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ACUTE POISONING. Major C J Porter RAMC Army Medical Directorate Emergency Medicine Registrar Bristol Royal Infirmary. Outline of lecture. Epidemiology Toxidromes History, examination and detective work General management Specific management Antidotes Scenarios. EPIDEMIOLOGY.

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acute poisoning

ACUTE POISONING

Major C J Porter RAMC

Army Medical Directorate

Emergency Medicine Registrar

Bristol Royal Infirmary

outline of lecture
Outline of lecture
  • Epidemiology
  • Toxidromes
  • History, examination and detective work
  • General management
  • Specific management
  • Antidotes
  • Scenarios
epidemiology
EPIDEMIOLOGY
  • 4000 UK deaths per year (1/3 CO)
  • Most deaths outside hospital
  • 100,000 Hospital admissions (12%)
  • Not just overdoses: Illicit drugs, Alcohol
epidemiology1
EPIDEMIOLOGY
  • Self poisoning:
      • F>M
      • 1/3 >one drug
      • Taken with alcohol: F: 40% M: 60%
  • Repeated self-poisoning: 11% of admissions
suicide
SUICIDE
  • 2% of male deaths
  • 1% of female deaths
  • Method:
      • Female: Poisoning 40%
      • Male: Gas / Hanging / Suffocation
  • Self-harm parasuicide:
      • 1% dead after 12 months
      • 3-5% dead after 5-10 years
toxidromes
Toxidromes
  • Patterns of signs and symptoms
  • Useful to help in diagnosis and treatment of unknown poisons
opiates
Opiates
  • Respiratory depression
  • Cardiovascular depression
  • Reduced level consciousness
  • Pinpoint pupils
  • Pulmonary oedema
  • Hypothermia
  • (Rapid response to Naloxone)
common causes
Common causes
  • Opiates – heroin, morphine etc
sympathomimetics stimulants
Sympathomimetics /Stimulants
  • Agitation/delusions/paranoia
  • Fight/Flight response
  • Tachycardia
  • Hypertension
  • Arrhythmias
  • Dilated pupils
  • Seizures
  • Hyperpyrexia
common causes1
Common causes
  • Cocaine
  • Amphetamines
  • Decongestants
  • Ecstasy
anticholinergic
Anticholinergic
  • Tachycardia
  • Arrhythmias
  • Pupils: mid-point or dilated / divergent
  • Confusion / drowsiness / coma
  • Seizures
  • Dry flushed skin
  • Urine retention
  • Hypertonia, Hyper-reflexia, Myotonic jerks
anticholinergic signs
Anticholinergic signs
  • Hot as a hare
  • Blind as a bat
  • Dry as a bone
  • Red as a beet
  • Mad as a hatter
common causes2
Common causes
  • Antidepressants-Tricyclics
  • Antihistamines
  • Atropine
  • Antipsychotics
  • Antispasmodics
serotonin syndrome
Serotonin Syndrome
  • Similar to anticholinergic syndrome
    • loss of consciousness: uncommon
    • sweating and tremor: common
  • Agitation
  • Delirium
  • Hypertonia / myoclonus
  • Tachycardia
  • Tachypnoea
common causes3
Common Causes
  • SSRIs
  • MAOIs (Hyperpyrexia / Hypertensive crisis)
cholinergic
Cholinergic
  • Brady/tachycardia
  • Confusion/reduced GCS
  • Pinpoint pupils
  • Seizures
  • Weakness
  • SLUDGE
  • Pulmonary oedema
sludge
SLUDGE
  • S sweating salivation
  • L lacrymation
  • U urinary frequency urgency
  • D diarrhoea
  • G gastrointestinal discomfort
  • E eyes pinpoint
common causes4
Common causes
  • Organophosphates
  • Physostigmine
  • Some mushrooms
  • Nerve agents
salicylism aspirin
Salicylism: Aspirin
  • Impaired hearing
  • Tinnitus
  • Sweating
  • Warm skin
  • Hyperventilation
  • Cinchonism: Quinine (salicylism + blindness)
management overview
Management Overview
  • History & assessment of vital signs
      • ANY concerns: move patient to RESUS

A B C D

DEFG

  • Supportive care (O2, IV Fluids)
  • Prevent absorption
  • Increase elimination
  • Antidotes
  • PSYCHOLOGICAL ASSESSMENT
history
History
  • What?
  • When?
  • How much? (mg/kg)
  • What else?
  • Why?
collateral history
Collateral history
  • Paramedics
  • Family / friends
  • Notes
  • Look in pockets – carefully!!!
detective work
Detective work
  • BNF
  • Toxbase
  • Tablet identification aids: TICTAC
  • Poisons advice: NPIS
  • Plant identification books
  • National teratology information service
initial examination
Initial examination
  • Treat problems as you find them!!
  • Airway
  • Breathing
  • Circulation
  • Disability – GCS/AVPU and Pupils
  • DON’T EVER FORGET GLUCOSE
observations
Observations
  • Saturations and respiratory rate
  • Pulse and blood pressure
  • GCS
  • Pupils
  • Temperature
  • GLUCOSE
investigations
Investigations
  • All Patients
    • Glucose
    • U&E
    • Paracetamol & Salicylate
  • As indicated
    • LFT
    • Co-ag / INR
    • CK
    • ABG / VBG
    • ECG
    • CXR
  • Urine toxicology screen
reduce absorption
Reduce absorption
  • Emesis – No role
  • Activated charcoal within 1 hour
  • Gastric lavage – rarely
  • Whole bowel irrigation - rarely
increase elimination
Increase elimination
  • Urinary alkalinisation
  • Multi-dose Activated Charcoal
  • Haemodialysis
  • Haemoperfusion
  • Plasma exchange
  • Forced alkaline diuresis(no longer recommended)
paracetamol
Paracetamol
  • Very common: 40% poisons admissions
  • Often asymptomatic
  • Can be lethal – 200-300 deaths/year
  • Check blood level at 4 hours
  • Two treatment lines normal and high risk
  • Given IV N-acetylcysteine
paracetamol metabolism
Paracetamol metabolism
  • Metabolised by glucuronidation (60%),

Sulphation (35%) and oxidation (10%)

  • Cytochrome p450 produces NAPQI
  • NAPQI toxic causes hepatocellular necrosis – irreversible binding
  • NAPQI detoxified by conjugation with glutathione
high risk
High Risk
  • Increased oxidation
    • Chronic alcohol use
    • Drugs
  • Reduces glutathione stores
    • Malnutrition
    • Eating disorders
    • Chronic liver disease
n acetylcysteine
N-acetylcysteine
  • Most effective within 8 hours
  • Precursor for glutathione production
  • Can cause anaphylactoid reactions
  • Consider starting before paracetamol result if:
    • Presenting > 8 hrs & >150mg/kg taken
    • Staggered overdose
patient 1
Patient 1
  • 20 year old woman who takes a handful of paracetamol tablets
  • No drug history
  • No alcohol use
  • Fit and well
  • Blood level is 80mg/l
no need to treat
No need to treat
  • Patient is not high risk
  • Level at 4 hours is below even the high risk line
patient 2
Patient 2
  • 70 year old man
  • Takes 20 paracetamol 6 hours before presenting
  • Alcoholic
  • No drug history
  • Blood level 100mg/l
treat
Treat
  • Patient is high risk
  • Level is above the high risk line
  • Delayed presentation means need to act fast
patient 3
Patient 3
  • 17 year old epileptic
  • 25 codydramol 2 hours before attendance
  • Taking carbamazepine
  • Blood level at 4 hours is 120mg/l
treat1
Treat
  • High risk patient
  • Level above the high risk line
patient 4
Patient 4
  • 35 year old man who presents after taking 24 paracetamol over a period of 24 hours
  • No drug history
  • Fit and well
  • Blood level 20mg/l
treat2
Treat
  • Staggered overdoses are difficult
  • Poisons advice is to give IV acetylcysteine
  • Levels are not that helpful
  • Need to monitor Liver function, clotting and renal function
  • May need discussing with Liver Unit if abnormal
paracetamol1
PARACETAMOL

DEADLY PITFALLS

  • The Prescott Nomogram High Risk Line
  • Staggered Overdoses
  • Management of late presentation
  • Recheck U&E, LFT, INR after N-acetylcysteine
tricyclics
Tricyclics
  • Antidepressants
  • Dangerous: US 60-70% fatal ODs
  • UK commonest fatal OD per prescription
  • 10% unconscious patient will fit
    • Treat fits with diazepam/lorazepam
tricyclic effects
Tricyclic effects
  • Anticholinergic toxidrome
  • The 3 C’s
    • Coma
    • Convulsion
    • Cardiac
tricyclics cardiac effects
Tricyclics cardiac effects
  • Quinidine effects lead to arrhythmias
  • ECG
    • Sinus tachycardia
    • Broad QRS: RBBB
    • Prolonged QT interval
    • Right axis deviation
  • Severe poisoning – VT, bradycardia, heart block
  • QRS > 160mS = ↑↑risk of seizures and cardiac toxicity
tricyclics1
Tricyclics
  • ABG
    • Hypoxaemia
    • Metabolic acidosis
    • Respiratory acidosis
tricyclics2
Tricyclics
  • Management:
    • EARLY ITU REFERRAL
    • SODIUM BICARBONATE
      • If hypotension resistant to fluid challenge
      • Dysrhythmias
      • Convulsions
    • Consider IV Magnesium for resistant dysrhythmia
salicylate
Salicylate
  • Salicylism
  • Dehydration
  • Confusion /coma
  • Seizures
  • Haemetemesis
  • Hypoglycaemia
salicylate1
Salicylate
  • Metabolic and acid-base disturbance
  • Complex
  • Respiratory alkalosis – direct stimulation to over breathe
  • Metabolic acidosis- acid, impaired normal metabolism, production of lactic acid
  • Check ABG / VBG
salicylate2
Salicylate
  • Severity of ingested dose:
      • >150 mg/kg: mild
      • >250 mg/kg: moderate
      • >500 mg/kg: severe
salicylate management
Salicylate management
  • Tailor treatment to symptoms
  • Fluids
  • Reduce absorption:
      • Activated charcoal
      • Gastric lavage (>500 mg/kg and <1 hour)
  • Increase elimination:
      • Urinary alkalinisation
  • Cooling
  • Glucose if hypoglycaemic
salicylate management1
Salicylate management
  • <350mg/L: oral fluids
  • >350mg/L: urinary alkalinisation
  • >700mg/L: haemodialysis
  • DISCUSS WITH NPIS
salicylate3
Salicylate

DEADLY PITFALL

  • Salicylate levels can continue to rise following admission (10% of cases)
    • Repeat levels every until peaked
opiates1
Opiates
  • Common
  • Act on μ-receptors
  • Reversible with Naloxone
  • Naloxone pure opioid antagonist
  • Naloxone
      • Short half life: may need repeated doses
  • Give IV +/- IM & may need IVI
antidotes
Antidotes
  • Opiates – naloxone
  • Paracetamol – acetylcysteine/methionine
  • Beta-blockers – glucagon
  • Insulin – glucose
  • Iron – desferrioxamine
  • Carbon monoxide – oxygen
  • Methanol - ethanol
  • (Benzodiazepines – flumazenil)
scenario 1
Scenario 1
  • 20 year old IVDU found by ambulance crew unconscious
  • Needle lying by side
  • Resp rate 6, Sats 94% on air
  • 60bpm BP 100/55
  • Responds to pain
what next
What next?
  • A – Give naloxone
  • B – Check airway
  • C – Take history
  • D – Give flumazenil
check airway
Check airway
  • Check airway patent
  • Give oxygen
  • Call for senior help
  • Check glucose
  • Give naloxone IM and IV
scenario 2
Scenario 2
  • 30 year old woman
  • Taken some white tablets 4 hours earlier
  • Feels completely well
  • Felt depressed after argument with partner
  • Usually fit and well
what next1
What next?
  • A – Start N-Acetylcysteine
  • B – Discharge as she is obviously well
  • C – Find out what the tablets are
  • D –Take blood for paracetamol levels
take bloods
Take bloods
  • Early treatment is essential in paracetamol overdose
  • Need to know what her levels are as soon as possible
scenario 3
Scenario 3
  • 45 year old man works in local aquarium
  • Put right hand into tank and got stung by a lion fish
  • Respiratory rate 16 sats 100% on air
  • Pulse 100 bpm 160/80
  • Fully conscious
  • Extreme pain in hand
what next2
What next?
  • A – Panic you know nothing about lion fish!
  • B – Look on Toxbase
  • C – Ring local zoo
  • D – Ask a senior who also knows nothing about Lion fish!
toxbase
Toxbase
  • Patient needs cardiovascular monitoring
  • Analgesia
  • Hand in water as hot as can tolerate
  • Lion fish toxin is heat labile
  • Carefully remove spines if present
  • Few hours later patient feels much better goes home
summary
Summary
  • Common
  • Approach using:

A B C D

DEFG

  • Consider the toxidromes
  • Early senior help / Early ITU referral
  • Supportive Care
  • Antidotes
  • Psychological assessment