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OVERDOSE: THE BAND. Mr. RR, 36yo Male Brought in by EMS/CPS Found in appt building foyer asleep with friend who “escaped” Not arousable, no I.D. Smells.

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Presentation on theme: "OVERDOSE: THE BAND. Mr. RR, 36yo Male Brought in by EMS/CPS Found in appt building foyer asleep with friend who “escaped” Not arousable, no I.D. Smells."— Presentation transcript:

1 OVERDOSE: THE BAND

2 Mr. RR, 36yo Male Brought in by EMS/CPS Found in appt building foyer asleep with friend who “escaped” Not arousable, no I.D. Smells “fruity” GCS “3” but non-purposefull movements of all limbs present No signs of trauma, OPA accepted

3 TOXICOLOGY I MANAGEMENT OF O.D. AND DECONTAMINATION ISSUES KEVIN HANRAHAN DR. DAVID JOHNSON

4 OUTLINE GENERAL CONCEPTS RESUSCITATION HISTORY TOXICOLOGY PHYSICAL TOXIDROMES INVESTIGATIONS GENERAL DECONTAMINATION G.I. DECONTAMINATION -ORAL REMOVAL -BINDING -MECHANICAL FLUSHING ENHANCED ELIMINATION ANTIDOTES DISPOSITION

5 Nontoxic Ingestions Only one substance in exposure Substance absolutely defined No hazards on product label Unintentional Route known Approximate amount known Asymptomatic with easy follow-up

6 Setting Occupational-eg. xylene Recreational Medical environmental I wonder what this xylene would taste like

7 Portals of Entry Ingestion,most common historically(76%) Inhalation(8%) Cutaneous/mucous membrane(6%) Injection-meds -drugs of abuse Insufflation

8 PADIS 03/04

9 PREVALENCE 2 Million toxic exposure in U.S rd leading cause of death Mortality from acute poisoning <1% Peds account for 80% 10% admitted, usually accidental Adults-20%,rarely accidental,90% admitted to hospital Accounts for 1% admission,10% ICU

10 PADIS APRIL 04/MAR 05 AGE DISTRIBUTION

11 CIRCUMSTANCES- PADIS 03/04

12 PADIS O3/04 OUTCOMES

13 PADIS 03/04 SUBSTANCE%KIDS%ADULT OTC pain & fever meds Household cleaning prod Cosmetics & personal care Mental health meds Alcohols Anti anx & sedatives ?? Fumes/gases/vapors Plants Foreign bodies Pesticides3.64.4

14 RESUSCITATION Occurs simultaneously with Dx Important as support may be only Tx for most overdoses Vitals, all 6 critical in toxicology T/BP/HR/RR/SAT/BS Airway-patent & protected? -intubate for GCS<9 Breathing-vitals and auscultate Circulation-vitals,establish IV,EKG

15 RESUSCITATION cont’d Decide:stable/unstable :?heavy hitter eg TCA, Bblocker etc Antidote-rarely takes precedence over ABC (cyanide toxicity) Coma Cocktail-hypoxia -wernicke’s -opioid intox. -hypoglycemia

16 “HEAVY HITTERS” Largest number of deaths in 2000 in U.S. -analgesics -antidepressants -sedative/hypnotics/antipsychotics -stimulants -street drugs -CV drugs -alcohols

17 RESUSCITATION cont’d Seizures -BZD.,phenobarb, not dilantin Hypotension -isotonic fluids,bicarb,hi dose levo/dop Vent. Arhythmia -bicarb bolus,lidocaine,BB in chloral hydrate -see ACLS for specific toxins

18 COMA COCKTAIL Cheap Minimal risk Simple Oxygen as per need D50W,50g,adult 4ml/k D25W or 10ml/k D10W Pediatrics

19 THIAMINE Not necessary in kids 100mg IV/IM qdaily ?before D50W? Previously thought to prevent Wernicke’s encephalopathy

20 WHERE’S THE EVIDENCE ?

21 Thiamine/Glucose Originally came from 5 case reports of Wernicke’s precipitated or made worse by glucose before thiamine All 5 had severe nutritional deficiencies, several comorbid illnesses and received glucose for several days before thiamine was administered Therefore don’t delay glucose in ED for thiamine Hack,JB,JAMA 1988

22 NALOXONE (NARCAN) MG IV/IM, +/- restraints min. response time 2 nd dose 2/3 of first Observe 2-3h Triad of dec. LOC,miosis,resp dep. Resp status only reliable way to determine effect of narcan. Other drugs affect LOC and some opioids can cause mydriasis

23 NALOXONE 730 pts prehospital tapes/sheets reviewed in AMS pts. for response to Narcan and clinical presentation. RR<12,pinpoint pupils,circumstantial evidence of opiate abuse all predictive of response Use of these criteria would decrease Narcan use by75-90% without missing any responders Hoffman,JR,Annals of Emergency Med., 1991

24 FLUMAZENIL AS PART OF THE COMA COCKTAIL? Retrospective analysis of 35 consecutive comatose pts Divided into low and non-low risk for sz. based on clinical and ECG(proconvulsive OD’s) Only 4 were assessed as low risk High risk of sz. In non-low risk group Low risk might benefit but very small minority of pts. Gueye,PN,Annals of Emergency Medicine, 1996 Flum. May also precip. Arrythmia in TCA

25 TOXICOLOGICAL HISTORY MOST IMPORTANT DIAGNOSTIC TEST # of pts/type of exp/ amounts,dose/route/intent “all OD’s are liars” Corroborate with MD/pharmacist/EMS/witnesses Info on environment:empty bottles, odours,material,hobbies,notes AMPLE

26 Toxic Features History -suicide, prev. O.D. or abuse -psychiatric or polypharmacy Physical -arrest,bronchospasm,dysrythm nyd - thermia/tension -AMS,sz.,rigidity,dsytonia,rotary nystagmus Investigation -anion/osmolar gap, K-Na-gluc -renal/hepatic failure,rhabdo,aspiration

27 TOXICOLOGICAL PHYSICAL Expose, look for hidden substances Waist bands,skin folds,groin Watch for sharps

28 NEEDLE COLLECTION Bright yellow disposal boxes in easily accessible locations encourage IV drug users to safely discard used syringes. The project collected 22,245 needles in 2001.

29 GENERAL APPEARANCE LOC;agitation,obtundation,confus. Skin;cyanosis,flushing,diaphoresis dryness, Injuries,injections,bullae,bruising (may be from trauma,dec LOC longterm or coagulopathy)

30 ODOURS Almonds Eggs Fish Garlic Fresh hay Geraniums Swimming pool Mothball Violets Wintergreeen peanuts Cyanide Hydrogen sulf Sinc sulfide Org phosporous Phosgene Lewisite Chlorine gas Camphor,naptha Turpentine Methyl salicylate vacor

31 SKIN FINDINGS CyanosisDeoxyhemoglobin or methemoglobin YellowingCarotene veg.,cigs,picric acid, Dinitrophenol flushingAntichol,scombroid,rectal F.B, Disulfiram,niacin,nitratres GrayMetallic silver or gold EscharAnthrax,radioactive,brown recluse spider, BullaeBarbs,chemotherapies Red skinCholinerg,vanco,CO,boric acid Nail linesArsenic,chemotherapy

32 CNS LOC/cognition Tone Reflexes Coordination Ambulation

33 Toxins Causing Seizures Amphetamines Antihistamines/ anticholinergics Caffeine/theoph Antipsychotics Carbamates CO Cocaine Hypoglycemics Chlorambucil Propranolol salicylates Cyclic antidepress Ethylene glycol Isoniazid Lead Lidocaine Lithium Methanol Organophosphates Phencyclidine Withdrawal from ETOH/sedatives

34 Toxins Affecting Tone Dystonic reactions DsykinesiasRigidity HaldolAnticholinergicBlack widow MetoclopramideCocaineMalign hyperth OlanzapinePhencyclidineNeur malig syn PhenothiazinesRisperidoneStrychnine RisperidoneFentanyl phencyclidine

35 Toxins Causing AMS DEPRESSEDAGITATEDDELIRIUM Sympatholytics Sympathomim etics ETOH/drug withdrawal Adrenergics bl Adrenergic agAnticholinergics Antiarrhythmic AmphetAntihist AntihypertensCaffeineCO Antipsychotics Cocaine Cimetidine Cholinergics ErgotsHeavy metals BethanecholMAOI’sLithium CarbamatesTheophylline Salicylates Nicotine Anticholiner

36 DEPRESSEDAGITATEDDELIRIUM Organophosantihistamine PhysostigmineAntiparkinson PilocarpineAntipsychotic Sedat/hypnotAntispasmodic AlchoholsCyclic antidepr BarbsCyclobezaprine BZDDrug withdraw Gamma HydroxB-blockers EthchlorvynolClonidine NarcoticsEthanol AnalgesicsOpioids AntidiarhealSed/hypnotic

37 DEPRESSEDAGITATEDDELIRIUM CyanideMarijuana Hydrogen sulfide Mescaline Hypoglycem ic LSD lithium

38 EYES Pupils: size, reactivity,equality Dysconjugate gaze lacrimation

39 Toxins Affecting Pupil Size MiosisMydriasis Barbiturates Amphetamines Carbamates Anticholinergics ClonidineAntihistamines EthanolCocaine Isopropyl alcohol Cyclic antidepressant OrganophosphatesDopamine Opioids Glutethimide PhencyclidineLSD PhenothiazinesMAOI’s PhysostigminePhencyclidine Pilocarpinedemerol

40 MOUTH (with suction) Retained contents or pills Gag Dryness/salivation

41 Lungs Air entry oxygenation wheezing bronchorhea

42 TOXINS CAUSING HYPOVENTILLATION Alcohols Barbs Botulinum Cyclic antidepress Neuromuscular blockade Opioids Sedative/hypnot Snake bite Strychnine tetanus

43 HEART/PULSES Rate Rhythm Regularity Peripheral pulses/perfusion

44 TOXINS AFFECTING PULSE Tachycardia Common -TCA -CO -anticholinerg eg. Gravol -adrenergic eg. cocaine Bradycardia Common -opioids -cholinergics -BBlockers

45 ABDOMEN Bowel sounds Rigidity Urinary retention tenderness

46 TOXIDROMES Physiological groups Based on VS,general appearance, skin,eyes,mm,etc. Also basic labs

47 DO THE BASIC FINDINGS MATCH WITH A POISON ? Basis for toxidrome Eg. Autonomic syndromes sympathetic parasympathetic Adrenergic symptoms,eg. cocaine Cholinergic,eg organophospates Anticholinergic, eg. gravol No bowel sounds,dry skin,blurry vis,fever etc S.L.U.D.G.E Tahycardia,htn, diaphoresis, mydriasis,etc

48 Autonomic Nervous System NIC NE S NIC MUSC PS NIC NMJ

49 ToxidromeAgentFindings OpioidsHeroineDec. loc,miosis,dec.RR SympathoCocaineAgitation,mydriasis,diap horesis,tachy,etc CholinergicOrganophS.L.U.D.G.E. AnticholAtropineDry,red,AMS,hyper-t etc SalicylatesASAAMS,resp alk,met acid et HypoglycInsulinAMS,diaph,tachy,etc SerotoninSSRIAMS,inc tone,hyper-t

50 Toxins Affecting Temperature Hypothermia -TCA,Li,Phenothiazin -alcohol,barbs,opium -hypoglycemics colchicine,akee fruit -AMS in winter Hyperthermia -LSD,cocaine,PCP, amphetamines -antichol,antihist -TCA,MAOI,SSRI phenothiazines -ASA -malign hyper/NMS

51 TOXINS AFFECTING BREATHING Hypoventilation-eg alcohols,BZD., opioids Bronchospasm- eg cocaine, BB, aspiration from AMS

52 INVESTIGATIONS PROGRESSIVE TESTING CBC&D,CHEM 7,ABG,LFT osmolality EKG CXR FLAT PLATE XR SPECIFIC DRUG LEVELS Tox. Screens

53 Anion Gap Acidosis Toxins Acetominophen Amiloride Ascorbic acid CO Colchicine Nipride Dapsone Epi Ethanol Ethylene glycol Formaldehyde Hydrogen sulfide Iron isoniazid Ketamine Metformin Methanol Niacin NSAIDS Papaverine Paraldehyde Phenformin Propofol Salicylates Terbutaline Tetracycline Toluene verapamil

54 OSMOLAR GAP VARIABILITY “NORMAL” OSMOLAR GAP 8-10 Distribution curve puts real normal between -?1 and Therefore gap of 10 in someone who’s “resting” gap is 2 may contain error of 8 Methanol toxic >6.2mmol/l

55 Toxins with Inc. Osmolal gap Ethanol Ethylene glycol glycoaldehyde Glycine IV immunoglobulin Isopropanol 2(NA)+Gluc+bun +/-1.25(etoh) Mannitol Methanol/from aldehyde Propylene glycol Radiocontrast Hypermagnesemia sorbitol

56 EKG EKG findings in TCA:sinus tach,inc. QRS/QTc intervals, inc PR interval RAD in the T40ms frontal QRS plane I neg/AVR pos, in T40ms Due to quinidine like effect on RBBB in TCA 8.6 times more likely in TCA OD 83%sens, 63% spec Wolfe, TR, Ann of Emerg Med, 1989

57 EKG EKG IN TCA

58 ACLS Rx of Toxic Dysrythmias Stimulant/Sympathomimetics -consider BZD,Ablockers,Lidocaine NaHCo3, not Bblockers CCB’s -consider mixed A/B agonists, pacer, Ca++,insulin euglycemia Bblockers -consider pacer,mixed A/B agonists, glucagon/insulin euglycemia ACLS Handbook of Emerg Card Care 2000

59 RADIOLOGY CXR if prompted by Hx, Px or specific other findings like hypoxia Flat plat may be considerred for FB or ingestions of radiopaque toxins eg iron CT scan for AMS r/o HI and ICP if indicated

60 TOX SCREENS Marijuana/opioids/cocaine/amphetamine/ TCA/barbs/BZD/phencyclidine Usually does not affect assessment or outcome acutely False +:amphet-propranolol,cpz etc TCA-flexeril,mellaril,etc False -:opioid-demerol,heroin amphet-MDMA, benzo-rohypnol

61 TOX SCREENS cont’d Slow to return Most OD’s treated with support alone Chronic ingestion eg. Marijuana may confuse issue Less frequent intoxicants not quickly available May be helpful in persistant sick without obvious etiology In kids may be helpful for neglect/abuse situations

62 APAP/ASA/ETOH Frequent co-ingestants Relatively quick May help sort out multiple ingestion scenario May help psych. with ongoing assessment

63 GENERAL DECONTAMINATION It’s great the fire department provides us with these sprinklers on hot days

64 GROSS DECONTAMINATION Remove patient from substance Remove substance from patient Undress(including jewelry,watches – biohazard) Wash, head to toe In mass casualty done in field or in isolation area outside ambulance bays in most hospitals Staff need full PPE

65 GROSS DECONTAMINATION Colonoscopy booth

66 EYES Copious (usually 2L) irrigation Normal saline best but tap will do 0.5% tetracaine, lid retractors helpful 1ml tetracaine in 100ml saline

67 EYE IRRIGATION

68 EYES cont’d Alkali exposure may require 1-2h of irrigation given deep penetration NS ph 5.6 After equilibration (10min) Tear film ph<8

69 GI DECONTAMINATION Oral removal-emesis -lavage Binding Mechanical flushing

70 EMESIS Derived from emetine and cephaline (plants) Works centrally on chemotactic trigger zone and stomach Dose 30ml (15ml in 1-12) with sips

71 IPECAC cont’d Can repeat once 90% vomit in 20m 97% 2 nd dose Ave. 3-5 vomits Done in 2h If 30m 18-52% If 60m 31-36%

72 IPECAC CONTRAINDICATIONS AMS or drugs that can cause rapid(<60mins) AMS (TCA,eucalyptus,strychnine) Active or prior vomiting Caustic/corrosive ingestion >pulmonary than GI toxicity (hydrocarbons) Ingestion which can cause sz. Debilitated/elderly or medical made worse by vomiting

73 IPECAC COMPLICATIONS Boerhaves’ syndrome Malory-Weiss tears Intractable vomitting Inability to give oral treatments

74 IPECAC INDICATIONS Very limited in hospital setting Rare-larger pills than orogastric tube in recent ingestion(<60min) that can’t be absorbed by charcoal on a Tuesday when the moon is full! At home if remote, recent and no contraindications

75 IPECAC INDICATIONS cont’ “syrup of Ipecac should not be administered routinely in the management of poisoned patients…There is no evidence from clinical studies that ipecac improves the outcome of poisoned patients and its routine administration in the ED should be abandonned” AACT Position paper, Journal of Toxicology, 2004 AMERICAN ACADEMY OF CLINICAL TOXICOLOGY (AACT)

76 OROGASTRIC LAVAGE LL decubitus position 36-40F(adult),22-24F(kids) Chin to xyphoid measurement Room temp tap water untill clear Instillation of charcoal before removing if indicated

77 OG LAVAGE CONTRAINDICATIONS Pills too big Non-toxic ingestion Non-life threatening ingestion GI hem, perf or recent Sx Airway not assured Material lung danger>GI tract (hydrocarbon,corrosive)

78 OG LAVAGE COMPLICATIONS Tracheal lavage Aspiration, tension pneumo, charcoal empyema Atrial/ventricular ectopy Esoph, trach or gastric trauma or perforation Desaturation, laryngospasm Tube knot formation fluid/lyte imbalance

79 OG LAVAGE EVIDENCE Prospective study of 808 pts with presumed OD Odd/even day gastric emptying(GE) with either ipecac or lavage based on LOC. Others got charcoal GE did not alter LOS,length of intubation,ICU LOS, GE increased ICU admits for asp. Pneum Merigian, KS, Amer. J. of Emerg. Med. 1990

80 GE EVIDENCE cont’d PRCT of 876 pts with OD Odd/even day randomization for GE/AC or just AC GE was lavage or ipecac No difference in outcome regardless of time to presentation Pond,SM,Medical J. of Australia,1995

81 AACT INDICATIONS Not routinely recommended Not if greater than 60mins Not if not life threatenning Must have assured airway No definite evidence that it improves outcome and may cause morbidity

82 CHARCOAL (GUT TOXIN ADSORPTION)(GI DIALYSIS)

83 ACTIVATED CHARCOAL(AC) Pyrolysis of carbanaceous material Steam cleaned to increase the surface area (activated) Adsorbs (holds to surface) toxins in the gut lumen Improves gut/blood gradient (GI dialysis) for previously absorbed Binds substances excreted in bile interrupting enterohepatic circ.

84 Toxins Not Adsorbed by AC Alcohols Hydrocarbons Organophosphates Carbamates acids Potassium DDT Alkali Iron lithium

85 AC cont’d Decreased benefit with time as toxin travels beyond pylorus At 30 min mean bioavailability decreased by 70% At 60 min by 37% No good studies that show clinical benefit of single dose AC (AACT)

86 AC BENEFITS Decontaminating gut non-invasively Rapid administration Safe in adults and kids Can be administered with juice, water or by OG 1g/kg or 50g in most adults +/- cathartic with first dose

87 AC EVIDENCE RCT with 1479 pts. randomized to AC + supportive measures or support alone Measured clinical deterioration, LOS in ED or hospital, complications and length of intubation Trial done over 24 mos., lge urban center Merigian,KS, Amer. J. of Therapeutics, 2002

88 AC EVIDENCE cont’d No sig. difference in length of intubation,LOS for hospital and complication rate Longer ED stay (6.2vs5.3h) and more vomiting (23vs13%)in AC group No benefit of AC over support alone Merigian, KS, Am.J.Therepeutics, 2002

89 AC CONTRAINDICATIONS Perforation or abnormal GI tract If emergency endoscopy planned e.g. caustics Unprotected airway Increased risk from aspiration (eg Hydrocarbons)

90 AC COMPLICATIONS Aspiration Impaction with abnormal motility Vomiting Corneal abrasions

91 AC INDICATIONS Ingestion of any drug known to be adsorbed by charcoal with toxic ingestion Does not work for lithium, iron, lead Unknown ingestion with protected airway Lack of good clinical data for or against Therefore Not routine (AACT) Best within 1 hour (AACT) No evidence it improves outcome (AACT)

92 MULTIPLE DOSE CHARCOAL.25-.5G/kg on subsequent doses Q1-4h Only first dose has cathartic Indications-large ingestions -substances that form bezoars or are injurious -slow release toxins -enterohepatic/enteric circul. substances

93 Multi-dosable AC Amytrityline Amoxapine Baclofen? BZD’s? Buproprion? Carbamazepine Chlordecone Dapsone Dig Disopyramide Glutethimide Maprotiline Theophylline sotalol Meprobamate Methyprylon Nadolol Nortriptyline Phencyclidine Phenobarb Phenylbutazone Phenytoin Pyroxicam Propoxyphene Quinine Salicylates?

94 MULTI-DOSE AC cont’d Contraindicated in non-life- threatening ingestions and toxins which slow GI motility as these increase risk of aspiration from gastric distention and impaction of charcoal No specific AACT position statement

95 CATHARTICS

96 Sorbitol 70% (1g/kg) or 250ml of 10% mag citrate (4ml/kg in kids) Studies consistently show decreased transit time for charcoal Krenzolok,EP,Ann Em Med, 1985 Harchelroad,F,J.Clin. Tox., 1989 Cathartic alone not effective Minton,NA, J Clin Tox.,1995 Al-Shareef,AH,Hum Exp Tox.,1990 Peak plasma concentrations decrease with cathartics Picchioni, AL, J Toxicol Clin Toxicol, 1982 Goldberg, MJ, Clin Pharmacol Ther, 1987

97 Cathartics Indications Same as single dose charcoal Ingestions unknown or known to be adsorbed by charcoal with protected airway AACT-not alone, not endorsed routinely with or w/o charcoal, single dose if used

98 Cathartics complications Nausea, vomitting, abdo cramps Volume depletion, electrolyte disturb Hypermagnesemia in renal impaired if magnesium product Hypernatremia if Na product

99 Cathartics Contraindications Ingestions that cause diarhea Kids <1 or very old Mag citrate in renal failure Obstruction, no BS, abdo trauma,recent abdo Sx,perf. corrosive ingestion Heart block Hypotense,vol. deplete, lyte imbal.

100 WHOLE BOWEL IRRIGATION (WBI) Electrolyte/osmotic balanced polyethylene glycol (Golytely) Mechanically forces ingested toxins through the bowel 2L/h (adult), ml/h(peds) Until clear rectal fluid

101 WBI Indications-AACT 1997 No controlled clinical studies showing improved outcomes but some volunteer studies Not routine Consider in slow release or enteric coated toxic ingestions Theoretic potential in iron and other non- adsorbables(Li,lead,zinc) Theoretic in delayed presentation, large amounts, drug packers (Farmer, JW, J Clin Gastro, 2003)

102 WBI complications Nausea, vomiting, cramps,bloating Pulmonary aspiration Rectal irritation Increased nursing care !!

103 WBI Contraindications Diarhea or substances that cause it Absent bowel sounds Intractable vomiting Obstruction, ileus,perforation,hem Hemodynamic instability Compromised airway

104 ENHANCED ELIMINATION Urinary-diuresis -alkalinization -acidification Dialysis Hemoperfusion hemofiltration

105 DIURESIS Not been well studied Consists of achieving 3-6ml/k/h u/o Isotonic fluids and diuretics Not recommended Causes electrolyte imbalance,pulmonary edema,raised ICP Also doesn’t work

106 Urinary Alkalinization Helpful in some ingestions Weak acids held within renal tubule and excreted with bicarb 3 amps (150 ml) of bicarb in 850 D5W at 250/h Goal urine pH Must have normal K+ so add 40 meq kcl to bag after initially correcting hypokal.

107 URINARY ALKALINIZATION TissuesPlasmaUrine pH 6.8 HA H + + A - pH 7.4 HA H + + A - pH 8.0 (alkalinized) HA H + + A -

108 GOAL PH

109 Alkalinizable Toxins ASA Uranium Quinolones Primidone Phenobarb methotrexate 2,4 dichorphenoxy- acetic acid Flouride Isoniazid methobarbitol

110 Urinary Alk. Complications Dec. K+ Volume overload (CHF) pH shifts

111 Urinary Alk. Containdication Can’t tolerate fluid or Na+ load Hypokalemia Renal failure Toxin known not to respond

112 Acidification of Urine Virtually never used Potential for myoglobinuric renal tubular injury Systemic acidosis additive Arginine/lysine hydrochloride or ammonium chloride ? Use in amphetamine/phencyclidine

113 DIALYSIS I am sure happy to be here today

114 Dialysis Removes both the toxin and it’s metabolites Removes toxins that can’t be adsorbed by charcoal Less effective with lge mol wgt, protein bound, large vol. dist.

115 Hemodialysis Indications Dialysable toxin that is life threatenning Peritoneal dialysis rarely used

116 Dialysis Contraindications Hemodynamic instability Small children (exchange transfusion better) Poor vascular access Profound bleeding diathesis

117 Dialysis Complications Fluid shifts Electrolyte imbalance Bleeding at access site Infection Intracranial hemorhage

118 Hemoperfusion Charcoal filter in dialysis machine Works better for large molecule size and protein bound if adsorbable Needs small volume of distribution Must not be highly tissue bound Rarely used

119 Hemoperfusion Complications Cartridge saturation Thrombocytopenia (plt dec by 30%) Hypoglycemia, hypocalcemia Access complications Hypothermia (pump not heated) Charcoal embolization

120 Hemoperfusion cont’d Works Phenobarb,phenytoin,theophylline, carbamazepine,paraquat, glutethimide Doesn’t Work Heavy metals,ethanol,methanol,CO, cocaine

121 Hemofiltration Removes toxins by convection through a highly porous membrane Works well with toxins with large volume of distribution, extensive tissue binding Works well for large molecular wgt substances Not well studied

122 ANTIDOTES Increases the mean lethal dose of a toxin or favorably affects the effect of the toxin Specific indications Beyond the scope of this lecture

123 ANTIDOTES eg. Drug/PoisonAntidote AcetominophenN-acetylcysteine AntichonergicsPhysostigmine AnticholinesterasesAtropine BenzodiazepinesFlumazenil Black Widow BiteEquine Antivenin Carbon MonoxideOxygen Coral Snake BiteAntivenin CyanideAmyl Nitrate,etc

124 Antidotes cont’d DigoxinDigibind Ethylene glycolEthanol/fomepizole Heavy metalsDimercaprol,EDTA HypoglycemicsDextrose IronDeferoxamine IsoniazidPyridoxine MethanolEthanol,fomepizole MethemoglobinemiaMethylene blue OpioidsNaloxone OrganophospatesAtropine,pralodox. Rattlesnake biteantivenin

125 INDICATIONS FOR THE ICU PaCo2 >45 ( Brett, AS, Arch Int Med,1987) Intubation need Seizures Arrhythmias Prolonged QRS >.12s SBP <80 2 nd or 3 rd degree AV block GCS <12 (unresponsive to verbal) Dialysis Staffing (babysitting suicidal) Hypo/Hyperthermia Naloxone drip

126 EXCELLENT REVIEW ARTICLE Babak, M, Jerrold, BL, Patrick, M, “Adult Toxicology in Critical Care” Chest, 2003;123:

127 ??? QUESTIONS ???


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