2. Toxidrome Potpourri Khalid Jaboori, M.D. Faculty Development Fellow Madigan Army Medical Center

3. Toxidromes Objectives –Discussed why recognition is important –Identified Classic symptoms – Diagnosed –Understand Treatment modalities

4. Why do we care? 2.3 million calls to Poison Control Centers/yr 26% needed medical care/ER visit 7% needed admission Poisoning = leading cause of injury releated death in the US, passing MVAs!!

5. Who/What/Where? EVERYBODY!! >70% of poison control calls involve children <6yo Most common= analgesics, sedatives, antidepressants >90% of exposures occur at home

6. Key Questions to ask What was the agent? How much of the agent? When was it ingested? What else was ingested? (ETOH) Why? Use anyone you can for info (family, friends, etc) !!

7. Key Management Principles ABCDs Look (pupil size, track marks, skin) Listen (breathing, mentation) Feel (temperature, sweating, HR) Smell (fruity odor, ETOH) DON’T TASTE!!

8. Key Management Principles Decrease drug absorption: lavage, absorbants, decontaminate Increase elimination: Diuresis/ hemodialysis Antagonize drug effects: Naloxone, Flumazenil, Digibind, etc.

9. Acetaminophen

10. Rapidly absorbed in GI tract Toxic dose = 7.5g in adults, >150mg/kg in children Peak plasma levels ~4hrs after ingestion Although ½ life ~3hrs, can have liver toxicity up to 17hrs post ingestion Sx = anorexia, nausea, vomiting, diaphoresis Check nomogram Tx= Activated charcoal, N-acetylcysteine per nomogram

11. Salicylates

12. Salicylates (ASA and more)! 150mg/kg= intoxication, blood levels >80mg/dl = severe sx 3 teaspoons Ben-Gay = ~7000mg =90 baby ASA Hyperventilation  resp alkalosis  alkauria then aciduria  hypokalemia  metabolic acidosis Nausea/tachypnea/vomiting/diaphoresis/ti nnitus are early signs Tx = lavage/ activated charcoal / alkalinize

13. OPIOIDs

14. OPIOIDS 4.6 deaths/100,000 in the US 3 rd most common cause of accidental death Decreases ventilation by blunting physiologic responses to hypercapnia and hypoxia Sx= AMS, hypopnea, hypovent, miosis, absent bowel sounds High risk = >100mg Morphine eq/day Tx: Naloxone, can give naltrexone

15. BENZODIAZEPINES

16. Medicare spends >$171 million/yr with nearly 17 million perscriptions Similar to ETOH toxicity: CNS depression, drowsiness, slurred speech, nystagmus, coma, resp depression, hypotension Can confirm via urine testing Tx: Flumazenil

17. Ethylene Glycol/ Methanol

18. Can be inhaled or ingested 1g/kg = lethal Profound anion gap metabolic acidosis Oligo/hematuria, flank pain, tetany = ethylene glycol Visual blurring, central scotomoa, blindness, mydriasis = methanol Can have elevated lactate, urine oxalate cryst Tx =bicarb, Fomepizole, hemodialysis, folic acid, B12, Mag

19. Organophosphates

20. Absorbed via all routes include skin mucosa Inhibit ACH = cholinergic sx Dumbells-muscarnic receptors= diarrhea, urination, miosis (pinpoint), bradycardia, emesis, lacrimation/lethargy, salivation OR….Nictonic receptors: Mydriasis, Tachypnea/cardia, weakness, fasciulations Tx = ATROPINE, PRALIDOXIME [dry as a bone, mad as a hatter, red as a beet, blind as a bat, hot as a hare]

21. Rumack Matthew Nomogram

22. Methamphetamine

23. Used clinically for ADHD, off label narcolepsy Can be made with OTC cold meds (ephedrine/pseudpehedrine) Sx: diaphoresis, HTN, tachycardia, agitation, psychosis, mydriasis Can appear malnourished, hypervigilant Dx: blood/urine test, buproprion can make test (+) Tx: BZ, Airway management, IVF

24. Bath Salts

25. Beta-ketone amphetamine analogs Can be snorted, smoked, or injected Unknown toxic dose Sx: chest pain, palpitations, tachycardia, HTN, agitation Difficult to detect by routine drug screen Tx: control agitation (BZ), airway management, monitor lytes/glucose

26. IRON (man)

27. IRON One of the most common cause of death in toddlers Toxic dose 10-20mg/kg elemental Fe Sx: nausea, vomiting, abd pain, diarrhea  latent phase  shock  hepatic failure  gastic outlet obstruction Tx: ABCs, fluids, (+)/(-) Deferoxamine can cause resp depression and ARDS

28. ETOH

29. 220 ER visits/100,000/yr, cost: ~1B/yr WA state legal limit =.08 Sx: slurred speech, disinhibition, ataxia BAC of.25-.40 can cause stupor, coma Fatal BAC varies, usually >.50 Tx: ABCs, IVF, Flumazenil, Metadoxine, Hemodialysis, thiamine

30. Carbon Monoxide

31. Great imitator! Sx: HA, weakness, muscle cramps, AMS, cyanosis, convulsions, coma Check if housemates have similar sx PE = signs of tissue hypoxia/cherry red skin Tx: 02, may need prolonged 02 tx (2hr of 100% 02 6-10L/min daily X3-4 months) or Hyperbaric 02 if avaliable

32. Lead

33. Usually from exposure from old lead based products, soil, folk remedies, toys, jewelry Check for kids with PICA Suspect in children with growth retardation, behavioral/attention d/o (grade C) Hospitalization = BLL of >70mcg/dl Sx: pain in abdomen, resistant to tx anemia Tx: Chelation: Succimer, Dimercapol (BAL), Edetate Calcium Disodium (CaEDTA)

34. TCAs

35. Toxicity = >4mg/kg in 1 hr May see cardiac toxicity (dysrythmia, heart block, broad QRS, wide QT interval) Anticholinergic Sx: dry mouth, dry eyes, dilated pupils, urinary retention, blurred vision, confusion, delirium, coma, convulsions Tx = activated charcoal, 02, NaBicarb

36. SPICE/Synthetic Cannabinoids

37. SPICE/Synth Cannabinoids AKA Spice, K2, Spice Diamond, Chill X Ingest or inhale Sx: red eyes, tachycardia, anxiety, aggressive behavior, paranoia, hallucinations, inability to speak, dystonia, seizures Difficult to detect Tx: no reversal agent, supportive care, BZs

38. Washington State Poison Center

39. American Association of Poison Control Centers

40. Neat websites US Dept of Health and Human Services, household products database: http://hpd.nlm.nih.gov/index.htm American Association of Poison Control Centers: http://www.aapcc.org/ National Capital Poison Center: http://www.poison.org/