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MANAGEMENT OF ACUTE POISONING. Kent R. Olson, MD Medical Director - SF Division California Poison Control System. Lessons from history. A young princess ate part of an apple given to her by a wicked witch She was found comatose and unresponsive, as if in a deep sleep

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management of acute poisoning

MANAGEMENT OF ACUTE POISONING

Kent R. Olson, MD

Medical Director - SF Division

California Poison Control System

lessons from history
Lessons from history...
  • A young princess ate part of an apple given to her by a wicked witch
  • She was found comatose and unresponsive, as if in a deep sleep
  • Airway positioning and mouth to mouth ventilation were performed, and she recovered fully
lesson
Lesson:

Best antidote = good supportive care

(Love’s first kiss)

initial management abcds
Airway

Breathing

Circulation

Dextrose, drugs, decontamination

Initial management: ABCDs
airway issues
Major cause of morbidity in OD

Risks:

Floppy tongue can obstruct airway

Loss of protective reflexes may permit pulmonary aspiration of gastric contents

Airway issues
assessing the airway
“Gag” reflex

Indirect measure

May be misleading

Can stimulate vomiting

Alternatives

Assessing the airway
breathing
Assess visually

ABG: pCO2 reflects ventilation

Pulse oximetry provides convenient, noninvasive evaluation of O2 saturation

Breathing
pitfalls
pO2 measures dissolved oxygen

Pulse oximetry can miss abnormal hemoglobin states, eg:

Carbon monoxide

Methemoglobinemia

Pitfalls
interventions
Endotracheal intubation

Protects airway

Allows for mechanical ventilation

Reverse coma?

Naloxone: note T½ = 60 min

Flumazenil?

Interventions
case continued
The patient has no gag reflex, and does not resist intubation. However, he is awake and sitting up 2 hours later.

Admits to using “GHB”

Case, continued…
slide14
Gamma Hydroxybutyrate

Rapid-acting general anesthetic

Structural analogue of GABA

Very short duration

May see seizure- like movements or hypertonicity

GHB
case 2
47 year old stockbroker attempts suicide

BP 70/50, HR 50/min

Junctional rhythm

Hx: uses an antihypertensive

Case 2
circulation plumbing
Pump working?

Enough volume (is it primed)?

Adequate resistance (no leaks)?

Circulation = plumbing
management of hypotension
Hypovolemia?

IV fluid challenge

Pump?

Dopamine

Inadequate vascular resistance?

Norepinephrine, phenylephrine

Management of Hypotension
antihypertensives
Diuretics

Beta blockers

Calcium channel blockers

ACE Inhibitors

Centrally acting agents (eg, clonidine)

Vasodilators

Antihypertensives
calcium channel blockers
Bad ODs!!

Low Toxic:Therapeutic ratio

High mortality

Calcium channel blockers
slide21

Decreased

Automaticity

& Conduction

Negative

Inotropic

Effects

Dilated Vascular

Smooth Muscle

SVR

HR

CO

AV Block

SHOCK

case 3
Another patient arrives from the first dance club

Multiple seizures with only brief pauses

Temp 107 F!

Case 3:
common causes of seizures
TCAs

Amphetamines/cocaine

Isoniazid (INH)

Diphenhydramine

Theophylline

Strychnine

Common causes of seizures
hyperthermia
Disastrous complication!

Brain damage

Cardiovascular collapse

Rhabdomyolysis

Multiple organ failure

Hyperthermia
hyperthermia treatment
Stop the seizures

Benzodiazepines, phenobarbital

Vitamin B-6 for INH

Stop muscle hyperactivity

Neuromuscular blockers

External cooling

Hyperthermia - Treatment
gut decontamination after od
Limit systemic absorption

Induce vomiting?

Pump the stomach?

Activated charcoal

Gut decontamination after OD
induce vomiting
Syrup of Ipecac?

Soapy water?

Don’t use:

Finger gag

Salt water

Copper sulfate

Induce vomiting
ipecac induced emesis
Easy to perform, but

Not very effective

Contraindicated:

Comatose/convulsing

Ingested corrosive or hydrocarbon

Rapid-acting CNS agent

No longer used

Ipecac-induced emesis
pumping the stomach
Cooperation not required

MD sense of “control”

Punitive value?

Pumping the stomach
gastric lavage
May stimulate gagging, vomiting

Risky if airway reflexes dulled

Lack of proven efficacy

Used rarely

Gastric lavage
activated charcoal
Finely divided powdered material

Huge surface area

Binds most drugs/poisons

Exceptions:- Iron- Lithium

Activated charcoal
whole bowel irrigation
Mechanical flush

Balanced salt solution with PEG

No net fluid gain/loss

Good for:

Iron

Lithium

Sustained-release pills, foreign bodies

Whole bowel irrigation
antidotes
The best antidote is supportive care

Examples of antidotes:

Digoxin-specific antibodies

Atropine & 2-PAM

N-acetylcysteine

Antidotes: