Poisoning/Overdose General Management Poisoning is Exposure to substance that is toxic in any amount

Exposure to substance in excess amount resulting in toxic effects Overdose Exposure to substance in excess amount resulting in toxic effects

1998 TESS* Data 2,241,082 reported human exposures 97.9 % at home Peak volume 4pm-10pm 91% of calls 8pm-midnight *The Toxic Exposure Surveillance System (US based)

Exposures by Age Fatalities < 6 years old 52.7% 0.03% of total exposures ages 20 - 49 years = 56% >6 years = 2.1%

Number of Substances 92.8% of all cases--one substance 44.7% of fatal cases-->2 substances

Management Location Managed on site 75.2% Treated, released at ER only 12.3% Admitted to critical care 2.7% Refused referral * 2.0%

Therapy No therapy 11.9% Observation only 12.7% Decontamination only 59.6% Activated charcoal 6.8% Ipecac 1.2%

Most Common Substances Cleaning substances 10.2% Analgesics 9.6% Cosmetics 9.4% Plants 5.5% Foreign bodies 4.6% Cough, cold 4.5% Bites, stings 4.1% Insecticides, pesticides, rodenticides 3.9% Sedative, hypnotics, antipsychotics 3.2% Antidepressants 3.0% Hydrocarbons 3.0% Alcohols 2.5%

Largest Number of Deaths Analgesics 264 Antidepressants 152 Stimulants, street drugs 118 Cardiovascular medication 118 Sedatives, hypnotics 89 Alcohols 56

Indicators Sudden onset of CNS signs: Sudden onset of: Seizures Coma Decreased LOC Bizarre behavior Sudden onset of: Abdominal pain Nausea Vomiting

Indicators cont Sudden onset of unexplained illness Bizarre, incomplete, evasive history Trauma (>50% of adult trauma EtOH, drug-related) Pediatric patient with arrhythmias

History What? How much? How long? Multiple substances? Treatment attempted? How? Whose advice? Psychiatric history? History of suicide?

Scene Survey Check out scene for : Where do you look for clues? 1 2 3 4 Where do you look for clues?

General Management Support ABC’s Secure airway, secure with advanced airway if needed Ensure adequate oxygenation, ventilation Maintain adequate circulation Monitor ECG Obtain vascular access Manage hypotension initially with volume Use vasopressors cautiously

General Management Keep patient calm Maintain normal body temperature Evaluate nature/toxicity of poison Check container, package insert, poison center information Treat the patient, not the poison

General Management Rule out (differential diagnosis) Trauma Neurological disease Metabolic disease Base general management on route of poison entry

Poison Entry Prevent absorption from GI tract Ingestion Inhalation Remove from exposure; Support oxygenation, ventilation Absorption Remove from skin surface Injection Slow movement from injection site throughout body

Objective Remove from GI tract before absorption occurs Ingested Poisons Objective Remove from GI tract before absorption occurs

Ipecac RARELY used anymore If used, has to have been initiated within few minutes after ingestion Vomiting in 20-30 minutes Only removes about 32% of contaminate Many contraindications

Ipecac Dose Follow with 2-3 glasses of water 15 cc if 12 months to 12 years old 30 cc if >12 years old Follow with 2-3 glasses of water Keep patient ambulatory if possible

Ipecac If no vomiting after 20 minutes, repeat When emesis occurs, keep head down Collect, save vomitus for analysis

Ipecac Contraindications Comatose or no gag reflex Seizing or has seized Caustic (acid or alkali) ingestion Low viscosity hydrocarbon ingestion Late term pregnancy

Ipecac Contraindications Severe hypertension, cardiovascular insufficiency, possible AMI Ingestion of: Strychnine Phenothiazines (Thorazine, Stellazine, Compazine) Tricyclic antidepressants Iodides Silver Nitrate

Lavage Commonly used in ED’s Removes about 31% of substance Helps get activated charcoal in patient, especially if patient is unconscious Not helpful for sustained release tablets Will not remove large tablets

Activated Charcoal Adsorbs compounds, prevents movement from GI tract Very effective at adsorbing substances Binds about 62% of toxin Dose 5 - 10X estimated weight of ingested chemical

Activated Charcoal Inactivates Ipecac Do not give until vomiting stops Do not give with Cyanide Methanol Tylenol (+) Containers must be kept airtight Can be given PO via slurry or by NG

Inhaled Poisons Objective: Move to fresh air; optimize ventilation and protect personnel from exposure

Absorbed Poisons Objective: Remove poison from skin Liquid: Wash with copious amounts of water Powder: Brush off as much as possible, then wash with copious amounts of water Protect personnel from exposure

Dilute / Irrigate / Wash Use soap, shampoo for hydrocarbons No need for chemical neutralization - heat produced by reaction could be harmful

Eye Irrigation Wash for 15 minutes Use only water or balanced salt solutions Remove contact lenses Wash from medial to lateral

Examples of Specific Toxins

Acids Examples Severe burning of stomach Absorption, systemic acidemia Toilet bowl cleaner Rust remover Phenol (carbolic acid) Hydrochloric acid Severe burning of stomach Absorption, systemic acidemia

Acids Loss of airway = most immediate threat Secure airway against edema IV with RL, NS for volume loss Emesis, gastric lavage contraindicated Dilution with water, milk NOT recommended

Alkalis Examples Severe burning of esophagus, stricture formation Drain cleaner Washing soda Ammonia Lye (sodium hydroxide) Bleach (sodium hypochlorite) Severe burning of esophagus, stricture formation

Alkalis Loss of airway = most immediate threat Secure airway against edema IV with LR, NS for volume loss Emesis, gastric lavage contraindicated Dilution with water, milk NOT recommended

Hydrocarbons Examples Kerosene Gasoline Lighter fluid Turpentine Furniture polish

If the patient is coughing, aspiration has occurred Hydrocarbons Signs/Symptoms Choking, coughing, gagging Vomiting, diarrhea, severe abdominal pain Chemical pneumonitis, pulmonary edema If the patient is coughing, aspiration has occurred

methyl alcohol wood alcohol wood naphtha Methanol methyl alcohol wood alcohol wood naphtha

Methanol Sources Industry Household solvents Paint remover Fuel, gasoline additives Canned heat Windshield washer antifreeze

Methanol Toxic dose Fatal oral: 30-240ml Minimum: 100 mg/kg Example Windshield washer fluid 10% Methanol 10 kg child needs only 10 cc to be toxic

Methanol Mechanism of toxicity Methanol slowly metabolized to formaldehyde Formaldheyde rapidly metabolized to formic acid Acidosis Ocular toxicity

Methanol Metabolism H O C C H O H O C O C H Methanol Formaldehyde Alcohol dehydrogenase C H O Formaldehyde Aldehyde dehydrogenase H O C Formic Acid O C H + _

Cyanide

But first… A little review of biochemistry and biophysics

Staying alive requires energy... The natural tendency of the universe is for things to become more disorderly. This trend toward disorder is called entropy. Complex systems (including us) don’t tend to last long, unless… They have a constant supply of energy to combat entropy.

Organisms capture and store the energy they need in the form of... Adenosine Triphosphate (ATP) The “currency” cells use to pay off the energy debt built up fighting entropy. Formed by capturing energy released as the cell breaks down large molecules through glycolysis and the Krebs Cycle.

Putting It All Together Cells have to have energy to stay alive. Cells get energy by breaking down glucose in two phases: glycolysis and the Krebs Cycle. Glycolysis yields 2 ATP and pyruvate. Pyruvate is changed to acetate (acetyl-CoA) and sent to the Krebs Cycle. The Krebs Cycle strips hydrogen and electrons off acetate and feeds them into the electron transport chain. Movement of electrons down the transport chain releases energy which is trapped as ATP. At the end of the chain, the electrons combine with hydrogen and oxygen to form water. CN messes with this !

Cyanide Chemical, plastic industries Metallurgy, jewelry making Blast furnace gases Fumigants, pesticides Present in various plants apples, pears, apricots, peaches, bitter almonds Remember there is CN gas released by BURNT plastics (e.g fire!!)

Cyanide Antidote Kit Amyl nitrite, sodium nitrite Sodium thiosulfate Only be used in serious cyanide poisonings Can induce life-threatening tissue hypoxia secondary to methemoglobinemia Sodium thiosulfate Can be used by itself Is relatively benign

Salicylates

Salicylates Examples Uses Aspirin Oil of wintergreen Analgesics Antipyretics Anti-inflammatories Platelet function inhibitors

Salicylates Mechanism of Toxicity Direct stimulation of respiratory center, causing respiratory alkalosis Irritation of gastrointestinal tract, causing decreased motility, pylorospasm, nausea, vomiting, hemorrhagic gastritis Decreased prothrombin levels/platelet dysfunction, causing prolonged clotting times Uncoupling of oxidative phosphorylation

Results of Oxidative Phosphorylation Uncoupling ATP production decreases, resulting in CNS and cardiovascular failure. Cells attempt to compensate by increasing the rate they process glucose anaerobically through glycolysis. Lactic and pyruvic acids accumulate, leading to metabolic acidosis. Hypoglycemia results as liver sugar stores are depleted. In absence of sugar cells begin to metabolize lipids, ketone bodies are produced, acidosis worsens. Energy normally trapped as ATP is wasted as heat, causing a rise in body temperature. The rise in body temperature accelerates metabolism, increasing tissue oxygen demand and worsening acidosis.

Suspect in any child with sudden onset of tachypnea Salicylates Clinical Presentation: Acute Toxicity Coma Seizures Hypoglycemia Hyperthermia Pulmonary edema Vomiting Lethargy Hyperpnea Respiratory alkalosis Metabolic acidosis Suspect in any child with sudden onset of tachypnea

Salicylates Clinical Presentation: Chronic Toxicity Usually young children, confused elderly Confusion, dehydration, metabolic acidosis Higher morbidity, mortality than acute overdose Cerebral, pulmonary edema more common

Salicylates Acute Toxicity Management Oxygen, monitor, IV GI tract decontamination Activated charcoal Replace fluid losses, but do NOT overload Control hyperthermia

Salicylates Acute Toxicity Management Bicarbonate for metabolic acidosis D50W for hypoglycemia Diazepam for seizures

Acetaminophen

Acetamophen Examples Uses Tylenol Tempra Many drugs contain this also Analgesic Antipyretic

Acetaminophen Mechanism of toxicity N-acetyl p-benzoquinonimine, normal product of acetaminophen metabolism, is hepatotoxic Normally is detoxified by glutathione in liver In overdose, toxic metabolite exceeds glutathione capacity, causes liver damage

Acetaminophen Management Induce emesis Do NOT give activated charcoal in general Give specific acetaminophen antidote

MUCOMYST Acetaminophen The specific antidote for acetaminophen toxicity. MUCOMYST

Mucomyst N-acetylcysteine Another sulfur-containing amino acid Substitutes for glutathione. Allows continued detoxification of NAPBQI. 140mg/kg initially followed by 70mg/kg every 4 hours 17 times. Tastes, smells like rotten eggs Mix with chilled fruit juice to decrease odor, taste

More to come Review Cocaine OD TCA OD Opoid OD MDMA - E GHB