Poisoning

Dr Tom Miller ACCS EM CT2

Aims and Objectives

      

Definitions Assessment of a 'poisoned patient' Common ingestants Toxidromes Management and treatment Case studies Summary

Rules of Engagement
   

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Definition


poison [ p z n] n 1. (Medicine) any substance that can impair function, cause structural damage, or otherwise injure the body Related adj toxic 2. something that destroys, corrupts, etc. the poison of fascism 3. (Chemistry) a substance that retards a chemical reaction or destroys or inhibits the activity of a catalyst 4. (Physics / General Physics) a substance that absorbs neutrons in a nuclear reactor and thus slows down the reaction. It may be added deliberately or formed during fission what's your poison? Informal what would you like to drink? vb (tr) 1. (Medicine) to give poison to (a person or animal) esp with intent to kill 2. to add poison to 3. to taint or infect with or as if with poison 4. (foll by against) to turn (a person's mind) against he poisoned her mind against me 5. (Chemistry) to retard or stop (a chemical or nuclear reaction) by the action of a poison 6. (Chemistry) to inhibit or destroy (the activity of a catalyst) by the action of a poison [from Old French puison potion, from Latin p ti a drink, esp a poisonous one, from p t re to drink]

Poison

Any substance that can impair function, cause structural damage or otherwise injure the body

Assessment

History Examination Special Investigations

Assesment
History
    

What's been taken + what else (alcohol) When was it taken What's happened since Who PMSH (EDMS) Why

Common ingestants
ALCOHOL Paracetamol Aspirin Tricyclic anti-depressants 'Sleeping tablets' Anti-convulsants Cardiovascular drugs

Unconscious / Uncooperative
   

Family ?who rang 999 Paramedics Prescriptions Past history

Examination
   

A NPA, Guedel, ETT, **O2** B - ?Assist - BMV, Sats monitor C BP / Pulse D GCS / Conscious level / Pupils / Focal neurology / GLUCOSE E Exposure / Everything else Evaluate

Information

Toxbase - www.toxbase.org National Poisons information service www.npis.org

Toxidromes

Anticholinergic
Agitated Tachycardia Warm, dry and flushed Mydriasis Myoclonus Seizures Dysryhthmias Blind as a bat, mad as a hatter, hot as hades, red as a beet, bowel and bladder lose their tone, heart runs alone

The four aunties Anti-depressants Anti-psychotics Anti-histamine Anti-parkinons

The others Atropine Scopolamine Amantadine Jimson Weed

Cholingeric
SLUDGE Confusion / Stupor Salivation Incontinence Cramps / Vomiting Diaphoresis Pulm oedema Miosis Bradycardia Seizures Organophosphates Mushrooms

Sympathomimetric
Delusions Agitation Tachycardia Hypertension Diaphoresis Hyperreflexia Seizures Dysrythmias Cocaine 'Phets' MDMA Caffeine Theophylline

Seretonin
Fever Tremor Incoordination Mental status change Diaphoresis Myoclonus Diarrhoea Rigidity SSRIs + MAOIs (selegeline)

Opiates / Sedatives
Resp depression Coma Miosis ALI Ileus Hyporeflexia Track marks Narcotics Benzos Barbituates

Special Investigations
FBC U+Es LFTs Clotting ABG ECG CXR ?CT Brain P+S levels - ALWAYS On arrival 4 hours after ingestion

Management
Basic principles: 1. Prevent absorption 2. Symptomatic and supportive treatment 3. Promote elimination 4. Specific antidotes

Paracetamol
- Amount taken and when - Usually asymptomatic - Levels at 4 hours post ingestion - Check for 'high risk' for liver (alcohol/hepatitis/inducers eg antiepileptics/St Johns Wort) - Acetylcysteine (Parvolex) if above/near treatment line or oral Methionine - Beware 'staggered OD'

Salicylate
Nausea, vomiting Vertigo Dizzines Fever, sweating Confusion Resp alkalosis Metabolic alkalosis Metabolic acidosis Minimal toxic dose 150mg/Kg Severe symptoms > 300mg/Kg

Treatment
ABC Activated charcoal Gastric lavage Alkaline diuresis HF

Tricyclics
Life threatening arrhythmias and hypotension Low threshold for Sodium Bicarbonate Anti-cholinergic

Opiates
ABC Naloxone 0.4mg increments up to 2mg Watch out they might be a bit 'fighty' Naloxone infusion if needed

Miscellaneous Antidotes
Digoxin - Digoxin antibodies - Digibind Cyanide - Hyroxycobalamin in Cyanokit Benzodiazepines - Flumazenil (but NEVER in mixed OD) Methanol Ethanol / Fomepizole Organophosphates Atropine and pralidoxime Carbon monoxide - Oxygen Calcium channel blockers - Calcium Beta blockers - Glucagon

Case study
23 Female Argument with boyfriend Says took 'loads' of pills Paracetamol, maybe zopiclone Taken 2 hours ago with litre white lightning ABC normal No hepatic tenderness

Management
TOXBASE P+S levels at 4 hrs Observe Refer psychs for assessment of safety

Case study 2
34 Male Standby - unresponsive ?apnoeic On arrival: Poorly kempt, Everton shirt from 2003, track marks to arms

Assessment / Management
A Simple manoeuvres, NPA / Guedel B O2, BMV C IV access, BP 110/60, P 95 D Pin point pupils, GCS 3, BSL 5.5

Naloxone

Case study 3
Standby 45 Male, PMSH HTN / IHD Domestic argument OD Paramedics report Diltiazem SR, Bisoprolol, antidepressants, 'sleeping tablets' unknown quantities

Assesment Management
A - ? safe no tone (GCS 3) - Call for help - Airway Manoeuvres - Airway adjuncts - Anaesthetics

B Resp rate 12, shallow, sats 90% - Support ventilation BMV - High flow 02

The trouble zone

C BP 80/35, P. 50, ECG sinus tachycardia - IV access - Fluid challenge - Calcium - Glucagon - Inotropes

Deposition
- ICU as intubated and requiring inotopes / vasopressors - Long acting calcium channel antagonist turned out to be a huge quantity (plus a lot of other meds)! - Extubated after 36 hrs - No lasting (physiological) problems

Quiz
1. Name three common ingestants in OD 2. Give one example of 'increased risk' in Paracetamol OD 3. 3 signs in cocaine overuse/overdose (? syndrome) 4. Give 3 observations in anti-cholinergic syndrome 5. Antidote to opiates 6. Name one website to use for management advice 7. Which basic investigation must 'never be forgotten'? 8. One plant which causes anti-cholinergic syndrome 9. Treatment of Beta Blockers and why does it work? 10. Why is this presentation on a blue background?

Summary
Definition Common ingestants Toxidromes Assessment / Management Case studies Quiz

CPD
Find and look at treatment for paracetamol OD Usually on Obs ward

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