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Diagnosis of Poisoning

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Title: Diagnosis of Poisoning


1
Diagnosis of Poisoning
  • Kent R. Olson, MD, FACEP
  • Medical Director
  • California Poison Control System,
  • San Francisco Division
  • University of California, San Francisco

2
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3
Lessons from history
  • A young princess ate part of an apple given to
    her by a wicked witch
  • She presented comatose and unresponsive (as if
    she was in a deep sleep)
  • Airway positioning and mouth to mouth
    ventilations were performed, and she recovered

4
Diagnosis of Poisoning
  • Rule 1 Take good care of the patient
  • ABCDs
  • Airway
  • Breathing
  • Circulation
  • Dextrose, Drugs Decontamination
  • Rule out
  • Head trauma, Meningitis, Sepsis
  • Metabolic disorders

5
Diagnosis of Poisoning
  • Rule 2 Get a good history
  • Check multiple sources
  • Patient
  • Family, Friends
  • Paramedics, Pharmacy
  • Circumstances
  • What was taken?
  • How much?
  • When?

6
Diagnosis of Poisoning
  • Rule 3 Do a good physical exam
  • Toxicologic physical exam
  • Mental status
  • Vital signs (all of them)
  • Pupils
  • Bowel sounds
  • Muscle tone and activity
  • Skin dry or diaphoretic?
  • Look for an autonomic syndrome

7
Autonomic Syndromes
  • Sympathetic Cholinergic
  • Blood Pressure /--
  • Pulse Rate /--
  • Pupils dilated pinpoint
  • Peristalsis -
  • Skin sweaty sweaty

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Autonomic Syndromes
  • Sympathetic Sympatholytic
  • Blood Pressure --
  • Pulse Rate --
  • Pupils dilated small
  • Peristalsis - -
  • Skin sweaty -

10
Autonomic Syndromes
  • Anticholinergic Cholinergic
  • Blood Pressure /--
  • Pulse Rate /--
  • Pupils dilated pinpoint
  • Peristalsis --
  • Skin dry sweaty

11
Autonomic Syndromes
  • Sympathetic Anticholinergic
  • Blood Pressure
  • Pulse Rate
  • Pupils dilated dilated
  • Peristalsis - --
  • Skin sweaty dry

12
Case Study
  • Two adolescents are brought to the ED by their
    parents because of agitation.
  • 1 BP 150/100, HR 120, pupils dilated, jumpy,
    diaphoretic.
  • 2 BP 130/90, HR 130, pupils dilated, distended
    bladder, dry flushed skin.

13
Sympathomimetic Syndrome
  • Common features
  • Agitation, psychosis
  • Hypertension, tachycardia
  • Dilated pupils
  • Diaphoresis
  • Hyperthermia
  • Common causes
  • Cocaine
  • Amphetamines (including MDMA - Ecstasy)
  • Phencyclidine (PCP)
  • Phenylpropanolamine (PPA) often causes severe
    hypertension with reflex bradycardia

14
Anticholinergic Syndrome
  • Common features
  • Dilated pupils
  • Dry, flushed skin
  • Sinus tachycardia
  • Ileus, urinary retention
  • Confusion, delirium
  • Common causes
  • Atropine related drugs
  • Plants (eg, jimson weed) mushrooms (eg, A.
    muscaria)
  • OTC Rx antihistamines
  • Tricyclic antidepressants

Mad as a Hatter Red as a Beet Blind as a Bat Dry
as a Bone
15
Case Study
  • A 28 year old woman presents groggy and confused.
    Pupils 7-8 mm. Skin dry and flushed. Bowel sounds
    diminished.
  • 130/90 120/min 14/min 37.8 C
  • Shortly after arrival she has a grand-mal
    seizure.
  • ECG monitor QRS 0.16 sec, wide complex
    tachycardia

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17
Tricyclic Antidepressant Overdose
  • Anticholinergic syndrome
  • The three Cs
  • Coma
  • Convulsions
  • Cardiac conduction abnormalities
  • QRS gt0.12 sec is a better predictor of toxicity
    than the serum drug level

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Common Causes of Seizures
  • Tricyclic antidepressants
  • Newer antidepressants esp. Wellbutrin
  • Cocaine, Amphetamines
  • Diphenhydramine
  • Isoniazid

20
Case Study
  • A 2 year old child is found unresponsive. The
    parents are suspected heroin users.
  • BP 80/50 HR 70 RR 6, shallow
  • Pupils 1 mm. Peristalsis decreased. Muscle tone
    flaccid. No sweating.
  • There is no response to 0.4 mg naloxone.

21
Case (cont.)
  • Common causes of miosis
  • Opioids
  • Other sympatholytic drugs
  • Phenothiazines
  • Cholinergic agents
  • CNS structural lesions

22
Case (cont.)
  • There was no response to repeated doses of
    naloxone to a total of 4 mg.
  • There was no response to flumazenil (total dose
    1.2 mg).
  • The parents found an opened bottle of clonidine
    0.1 mg on the kitchen floor.

23
Common Sympatholytic Agents
  • Opioids
  • Clonidine
  • Benzodiazepines
  • Barbiturates
  • Ethanol

24
Case Study
  • A 34 year old man drank an unidentified liquid.
    He vomited several times, and became weak and
    pale. In the ED
  • BP 150/100 HR 110
  • Pupils pinpoint. Profuse diaphoresis. Vomit has
    a chemical odor.
  • He develops muscle fasciculations and has a
    respiratory arrest.

25
Cholinergic Syndrome
  • SLUD
  • Salivation, Sweating
  • Lacrimation
  • Urination
  • Diarrhea, Vomiting
  • also muscle weakness paralysis

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27
Diagnosis of Poisoning
  • Rule 4 Use the laboratory appropriately
  • Routine labs
  • Arterial blood gases
  • Electrolytes anion gap
  • Osmolality
  • Toxicology testing
  • Tox screening
  • Specific stat quantitative tests

28
Case Study
  • A 44 year old man was found unconscious, with a
    suicide note and a half-empty bottle of whiskey.
  • BP 110/80 HR 110 RR 32
  • pH 7.47 pCO2 18 pO2 88
  • Na 140 K 3.8 Cl 106 HCO3 18
  • Ethanol 0.18 gm/dL

29
Anion Gap
  • Na - Cl - HCO3 8-12 mEq/L
  • Causes of increased gap SALAD
  • Salicylates
  • Alcohols
  • Lactic Acidosis
  • Anuria
  • DKA

30
Salicylate Intoxication
  • Typical mixed acid-base abnormality
  • Respiratory alkalosis
  • Metabolic acidosis
  • Treatment
  • Alkalinize urine, restore serum pH
  • Hemodialysis

31
Radiopaque Drugs Poisons
  • Unreliable - useful only if positive
  • Commonly radiopaque
  • Iron
  • Potassium
  • Calcium
  • Sometimes visible
  • Chloral hydrate
  • Phenothiazines
  • Sustained-release preparations

32
Case
  • A 16 year old was brought to the ED by paramedics
    after an overdose of Tylenol with codeine
  • She had small pupils, and was very sleepy/poorly
    responsive
  • Naloxone 2 mg increased pupil size and she became
    combative but not fully awake

33
Case, continued
  • Her mother was questioned
  • . . . I didnt say she overdosed. . . I told
    them I was worried about all the pain pills she
    was using for her headache. . .
  • Rectal Temp 102.5 F
  • LP pneumococcal meningitis!

34
Important Rule-Outs
  • ATOMIC
  • Alcohol check ETOH consider alcoholism
  • Trauma consider CT scan
  • Overdose other drugs involved?
  • Metabolic Na, glucose, O2, Thyroid, etc.
  • Infection consider LP
  • Carbon Monoxide obtain COHgb

35
Case Study
  • A 27 year old woman found obtunded with pinpoint
    pupils, awoke with IV naloxone, and admitted to
    ingestion of a few pain pills.
  • Does this patient need a Tox Screen?
  • She was treated with oral activated charcoal,
    observed for 4 hours, and released to psychiatry.

36
Case (cont.)
  • Three days later, she returned because of nausea,
    abdominal pain, and lethargy. She appeared
    jaundiced.
  • AST 8,000 PT 28 sec Bilirubin 3.6
  • Toxicology screen from the original visit
    revealed acetaminophen.

37
Acetaminophen
  • Pitfalls in Diagnosis
  • History
  • Not volunteered by patient
  • Hidden ingredient in many products
  • No initial specific symptoms
  • Physical exam laboratory
  • No initial specific findings
  • Only reliable test STAT acetaminophen

38
Comprehensive Toxicology Screening
  • Problems
  • Slow, expensive
  • Many drugs not included
  • Potential uses
  • Forensic questions
  • Possible brain death
  • Quick drugs of abuse screens
  • ? Useful - for JGP
  • Many drugs not included know your hosps limits
  • Should not use () test forensically unless
    confirmed

39
Toxicology Laboratory
  • Quantitative testing may be useful if
  • results will return quickly, and . . .
  • results will affect clinical management
  • Examples of specific useful levels
  • Acetaminophen
  • Carbon monoxide
  • Digoxin
  • Salicylate
  • Valproic acid

40
Diagnosis of Poisoning - Summary
  • Take good care of the patient
  • Get a good history
  • Do a good physical exam
  • Use the laboratory appropriately
  • Consult with the Poison Control Center
  • 1-800-411-8080 or 1-800-222-1222
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