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Introduction to Toxicology. Medical Toxicology.... . Is a board-accredited specialty requiring at least two years of training after residency in either emergency medicine, pediatrics, internal medicine or preventative medicine.

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Medical toxicology
Medical Toxicology....

  • Is a board-accredited specialty requiring at least two years of training after residency in either emergency medicine, pediatrics, internal medicine or preventative medicine.

  • Deals with the “diagnosis, management and prevention of poisoning and other adverse health effects due to medications, occupational and environmental toxins, and biological agents”


Introduction to toxicology


Part i approach to the poisoned patient
Part I: Approach to the poisoned patient.

  • “Attempts to identify the poison should not delay care.”

  • Initial management of the poisoned patient begins with the ABC’s.

  • ACLS algorithms apply in toxicology with only a few exceptions.

  • Once these are stable, begin considering how to minimize bioavailability. Then you may begin your history and physical.


History find out all of this information
History: find out all of this information:

The question words:

  • Which drug(s) were taken?

  • When was it taken?

  • How much was taken?

  • How was it taken?

  • Why was it taken?

  • Was anything else taken? (Consider co-ingestants: other things which may be in this person’s medicine cabinet.)


History continued
History continued....

  • Patients who overdose or use illicit drugs may be unreliable.

  • Gather info from paramedics, family, friends, the PCP, old medical records, pill bottles the patient has on them, their occupational environment or by having people return to the scene where the incident took place.


History continued1
History continued....

  • Obtain a clinical history from family/friends or paramedics:

    - patient’s behavior prior to arrival

    - changing vital signs

    - seizures


Physical examination
Physical Examination:

  • Vital Signs: You MUST obtain a full set of vital signs, including blood glucose.

  • Vital signs are the key to your initial management of the patient....


Vital signs pulse
Vital signs: Pulse

Bradycardia Tachycardia

(P.A.C.E.D.) (F.A.S.T.)

Propanolol, poppies Freebase

Anticholinesterases Anticholinergics/

Clonidine, CCB’s Antihistamines

Ethanol Amphetamines

Digoxin Sympathomimetics

Solvents

Theophylline


Vital signs temperature
Vital signs: Temperature

HypothermiaHyperthermia

(C.O.O.L.S.) (N.A.S.A.)

Carbon monoxide N.M.S., Nicotine

Opiates Antihistamines

Oral hypoglycemics Salicylates

Liquor Sympathomimetics

Sedatives/Hypnotics Anticholinergics

Antihistamines


Vital signs blood pressure
Vital signs: Blood pressure

HypotensionHypertension

(C.R.A.S.H.) (C.T.S.C.A.N.)

Clonidine, CCB’s Cocaine

Reserpine Thyroid supplements

Antihypertensives Sympathomimetics

Antidepressants Caffeine

Aminophylline Anticholinergics

Sedative/Hypnotics Amphetamines

Heroin (opiates) Nicotine


Vital signs respiration rate
Vital signs: Respiration rate

HypoventilationHyperventilation

(S.L.O.W.) (P.A.N.T.)

Sedative/Hypnotics PCP

Liquor Pneumonitis

Opiates Noncardiogenic

Weed (marijuana) pulmonary edema

Toxic met. acidosis


Physical neurologic exam
Physical: Neurologic exam

Mental statusSeizures

(AEIOU TIPS) (OTIS CAMPBELL)

Alcohol Organophosphates

Endocrine/Epilepsy Tricyclics

Intoxication INH/Insulin

Oxygen Sympathomimetics

Uremia Camphor/Cocaine

Trauma/Tumor Amphetamines

Infection Methylxanthines

Psychological PCP

Shock/Strokes Benzo withdrawal

Ethanol

Lead, Lithium

Lidocaine, Lindane


Physical exam pupils
Physical exam: Pupils

MiosisMydriasis

(C.O.P.S.) (A.A.A.S)

Cholinergics Antihistamines

Clonidine Antidepressants

Opiates Anticholiergics

Organophosphates (Atropine)

Pontine bleed Sympathomimetics

Phenothiazines (Cocaine)

Sedatives/Hypnotics


Physical dermatological exam
Physical: Dermatological exam

DiaphoresisRed SkinBlue Skin

(S.O.A.P.) CO Cyanosis

Sympathomimetics Boric Acid MetHb

Organophosphates Anticholinergics

ASA

PCP

Blistering

Barbituates, CO, Sedative hypnotics, snake/spider bites


Odors
Odors...

Bitter almonds: Cyanide

Mothballs: Camphor

Garlic: Organophosphates, Arsenic

Peanuts: Rodenticide

Carrots: Water hemlock

Rotten eggs: Sulfur dioxide, HS

Wintergreen: Methyl salicylates

Gasoline: Hydrocarbons

Fruity: DKA, Isopropanol

Pears: Chloral hydrate


Epidemiology of toxicology
Epidemiology of Toxicology...

The majority of poisonings were unintentional.... But, the majority of deaths secondary to poisoning were intentional.

Most poisonings are by ingestion and most poisonings occur at home.


Epidemiology continued
Epidemiology continued...

The most commonly reported poison?

Analgesics!

The least commonly reported?

Alcohol!

Which is associated with the most deaths?

Analgesics!

Which is associated with the least deaths?

Hydrocarbons!

The number one poisonous killer?

Carbon monoxide!


Lab tests diagnostics
Lab tests/Diagnostics...

EKG. Why?

To look for conduction delays and ischemia.

(sympathomimetics, B-blockers, TCA’s, digoxin, CCB’s, CO)

CMP. Why?

To calculate anion gap and osmolality. (CAT MUD PILES and ME DIE mnemonics)

Tylenol and Aspirin levels. Why?

Because of the frequency of abuse and co-ingestion.


Lab tests diagnostics continued
Lab tests/diagnostics continued...

Serum volatiles (this tells you quantitative amounts of alcohols). Why? When?

With AMS of unknown etiology, for legal purposes, for unexplained osmolar gaps.

Drug screens. Why? When?

With urine: Screening purposes only. (This rarely changes your management)

With blood: For quantitative information regarding specific ingestants.


Imaging
Imaging...

Chest XR:KUB:

(Pulmonary Edema) (C.O.I.N.S.)

(M.O.P.S.) Chloral hydrate

Meprobamate Cocaine packets

Methadone Opiate packets

Opiates Iron (Heavy metals)

Phenobarbital Neuroleptics

Propoxyphene Sustained release/

Salicylates enteric coated tabs.


Management
Management...

“Coma cocktail” (Dextrose, Narcan, Thiamine)

  • Check blood sugars (the sixth vital sign)

  • Narcan has side effects too!

  • Thiamine for the malnourished

    Flumazenil is reserved for people who we overdose with benzos!


Management gi decontamination
Management (GI decontamination)

  • Syrup of ipecac: Is not used

  • Gastric lavage:

    - Used with “moderate to severe overdoses” within an hour of ingestion. -There is a highly variable outcome with this intervention.

    -Lavage is contraindicated with ingestion of corrosives.


Gi decontamination continued
GI decontamination continued...

  • Activated charcoal:

    - Purported to be superior to lavage

    - Used in toxic ingestions within an hour of the ingestion.

    - Dosed as 1g/kg or 10:1 ratio of charcoal to poison

    - Given as single dose or multiple dose


Multiple dose not adsorbed
Multiple dose Not adsorbed

(A.B.C.D.) (C.H.A.R.C.O.A.L.)

Antimalarials Caustics/Corrosives

Aminophylline Heavy metals

ASA (?) Alcohols

Barbiturates Rapid onset cyanide

B-Blockers (?) Chlorine/Iodine

Carbamazepine Other insolubles (tabs)

Dapsone Aliphatics

Dilantin (?) Laxatives


Gi decontamination
GI decontamination...

Cathartics:

- Given with charcoal to enhance elimination

- Unproven efficacy when used alone.

Whole bowel irrigation:- May be effective for things not adsorbed by charcoal

- Used for body stuffers/packers


Decontamination via enhanced elimination
Decontamination via enhanced elimination...

Hemodialysis: Urine Alkalinization:

(I.S.T.U.M.B.L.E.) ASA, Phenobarbital

Isopropanol (Alkalinizing the urine with

Salicylates NaHCO3 to trap ions of weakly

Theophylline acidic agents to promote

Uremia excretion).

Methanol Titrate NaHCO3 to maintain

Barbiturates urinary pH of 7.5-8.0.

Lithium

Ethylene glycol


Management antidotes
Management (Antidotes)...

Toxin Antidote

Acetaminophen N-acetylcysteine

Anticholinergics Physostigmine

Arsenic/Lead BAL chelation

B-Blockers Glucagon

Benzos Flumazenil

CO O2, HBO

Cyanide Nitrites

Digoxin Digibind

Ethylene glycol/Methanol Fomepizole/Ethanol

Iron Deferoxamine

INH B6/Pyridoxine

Lead/Mercury Succimer/DMSA

Methemoglobinia Methylene blue

Opioids Naloxone

Organophosphates Atropine

TCA’s Sodium bicarbonate


Pitfalls
Pitfalls...

  • Ingestion of multiple agents is common

  • Dangerous drug combinations

  • Drugs masking the effects of other drugs

  • All altered mental status is not tox. Consider trauma (head bleeds) and metabolic causes (DKA, Thyroid, etc)


Pearls
Pearls...

  • Always begin with airway, breathing, circulation. The poisoned patient is not exempt from this mantra.

  • ACLS protocols generally apply to poisoned patients.

  • Treat the patient, not the poison. Observe vital signs and provide supportive care constantly.



Case 1
Case 1:

Mr. Smith, a 28 year old male presents in police custody complaining of chest pain. He has no other past medical history. No history of cardiac disease.

Patient further states that his chest pain began tonight about one to two hours after he was arrested by police. No history of trauma.Social history=Smokes 1 pack/day. Occasional EtOH.Family History= No cardiac deaths.

Mr. Smith


Physical exam
Physical exam...

  • General: Patient very agitated, clutching his chest.

  • Vitals: P 140, BP 220/130 RR-28 Temp- 103.2F

  • Eyes: Pupils 7mm, equal, EOMI

  • Lungs: Clear Bilaterally

  • Heart: Regular rate and rhythm, 2+/6 systolic murmur

  • Abd: Soft, Non-Tender, BS+

  • Neuro: No focal deficits.

  • Skin: Diaphoretic


Differential diagnosis
Differential diagnosis???

  • Sympathomimetics (cocaine? amphetamines?)

  • Anticholinergics?

  • Thyroid disease?

  • Solvents?

  • Antihistamines?

  • Undiagnosed hypertension?

  • Acute MI?

  • Malingering? (Why did his symptoms begin an hour after the arrest? Why not immediately?


What do you want to order
What do you want to order?

  • EKG? (grossly abnormal vital signs)

  • CMP?

  • TSH?

  • UTox?

  • Serum volatiles?

  • Imaging?

  • Cardiac enzymes?



How should this person s cocaine related chest pain be managed
How should this person’s cocaine related chest pain be managed?

  • Benzodiazepines- First line therapy (in high doses)

  • Nitroglycerin- for control of ischemic pain and HTN

  • Labetalol- alpha/beta blocker (the use of propranolol will leave the alpha portion unopposed theoretically exacerbating cocaine's toxicity). Alternatively, phentolamine could be used.

  • Nitroprusside- for refractory HTN


This person ingested bags of cocaine what is the best method of gi decontamination
This person ingested bags of cocaine. What is the best method of GI decontamination?

Ipecac

Whole Bowel Irrigation

Cathartics

Activated Charcoal

Dialysis

Urine alkalinization

Gastric lavage


Should other services be involved if so whom
Should other services be involved? If so, whom? method of GI decontamination?

  • Tox!

  • Surgery (Why?)

  • Cardiology (Why?)


The outcome
The outcome.... method of GI decontamination?

  • The patient's chest pain and hypertension eventually resolve with large doses of nitroglycerin and benzodiazepines.

  • The patient is administered activated charcoal and polyethylene glycol solution by the ED physician.

  • Because of the ST segment elevations, the cardiologist elects to give thrombolytics.

  • Since thrombolytics were "on board" the general surgeon refuses to take the patient to the OR for exploratory laparotomy and removal of the cocaine packets.

  • The patient is transferred to the ICU, where he eventually recovers and is discharged with a 10% ejection fraction.


Case 2
Case 2 method of GI decontamination?

  • The patient is a 18 year old male presenting to the ED by paramedics after found at home unresponsive, face down in bed. According to friends, the patient had consumed two beers and a glass of wine earlier that day following a period of depression. The patient was orally intubated in the field by paramedics after no response to D50 and naloxone administration.


Physical exam1
Physical exam: method of GI decontamination?

  • General: Patient responsive only to deep painful stimuli

  • Vitals: BP 150/70, HR=92, RR=24, T=95.4F

  • Lungs: CTA, BS Equal, (Intubated)

  • CV: RRR, no murmur

  • Abd: Soft, Non-Tender, No Trauma, No Masses

  • Rectal: Normal Tone, Heme-

  • Neuro: DTR's Hyporeflexive, Withdraws to Painful Stimuli


Differential diagnosis1
Differential diagnosis?? method of GI decontamination?

  • Alcohol intoxication?

  • Carbon monoxide?

  • Sedatives/Hypnotics? (benzos? barbiturates? muscle relaxants?)

  • Tylenol?

  • Trauma?

  • Large doses of narcotics?


What do you want to order1
What do you want to order? method of GI decontamination?

  • CBC?

  • CMP?

  • Serum osmolality?

  • Serum volatiles?

  • Urine toxicology screen for drugs of abuse?

  • EKG?


Results
Results: method of GI decontamination?

  • CBC: WBC 29K HCT=45

  • Lytes: Na=145 Cl=105 K=5.2 HCO3=5

  • BUN/Cr: 28/1.8 Glucose 180

  • Osm: 370 (Measured)

  • ETOH: 46

  • Calcium 7.0

  • Toxicology Screen: Pending

  • Toxic Alcohols: Pending

  • What is his anion gap? What is his osmolar gap?

    AG: 20. Osmolar gap: 370 – (2(Na) + Glu/18 +BUN/2.8 +ETOH/4.6) = 50! (50 is greater than 10, so..... )


Results continued
Results continued... method of GI decontamination?

  • EKG shows NSR. No interval changes. No ST, T or Q wave changes. Normal axis. Normal R wave progression

  • CXR: Shows normal sized heart and mediastinum. No effusions or infiltrates. No acute disease. ETT in proper position.


How do you want to manage this patient
How do you want to manage this patient? method of GI decontamination?

  • Supportive care only

  • Gastric lavage

  • Hemodialysis

    Is there a potential antidote for this?

    YES! Fomepizole!

    We don’t have any fomepizole. But we do have ethanol!


Outcome
Outcome... method of GI decontamination?

  • With a strong clinical suspicion for toxic alcohol ingestion, an ethanol drip is ordered, but due to pharmacy delay, the patient is orally loaded with 85 proof whiskey obtained from another patient in the ER waiting room.

  • Urine is positive for calcium oxalate crystals. Dialysis is initiated by the renal service, after which an ethylene glycol level of 310 mg/dl returns 12 hours later.

  • The patient recovers with mild renal insufficiency, and is subsequently followed-up by the psychiatric service for his depression.


References
References... method of GI decontamination?

1. Erickson TB et al. Toxicology Update: A Rational Approach to Managing the Poisoned Patient. Emerg Med Pract. 2001; 3(8): 1-28

2. Tuckler, Victor. Introduction to Toxicology handout

3. Rivers, Carol S. Preparing for the Written Board Exam in Emergency Medicine. 5th Ed. Volume II. PP 735-738

4. “Case studies in Toxicology” available at: http://www.uic.edu/com/er/toxikon/cases/allcase.htm

5. http://www.med.umich.edu/lrc/baliga/case02/images/infMI2. jpg