General Approach to the Poisoned Patient Bruce D. Anderson, PharmD, DABAT Director, Maryland Poison Center Assistant Professor, University of Maryland School of Pharmacy

The Maryland Poison Center

GOAL Students will be able to describe the evaluation and the most appropriate initial therapy for poisoning and overdose patients.

OBJECTIVES Describe the usual population of poisoning victims Describe the roles of a poison center Describe the nine main questions to ask when evaluating a poisoning patient Describe the general steps involved in the initial management of poisoning victims

Quiz! You are contacted about a normally healthy 18 month old who just ingested the packet of silica gel that was in the new shoe box. What would you recommend: management in the ED or at home?

Quiz! The mother of a 3 year old calls you about the child ingesting a small amount of Visine ® eye drops. The exposure just happened and the child is fine. The bottle only contains 10 ml’s. How would you manage this case? What would you recommend: management in the ED or at home?

Quiz! A normally healthy 15 year old is helping his father build a deck. The child reaches into a wood pile and feels a sting on his hand. He looks down in time to see this spider crawling away. What would you recommend?

Maryland Poison Center Certified Regional Poison Center 24 hour service Certified “SPI’s” Poison prevention education Professional education

MPC: Overview Service program of the University of Maryland School of Pharmacy Located here since 1972 First year of operations, received 5,600 calls In 2012, MPC received 62,229 calls

MPC: (continued) Open 24 hours/day Staffed by pharmacists & nurses Nationally certified Specialists in Poison Information Board certified Medical Director Board certified Director Additional consultants available

Other Functions Recognition and prevention of exposures through community education and outreach Professional education to optimize patient care Data collection/reporting nationally Research to optimize patient care *

What’s the Mission? The mission of the Maryland Poison Center is to decrease the cost and complexity of poisoning and overdose care while maintaining and/or improving patient outcomes.

Bottom Line Save Lives Save Dollars

Bottom Line (continued) Save lives by providing emergency triage and treatment information to all callers. Save dollars by managing vast majority of patients (66%) safely and inexpensively at home.

Fiscal Impact: Last year, 22,883 poisoning patients were safely managed at home. Usual charge for ED evaluation and treatment: ~ $500 - $1,000 per patient Estimated cost savings: $11,441,500 to $22,883,000 per year

Poisonings - Epidemiology Over 2.2 million human poisonings in Approximately 1.1 million exposures occurred in children < age 6 years.

Poisonings - Epidemiology ~50% occur in children <6 years old. < 30 fatalities in children < 6 years old in 2012.

Why Pediatrics? Stages of child development Imitate adult behavior; Product may not be used or stored properly; Changes in the child’s environment (vacation, moving, going to a relatives house, etc). Siblings

Common Substances Cosmetics and personal care products Cleaning products Drugs (analgesics, cough and cold medicines, topicals, antibiotics, etc.) Plants Hydrocarbons Pesticides

Why Pediatric Poisonings Occur Susceptibility of young children stages of development imitate adult behavior Potentially dangerous circumstances lack of supervision child is hungry/thirsty product is in use/not stored properly “look-alikes ”

Can You Tell???

Substance Amount Route(s) Time of or since exposure Age/weight Symptoms present Previous treatment provided REASON for the exposure Pre-existing medical conditions Initial Assessment

If possible, identify physical findings: What does the patient LOOK like? Assess the WHOLE Patient!

Name the toxin that produces a smell of almonds. Quiz!

Cyanide!!! Answer

Any changes in urine, feces, fingernails, hair, etc? Assess vital signs: any changes in heart rate, blood pressure, temperature, respiratory rate? Changes in pupil size (e.g., miosis vs. midriasis)? Unusual eye movements? New neurologic findings (hypertonia vs. hypotonia; posturing, seizures, tremor, etc.)? Assess the WHOLE Patient!

Name the toxin that can cause the tongue to turn black? Quiz!

Bismuth Answer

Every patient has a story. The job of the clinician is to listen to that story, assess the quality of the information, relate all of the information to the physical findings and other objective information that’s available about your patient, and make reasonable assessments based on all of the information. Assess the STORY

Do you believe the story?

Assume that the story is INCORRECT and/or INCOMPLETE until you have objective information to support the story. Assess the STORY

Constellations of symptoms associated with specific toxins or groups of toxins. E.g., opioid toxidrome: CNS depression Respiratory depression Miosis Bradycardia Toxidromes

Initial Assessment Substance Amount Route(s) Time of or since exposure Age/weight Symptoms present Previous treatment provided REASON for the exposure Pre-existing medical conditions

Consider Poisoning for: any abrupt, unexplained change in mental status; victims of fire or trauma patients with previous psychiatric history patients that present with multiple symptoms

General Management ABC’s The vast majority of poisoning exposures can be managed supportively.

Supportive therapy (continued) Altered mental status: Give naloxone mg, glucose, and thiamine Monitor and treat seizures, fluid and electrolyte abnormalities, hypo/hyper thermia

Eye exposures: flush! Skin exposures: flush! Inhalation exposures: Move to fresh air! Injections: Mmmm…toughie Ingestion of toxins: Consider methods to prevent absorption. Can safely dilute almost any exposure with water General Decontamination

Don’t become a victim!

More effective than ipecac or the combination of ipecac + charcoal. Contraindications: ileus, foreign bodies Dose: 1-2 grams/kg or 10 X the amount of the ingested substance. Adverse effects: aspiration pneumonia (common), gastric obstruction (RARE). Activated Charcoal

Iron Lithium Sodium Potassium Lead Hydrocarbons Acids Bases Cyanide Activated Charcoal: Doesn’t Bind

Is it acceptable to administer activated charcoal to someone who is unconscious and unresponsive? Yes! Need to protect airway first Charcoal… Can You???

Is it acceptable to administer activated charcoal to someone who is intubated and being ventilated? Yes! Charcoal… Can You???

What are the situations where you CAN’T safely give charcoal??? Substance NOT bound by charcoal GI Obstruction Charcoal… When Can’t You..??

Saline cathartics (sorbitol, magnesium citrate) may be given along with charcoal to speed passage of the AC- drug complex through the GI tract. NOT NECESSARY May lead to fluid and electrolyte abnormalities Cathartics

Little or no advantage over the use of activated charcoal alone. Effectiveness is limited by the size of the tube. 30% return (adults) Gastric Lavage

Use PEG-ELS to flush the GI tract. Consider only for overdoses involving: Iron Lithium Sustained release preparations Contraindicated in patients with ileus Whole Bowel Irrigation

Multiple Dose Activated Charcoal (MDAC) Consider for: dapsone phenobarbital phenytoin theophylline DO NOT USE MULTIPLE DOSES OF CATHARTICS! Enhancement of Elimination

Alteration of URINE pH: acid or base Acidification of urine no longer performed because of risk of rhabdomyolysis and renal failure Alkalinization: check systemic pH Enhancement of Elimination (continued)

Does not work for substances with large volumes of distribution Hemodialysis/Hemoperfusion

Advantages: Corrects acid/base imbalances Corrects fluid and electrolyte imbalances Fairly common procedure Hemodialysis

Advantages: May clear some protein bound drugs Disadvantages: Not a common procedure Who has the cartridge? Hemoperfusion

HD: phenobarbital salicylates alcohols lithium HP meprobamate phenobarbital salicylates * theophylline Hemodialysis/perfusion

OpioidsNaloxone, nalmafene AcetaminophenAcetylcysteine Tricyclic AntidepressantsSodium Bicarbonate Calcium Channel BlockersCalcium, Glucagon, Insulin/glucose Beta BlockersGlucagon IronDeferoxamine BenzodiazepinesFlumazenil * DigoxinFAB fragments AnticholinergicsPhysostigmine Antidotes

CyanideAmyl Nitrite, Na Nitrite, sodium thiosulfate; or Hydroxocobalamin Carbon MonoxideOxygen Nitrates/nitritesMethylene blue Carbamates, Organophosphates Atropine, Pralidoxime (2-PAM) Ethylene glycol, methanolFomepizole or Ethanol SnakesAntivenin (CroFab) MetalsBAL, EDTA, Succimer, d-penicillamine Antidotes

Name something WAY BAD! What do you think? Name a substance that you believe is SO toxic, only one dose can be FATAL.

“One is Deadly” Camphor Clonidine Calcium channel blockers Methyl salicylate (oil of wintergreen) Topical imidazolines (like Visine) Benzocaine, lidocaine Oral hypoglycemics Diphenoxylate and atropine (Lomotil) Olanzapine, clozapine Hydrocarbons (petroleum distillates) Antifreeze (ethylene glycol, methanol) Caustics Acrylic Nail Glue Remover (acetonitrile)

Questions?