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Management of Acute Overdose . By: Peter Rempel March 27 th , 2013. Presentation Outline. Introduction and Statistics General management strategy Identification of Toxidromes Management of overdose for specific medications Role of pharmacist. Introduction - Overdose.

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Management of acute overdose

Management of Acute Overdose

By: Peter Rempel

March 27th, 2013

Presentation outline
Presentation Outline

  • Introduction and Statistics

  • General management strategy

  • Identification of Toxidromes

  • Management of overdose for specific medications

  • Role of pharmacist

Introduction overdose
Introduction - Overdose

  • Definition: The use of a substance in quantities greater than recommended.

  • Accidental vs. Intentional misuse

Epidemiology overdose
Epidemiology - Overdose

  • Approximately 2.3 million cases reported (US)

    • 50% caused by pharmaceutics

  • 41,592 deaths occurred in the US (2009)

    • 76%were unintentional

      • 91%caused by medications

  • Prevalence higher in males during the early years (0-12y)

    • Rates in females surpass males in older populations

Epidemiology continued
Epidemiology (Continued)

Most common pharmaceutics:

  • Analgesics (Opioids)

  • Sedative/hypnotic/antipsychotics

  • Antidepressants

  • Antihistamines

  • Cardiovascular drugs

  • Vitamins, cough and cold products

  • Rates of unintentional overdose has been steadily increasing

General management strategy
General Management Strategy

  • ABC management (vital signs)

  • Call Poison Control

  • Obtain best possible medical history

  • Order Labs

  • Prevent absorption of toxin

  • Enhance elimination (antidote)

General management strategy1
General management strategy

  • ABC management

    • Airway patency

      - head-tilt and chin-lift, removal of obstructions

    • Breathing

      -assisted ventilation

    • Circulation

      - colour change, sweating, decreased LOC

      - EKG, saline infusion, vasopressers

General management strategy2
General Management Strategy

  • Call Poison Control

    • Available 24/7 to provide poison treatment information

    • Help guide treatment strategy

    • Prevent unnecessary use of health care resources


General management strategy3
General Management Strategy

  • Obtain accurate history

    • Determine the causative agent

    • Dose

    • Time since exposure

    • Route

    • Demographics (age, weight)

    • Symptoms*

    • Physical Examination

What if you don’t know what medication/poison was ingested?

Identification of Toxidromes

What is a toxidrome
What is a Toxidrome?

  • Characteristic symptoms that are associated with a specific group of medications.

  • These group of symptoms are known as a “Toxidrome”

Identification of toxidromes
Identification of Toxidromes

Cholinergic Toxidrome

  • “SLUDGE”

    • Salivation, Lacrimation, Urination, Defecation, GI upset, Emesis

    • Miosis, diaphoresis, bradycardia

  • Causative Agents: Physostigmine, Organophosphates, Carbamate

Identification of toxidromes1
Identification of Toxidromes


  • Hot as a Hare - fever

  • Red as a Beet - flushing

  • Mad as a Hatter – confusion, delirium

  • Dry as a bone – dry skin/mucus membranes

  • Mydriasis, tachycardia, urinary retention

  • Causative Agents: Antihistamines, TCA`s, Anti-parkinsonmedications

Identification of toxidromes2
Identification of Toxidromes


  • Anxiety, Delusions, Sweating, Piloerrection, Seizures, Hyperreflexia, Mydriasis

  • Causative Agents: cocaine, salbutamol,, amphetamines, ephedrine, pseudoephedrine, methamphetamine

Identification of toxidromes3
Identification of Toxidromes

Sedative/Hypnotic/Opiate Toxidrome

  • Slurred speech, confusion , stupor, coma, apnoea, respiratory depression

  • Hypotension, bradycardia, miosis

  • Causative agents: opioids,anticonvulsants, antipyschotics, barbiturates, benzodiazepines, ethanol

General management strategy4
General Management Strategy

  • Order lab tests

    • Confirm offending agent(s)

    • Predict prognosis

    • Direct therapy/monitoring

      Includes:Toxicology screen, anion gap, osmol gap, CBC, BUN, SCr, blood glucose, electrolytes, EKG monitoring

General management strategy5
General Management Strategy

  • Prevent absorption

  • *Activated Charcoal- first line therapy in most emergency departments

  • Whole Bowel Irrigations- clears the GI tract using high volumes of PEG

  • OrogastricLavage- No benefit over the use of activated charcoal

  • Syrup of Ipecac- NO LONGER RECOMMENDED

General management strategy6
General Management Strategy

Activated Charcoal

  • Ability to adsorb substances due to its high surface area

  • Offending agent(s) become trapped by the charcoal and are excreted in the feces

    Dosing: 1g/kg po OR by NG tube (usually given multiple times)

    AE: aspiration pneumonia, GI obstruction

    Contraindications: presence of ileus

General management strategy7
General Management Strategy

Activated Charcoal

  • Does not adsorb the following compounds:

    • Iron

    • Lithium

    • Lead

    • Cyanide

    • Alcohol

General management strategy8
General Management Strategy

  • Enhance Elimination

  • Hemodialysis/Hemoperfusion

  • Administer Antidote

General management strategy9
General Management Strategy

Administer Antidote:

*See my website for a more exhaustive list

Opioid overdose managment
Opioid Overdose Managment

Opioid overdose management
Opioid Overdose Management

  • Signs and Symptoms?

    • Hint: Remember the toxidrome!

Opioid overdose management1
Opioid Overdose Management

  • Signs and Symptoms?

    • Hint: Remember the toxidrome!

    • Decreased LOC, RR, GI motility

    • Hypotension, bradycardia, miosis


  • Reverses effects from opioid overdose

  • Pure opioid receptor antagonist

  • Duration of action 30-120 minutes

  • 0.4-2mg (IV,IM,SC); repeat q2-3 minutes until reversal of symptoms

  • Use continuous IV infusion for exposure to long-acting opioids or SR formulations

Hamm J. Acute acetaminophen overdose in adolescents and adults.CriticalCare Nurse; Jun 2000; 20(3) 69-74

Hamm J. Acute acetaminophen overdose in adolescents and adults.CriticalCare Nurse; Jun 2000; 20(3) 69-74

N acetylcysteine

  • Indicated for the reversal of Acetaminophen toxicity

  • Hepatoprotective agent

  • Restores hepatic glutathione and acts as a glutathione substitute

  • Prevents the production of the toxic by-product of acetaminophen

N acetylcysteine dosing
N-acetylcysteine Dosing

  • 21 hour IV dosing regimen (3 doses)

    • LD: 150 mg/kg (Max 15g) over 1 hour

    • 2nd dose: 50 mg/kg (max 5g) over 4 hours

    • 3rd dose: 100 mg/kg (max 10g) over 16 hours

  • Oral dosing regimen also available (72 hours)

  • Therapy is guided by the Matthew-RumackNomogram

  • Matthew rumack nomogram

    The Merck Manual for Health Professionals. Acetaminophen Poisoning.

    Lipids 20 intralipid
    Lipids 20%- Intralipid®

    • Used in anaesthetic overdose and refractory cases (unlabelled use)

    • Mechanism unknown

    • Effective for lipophilic medication overdose

    • Suggested Dose:

      • 1.5 mL/kg bolus infused over 1 minute (may repeat up to 2 times)

      • Followed by 0.25 mL/kg/minute continuous infusion

    Role of the pharmacist
    Role of the Pharmacist

    • Role in both the community and hospital setting

    • Educating patients on the dangers of drug misuse

    • Identifying potential at risk patients

    • Identifying inappropriate medication regimens

    • Medication Reconciliation


    • Majority of overdoses are accidental

    • Rates of accidental overdose is steadily increasing

    • Identifying Toxidromes plays a vital role in the management of overdose

    • Activated charcoal and whole bowel irrigation are effective at lowering absorption

    • Pharmacists can play a role in both the prevention and treatment of an overdose


    • Clinical Practice Guidelines. Management of Drug Overdose & Poisoning. Ministry of Health, Singapore. May 2000.

    • Green SL, Dargan PI, Jones AL. Acute poisoning: understanding 90% of cases in a nutshell. Postgrad Med J. 2005;81:204-216.

    • Tenenbein M et al. Efficacy of ipecac-induced emesis, orogastriclavage, and activated charcoal for acute drug overdose. Annals of Emergency Medicine; 16(8): 838-841 

    • Lab Tests Online. Emergency and Overdose Drug Tests. Accessed March 22, 2013

    • Thim T, Niels HV, et al. Initial assessment and treatment with the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach. International Journal of General Medicine; 2012:5 117-121


    6) Centers for disease control and prevention. Home and Recreational Safety. Unintentional Poisoning Data and Statistics. Retrieved from ; accessed March 3, 2013

    7) HodgmanMJ et al. A review of Acetaminophen Toxicity.Crit Care Clin. 28 (2012) 499-516

    8) G Cave et al. Intravenous Lipid Emulsion as Antidote Beyond Local Anesthetic Toxicity: A Systematic Review. Academic Emergency Medicine: 2009; 16:815-824

    9) Boyer EW. Management of Opioid Analgesic Overdose.. N Engl J Med: 367;2 146-155

    Thank you for listening
    Thank you for listening