhythmias, ischemia
• Radiology
– CXR – aspiration, noncardiogenic
pulmonary edema
– Abdominal films useful in screening for
ingestions of radio-opaque materials
– What substances are visible on AXR?
 DECONTAMINATION
• DERMAL:OPC,Carbolic acid.
( remove clothes,wash with soap & water
for 15 min,NO forceful rubbing)
• EYE:wash conj. With running water or
saline for 20 min.
• Inhalation:CO ,CN.
1.Remove to fresh air
2.Care of resp.
• GIT
 Gastrointestinal
Decontamination

• Ipecac
• Gastric lavage
• Whole bowel irrigation
• Single dose activated charcoal
• Cathartics
 Ipecac
• Emetic – both peripherally and central acting
• >90% effective
• Dose 30cc PO :adults, 15cc >2yrs, 10cc 6-2yrs.
• IF failed within 30 m,repeat,if not then GL..

• Advantages
– Safe
– Efficient
– Less traumatic
• Contraindications
- Substance
- Patient
- Time passed
• Complications
– Diarrhea, lethargy/drowsiness, prolonged vomiting
Never Never Never
(Use Salty H2O) ????
 Gastric Lavage
36-40 Fr NG, sequential instillation and removal
•
of small volumes of isotonic fluid
• Indications
– Recent ingestion (<1-2 hr)
– Exceeds adsorptive capacity of initial AC
dosing
– Agents not adsorbed by AC
– Substances likely to form concretions
after overdose
– Substantial risk of toxicity, or  LOC
requiring intubation ( chloroquine,
colchicine, TCA, CCBs)
 Gastric Lavage
• Contraindications
Absolute Corrosives, froth-forming
Relative
Unprotected airway, coma
Convulsions
Hydrocarbons
Risk of GI bleed or perforation
Time factor (unless delayed)
• Complications
Aspn pneumonia, laryngospasm, hypoxia,
mechanical injury, fluid/electrolyte imbalances,
bradycardia, hypertension
 Activated Charcoal
• 1g/kg PO or NG
• Indications
– Within 1 hour of ingestion
– Nearly all suspected toxic ingestions except
– May be considered more than 1 hour after ingestion but
insufficient data to support or exclude use
• Contraindications
– Unprotected airway
– When AC therapy may increase risk and severity of
aspiration
– Corrosives (why??) , IO, hydrocarbons ,NOT
ADSORBED.
• Complications
– GIT obstruction, constipation, adsorb medication
 Drugs that don’t adsorb to
AC
• PHAILS
– Pesticides ???
– Hydrocarbons, Heavy metals (Fe,Hg,Pb)
– Acids/Alkalis/Alcohols
– Iron
– Lithium
– Solvents
– Gases
 INDICATIONS
OF
MDAC
• Drugs remain in GIT:
SR-prep:theophylline
concretions:salicyl. Phenobarbit.
slowing GIT motility:antichol.
• EHC:digoxine,dapson,TCA
• Passive diffusion from bl to lower GI
lumen:theophylline.
 Multiple Dose Activated
Charcoal
• Consider only if life-threatening amount of:
– Carbamazepine
– Phenobarbital
– Dapsone
– Quinine
– Theophylline

• May also increase elimination of :

– amitriptyline, propoxyphene, digitoxin, digoxin,
disopyramide, nadolol, phenylbutazone,
phenytoin, piroxicam, sotalol
 Whole bowel irrigation
• PEG via NG at 1-2 L/h (500cc/h in peds)
until effluent clear

• Indications
– Potentially toxic ingestion of SR prep
– Ingested packets of illicit drug (stuffers,
packers)
– Substances not adsorbed by AC
– Iron ingestions
 Whole bowel Irrigation
• Contraindications
– Bowel perforation or obstruction
– GI bleed
– Ileus
– Unprotected airway
– Hemodynamic instability
– Intractable vomiting
• Complications
– Nausea, vomiting, aspiration, cramps
 TYPES OF CATHASIS
• OSMOTIC:MgSO4(15-30g)in glass of
water.
• IRRITANT:Castor oil(60-100ml)
• Contraind.:GI Hge, IO,ileus,recent
bowel surgery,RF(Mg load)
• Complications:dehydration &
elec.imb
 Cathartics
• Sorbitol, Mg citrate, Phosphosoda
• May be an argument for adding to
initial dose of multiple dose activated
charcoal
• No studies have demonstrated a
benefit in clinical outcome with
cathartics
 Enhancing elimination
• Multiple dose activated charcoal
• Diuresis
• Alkalinization
• Hemodialysis
• Hemoperfusion
 Multiple Dose Activated
Charcoal
• Dose: 0.5 – 1 gm/kg/4hr
0.25 – 0.5 gm/kg/hr (NGT)
• Indications:
1.Drug remaining in the gut for long time
• SR prep. Ex theophylline
• Concretions (??)
• Slow GIT motility
2.EHC
3.Drug diffuse passively from blood to GIT lumen
 Alkalinization
• Enhances elimination of weak bases
by ion trapping
• Useful for:
– Salicylates, phenobarbital,
chlorpropamide, methotrexate,
myoglobin
• NaHCO3 1-2 mEq/kg IV
• Aim for Urine pH 7-8
• Must replace K
 Hemodialysis
• Blood passed across membrane with
countercurrent dialysate flow
• Toxins removed by diffusion
Properties required:
– Molecular weight < 500 daltons
– High water solubility
– Low or saturable plasma protein binding
– Low Vd (<1L/kg)
– Low endogenous clearance(<4ml/min/kg)
 Hemoperfusion
• Blood passed through cartridge
containing AC
• Toxins removed by adsorption
Properties required:
– Low Vd <1L/kg
– Low endogenous clearance <4cc/min/kg
– Adsorbable to AC
 Substances amenable to
hemodialysis or hemperfusion
• LET ME SAV P
– Lithium
– Ethylene glycol
– Theophylline

– MEthanol

– Salicylates
– Atenolol
– Valproic acid

– Potassium, paraquat
 Complications of
hemodialysis
• Bleeding at venous puncture site
• hypotension
• DVT
• Bleeding due to systemic
anticoagulation
• Infection
• Air embolus
 Antidotes
If after stabilization a toxin is
identified, there may be a specific
antidote
Antidotes (Cont’d)

antidote poison antidote poison

acetylcysteine acetaminophen ethanol MeOH, et glycol
Crotalid Crotalid snake flumazenil BDZ
Antivenin bite Fomepizole MeOH
atropine Carbamate or glucagon Β-blocker, CCB
organophosphate
Methylene blue methemoglobin
Ca gluconate or CCB or hydrogen
Ca chloride fluoride naloxone opioids
Cyanide kit cyanide physostigmine anticholinergic
Deferoxamine Iron pralidoxime organophosphate
Digoxine Digoxin, digitoxin pyridoxine isoniazid
immune Fab Sodium TCA, cocaine,
Dimercaprol Arsenic, bicarbonate salicylates
(BAL) mercury, lead
 Summary
• Airway with cervical spine control
• Breathing
• Circulation
• Drugs (coma cocktail),
Decontamination
• Elimination
• Find an antidote
• General management
 Bradycardia
• Propanolol (β-blockers),
phenylpropanolamine (-agonists)
• Anticholinesterase drugs(OPC)
• Clonidine, CCBs
• Ethanol / alcohols
• Digoxin, Darvon (opiates)
 Tachycardia
• Free base (cocaine/stimulants)
• Anticholinergics, antihistamines
• Sympathomimetics
• Theophylline (methylxanthines)
 Hypotension
• Clonidine
• Reserpine (antihypertensives)
• Antidepressants
• Sedative hypnotics
• Heroin (opiates)
 Hypertension
• Cocaine
• Theophylline, thyroid supplements

• Sympathomimetics
• Caffeine
• Anticholinergics, amphetamines
• Nicotine
 Hyperthermia
• Neuroleptic malignant syndrome
• Antihistamines
• Salicylates, sympathomimetics,
serotonin syndrome
• Anticholinergics, antidepressants
 Hypothermia
• Carbon monoxide
• Opiates
• Oral hypoglycemics/insulin
• Liquor (EtOH)
• Sedative hypnotics
 Seizures
• Organophosphates
• Tricyclic antidepressants
• INH, insulin
• Sympathomimetics

• Camphor, cocaine
• Amphetamines, anticholinergics
• Methylxanthines
• Phencyclidine
• Benzodiazepine withdrawal, botanicals
• Ethanol withdrawal
• Lithium, lidocaine
• Lead, lindane
 Pupils
Miosis Mydriasis
• Opiates/organophosphates • Antihistamines
• Phenothiazines, • Antidepressants
pilocarpine, pontine bleed
• Sedative hypnotics
• Anticholinergics
• Cholinergics/clonidine • Sympathomimetics
 Odors
• Bitter almonds – cyanide
• Fruity – DKA, isopropanol
• Minty – methyl salicylates
• Rotten eggs – sulfur dioxide,
hydrogen sulfide
• Pears – chloral hydrate
• Garlic – organophosphates, arsenic
• Mothballs - camphor
Radiodense substances that
may be visible on AXR
• CHIPES
– Chloral hydrate
– Heavy metals
– Iron
– Phenothiazines
– Enteric coated preps
– Sustained release preps
• Drug Packets
Questions

??
CPR
 CPR
• Position of the patient.
• Artificial respiration (mouth to mouth
breathing=rescue breathing)
• Ext. Chest compression with monitoring the
carotid or femoral pulse.
• Rate: (2 resp. /15 beats if one rescuer)
or (1 resp. /5 beats if two rescuers)
• IV line, Oxygen, intubation NaHCO3,
• Adrenaline 1 mg /5min IV.
• Ca chloride.
• DC shock
 SEQUENCE OF ACTION
• 1-Ensure safety of rescuer and victim
• 2-Check the victim & see if he
responds:gently shake his shoulders
& shout loudly:”Are you all right?”
• 3-If he responds by answering or
moving---check him & get assistance
• If he doesn’t respond:shout for help
• 4-Check position,airway open then
• LOOK for chest movements
• LISTEN at his mouth for breath
sounds
• FEEL for air on your cheek
• (for no more than 10 sec to
determine if he is breathing
normally)
• 5- If he is breathing:
Turn him into recovery position
Check for cont. breathing
Send for help
If not:ask for assistance
- turn him on his back
- tilt head, chin lift
-pinch soft part of his nose
-open his mouth a little but maintain chin
lift
-take a breath,place your lips around his mouth,
make good seal
-blow ,watch his chest take about 2 sec
- give him 2 rescue breaths
(each makes his chest rise & fall)
• 6-ASSESS CIRCULATION:

LOOK LISTEN & FEEL for normal

breathing,coughing or any movement

Check pulse(for no more than 10 sec)

• 7-If no signs of circ.(START CHEST
COMPRESSION)
• Combine rescue breathing & comp.
• After 15 comp. tilt head,lift chin & give 2
effective breaths and so on in a ratio of
15:2
• Stop to recheck for signs of circ only if he
makes a movement or takes a spont
breath;otherwise resuscitation should not
be interrupted
 CONTINUE UNTIL??
• QUALIFIED help arrives & takes
over

• The victim shows signs of life

• YOU become exhausted

 Notes On Tech. Of BLS
RESCUE BREATHING:
• only slight resistance should be felt
• each one should take about 2 seconds
• Blowing too quickly will force air into the
stomach & inc. the risk of regurgitation
• each should make the chest rise clearly
• The rescuer should wait for the chest to
fall fully during exp(about 2-4 sec)
CHEST COMPRESSION:
• The aim is to press down approx.4-5 cm &
apply enough pressure to achieve this
• Pressure should be firm,controlled &
applied vertically(erratic or violent action
is dangerous)
• You should not waste time to check the
presence of pulse.
• The presence of dilated pupils is an
unreliable sign & shouldn’t influence
Thank
You