1. Poisoning/Overdose
General Management

2. Exposure to substance that is toxic in any amount
Poisoning
Exposure to substance that is toxic in any amount

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

4. 1998 TESS Data 2,241,082 reported human exposures 97.9 % at home
Peak volume 4pm-10pm
91% of calls 8am-midnight

5. Exposures by Age
< 6 years old %
< 3 years old %

6. Fatalities 775 fatalities 0.03% of total exposures
ages years = 56%
>6 years = 2.1%

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

8. Management Location Managed on site 75.2%
Treated, released at ER %
Admitted to critical care %
Refused referral %

9. Therapy No therapy 11.9% Observation only 12.7%
Decontamination only 59.6%
Activated charcoal %
Ipecac %

10. Most Common Substances
Cleaning substances 10.2%
Analgesics %
Cosmetics %
Plants %
Foreign bodies %
Cough, cold %
Bites, stings %

11. Most Common Substances
Insecticides, pesticides, rodenticides 3.9%
Sedative, hypnotics, antipsychotics %
Antidepressants %
Hydrocarbons %
Alcohols %

12. Largest Number of Deaths
Analgesics
Antidepressants
Stimulants, street drugs 118
Cardiovascular medication 118
Sedatives, hypnotics
Alcohols

13. Indicators Sudden onset of CNS signs: Seizures Coma Decreased LOC
Bizarre behavior

14. Indicators
Sudden onset of:
Abdominal pain
Nausea
Vomiting

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

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

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

18. 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

19. General Management Rule out
Trauma
Neurological disease
Metabolic disease
Base general management on route of poison entry

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

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

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

23. 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

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

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

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

27. 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

28. 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

29. Activated Charcoal Inactivates Ipecac Do not give until vomiting stops
Do not give with
Cyanide
Methanol
Tylenol (+)
Containers must be kept airtight

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

31. 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

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

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