General Management of the Poisoned Patient Clin Pharm 501

1
General Management of the Poisoned Patient(Clin
Pharm 501)

• Donna Seger, M.D
• Medical Director
• Tennessee Poison Center
• Assistant Professor of Medicine and
• Emergency Medicine

2
Intentional Poisoning

• An overlooked category of child abuse

3
Adolescents

• 90 girls
• 25 - M.D. with 1 week
• Problems parents, boy or girlfriend, school,
  work
• 2/3 problems improve in 1 month
• 14 repeaters

4
Modes of Exposure

• Ingestion 75
• Dermal 7.9
• Inhalation 6.3
• Ocular 5.3
• Envenomation 3.6
• 2001 TESS Data

5
Management Principles
6
History

• Unreliable
• What
• When
• How much

• Accidental or self-inflicted
• First time or recurrent
• PMH

7
Physical Exam

• Temp!
• Neuro-external signs of trauma
• Mental status
• Apparently unconscious

8
Emergency Treatment

• A-airway
• B-breathing
• C-circulation
• Consider glucagon and/or insulin/glucose for
  hemodynamic instability in the young previously
  healthy poisoned patient
• Supportive Care highest priority
• Coma ? D50, Narcan, monitor

9
Laboratory Analysis

• Time is of the essence in comatose patient or
  hemodynamically unstable patient
• ABG will help you determine urgency

10
AGA
M ethanol U remia D KA P araldehyde I NH or
idiopathic lactic acidosis E thylene Glycol S
alicylates
11
Toxicology Screen

• Comma
• Fluctuating LOC
• Medical complications
• New Onset psychosis

12
Axioms

• Negative serum
• Serum level implications
• Lethal level
• Treat patient, not lab values

13
Quantitation

• APAP
• CO
• Digoxin
• EtOH
• Ethylene Glycol
• Heavy Metals
• Iron

• Lidocaine
• Lithium
• Methanol
• Methemoglobin
• Phenobarbital
• Phenytoin
• Salicylates
• Theophylline

14
Antidotes

• Beta Blocker Glucagon
• Benzodiazepine-?Flumazenil
• CO-O2-NBO v. HBO
• CN-CN Kit
• Digoxin Digibind
• Ethylene glycol EtOH 4MP
• Methanol EtOH 4MP

15
Antidotes (cont)

• OP Atropine PAM
• Opiates Naloxone
• Anticholinergic Physostigmine
• TCA NaHCO3
• Methgb Methylene Blue
• Acetaminophen - NAC

16
Flumazenil

• Contraindications
• ?TCA
• Hx head trauma
• Hx seizures
• Chronic BZDP use

17
EXPOSED BODY SURFACEDILUTION IS THE SOLUTION
TO POLLUTION
18
Emesis vs Gastric Lavage
19
Ipecac
Emetine
Alkaloids
Caphaeline
Early and late stages of vomiting
20
Toxicities

• GI vomiting and diarrhea
• Neuro-myopathy
• Cardiac - ? HR, ? QT, ? PR, inv T

21
There is no evidence that Ipecac improves outcome
22
Gastric Lavage

• Protect Airway
• Large Bore Tube (30-40 F)
• LLD Position
• Lavage Until Clear
• External Massage

23
There is no evidence that Gastric Lavage improves
outcome
24
Is Gastric EmptyingNecessary????
25
Management of Acutely Poisoned Patients Without
Gastric Emptying
Kulig et al. Annals of Emergency Medicine 1985
26

• Odd number days
• Gastric emptying

• Even-number days
• No gastric emptying

Patient alert, cooperative
1
2
Syrup of Ipecac activated charcoal
Oral activated charcoal only
Patient obtained, convulsing, intubated,
uncooperative
4
3
Gastric lavage, Activated charcoal
Activated charcoal by nasogastric tube without
lavage
Kulig et al. Am Emerg Med 1985
27

• No difference in (1 vs 2 and 3 vs 4)
• Severity of intoxication
• Patients admitted
• Clinical deterioration

• Lavage obtained patients did better than those
  given NG charcoal
• Within 1 hour

28
Conclude

• Satisfactory outcome without gastric emptying
• Ipecac no benefit hours after OD
• Gastric lavage no benefit 1 hour
• NO MANDATORY GASTRIC EMPTYING

29
Prospective Evaluation of Gastric Emptying in the
Self-Poisoned Patient
Merigian et al.Am J of Emerg Med, November 1990
30

• EVEN DAYS
• Asymptomatic Patient
• Activated Charcoal (Oral)

• ODD DAYS
• Asymptomatic Patient
• Observation Only

• Symptomatic Patient
• Gastric emptying
• (Ipecac-Induced Emesis
• or Gastric Lavage)

• Symptomatic Patient
• Activated Charcoal
• (oral or nasogastric)

• Activated Charcoal
• Oral or Ewald Gastric Tube

31
Conclusion

• Gastric Decontamination Limited Clinical Benefit

32
Prospective Evaluation of Gastric Emptying in the
Self-Poisoned Patient
Pond Medical Jnl of Australia 1995
33
ODD DAYS Emptied AC
EVEN DAYS AC
34
CONCLUSIONS

• No difference in outcome
• Clinical course
• Hospital stay
• complications

35
Single-Dose Activated Charcoal
36
Single-Dose oral Activated Charcoal in the
Treatment of the Self-Poisoned patient A
Prospective, Randomized Controlled Trial

• Merigian K, Blaho K Jnl of Therapeutics 2002

37

• ODD DAYS
• -Supportive Care

• EVEN DAYS
• -AC

38
Conclusions

• Vomiting in 23 receiving AC and 13 receiving
  supportive care
• No difference in length of stay
• No difference in incidence of complications

39
There is no evidence that SDAC improves outcome
40
MDAC

• Multiple dose activated charcoal
• Gastric dialysis-pulls drug across the blood/gut
  membrane due to osmotic gradient of drug
• phenobarbital, carbamazepine, theophylline,
  dapsone, quinine

41
Contraindications

• Bowel Perforation
• Bowel Obstruction
• GI Hemorrhage
• Hemodynamic Instability

42
Whole Bowel Irrigation

• Administration of 1-2 liters/h of go-lytely for
  first 5-6 hours following ingestion
• Mechanical removal of toxin

43
WBI

• Fe, Pb, As, Zn
• Sustained release (CCB)
• Packets of illicit drugs

44
Contraindications

• Coma
• Seizure
• CNS depression
• TCA

• Caustics
• Petroleum distillates
• Strychnine
• Camphor

45
Complications

• Nausea
• Vomiting

46
Elimination of Absorbed Substances
47
Elimination of Absorbed Substance

• Forced diuresis of no benefit
• Ion trapping via alkaline diuresis for specific
  toxins

48
Alkaline Diuresis

• Phenobarbital
• Aspirin

49
Indications for Hemodialysis/Hemoperfusion

• Deterioration despite supportive care
• Depression of midbrain function
• Complications of coma
• Hepatic, cardiac, or renal insufficiency

50
Drug Characteristics

• Enterohepatic circulation
• Small VD
• Little protein binding

51
Psychiatric Evaluation

• Suicide Risk Factors
• Older solitary male
• Suicide plan
• Previous attempts
• Recent lost
• Chronic serious illness
• History of drug or alcohol abuse
• Psychosis
• Sense of helplessness, hopelessness

52
Legal Aspects

• No court has upheld a patients right to refuse
  medical treatment subsequent to be a drug
  overdose.
• A patient who has attempted suicide has lost the
  right to refuse treatment

53
23 y-o found unconscious by friends

• Suicide note took pills
• To ED

54

• Unconscious
• Unresponsive
• BP 102/80
• HR 120
• Treatment?

55
Airway B C
56
ETI

• Unconscious patients do not have protective
  airway reflexes

57

Airway Breathing C
58
Ventilate
59
Airway Breathing Circulation
60
Blood PressurePulseHemodynamic
instability?????
61
Hemodynamic Instability in the poisoned patient

• Fluid (2 liters)
• Glucagon
• Insulin/glucose

62
Antidote
63

• Naloxone
• Glucose

64
Physical Exam
65

• Temperature
• Trauma
• Illness
• Drug abuse

66
Laboratory Analysis
67
ABGElectrolytesGlucoseCBCUDS
68
GID
69
?Gastric Lavage?Charcoal
70
Imaging Studies
71
Head CTCXR(C-spine)
72
Treatment?
73
Supportive Care
74
UDS

• Benzoylecgonine
• Marijuana
• Benzodiazepines