The poisoned patient
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The Poisoned Patient. Core Clerkship in Emergency Medicine University of Colorado at Denver Health Sciences Center. Objectives. Apply general emergency medicine management principles to the poisoned patient Review basic pharmacology and toxicology of common poisons

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The Poisoned Patient

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The poisoned patient

The Poisoned Patient

Core Clerkship in Emergency Medicine

University of Colorado at Denver Health Sciences Center


Objectives

Objectives

  • Apply general emergency medicine management principles to the poisoned patient

  • Review basic pharmacology and toxicology of common poisons

  • Utilize clues from the history, physical exam, and diagnostics to identify the poisons involved


First principle in poisoning management

First principle in poisoning management

  • Sick or not sick?

    • Poisoned patients can present with a broad spectrum of illness

  • If sick, start treatment

    • Resuscitation is always the first step- remember your ABCs


General principles of emergency management

General principles of emergency management

  • Resuscitation/Stabilization

  • Evaluation

    • Rule out the life-threats

    • Identify what you can

  • Symptomatic care/monitoring

    • Prevention of deterioration

    • Treat symptoms

    • Antidotes


Case altered mental status

Case – Altered Mental Status


Ems report

EMS Report

  • “This is a 57 yo male. We were called to his house by his son, who found him confused. The son is on the way here.

  • “On our arrival, we found a somnolent male who is not able to answer questions, is mildly diaphoretic, and had BP 135/75, HR 100, RR 32, and oxygen sat of 99% on room air. We have a 16 gauge IV in the left AC. D-stick was 95.

  • “Any questions for us before we leave?”


Ems report1

EMS Report

  • House was clean, no signs of an assault, etc.

  • No drug paraphernalia around

  • No medicalert bracelet or necklace

  • No open pill bottles near patient

  • Patient was found 5 ft from the bottom of a staircase


The patient s son arrives

The patient’s son arrives…

What would you like to ask his son?


His son tells you

His son tells you…

  • He talked to his dad yesterday, seemed normal

  • No significant PMH

  • PSHX: gallbladder taken out about 10 years ago

  • No medications except for something he occasionally takes for a “stomach flu bug”

  • SH: smoker : 40 pack/year hx, occasional social drinker

  • Wife died of cancer about a month ago—dad took her death “very hard”


Physical exam

Physical Exam

  • Vitals – T 38.2; BP 134/78; Pulse 102; RR 30; SaO2 98% on RA

  • Gen: 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

Sick or not sick?


Sick or not sick1

Sick or not sick

  • Sick but stable

  • No immediate airway, breathing or circulation interventions required

  • But altered mental status may be due to a life-threatening condition that requires prompt intervention


What s our differential diagnosis for this patient

What’s our differential diagnosis for this patient?


Broad differential diagnoses

Broad Differential Diagnoses

  • Neurologic

  • Malignant

  • Endocrine

  • Infection

  • Trauma

  • Toxicologic


Altered mental status

Altered Mental Status

  • Four life-threatening causes that require immediate treatment

    • Hypoxia (ruled out by normal pulse ox)

    • Hypotension/severe hypertension (ruled out by normal BP)

    • Herniation of the brainstem (ruled out by non-focal neurological exam)

    • Hypoglycemia (needs to be evaluated in every patient with altered mental status)


Get the best history possible

Get the best history possible

  • 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 exam1

Physical Exam

  • Thorough exam looking for clues:

    • Toxidromes- constellation of signs and symptoms of a particular poison

    • In the ED we always look for the “classic” presentation

  • Also look for signs of non-toxicologic causes:

    • Evidence of trauma, infection, metabolic or neurological causes, etc.


Common toxidromes

Common Toxidromes

  • Sympathomimetics

  • Anti-cholinergics

  • Cholinergics

  • Sedatives

  • Opiates


Sympathomimetics

Sympathomimetics

  • Cocaine, Amphetamines, PCP

    • Hypertension

    • Tachycardia

    • Diaphoresis

    • Mydriasis

    • Agitation

  • Does this sound like our guy?


Anticholinergics

Anticholinergics

  • 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?


Cholinergics

Cholinergics

  • 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


Cholinergics1

Cholinergics

  • Nicotinic effects - MTWThF

    • M-Mydriasis

    • T-Tachycardia

    • W-Weakness

    • TH-Hyperthermia

    • F-Fasciculations

  • Does this sound like our guy?


Opiates

Opiates

Opiates, Clonidine

  • Miosis

  • Hypotension

  • Bradypnea

  • Bradycardia

  • Hypothermia

  • CNS Depression

    Does this look like our guy?


Sedatives

Sedatives

Benzodiazepines, GHB

“Coma with normal vital signs”

  • CNS Depression

  • Normotensive

  • Mild bradypnea or normal RR

  • Does this look like our guy?


  • Toxins and vital signs

    Toxins 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


    Assessment

    Assessment

    • The history suggests an overdose, but we don’t know what

    • The physical exam is non-specific

      • No common toxidrome to suggest a diagnosis

      • Nothing to strongly suggest another cause

    • Time to gather more data….


    Diagnostic testing

    Diagnostic Testing

    What diagnostics might be helpful in this case?


    Diagnostics

    Diagnostics

    • General lab testing

      • Serum chemistry, blood gas to identify metabolic abnormalities

      • CBC, UA, CSF analysis to identify infection

      • Drug/alcohol screen to identify common drugs of abuse

    • Specific lab testing

      • Some poisons require specific testing


    The poisoned patient

    Labs

    • 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 now

    What is your assessment now?

    • What is the acid/base disturbance?

    • What is the differential for this acid/base disturbance?

    • Is this consistent with a common overdose?

    • How can we assess this problem?

    • Was the ECG, head CT, and CXR helpful?


    Salicylism aspirin poisoning

    Salicylism(Aspirin Poisoning)

    • Respiratory alkalosis

      • Direct stimulation of respiratory

        centers

        • Tachypnea

    • Metabolic acidosis

      • Aspirin is salicylic acid

      • Causes lactic acidosis by uncoupling oxidative phosphorylation

      • Causes ketosis by stimulating lipid metabolism

    • Confusion/cerebral edema


    Evaluation

    Evaluation

    • In most poisonings, symptoms do not correlate well with serum drug levels, so levels are not useful

    • Acute salicylate ingestion is one case where symptoms DO correlate with levels

      • Therapeutic is up to 30 mg/dl

      • This patient’s level was 75 mg/dl


    Poisoning management

    Poisoning Management

    • Supportive and symptomatic care are required for all poisonings


    Treating common poisoning symptoms

    Treating Common Poisoning Symptoms


    Poisoning management1

    Poisoning Management

    • Antidotal therapies are needed for only a few poisons. (Consult your EM book for detailed listings.)

    • Consider GI decontamination

      • Removal of drug or decrease absorption from GI tract


    Gi decontamination

    GI Decontamination

    • Ipecac syrup

      • No longer recommended for poisonings

    • Activated charcoal

      • Binds to most medications and potentially decreases GI absorption

      • Potentially useful within 1 hour of ingestion but no evidence of improved clinical outcomes

      • Aspiration is uncommon unless given by an NG tube or in patient with altered mental status


    Gi decontamination1

    GI Decontamination

    • Gastric Lavage

      • Insertion of large orogastric tube into the stomach and lavaging with several liters of fluid

      • Potentially useful in life threatening ingestions < 1 hour

      • Aspiration occurs in around 5% of patients


    The poisoned patient

    Borrowed from Vik Bebarta, “One Pill Can Kill”


    Gi decontamination2

    GI Decontamination

    • Whole Bowel Irrigation

      • Decreases GI transit time using PEG

      • Useful in life threatening ingestions when other methods not helpful


    Gi decontamination3

    GI Decontamination

    • Would GI decontamination be useful in this patient?

    • Do you think that this patient has more drug in the GI tract?


    Gi decontamination4

    GI Decontamination

    • He has a high salicylate level

    • He has been “confused for a couple of hours”

    • Probably not much drug left in the GI tract


    Specific treatments

    Specific Treatments

    Very few poisons require specific treatments such as:

    • Dialysis

    • Diuresis

    • Chelation

    • Cardiac pacing


    Salicylism treatment

    Salicylism - Treatment

    • Salicylate poisoning has a specific treatment

      • Alkaline diuresis – increase in urine pH favors movement of salicylate ion into urine

      • Dialysis for severe cases

        Is this patient sick enough to get dialysis?


    Non toxic ingestions small amounts

    Household bleach

    Cigarettes (<3)

    Cosmetics

    Glues/paste

    Hydrogen peroxide (medicinal)

    Matches

    Paint (indoor, latex)

    Shampoos, lotions

    Rat poison

    Detergents

    Chalk

    Laxatives

    Ink

    Antibiotics

    Antacids

    Non-Toxic Ingestions (Small amounts)


    Summary

    Summary

    • Always start with the ABCs

    • Target your history and physical for clues to the diagnosis

    • Labs and other testing may be useful

    • Most poisons only require supportive care

    • If you have questions call the Rocky Mountain Poison Center


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