1. Management of Poisoning Accidental or otherwise…

2. Case #1 You find a friend passed out on the bathroom floor. You see a pill bottle near by. What do you do? On arrival to the hospital, what do you expect them to do?

3. Basics of Poison Management Support physiological functions (airway, respiration, circulation) Poison identification Promotion of poison removal  Ipecac? Gastric lavage? Prevention of further absorption  Activated charcoal? Use of specific antidotes

4. Basics of Poison Management – promoting poison removal Pro’s and con’s of Ipecac  FDA slideshow on Ipecac FDA slideshow on Ipecac  Must be conscious  No petroleum distillates or caustic products  Only 25% of gastric contents Gastric lavage  May be unconscious  Won’t get large pills

5. Basics of Poison Management – preventing further absorption Activated charcoal  Binds to many chemicals, preventing absorption  May bind to antidotes  Challenging to adminster – a black slurry Use styrofoam cup with lid and straw Another FDA view of the subject Further research is still needed, but right now, Ipecac is still OTC (according to ePocrates)

6. Case #2 An alcoholic resorts to drinking ethylene glycol. He presents with the following lab results:  pH=7.26, PaCO 2 =26 mmHg, HCO3 - =16 mEq/L  BUN = 60 mg/dL, Cr = 2.5 mg/dL  K + = 6.0 mg/dL, Ca + + = 7.1 mg/dL What are your priorities? Fomepizole (Antizol) Fomepizole Sodium bicarbonate to alkalinize urine, ↑ excretion

7. Antidotes Toxic substanceAntidote Bethanechol (Parasympathomimetic), Neostigmine (cholinesterase inhibitor) Atropine Atropine (Anticholinergic)Physostigmine Morphine (Opiods)Naloxone (Narcan) Valium (diazepam), Ativan (lorazepam), Versed (midolazam) - (benzodiazepines) Flumazenil (Romazicon) DigoxinDigoxin immune Fab (Digibind) Warfarin (Coumadin)Vitamin K HeparinProtamine sulfate Insulin induced hypoglycemiaGlucagon AcetaminophenAcetylcysteine (Mucomyst)

8. Case #3 A young child sees his grandma take some “M&Ms”. When grandma takes a nap, the 4 year old decides to help himself. Grandma is being treated for anemia. Deferoxamine (Desferal) Deferoxamine Penicillamine (Cuprimine) Penicillamine Lead poisoning – Give edetate calcium disodium (calcium EDTA) or DMSADMSA Arsenic, mercury, gold – Give dimercaproldimercaprol

9. Case #4 A child drinks the oil of wintergreen (methyl salicylate) used in his vaporizer. He develops nausea and vomiting followed by rapid breathing, ringing in the ears, sweating, and fever. Later, he develops light-headedness, drowsiness, confusion, seizures, and difficulty breathing. (remember the cross-country runner?)

10. Case #5 A client takes Tylenol in between Percocet to treat pain. He then gets a cold and also takes a “cold pill.” http://www.merck.com/mmhe/sec24/ch297/ch 297b.html http://www.merck.com/mmhe/sec24/ch297/ch 297b.html Maximum daily dose was considered 4 grams – now better to stay below 3 grams.now better to stay below 3 grams

11. Agents of Bioterrorism (Aerosolized) Anthrax – treat with ciprofloxacin, doxycycline Yersinia pestis (pneumonic plague) – treat with streptomycin, gentamicin  Endemic in Southwestern US (New Mexico) Small pox – treat with?? Antivirals  Immunization (vaccination) better Clostridium botulinum – give botulinum antitoxin Ricin – support airway / GI hemorrhage - no antidote Ricin

12. Nerve Gas Sarin  Is a cholinesterase inhibitor (excessive cholinergic stimulation, neuromuscular blockade)  Treat with atropine  Also give pralidoxime (2-PAM Chloride), and diazepam

13. Review of fundamentals Always look up drugs!! Watch for look-alike/sound-alike drugs Read back orders – ask questions if not certain of drug! Questions????