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

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

3. 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)

4. Exposures by Age Fatalities < 6 years old 52.7%
0.03% of total exposures
ages years = 56%
>6 years = 2.1%

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

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

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

8. Most Common Substances
Cleaning substances %
Analgesics %
Cosmetics %
Plants %
Foreign bodies %
Cough, cold %
Bites, stings %
Insecticides, pesticides, rodenticides %
Sedative, hypnotics, antipsychotics %
Antidepressants %
Hydrocarbons %
Alcohols %

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

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

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

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

13. Scene Survey Check out scene for : Where do you look for clues? 1 2 34
Where do you look for clues?

14. 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

15. 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

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

17. 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

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

19. 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

20. 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

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

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

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

24. 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

25. 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

26. 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

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

28. 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

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

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

31. Examples of Specific Toxins

32. 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

33. 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

34. 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

35. 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

36. Hydrocarbons Examples Kerosene Gasoline Lighter fluid Turpentine
Furniture polish

37. 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

38. methyl alcohol wood alcohol wood naphtha
Methanol
methyl alcohol
wood alcohol
wood naphtha

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

40. 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

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

42. 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 + _

43. Cyanide

44. But first…
A little review of biochemistry and biophysics

45. 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.

46. 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.

47. 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 !

48. 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!!)

49. 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

50. Salicylates

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

52. 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

53. 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.

54. 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

55. 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

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

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

58. Acetaminophen

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

60. 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

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

62. MUCOMYST Acetaminophen
The specific antidote for acetaminophen toxicity.
MUCOMYST

63. 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

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