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CASES IN MEDICAL TOXICOLOGY. Steven R. Offerman, MD Department of Emergency Medicine Kaiser Permanente Northern California South Sacramento Medical Center Sacramento, CA. (800) 411 - 8080. KAISER TOXICOLOGY. CASE #1.

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cases in medical toxicology

CASES IN MEDICAL TOXICOLOGY

Steven R. Offerman, MD

Department of Emergency Medicine

Kaiser Permanente Northern California

South Sacramento Medical Center

Sacramento, CA

case 1
CASE #1
  • A 32yo alcoholic male presents to the ED complaining of “severe” migraine HA
  • He reports taking two vicodin every 2 hours without relief, last dose about 3 hrs
  • HA is similar to past migraines though severe, no numbness or weakness, denies abdominal pain or vomiting
case 15
CASE #1
  • Awake and alert. Appropriate/lucid. Wearing sunglasses. Pupils are midrange and reactive. Some photophobia. Lungs are clear. Abdomen soft with mild epigastric TTP. Neuro exam is normal.
  • CBC normal. Electrolytes normal.
case 16
CASE #1
  • Acetaminophen level of 71mg/dL, AST=64, ALT=55, T bili=1.1
  • Serum ethanol level of 95 mg/dL
  • No scleral icterus, no stigmata of liver disease
case 17
CASE #1
  • Acetaminophen level of 71mg/dL, AST=64, ALT=55, T bili=1.1
  • Serum ethanol level of 95 mg/dL
  • No scleral icterus, no stigmata of liver disease
potential toxicity
POTENTIAL TOXICITY
  • Acute: 7g (10g)
  • Chronic: 4g per day (7g)
  • Susceptible patients (alcoholics, ACs, INH)
    • Similar risk for acute ingestion
    • Potential higher risk in chronic ingestions (4g)
risk assessment
RISK ASSESSMENT
  • Only two types of toxic ingestions!
  • Acute ingestion + known TOI (<24 hr)
    • Place on nomogram
  • Unknown TOI / Chronic ingestion
    • Check APAP + AST/ALT
    • No NAC if <5 and normal AST/ALT
n acetylcysteine
N-ACETYLCYSTEINE
  • Very effective – 100% within 8 hours
  • Oral in U.S. – IV in Europe
  • Dose: 140mg/kg load, 70mg/kg Q 4hrs
    • Traditional – 72 hours
    • Short course – reassess at 20 hours
intravenous nac
INTRAVENOUS NAC
  • Oral preparation vs Acetadote®
  • Concern is anaphylactoid reactions
  • Indications:
      • Can’t tolerate oral NAC
      • Contraindication to oral therapy
      • Ongoing GI decon (coingestant)
      • Fulminant hepatic failure?
      • Pregnant patient?
case 2
CASE #2
  • 25 month old male brought into the ED by parents after he was found eating D-con rat poison.
  • He was found 30 minutes ago with pellets in his mouth and in the front of his diaper.
  • He has been behaving normally and has not vomited.
  • He appears normal in the ED.
brodifacoum
BRODIFACOUM
  • Warfarin derivative – “Superwarfarin”
    • Highly potent
    • Long half-life
    • Dehydration
brodifacoum20
BRODIFACOUM

Ann Emerg Med 2002; 40: 73-5

case 3
CASE #3
  • 13 yo male is brought into clinic by his mother.
  • She states “I think my son is on drugs.” He has been behaving strangely and hanging out with “the wrong crowd.”
  • The patient denies any drug use.
  • The mother insists that you test for “drugs.”
drug testing
DRUG TESTING?

Arch Pediatr Adolesc Med 2006; 160: 146-50

urine immunoassay24
URINE IMMUNOASSAY
  • Opiates
  • Cocaine metabolite
  • Amphetamine
  • Benzodiazepines
  • Barbiturates

* No urine screen can confirm intoxication, only exposure

the good
THE GOOD
  • Cocaine metabolite = Benzylecogonine
    • Benzylecogonine longer lived
    • No false positives
  • Marijuana = cannibinoids (THC)
    • No false positives except Efavirenz
  • Barbiturates
    • Detects most class members reliably
the bad
THE BAD
  • Opiates
      • Opiates screen, not opioids
  • Benzodiazepines
      • Test for oxazepam metabolite
  • PCP
      • Cross reacts with DXM & ketamine
opiates vs opioids
OPIATES VS OPIOIDS
  • Opiates = from the poppy
    • Morphine, codeine, thebaine
  • Opioids = synthetic or semi-synthetic

TARGET (300 ng/mL)

20,000 ng/mL

benzos
BENZOS
  • Urine immunoassay detects Oxazepam
the ugly
THE UGLY
  • Amphetamines
      • Many false positives
      • Poor cross-reactivity with sympathomimetic amines
  • TCA screen
      • So many false positives that a positive test is more likely false than true
amphetamine positive
AMPHETAMINE POSITIVE
  • Legal amphetamines
      • Vicks inhaler (l-methamphetamine)
      • Dexamphetamine (Dexadrine, Adderall)
      • Methylphenidate (Ritalin, Concerta)
  • Drugs metabolized to amphetamines
      • Benzaphetamine, clobenzorex, famprofazone, fenoproporex,selegiline (D-methamphetamine)
amphetamine positive33
AMPHETAMINE POSITIVE
  • Cross reactive stimulants
      • Ephedrine, fenfluramine, MDA,MDMA, PMA, phenteramine, phenmetrazine, pseudophedrine, phenylpropanolamine, and other amphetamine analogs
  • Cross reactive nonstimulants
      • Buproprion (Wellbutrin), chlorpromazine, labetalol, ranitidine, sertraline (Zoloft),trazadone, trimethbenzamide (Tigan)
case 4
CASE #4
  • 44 yo male presents to a London hospital with severe abdominal pain, vomiting, and diarrhea.
  • Upon presntation he is found to have pancytopenia. He was previously healthy.
  • Over the first 5 days of his hospitalization he develops alopecia.
polonium 210
POLONIUM 210
  • Intense alpha emitter
  • Dangerous when incorporated into body
  • 5 million times more toxic than hydrogen cyanide by weight (LD50 50ng vs 250mg)
case 5
CASE #5
  • A 74 year-old man is brought in by his son for dizziness that is worse with standing
  • Pt has a history of mild dementia and hypertension
  • He lives alone and doesn’t remember his meds
  • Initial vitals are: 90/55 75 18 37.4
  • He seems mildly confused
case 547
CASE #5
  • In the ED, he becomes progressively more bradycardic, hypotensive, and disoriented
  • His vitals now are BP=72/34 and HR=30
slide51

All substances are poisons; there is none which is not a poison. The right dose differentiates poison from remedy. - Paracelsus (1493-1541)

calcium channel blockers52
CALCIUM CHANNEL BLOCKERS
  • Most commonly Rxed CV drug class
    • 5% of toxic deaths in 2004 (TESS)
ccb management
Initial / Supportive

ABCs

Fluids

Atropine?

Decontamination

Pharmacotherapy

Calcium

Catecholamines

Glucagon

Insulin/Glucose (HIE)

PDE inhibitors

Cardiac pacing

IA Balloon Pump

CCB MANAGEMENT
ccb management55
Initial / Supportive

ABCs

Fluids

Atropine?

Decontamination

Pharmacotherapy

Calcium

Catecholamines

Glucagon

Insulin/Glucose (HIE)

PDE inhibitors

Cardiac pacing

IA Balloon Pump

CCB MANAGEMENT
ccb decon
CCB DECON
  • BE AGGRESSIVE!!
    • Gastric Lavage (early presentations)
    • SD Activated Charcoal (all)
    • MD Activated Charcoal (SR preps)
    • Whole Bowel Irrigation (SR preps)
    • Hemodialysis – No role for CCBs
calcium therapy
CALCIUM THERAPY
  • Calcium Chloride (Inotropic agent)
    • 1g bolus (10 mL of 10% sol’n)
    • Drip at 1-3g per hour in Normal Saline
      • Central Line
      • Monitor ionized Ca

(Goal = 2.5-3 mEq/L)

** Calcium gluconate can be used but 1/3 calcium load per mg

glucagon
GLUCAGON
  • Dose
    • 5-10 mg over 1-2 minutes
    • Infusion: Response dose / hour
  • Adverse effects
    • Nausea / vomiting
    • Hyperglycemia
    • Rare allergy (recombinant)
hie therapy
HIE THERAPY

Boyer et al. Ped Emerg Care 2002; 18: 36

hie therapy61
HIE THERAPY
  • Insulin / Glucose
    • Animal data
    • Human case series and reports
    • Exact mech unknown – carbo utilization
  • High Dose !!
    • Insulin 1 U/kg bolus
    • Insulin infusion 0.5 – 1 U/kg/hour
ccb bb poisoning insulin
CCB/BB Poisoning - Insulin

Boyer et al. Ped Emerg Care 2002; 18: 36

case 6
CASE #6
  • A 14 month-old female was brought in after snakebite to the face when she encountered a snake while playing in her backyard.
deadly envenomation
DEADLY ENVENOMATION
  • Death is rare! (~5 deaths per year)
  • Local effects usually most prominent

(Limb threat >> Life threat)

  • Life-threatening envenomations:
    • Intravascular strikes
    • Anaphylactoid
    • Facial / neck strikes
crotaline fab antivenom
CROTALINE FAB ANTIVENOM
  • Fab-antibody based antidote (digibind)
    • Ovine (sheep) serum
    • 4 North American snakes

(Western & Eastern DB, Mojave, cottonmouth)

    • More potent
    • Fewer allergic reactions
    • No serum sickness