Toxicologic EmergenciesErin Moorcones, RN, MSN

Sharon Brown, RN

Toxicologic emergencies include acute poisonings and intake of drugs/alcohol.

92% of these emergencies occurred in the home according to the American Association of Poison control in 2004.

* 51.3% in children <6, and 38% in children <3 * 94% of toxic exposures were acute and 84%

unintentional. * Therapeutic medication errors were 10% of all

poisonings. In 2004. 1.3 millions ER visits were associated w/ drug

ingestion. Always consider organic causes.

General Strategy

HPI- information regarding ingestion, route of exposure, reason for exposure, efforts to treat

PMH- diseases, trauma, SA history, pysch history, support network, environmental,

RF- family history, gateway substance use, peer influence, pysch disorders.

Physical exam- general appearance, inspection auscultation, palpation.

Diagnostic- Labs, imaging Treatment/evaluation

Interventions to prevent of decrease absorption of drugs or chemicals

Irrigation- -remove all clothing, flush surfaces with saline. - indicated= organophosphate, gasoline, acids - alkali solutions require longer irrigation Ipecac- contraindicated in drugs causing CNS

depression Gastric lavage- best if initiated w/I 60 minutes. - potential for aspiration, caution w/ ingestion of

caustic substances Cathartic administration- Mg sulfate, mag citrate. Must

have bowel sounds Activated charcoal- used to absorb ingested chemicals

Pediatric considerations

Growth & development- * dec renal clearance in children <6m, has effect on half-life

and duration on drugs * infants have fewer binding sites for drugs, leading to >

chance of toxic effects * lower glycogen stores place child at risk for hypoglycemia PEARLS * most poisonings occur in children <6yrs old in home *Munchausen by proxy must be considered * very young children less likely to develop hepatotoxicity w/

Tylenol overdose * adolescents higher risk for recreational abuse * suicide attempts are infrequently intended to result in death

Geriatric considerations

Aging related * high risk for therapeutic med errors due to large

number of medications prescribed *decreased renal clearance= toxicity * slowed metabolism of meds leads to > chance

of toxicity PEARLS * consider salicylism poison in older adults *eliminate mental illness, SA, or depression * older adults forget meds or take extra

ALCOHOL

Most common drug used in U.S. Involved in 70% of overdoses in ED Affects all SES, male/female. It is metabolized in the liver and affects

all body systems (CNS, GI, & CV) May be used in conjunction with other

drugs

Important Assessment information

PMH-Hx of problems related to drinking, concurrent medication use, and presenting symptoms.

General Assessment- may he hypo/hyperthermic * monitor gait, LOC, inspect for injuries. Diagnostic- labs, Xray, CT scans Planning/treatment- ABC’s monitor airway, treat injuries, referrals,

minimize fall risk, seizure precautions Evaluation- airway, LOC< VS

Alcohol, cont.

ETOH Seizures› Shorter duration than grand mal

Vitamin and Electrolyte deficits› Decreased Mg = decreased seizure

threshold, decreased thiamine – must replace thiamine before glucose

TX – ABC’s, IVF. Body will absorb approx 0.02/hr.

Charcoal will not absorb ETOH

Alcohol, cont.

Alcohol withdrawal syndrome› Occurs in heavy drinkers that abruptly stop› Can begin within 8 hours of last drink› S/S – elevated HR, diaphoresis, fever,

tremors, anxiety, hallucinations› TX – ABC’s, IVF, Banana Bag (Thiamine,

MVI, Mg, folic acid, K), Ativan, Valium, Librium

Delirium Tremens (DT’s)

Begins 48-72 hours after last drink Peaks at 4 days after Acute, life threatening emergency Can last 2-3 days S/S- HTN, increased HR, tremors,

hallucinations Social services needs to be involved

Opiate Use-

Substances derived from opium poppy, most prescribed for severe pain

Morphine, heroin, hydrocodone, oxycodone, ultram, fentanyl.

They interfere with a patients perception of pain, produce brief euphoria followed by pleasant dream state

Death occurs from the side effects of the drugs Common for poly drug use

Opiate assessment Information- substance ingested, freq of use,

PMH (HIV, hepatitis) Physical exam- general- what would you see pupils would be? What other things would you

find on inspection? Classic Triad – Pinpoint puplis, decreased RR, coma

auscultation- crackles Diagnostic- urine tox, CBC, CXR Treatment- Narcan – slowly! Evaluation- airway, VS, LOC

Cocaine use

Cocaine use, very popular. Cocaine can be snorted, smoked, or injected Cocaine stimulates CNS and ANS system to

increase the release of catecholamines from the adrenergic nerve terminals. It blocks reuptake of dopamine/norepinephrine.

Causes- euphoria, increased motor activity, insomnia

Treatment aimed at supportive measures.

Cocaine assessment tips

Important to assess route ingested PMH- meds, diseases, Assessment- monitor for seizures, hypertension,

tachycardia, hyperthermia. * may have perforated nasal septum Diagnostic- labs, head CT, EKG Treatment- O2, IV, Meds ( haldol) Dilated pupils are hallmark sign

Amphetamines

Synthetic sympathomimetics that stimulate the CNS and produce feeling of “energy”.

May see “body packers” in ED. Can be prescribed for weight loss, ADD, mood Commonly present with heart racing, feeling sad

they are being touch by ants Decrease risk for violence

Drugs and key points

Lysergic Acid Diethylamide Use- (LSD) - causes changes in thoughts, mood, perception, and

consciousness. Hallucinogenic effect lasts 6-12 hrs and may include visual illusions, alteration in sound and color.

- absorb through the skin. It is colorless/odorless - no withdrawal, no physical dependence Phencyclidine Use (PCP)- dissociative anesthetic that

decreases awareness of surroundings. Similar properties to ketamine.

- affects CNS system causing stimulation/depression or cholinergic effects

- common names “angel dust”, Cadillac, CJ, killer weed - complications- rhabdomyolysis, renal failure, cerebral hem

Gamma-Hydroxybutyrate (GHB)- used to be anesthetic.

- GHB used as – diet aid, muscle building agent, date rape drug, sexual enhancer

- regulated schedule 1 CS - side effects- sedation, amnesia, resp depression,

LOC Inhalants- vapors from volatile substances, cheap

high. Produce a floating or numbing sensation and euphoria. They are readily absorbed into blood stream and cross BBB, reaching brain in high concentrations.

- LTE- neurologic, renal, cardiac

Carbon Monoxide Poisoning

CO is colorless, odorless, tasteless gas that binds to Hgb to form COHb.

The combination decreases ability of blood to carry O2 leading to severe hypoxia.

Sources- exhaust system,. Smoke from wood fires, propane heaters, hibachi grills.

Length of exposure correlates with symptoms S/S- HA, n/v, CP, cherry red skin, possible

ischemia noted on EKG Treatment- 100% o2, possible hyperbaric

Salicylate Poisoning

Salicylate use has decreased due to the attention from Reye’s syndrome.

The elderly are at risk for chronic toxicity due to dec renal function and use of aspirin for medical problems. This outs them at risk for development of ulcers, bleeding, metabolic acidosis.

Salicylate poisoning affects GI mucosa, coagulation, neuro system, and acid-base balance.

Peak serum levels are 6 hours after short-term ingestion(depending on pill ingested)

Toxic dose is 150-200mg/kg, and >500mg/kg is lethal

Salicylate OD treatment

O2- hyperventilation if acidosis present Large amt of fluids for renal clearance

and hydration Prevent absorption- gastric lavage,

bowel irrigation Meds- activated charcoal, NaBicarb,

replace electrolytes (K)

Acetaminophen Poisoning

Very common drug used in over the counter products, and in combination with narcotics.

Rapidly absorbed from GI tract, metabolized in liver

Toxicity produces delayed coagulopathies, hepatic necrosis, elevated LFT’s.

Children can metabolize better, and therefore affected less.

S/S- malaise, n/v (24-48hrs), later right upper quad pain, dec UO, jaundice, hypoglycemia, DIC

Acetaminophen-Diagnosis/treatment

Serum levels 4 hrs after ingestion, labs Treatment- * O2, IV, activated charcoal, Mucomyst (oral, GI

tube, IV)Serial levels must be obtainedPysch evaluation

Tricyclic Antidepressant Poisoning (TCA)

Extremely lethal due to narrow therapeutic index.

Produce cardiotoxic effects, CNS depression. Absorbed in the GI tract and rapidly distributed. Once absorbed bind to plasma proteins, and hard

to remove. Ex- Elavil, trazodone, nortriptyline

TCA poisonings

S/S- LOC changes, hypotension, possible CA, cardiac dysrhythmia’s ( ST, PVC’s, SVT. VT), fine tremors. Wide QRS

Diagnostic- tox screen, labs, ECG, UA Treatment- O2, IV, activated charcoal, benzo’s for

SE, NaBicarb for QRS widening.

Iron poisoning

Impt cause morbidity/mortality in children Most cases unintentional ingestion by toddlers Toxicity depends on the amount of elemental iron

found in preparation OD can produce GI hemorrhage and CV collapse

Phases of Fe Toxicity

Phase 1- less than 6hrs post ingestion - symptoms include vomiting, abdominal pain,

bloody diarrhea, and lethargy Phase 2- 6-12 hrs post ingestion - “recovery phase”, may appear to improve Phase 3- 12-48hr post ingestion - CV collapse, shock, metabolic acidosis, GI

bleeding, coagulopathy, hepatic injury, sepsis, coma

Phase 4- >48hrs - if pt survives, intestinal strictures and obstructions

may develop

Treatment of Fe toxicity

Meds- Desferal- binds to iron and increases renal

excretion NaBicarb to correct acidosis Bowel irrigation ALS

Petroleum Distillate Poisoning

Include gasoline, kerosene, paint thinner, motor oil.

Spread over lung surfaces, causing chemical pneumonitis

Some have ability to produce systemic effects (dysrhythmias & seizures)

Organophosphate Poisoning

s/s- diaphoresis, urination, lacrimation, salivation, diarrhea, seizures, tremors, miosis, tremors, weakness.

Found in insecticides, chemical weapons,. Peds and elderly more at risk b/c of lower levels

of cholinesterase Treatment- 2-PAM, abx, benzo, atropine

Organophosphate

MUDDLES› Miosis, Urination, Defecation, Diaphoresis,

Lacrimation, Excitation, Salivation SLUDGEM

› Salivation, Lacrimation, Urination, Defecation, GI upset, Emesis, Miosis

Digoxin Toxicity

Common drug in elderly to increase myocardial contractility

May result from OD, hypo-kalemia, advanced heart disease with conduction disturbances.

Very common because toxicity level is very close to therapeutic level.

S/S-disoriented, hypotension, photophobia, pupil mydriasis, abdominal tenderness, halos

Treatment- replace K/Mg, dilantin for dysrhythmia’s. avoid beta blockers, digibind

Benzodiazepine

Effects are increased with consumption of alcohol

S/S – slurred speech, incoordination, drowsiness, lethargy

Antidote ~ RomaziconMay give charcoal

Calcium Channel blocker

Toxic therapeutic margin is small. Children can be symptomatic with as little as one pill

Meds include Verapamil, Nifedipine, Cardizem

S/S – marked hypotension, bradycardia, irregular HR, SOB

Antidote ~ Calcium Chloride Keep pacer at bedside

Beta Blockers

“Olol’s” Usually S/S are seen within 1-2 hours of

ingestion, but as little as 20 minutes Bradycardia, hypotension,

hypoglycemia. EKG will show prolonged PR and wide QRS

Antidote ~ Glucagon!

Cyanide Poisoning

Lethal poisoning. Can cause death within 2 minutes of inhalation

Found in industrial fumigants, insectisides, silver polish

Related to long term use of Nipride Also found in pits of apricots, cherries,

and peaches

Cyanide

S/S – burning sensation in throat/mouth Breath smells of bitter almonds TX

› Cyanide antidote kit Includes methemoglobinemia and thiocynate

Control seizures with Ativan/Valium