1. Cases --Poisoned Patients
Donna Seger MD
Medical Director
TN Poison Center
Asst. Prof of Medicine and Emerg Medicine
VUMC

2. 2 year old female
Wine
Sleepy, arousable
Normal vital signs

3. ETOH in children
Þ hypoglycemia

4. Treatment? Serum glucose 60 ng/dL Ipecac? Gastric lavage?
Single dose activated charcoal?

5. GI Decontamination Ipecac-No
Gastric Lavage- consider in an obtunded patient within one hour of ingestion
Single-dose Activated Charcoal-consider if drug adsorbed to AC and within one hour of ingestion
Whole Bowel Irrigation-within 5 hours-packets, SR prep, ions

6. 70 year old manic-depressive female overdoses on her own Lithium sometime in the past 24 hours. She is asymptomatic
Serum Lithium concentration is 4.5 meq/L

7. Serum level one hour later is 4.6 meq/L
Patient is becoming agitated
Ativan is administered

8. Two hours later the patient has a respiratory arrest

9. Toxicity GI - n/v/d Neuro - ataxia, tremor, stupor
Cardiac - terminal manifestations

10. Well absorbed in GI
5 days to reach steady state
1/2 life = hours
Elimination via kidney
Abs with Na+ in PT

11. Lithium
â Norepi in CNS
Substitutes for Na+ in extracellular fluid. Not removed by Na+-K+ pump which prevents re-entry of K+ that diffused from cell during depolarization
Toxicity-â Li clearance

12. Lorazepam (Ativan) BZDP
Less lipophilic than diazepam, but penetrates BBB more quickly
Does not redistribute into fat stores as rapidly, so longer duration of action
1/2 life = 12 hours
Respiratory depression

13. Button Batteries

14. 40 year old female
Antidepressant ingestion
Unconscious
BP 40

15. TCA
Toxicity
CNS CV
Quinidine-sodium channel blocker
Anticholinergic

16. NaHCO3
NaHCO3
NaHCO3
NaHCO3
NaHCO3
NaHCO3
NaHCO3
NaHCO3
NaHCO3

17. 12 year old male ingested unknown amount of Voltaren
O/A, unresponsive, BP 60/0

19. Management Principles

20. History Unreliable What When How much Accidental or self-inflicted
First time or recurrent
PMH

21. Physical Exam Temp! Neuro-external signs of trauma Mental status
“Apparently unconscious”

22. Emergency Treatment A-airway B-breathing C-circulation
Consider glucagon and/or insulin/glucose for hemodynamic instability in the young previously healthy poisoned patient
Supportive Care – highest priority
Coma  D50, Narcan, monitor

23. Laboratory Analysis
Time is of the essence in comatose patient or hemodynamically unstable patient
ABG will help you determine urgency

24. AGA
M ethanol
U remia
D KA
P araldehyde
I NH or idiopathic lactic acidosis
E thylene Glycol
S alicylates

25. Toxicology Screen Comma Fluctuating LOC Medical complications
New Onset psychosis

26. Axioms “Negative serum” Serum level – implications Lethal level
Treat patient, not lab values

27. Quantitation APAP CO Digoxin EtOH Ethylene Glycol Heavy Metals Iron
Lidocaine
Lithium
Methanol
Methemoglobin
Phenobarbital
Phenytoin
Salicylates
Theophylline

28. Antidotes Beta Blocker – Glucagon Benzodiazepine-?Flumazenil
CO-O2-NBO v. HBO
CN-CN Kit
Digoxin – Digibind
Ethylene glycol – EtOH; 4MP
Methanol – EtOH; 4MP

29. Antidotes (cont) OP – Atropine; PAM Opiates – Naloxone
Anticholinergic – Physostigmine
TCA – NaHCO3
Methgb – Methylene Blue
Acetaminophen - NAC

30. Flumazenil Contraindications TCA Hx head trauma Hx seizures
Chronic BZDP use

31. Elimination of Absorbed Substances

32. Elimination of Absorbed Substance
Forced diuresis of no benefit
Ion trapping via alkaline diuresis for specific toxins

33. Alkaline Diuresis
Phenobarbital
Aspirin

34. Indications for Hemodialysis/Hemoperfusion
Deterioration despite supportive care
Depression of midbrain function
Complications of coma
Hepatic, cardiac, or renal insufficiency

35. Drug Characteristics Enterohepatic circulation Small VD
Little protein binding

36. Psychiatric Evaluation
Suicide Risk Factors
Older solitary male
Suicide plan
Previous attempts
Recent lost
Chronic serious illness
History of drug or alcohol abuse
Psychosis
Sense of helplessness, hopelessness

37. Legal Aspects
No court has upheld a patient’s right to refuse medical treatment subsequent to be a drug overdose.
A patient who has attempted suicide has lost the right to refuse treatment

38. 23 y-o found unconscious by friends
Suicide note – “took pills
To ED

39. Unconscious
Unresponsive
BP 102/80
HR 120
Treatment?

40. Airway B C

41. ETI
Unconscious patients do not have protective airway reflexes

42. Airway
Breathing C

43. Ventilate

44. Airway Breathing Circulation

45. Blood Pressure Pulse Hemodynamic instability ?????

46. Hemodynamic Instability in the poisoned patient
Fluid (2 liters)
Glucagon
Insulin/glucose

47. Antidote

48. Naloxone
Glucose

49. Physical Exam

50. Temperature
Trauma
Illness
Drug abuse

51. Laboratory Analysis

52. ABG Electrolytes Glucose CBC UDS

53. Gastrointestinal Decontamination ??????????????????????????????

54. Imaging Studies

55. Head CT CXR (C-spine)

56. Treatment?

57. Supportive Care

58. UDS
Benzoylecgonine
Marijuana
Benzodiazepines