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Identifying Poisoning. Is This Patient Poisoned, And If So, With What?. The Dose Makes The Poison. “What is there that is not poison? All things are poison and nothing [is] without poison. Solely the dose determines that a thing is not a poison”. Philip Theophrastus Bombast von Hohenheim

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identifying poisoning

Identifying Poisoning

Is This Patient Poisoned,

And If So, With What?

the dose makes the poison
The Dose Makes The Poison

“What is there that is not poison? All things are poison and nothing [is] without poison. Solely the dose determines that a thing is not a poison”

Philip Theophrastus Bombast von Hohenheim

aka PARACELSUS (1493-1541)

goal of clinical management
Goal of Clinical Management

To proceed from undifferentiated signs and symptoms in a patient [without a dependable history] to a reasonable diagnosis ....... in order to initiate appropriate therapy.

  • Rapid
  • Organized
  • Efficient
  • Safe
  • Effective
is this patient poisoned
Is This Patient Poisoned
  • A 37 year old female with a history of a seizure disorder presents with:
    • Fever (38.5oC)
    • A rash (shown)
  • Only medication, phenytoin 300 mg/day for years
  • No occupational exposures
  • No significant hobbies
is this patient poisoned5
Is This Patient Poisoned
  • Laboratories
    • 21% Eosinophils
    • An AST of 300 IU/L
  • Diagnosis:
    • Anticonvulsant hypersensitivity syndrome
the history
The History
  • The toxin
    • Medications, Hobbies, Occupation
    • The form and route
    • Amount
    • Elapsed time
  • Symptoms
    • Current or resolved symptoms
    • Timing of symptom onset
    • Prior therapy administered
is this person poisoned
Is This Person Poisoned
  • A 28 year old female is brought to the hospital because of “lethargy”
  • No past medical or surgical history
  • No medications
  • No hobbies
  • Full time student
slide8
Vital signs normal
  • Slight nystagmus
  • Slight lethargy easily arousable
  • Dull expression
  • Flat affect
  • Not bothered by her condition
  • Slightly unsteady gait
slide9
Basic laboratory studies normal
  • ECG normal
  • CT scan normal
  • Lumbar puncture normal
  • Urine positive for benzodiazepines
    • Flumazenil given
    • Mental status normal
    • Police investigation results
how are poisoned patients different
How Are Poisoned Patients Different
  • Suicide note
  • Empty bottles
  • Occupational or environmental cluster
  • Psychiatric history
  • Substance abuse / misuse
  • Inconsistencies
    • Cardiac findings in young people
    • Vital signs not consistent with mental status
toxidrome toxicologic syndrome
Toxidrome = Toxicologic Syndrome
  • Toxidrome recognition allows rapid clinical diagnosis and targeted therapy.
    • Patient history
    • Vital signs
    • Targeted physical examination
    • Rapid, bedside laboratory testing
      • Metabolic
        • Glucose
        • Acid-base
      • ECG
toxicologic physical examination
Toxicologic Physical Examination
  • Vital signs
    • Including temperature and pulse oximetry
  • Key organ system
    • Mental status
    • Pupils
    • Skin
    • Bowels
    • Bladder
toxidrome
Toxidrome

Symptoms

&

Signs

History

Vital signs

Simple labs

we do this will all patients
We Do This Will All Patients
  • Headache
  • Fever
  • Altered mental status
  • Rash
  • = Meningococcal meningitis
opioids
Opioids
  • CNS depression
  • Miosis
  • Respiratory depression
  • Gastrointestinal Stasis
  • Relative bradycardia
  • Relative hypothermia
sympathomimetic
Sympathomimetic
  • Hypertension, tachycardia, hyperthermia, tachypnea
  • Mydriasis
  • Diaphoresis
  • Psychomotor agitation
anticholinergic antimuscarinic
AnticholinergicAntimuscarinic
  • Hypertension, tachycardia, hyperthermia, tachypnea
  • Mydriasis
  • Psychomotor agitation or somnolence
  • Dry flushed skin
  • Absent bowel sounds
  • Urinary retention
remember
Remember
  • Hot as a Hare: warm skin
  • Dry as a bone: dry skin and mouth
  • Blind as a Bat: cycloplegia, mydriasis
  • Red as a Pepper: flushed skin
  • Full as a flask: urinary retention
  • Mad as a Hatter: altered mental status, hallucinations
differentiation
Differentiation
  • Anticholinergic vs Sympathomimetic
    • Pupils?
    • Skin
    • Bowels
    • Bladder
cholinergic
Muscarinic

Salivation

Lacrimation

Urination

Defecation

Bronchorrhea

Bradycardia

Miosis

Nicotinic

Muscle weakness

Fasciculations

Paralysis

Hypertension

Tachycardia

Mydriasis

Cholinergic
salicylates
Salicylates
  • Nausea and vomiting
  • Tinnitus
  • Tachypnea and hyperpnea, rarely hyperthermia
  • Diaphoresis
  • Respiratory alkalosis
  • Metabolic acidosis
  • Ketonuria
tricyclic antidepressant
Tricyclic Antidepressant
  • Somnolence, lethargy, or coma
  • Tachycardia and hypotension
  • Seizures
  • Abnormal ECG
  • Anticholinergic findings
hypoglycemia
Hypoglycemia
  • Tachycardia
  • Diaphoresis
  • Tremor
  • Altered mental status
    • Decerebrate posturing
    • Decorticate posturing
    • Fixed and dilated pupils
incidence of hypoglycemia
Incidence of Hypoglycemia
  • True incidence probably unknown
  • In 12 months 125 patients were diagnosed at the Harlem Hospital ED
      • Malouf and Brust: Ann Neurol 1985;17:421-430
  • 29/340 (8.5%) consecutive EMS runs for AMS, were identified with hypoglycemia
      • Hoffman: Ann Emerg Med 1992;21:20-24.
hypoglycemia25
Hypoglycemia
  • Using the classic findings hypoglycemia
    • Altered mental status
    • Tachycardia
    • Diaphoresis
    • And/or a history of diabetes
  • to predict a response to D50W, 25% of hypoglycemic patients would be missed
      • Hoffman: Ann Emerg Med 1992;21:20-24
hypoglycemia with a normal glucose
Hypoglycemia With A Normal Glucose
  • Poorly controlled diabetics had symptoms at glucose levels significantly higher than well controlled diabetics:
  • 4.3 vs 2.9 mmol/L
      • Boyle: N Engl J Med 1988;318:1487-1492
tackling toxidromes
Tackling Toxidromes
  • Good history
  • Directed physical examination
    • Vital signs, pupils, skin, bowel bladder
  • Simple tests
    • Rapid glucose, ECG, ABG, UA, etc
  • Simple interventions
think about
Think about…
  • Ethanol
  • Paracetamol (acetaminophen)
    • About 1 out of 500 suicidal patients has an unexpected, treatable level

Ashbourne J. Ann Emerg Med 1989;18:1035

  • Assessment of other potential exposures
  • Assessment of pregnancy
provide life saving care
Provide Life-Saving Care
  • Treat the Patient Before the Poison:
    • Airway
    • Breathing
    • Circulation
  • Rare immediate Antidotes
    • Cyanide kit
poisoning includes deficiencies
Poisoning Includes Deficiencies
  • Withdrawal syndromes
    • Alcohol
    • Sedatives
    • Opioids
    • Etc
  • Metabolic
    • Thiamine (Wernicke’s encephalopathy)