2/1/2013 According to the American Academy of Poison Control - PDF document

2/1/2013 According to the American Academy of Poison Control Centers, what is the most common intervention performed in the management of acutely poisoned patients? Anti’dos and don’ts: Pearls and pitfalls in the use of antidotes • A. Administration of sodium bicarbonate • B. Administration of the the cyanide antidote kit Craig Smollin MD • C. Administration of n-acetylcysteine Associate Medical Director, California Poison Control System - SF Division Assistant Professor of Emergency Medicine, UCSF • D. Administration of calcium gluconate • E. None of the above Most common interventions in poisoning The first rule of surfing... The ABC’s of the poisoned patient The first rule of poisoning... Airway Breathing Cirulaiton Drugs, dextrose, decontamination Poisoned patient need good supportive care! Exposure, enhanced elimination 1

2/1/2013 Suggested antidotes for stocking For this talk • Acetylcysteine • Ethanol or fomepizole • Antivenin (rattlesnake) • Flumazenil • Antivenin (black widow spider) • Glucagon hydrochloride • Atropine sulfate • Methylene blue • Atropine sulfate • Methylene blue • Botulism antitoxin • Naloxone hydrochloride • Calcium chloride • Octreotide acetate • Calcium chloride • Calcium gluconate • Physostigmine salicylate • Calcium gluconate • Calcium disodium EDTA • Postassium iodide • Cyanide antidote kit or • Pralidoxime chloride • Pralidoxime chloride • Pyridoxine hydrochloride • Pyridoxine hydrochloride hydroxocobalamin • Defuroxamine • Prussian blue • Digoxin Immune Fab • Sodium bicarbonate • Dimercaprol Case 1 Case 1 • A 57 year-old male with h/o benzodiazepine abuse presents after found by EMS with altered mental status. • Vital signs = BP 159/96, P 105, RR 20, 97% RA Initial GCS in the field was reported as 11. Upon arrival in • the ED he is confused and ataxic with slurred speech. He Initial FSG = 41 mg/dL is noted to be mildly hypertensive, tachycardic and he has diaphoresis. Clinical signs and symptoms of hypoglycemia Case 1 Autonomic Neuroglycopenic ? • A 57 year-old male with h/o benzodiazepine abuse • Tremor • Dizzy/lightheaded • Hypothermia presents after found by EMS with altered mental status. • Tachycardia • Confusion • Bradycardia Initial GCS in the field was reported as 11. Upon arrival in • Sweating • Ataxia • Pallor • Blurred vision the ED he is confused and ataxic with slurred speech. He • Weakness • Paresthesias is noted to be mildly hypertensive, tachycardic and he has • Nausea • Focal neuro deficit diaphoresis. • Hunger • Seizures • Palpitations • Coma 2

2/1/2013 Case 1 A problem of persistent hypoglycemia... Drugs and toxins commonly associated with hypoglycemia • Patient receives 1 amp D50 with improvement in GCS to • • Insulin Alcohol 14. • • • sulfonylureas Ackee fruit He confirms that he has no h/o diabetes and did not overdose on any medications. • • Pentamidine VPA • Utox positive for cocaine, benzo, opiates and methadone • • Aspirin Quinine • One hour later the patient has recurrent hypoglycemia with • • Beta blockers Vacor repeat glucose = 47 mg/dL When purchasing valium on the street which of these pills do you want? A. B. Which of the following has been shown to be the most effective in The use of octreotide for sulfonylurea overdose the treatment of persistent hypoglycemia related to sulfonylureas? • Longer acting analogue of somatostatin • A. Boluses of D50 as need to maintain blood sugar • Acts on pancreatic islet cells to reduce insulin secretion • B. Place patient on a D10 infusion • • Effective in reducing glucose requirements in patient C. Feed the patient a carbohydrate rich meal sulfonylurea overdose • D. Start octreotide • Adult dosing: 50-100 mcg SQ every 6 hours • E. All of the above • Peds dosing: 5 mcg/kg divided every 6 hours. 3

2/1/2013 Rat Poisons Case 2 • Super warfarins • • Phosphides A 29 year-old male presented to the ED after a suicide • attempt by ingesting a large amount of rat poison. In the Strychnine ED the patient was diaphoretic and in respiratory distress. • Vacor • Vital signs = BP 113/99, P 100, RR 28, O2 sat 88% on RA. • Arsenic • PE significant for profound diaphoresis, diffuse rhonchi • throughout both lung fields, tachycardia, urinary Bromethalin incontinence, and muscle fasciculations. • Sodium fluoroacetate • Tetramine Case 2 SLUDGE • Salivation • A 29 year-old male presented to the ED after a suicide • attempt by ingesting a large amount of rat poison. In the Lacrimation • ED the patient was diaphoretic and in respiratory distress. Bronchorrhea • Urination • • Vital signs = BP 113/99, P 100, RR 28, O2 sat 88% on RA. Bronchoconstriction • Defecation • • PE significant for profound diaphoresis, diffuse rhonchi Bradycardia • GI irritation throughout both lung fields, tachycardia, urinary incontinence, and muscle fasciculations. • Emesis Why should emergency physicians be able to “Tres Pacitos” recognize and treat this rare poisoning? • Carbamates and organophosphates are still used as insecticides. • International travel and immigration increase the possibility of encountering patients who have ingested toxic substances from other countries. • Increased concerns of terrorism 4

2/1/2013 Rx of organophosphate and carbamate toxicity Case 3 • • A 45 year-old female with a history of depression presents Special attention to airway and breathing 1 hour after a large ingestion of her antihypertensive • Intubation medications. On arrival she is somnolent but arousable and • has a GCS of 14. Administration of antidote titrated to secretions • • Vital signs: BP 83/50, HR 65, RR 18, O2 sat 98% RA Atropine (often in large doses) • • Finger stick glucose = 235 Pralidoxime • Rigorous IV hydration • Decontamination Case 3 Where are the calcium channels? Location Effect of blockade Intervention • Ca+ administration • • Myocardial depression A 45 year-old female with a history of depression presents • Atropine • Sinus bradycardia Heart • Vasopressors 1 hour after a large ingestion of her antihypertensive • AV node blockade • Cardiac pacing medications. On arrival she is somnolent but arousable and has a GCS of 14. • Vasodilation • Intravenous fluids Peripheral • • decreased afterload • Ca+ administration Vital signs: BP 83/50, HR 65, RR 18, O2 sat 98% RA vasculature • systemic hypotension • Vasopressors • Finger stick glucose = 235 • Hypoinsulinemia • Ca+ administration • Insulin resistance Pancreas • High dose insulin • Hyperglycemia Hyperglycemia a predictor of poor outcome High dose insulin euglycemia therapy (HIET) 5

2/1/2013 Which of the following studies would be the most helpful in Case 4 determining the diagnosis? • A 34 year old HIV+ woman presents with a complaint of • feeling light headed, nauseated, and short of breath. Vital A. Carboxyhemoglobin level signs were BP 124/88, P 116, RR 18, O2 sat 82% on non- • B. Sulfhemoglobin level rebreather, afebrile. She was in no respiratory distress, but appeared to have blue discoloration of the lips, gums, face • C. LFT’s and peripherally in the digits and nail beds. The rest of the • exam was unremarkable. D. Methemoglobin level • • Arterial blood gas = pH 7.44, pCO2 31, pO2 307, Sat 98%, E. None of the above Lactate 1.0. Case 4 • A 34 year old HIV+ woman presents with a complaint of feeling light headed, nauseated, and short of breath. Vital signs were BP 124/88, P 116, RR 18, O2 sat 82% on non- rebreather, afebrile. She was in no respiratory distress, but appeared to have blue discoloration of the lips, gums, face and peripherally in the digits and nail beds. The rest of the exam was unremarkable. • Arterial blood gas = pH 7.44, pCO2 31, pO2 307, Sat 98%, Lactate 1.0. • Methemoglobin level = 41% Common drugs and toxins producing Methgb Drugs Toxins • Local anesthetics • Aniline dyes • Chloraquin • Benzene derivatives • Dapsone • Nitrates or nitrites (food, water) • Metaclopramide • Paraquat • Nitrites • Phenazopyridine • Primaquin • Sulfamethoxazole 6