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Management of Acute Overdose . By: Peter Rempel March 27 th , 2013. Presentation Outline. Introduction and Statistics General management strategy Identification of Toxidromes Management of overdose for specific medications Role of pharmacist. Introduction - Overdose.

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management of acute overdose

Management of Acute Overdose

By: Peter Rempel

March 27th, 2013

presentation outline
Presentation Outline
  • Introduction and Statistics
  • General management strategy
  • Identification of Toxidromes
  • Management of overdose for specific medications
  • Role of pharmacist
introduction overdose
Introduction - Overdose
  • Definition: The use of a substance in quantities greater than recommended.
  • Accidental vs. Intentional misuse
epidemiology overdose
Epidemiology - Overdose
  • Approximately 2.3 million cases reported (US)
    • 50% caused by pharmaceutics
  • 41,592 deaths occurred in the US (2009)
    • 76%were unintentional
      • 91%caused by medications
  • Prevalence higher in males during the early years (0-12y)
    • Rates in females surpass males in older populations
epidemiology continued
Epidemiology (Continued)

Most common pharmaceutics:

  • Analgesics (Opioids)
  • Sedative/hypnotic/antipsychotics
  • Antidepressants
  • Antihistamines
  • Cardiovascular drugs
  • Vitamins, cough and cold products
  • Rates of unintentional overdose has been steadily increasing
general management strategy
General Management Strategy
  • ABC management (vital signs)
  • Call Poison Control
  • Obtain best possible medical history
  • Order Labs
  • Prevent absorption of toxin
  • Enhance elimination (antidote)
general management strategy1
General management strategy
  • ABC management
    • Airway patency

- head-tilt and chin-lift, removal of obstructions

    • Breathing

-assisted ventilation

    • Circulation

- colour change, sweating, decreased LOC

- EKG, saline infusion, vasopressers

general management strategy2
General Management Strategy
  • Call Poison Control
    • Available 24/7 to provide poison treatment information
    • Help guide treatment strategy
    • Prevent unnecessary use of health care resources
general management strategy3
General Management Strategy
  • Obtain accurate history
    • Determine the causative agent
    • Dose
    • Time since exposure
    • Route
    • Demographics (age, weight)
    • Symptoms*
    • Physical Examination
what is a toxidrome
What is a Toxidrome?
  • Characteristic symptoms that are associated with a specific group of medications.
  • These group of symptoms are known as a “Toxidrome”
identification of toxidromes
Identification of Toxidromes

Cholinergic Toxidrome

  • “SLUDGE”
    • Salivation, Lacrimation, Urination, Defecation, GI upset, Emesis
    • Miosis, diaphoresis, bradycardia
  • Causative Agents: Physostigmine, Organophosphates, Carbamate
identification of toxidromes1
Identification of Toxidromes


  • Hot as a Hare - fever
  • Red as a Beet - flushing
  • Mad as a Hatter – confusion, delirium
  • Dry as a bone – dry skin/mucus membranes
  • Mydriasis, tachycardia, urinary retention
  • Causative Agents: Antihistamines, TCA`s, Anti-parkinsonmedications
identification of toxidromes2
Identification of Toxidromes


  • Anxiety, Delusions, Sweating, Piloerrection, Seizures, Hyperreflexia, Mydriasis
  • Causative Agents: cocaine, salbutamol,, amphetamines, ephedrine, pseudoephedrine, methamphetamine
identification of toxidromes3
Identification of Toxidromes

Sedative/Hypnotic/Opiate Toxidrome

  • Slurred speech, confusion , stupor, coma, apnoea, respiratory depression
  • Hypotension, bradycardia, miosis
  • Causative agents: opioids,anticonvulsants, antipyschotics, barbiturates, benzodiazepines, ethanol
general management strategy4
General Management Strategy
  • Order lab tests
    • Confirm offending agent(s)
    • Predict prognosis
    • Direct therapy/monitoring

Includes:Toxicology screen, anion gap, osmol gap, CBC, BUN, SCr, blood glucose, electrolytes, EKG monitoring

general management strategy5
General Management Strategy
  • Prevent absorption
  • *Activated Charcoal- first line therapy in most emergency departments
  • Whole Bowel Irrigations- clears the GI tract using high volumes of PEG
  • OrogastricLavage- No benefit over the use of activated charcoal
  • Syrup of Ipecac- NO LONGER RECOMMENDED

general management strategy6
General Management Strategy

Activated Charcoal

  • Ability to adsorb substances due to its high surface area
  • Offending agent(s) become trapped by the charcoal and are excreted in the feces

Dosing: 1g/kg po OR by NG tube (usually given multiple times)

AE: aspiration pneumonia, GI obstruction

Contraindications: presence of ileus

general management strategy7
General Management Strategy

Activated Charcoal

  • Does not adsorb the following compounds:
    • Iron
    • Lithium
    • Lead
    • Cyanide
    • Alcohol
general management strategy8
General Management Strategy
  • Enhance Elimination
  • Hemodialysis/Hemoperfusion
  • Administer Antidote
general management strategy9
General Management Strategy

Administer Antidote:

*See my website for a more exhaustive list

opioid overdose management
Opioid Overdose Management
  • Signs and Symptoms?
    • Hint: Remember the toxidrome!
opioid overdose management1
Opioid Overdose Management
  • Signs and Symptoms?
    • Hint: Remember the toxidrome!
    • Decreased LOC, RR, GI motility
    • Hypotension, bradycardia, miosis
  • Reverses effects from opioid overdose
  • Pure opioid receptor antagonist
  • Duration of action 30-120 minutes
  • 0.4-2mg (IV,IM,SC); repeat q2-3 minutes until reversal of symptoms
  • Use continuous IV infusion for exposure to long-acting opioids or SR formulations

Hamm J. Acute acetaminophen overdose in adolescents and adults.CriticalCare Nurse; Jun 2000; 20(3) 69-74


Hamm J. Acute acetaminophen overdose in adolescents and adults.CriticalCare Nurse; Jun 2000; 20(3) 69-74

n acetylcysteine
  • Indicated for the reversal of Acetaminophen toxicity
  • Hepatoprotective agent
  • Restores hepatic glutathione and acts as a glutathione substitute
  • Prevents the production of the toxic by-product of acetaminophen
n acetylcysteine dosing
N-acetylcysteine Dosing
  • 21 hour IV dosing regimen (3 doses)
      • LD: 150 mg/kg (Max 15g) over 1 hour
      • 2nd dose: 50 mg/kg (max 5g) over 4 hours
      • 3rd dose: 100 mg/kg (max 10g) over 16 hours
  • Oral dosing regimen also available (72 hours)
  • Therapy is guided by the Matthew-RumackNomogram
matthew rumack nomogram

The Merck Manual for Health Professionals. Acetaminophen Poisoning.

lipids 20 intralipid
Lipids 20%- Intralipid®
  • Used in anaesthetic overdose and refractory cases (unlabelled use)
  • Mechanism unknown
  • Effective for lipophilic medication overdose
  • Suggested Dose:
      • 1.5 mL/kg bolus infused over 1 minute (may repeat up to 2 times)
      • Followed by 0.25 mL/kg/minute continuous infusion

role of the pharmacist
Role of the Pharmacist
  • Role in both the community and hospital setting
  • Educating patients on the dangers of drug misuse
  • Identifying potential at risk patients
  • Identifying inappropriate medication regimens
  • Medication Reconciliation
  • Majority of overdoses are accidental
  • Rates of accidental overdose is steadily increasing
  • Identifying Toxidromes plays a vital role in the management of overdose
  • Activated charcoal and whole bowel irrigation are effective at lowering absorption
  • Pharmacists can play a role in both the prevention and treatment of an overdose
  • Clinical Practice Guidelines. Management of Drug Overdose & Poisoning. Ministry of Health, Singapore. May 2000.
  • Green SL, Dargan PI, Jones AL. Acute poisoning: understanding 90% of cases in a nutshell. Postgrad Med J. 2005;81:204-216.
  • Tenenbein M et al. Efficacy of ipecac-induced emesis, orogastriclavage, and activated charcoal for acute drug overdose. Annals of Emergency Medicine; 16(8): 838-841 
  • Lab Tests Online. Emergency and Overdose Drug Tests. Accessed March 22, 2013
  • Thim T, Niels HV, et al. Initial assessment and treatment with the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach. International Journal of General Medicine; 2012:5 117-121

6) Centers for disease control and prevention. Home and Recreational Safety. Unintentional Poisoning Data and Statistics. Retrieved from ; accessed March 3, 2013

7) HodgmanMJ et al. A review of Acetaminophen Toxicity.Crit Care Clin. 28 (2012) 499-516

8) G Cave et al. Intravenous Lipid Emulsion as Antidote Beyond Local Anesthetic Toxicity: A Systematic Review. Academic Emergency Medicine: 2009; 16:815-824

9) Boyer EW. Management of Opioid Analgesic Overdose.. N Engl J Med: 367;2 146-155

thank you for listening
Thank you for listening