the poisoned patient
TRANSCRIPT
The Poisoned The Poisoned PatientPatient
Core Clerkship in Emergency Medicine Core Clerkship in Emergency Medicine University of Colorado at Denver Health University of Colorado at Denver Health
Sciences CenterSciences Center
ObjectivesObjectives Apply general emergency medicine Apply general emergency medicine
management principles to the management principles to the poisoned patientpoisoned patient
Review basic pharmacology and Review basic pharmacology and toxicology of common poisons toxicology of common poisons
Utilize clues from the history, Utilize clues from the history, physical exam, and diagnostics to physical exam, and diagnostics to identify the poisons involvedidentify the poisons involved
First principle in poisoning First principle in poisoning managementmanagement
Sick or not sick?Sick or not sick? Poisoned patients can present with Poisoned patients can present with
a broad spectrum of illnessa broad spectrum of illness If sick, start treatmentIf sick, start treatment
Resuscitation is always the first Resuscitation is always the first step- remember your ABCsstep- remember your ABCs
General principles of General principles of emergency managementemergency management
Resuscitation/StabilizationResuscitation/Stabilization EvaluationEvaluation
Rule out the life-threatsRule out the life-threats Identify what you canIdentify what you can
Symptomatic care/monitoringSymptomatic care/monitoring Prevention of deteriorationPrevention of deterioration Treat symptomsTreat symptoms AntidotesAntidotes
Case – Altered Mental Case – Altered Mental StatusStatus
EMS ReportEMS Report ““This is a 57 yo male. We were called to This is a 57 yo male. We were called to
his house by his son, who found him his house by his son, who found him confused. The son is on the way here.confused. The son is on the way here.
““On our arrival, we found a somnolent On our arrival, we found a somnolent male who is not able to answer questions, male who is not able to answer questions, is mildly diaphoretic, and had BP 135/75, is mildly diaphoretic, and had BP 135/75, HR 100, RR 32, and oxygen sat of 99% on HR 100, RR 32, and oxygen sat of 99% on room air. We have a 16 gauge IV in the room air. We have a 16 gauge IV in the left AC. D-stick was 95.left AC. D-stick was 95.
““Any questions for us before we leave?”Any questions for us before we leave?”
EMS ReportEMS Report
House was clean, no signs of an House was clean, no signs of an assault, etc.assault, etc.
No drug paraphernalia aroundNo drug paraphernalia around No medicalert bracelet or necklaceNo medicalert bracelet or necklace No open pill bottles near patientNo open pill bottles near patient Patient was found 5 ft from the Patient was found 5 ft from the
bottom of a staircasebottom of a staircase
The patient’s son The patient’s son arrives…arrives…
What would you like to What would you like to ask his son?ask his son?
His son tells you…His son tells you… He talked to his dad yesterday, seemed He talked to his dad yesterday, seemed
normalnormal No significant PMHNo significant PMH PSHX: gallbladder taken out about 10 years PSHX: gallbladder taken out about 10 years
agoago No medications except for something he No medications except for something he
occasionally takes for a “stomach flu bug” occasionally takes for a “stomach flu bug” SH: smoker : 40 pack/year hx, occasional SH: smoker : 40 pack/year hx, occasional
social drinkersocial drinker Wife died of cancer about a month ago—dad Wife died of cancer about a month ago—dad
took her death “very hard” took her death “very hard”
Physical ExamPhysical Exam Vitals – Vitals – T 38.2; BP 134/78; Pulse 102; RR
30; SaO2 98% on RA Gen: Confused, drowsyGen: Confused, drowsy Skin: moist and flushed, no lesions, no
cyanosis Pupils: mid position (not constricted or
dilated) and reactive CV: tachy RR, no murmur/rubs/gallops Lungs: CTA bilaterally Bowel sounds: present No evidence of trauma, neck is not stiff Neuro: otherwise nonfocal
Sick or not Sick or not sick?sick?
Sick or not sickSick or not sick Sick but stableSick but stable No immediate airway, breathing or No immediate airway, breathing or
circulation interventions requiredcirculation interventions required But altered mental status may be But altered mental status may be
due to a life-threatening condition due to a life-threatening condition that requires prompt interventionthat requires prompt intervention
What’s our What’s our differential diagnosis differential diagnosis
for this patient?for this patient?
Broad Differential Broad Differential DiagnosesDiagnoses
NeurologicNeurologic MalignantMalignant EndocrineEndocrine InfectionInfection TraumaTrauma ToxicologicToxicologic
Altered Mental StatusAltered Mental Status Four life-threatening causes that Four life-threatening causes that
require immediate treatmentrequire immediate treatment Hypoxia (ruled out by normal pulse ox)Hypoxia (ruled out by normal pulse ox) Hypotension/severe hypertension (ruled Hypotension/severe hypertension (ruled
out by normal BP)out by normal BP) Herniation of the brainstem (ruled out by Herniation of the brainstem (ruled out by
non-focal neurological exam)non-focal neurological exam) Hypoglycemia (needs to be evaluated in Hypoglycemia (needs to be evaluated in
every patient with altered mental status)every patient with altered mental status)
Get the best history Get the best history possiblepossible
Often unreliable or unobtainable from patient
Rely on EMS, bystanders, family members and other physicians
Psychiatric files Obtain bottles/medications from home
Any missing pills, amount, time of ingestion Environmental setting Check pockets, bags, belongings
Physical ExamPhysical Exam Thorough exam looking for clues:Thorough exam looking for clues:
Toxidromes- constellation of signs and Toxidromes- constellation of signs and symptoms of a particular poisonsymptoms of a particular poison
In the ED we always look for the In the ED we always look for the “classic” presentation“classic” presentation
Also look for signs of non-toxicologic Also look for signs of non-toxicologic causes:causes: Evidence of trauma, infection,
metabolic or neurological causes, etc.
Common ToxidromesCommon Toxidromes SympathomimeticsSympathomimetics Anti-cholinergicsAnti-cholinergics CholinergicsCholinergics SedativesSedatives OpiatesOpiates
SympathomimeticsSympathomimetics Cocaine, Amphetamines, PCP
Hypertension Tachycardia Diaphoresis Mydriasis Agitation
Does this sound like our guy?
AnticholinergicsAnticholinergics Antihistamines, some plants, side effect of
many drugs Tachycardia Hyperthermia Dry skin Mydriasis Decreased bowel sounds Urinary retention Delirium, agitation
Hot as a hare, Dry as a bone, Red as a beet, Mad as a hatter, Blind as a bat. Does this sound like our guy? Does this sound like our guy?
CholinergicsCholinergics Organophosphates, Carbamates, Nerve agents Effects both muscarinic and nicotinic
receptors Muscarinic effects
S- SALIVATION, SEIZURE L- LACRIMATION U- URINATION G- GI DISTRESS (diarrhea & vomiting) B- BRONCHORRHEA A- ABDOMINAL CRAMPS M- MIOSIS
CholinergicsCholinergics Nicotinic effects - MTWThF
M-Mydriasis T-Tachycardia W-Weakness TH-Hyperthermia F-Fasciculations
Does this sound like our guy?
OpiatesOpiatesOpiates, Clonidine
Miosis Hypotension Bradypnea Bradycardia Hypothermia CNS Depression
Does this look like our guy?
SedativesSedativesBenzodiazepines, GHB
“Coma with normal vital signs” CNS Depression Normotensive Mild bradypnea or normal RR
Does this look like our guy?
Toxins and Vital SignsToxins and Vital Signs Hyperthermia - aspirin, cocaine, anticholinergics Hypothermia - opioids, sedatives Hypertension - stimulants, tricyclics,
antihistamines Hypotension - blood pressure medications, opioids Tachycardia - stimulants, vasodilators,
anticholinergics Bradycardia - beta-blockers, Ca Ch blockers,
clonidine, digoxin Tachypnea- aspirin, amphetamines, CO Bradypnea- narcotics, clonidine, ETOH
AssessmentAssessment The history suggests an overdose, The history suggests an overdose,
but we don’t know whatbut we don’t know what The physical exam is non-specificThe physical exam is non-specific
No common toxidrome to suggest a No common toxidrome to suggest a diagnosisdiagnosis
Nothing to strongly suggest another Nothing to strongly suggest another causecause
Time to gather more data….Time to gather more data….
Diagnostic Diagnostic TestingTesting
What diagnostics might What diagnostics might be helpful in this case?be helpful in this case?
DiagnosticsDiagnostics General lab testingGeneral lab testing
Serum chemistry, blood gas to identify Serum chemistry, blood gas to identify metabolic abnormalitiesmetabolic abnormalities
CBC, UA, CSF analysis to identify CBC, UA, CSF analysis to identify infectioninfection
Drug/alcohol screen to identify common Drug/alcohol screen to identify common drugs of abusedrugs of abuse
Specific lab testingSpecific lab testing Some poisons require specific testing Some poisons require specific testing
LabsLabs Na 135 K 3.5 Cl100 HCO3 15 Glucose 120 BUN 25 Cr 1.0 ABG 7.50/15/90/16/-12 EtOH undetectable Urine drug screen negative for drugs
of abuse ECG – sinus tachycardia Head CT – negative CXR - normal
What is your assessment What is your assessment now?now?
What is the acid/base disturbance?What is the acid/base disturbance? What is the differential for this What is the differential for this
acid/base disturbance?acid/base disturbance? Is this consistent with a common Is this consistent with a common
overdose?overdose? How can we assess this problem? How can we assess this problem? Was the ECG, head CT, and CXR Was the ECG, head CT, and CXR
helpful? helpful?
SalicylismSalicylism(Aspirin Poisoning)(Aspirin Poisoning)
Respiratory alkalosisRespiratory alkalosis Direct stimulation of respiratory Direct stimulation of respiratory centerscenters
TachypneaTachypnea Metabolic acidosisMetabolic acidosis
Aspirin is salicylic acidAspirin is salicylic acid Causes lactic acidosis by uncoupling Causes lactic acidosis by uncoupling
oxidative phosphorylationoxidative phosphorylation Causes ketosis by stimulating lipid Causes ketosis by stimulating lipid
metabolismmetabolism Confusion/cerebral edemaConfusion/cerebral edema
EvaluationEvaluation In In mostmost poisonings, symptoms do not poisonings, symptoms do not
correlate well with serum drug correlate well with serum drug levels, so levels are not usefullevels, so levels are not useful
Acute salicylate ingestion is one case Acute salicylate ingestion is one case where symptoms where symptoms DODO correlate with correlate with levelslevels Therapeutic is up to 30 mg/dlTherapeutic is up to 30 mg/dl This patient’s level was 75 mg/dlThis patient’s level was 75 mg/dl
Poisoning ManagementPoisoning Management Supportive and symptomatic care Supportive and symptomatic care
are required for all poisoningsare required for all poisonings
Treating Common Treating Common Poisoning SymptomsPoisoning Symptoms
SymptomSymptom TreatmentTreatmentNoneNone ObservationObservationHypoglycemia GlucoseSomnolence/comaSomnolence/coma IntubationIntubationAgitation/seizuresAgitation/seizures Sedatives Sedatives
(benzodiazepines)(benzodiazepines)HypotensionHypotension Fluids/adrenergic Fluids/adrenergic
pressorspressorsCardiac arrhythmiaCardiac arrhythmia Sodium bicarbonate, Sodium bicarbonate,
calcium, anti-calcium, anti-dysrhythmics, pacingdysrhythmics, pacing
Vomiting Vomiting Anti-emetics, IVFAnti-emetics, IVF
Poisoning ManagementPoisoning Management Antidotal therapies are needed for Antidotal therapies are needed for
only a few poisons. only a few poisons. (Consult your EM book (Consult your EM book for detailed listings.)for detailed listings.)
Consider GI decontaminationConsider GI decontamination Removal of drug or decrease absorption Removal of drug or decrease absorption
from GI tractfrom GI tract
GI DecontaminationGI Decontamination Ipecac syrupIpecac syrup
No longer recommended for poisoningsNo longer recommended for poisonings Activated charcoalActivated charcoal
Binds to most medications and potentially Binds to most medications and potentially decreases GI absorptiondecreases GI absorption
Potentially useful within 1 hour of ingestion Potentially useful within 1 hour of ingestion but no evidence of improved clinical but no evidence of improved clinical outcomesoutcomes
Aspiration is uncommon unless given by an Aspiration is uncommon unless given by an NG tube or in patient with altered mental NG tube or in patient with altered mental statusstatus
GI DecontaminationGI Decontamination Gastric LavageGastric Lavage
Insertion of large orogastric tube into Insertion of large orogastric tube into the stomach and lavaging with several the stomach and lavaging with several liters of fluidliters of fluid
Potentially useful in life threatening Potentially useful in life threatening ingestions < 1 houringestions < 1 hour
Aspiration occurs in around 5% of Aspiration occurs in around 5% of patientspatients
Borrowed from Vik Bebarta, “One Pill Can Kill”
GI DecontaminationGI Decontamination Whole Bowel IrrigationWhole Bowel Irrigation
Decreases GI transit time using PEGDecreases GI transit time using PEG Useful in life threatening ingestions Useful in life threatening ingestions
when other methods not helpfulwhen other methods not helpful
GI DecontaminationGI Decontamination Would GI decontamination be useful Would GI decontamination be useful
in this patient? in this patient? Do you think that this patient has Do you think that this patient has
more drug in the GI tract?more drug in the GI tract?
GI DecontaminationGI Decontamination
He has a high salicylate levelHe has a high salicylate level He has been “confused for a couple He has been “confused for a couple
of hours”of hours” Probably not much drug left in the Probably not much drug left in the
GI tractGI tract
Specific TreatmentsSpecific TreatmentsVery few poisons require specific Very few poisons require specific
treatments such as:treatments such as: DialysisDialysis DiuresisDiuresis ChelationChelation Cardiac pacingCardiac pacing
Salicylism - TreatmentSalicylism - Treatment Salicylate poisoning has a specific Salicylate poisoning has a specific
treatmenttreatment Alkaline diuresis – increase in urine Alkaline diuresis – increase in urine
pH favors movement of salicylate ion pH favors movement of salicylate ion into urine into urine
Dialysis for severe casesDialysis for severe cases
Is this patient sick enough to get Is this patient sick enough to get dialysis?dialysis?
Non-Toxic Ingestions Non-Toxic Ingestions (Small amounts)(Small amounts)
Household bleachHousehold bleach Cigarettes (<3)Cigarettes (<3) CosmeticsCosmetics Glues/pasteGlues/paste Hydrogen peroxide Hydrogen peroxide
(medicinal)(medicinal) MatchesMatches Paint (indoor, Paint (indoor,
latex)latex)
Shampoos, lotionsShampoos, lotions Rat poisonRat poison DetergentsDetergents ChalkChalk LaxativesLaxatives InkInk AntibioticsAntibiotics AntacidsAntacids
SummarySummary Always start with the ABCsAlways start with the ABCs Target your history and physical for Target your history and physical for
clues to the diagnosisclues to the diagnosis Labs and other testing may be useful Labs and other testing may be useful Most poisons only require supportive Most poisons only require supportive
carecare If you have questions call the Rocky If you have questions call the Rocky
Mountain Poison CenterMountain Poison Center
