1. EM Clerkship: Approach to Overdose/ Poisoned ED Patients
version

2. Objectives Describe US Poison Systems/Services
Poison Epidemiological Highlights
Describe common Toxidromes
Describe Indications for Tox Screens and other diagnostic tests
Describe GI Decon Options, Indications
List Common Antidotes

4. 800 222-1222 Regional Poison Centers
Martin TG
Regional Poison Centers
Major Med Centers/ High Call Volume
Many Toxicological Info Resources
Available 24 hr/d, 7 d/wk
Certified Specialists in Poison Info
Med Tox Board Certified Backup
Follow Up Calls - Determine Outcome
AAPCC National Poison Data Base (NPDS)
Requirements for Regional Poison Center certification
UW-TOX

5. 1995 US Poisonings Exposures 2,400,000 ED Visits 1,000,000 42%
Hospitizations 215,000 9%
Deaths 18,549 <1%
80% DOA

6. Fatal Accidents SEA/KC 2008
S/KC 2008 Medical Examiner Report

7. 99 - 04 Nonsuicide drug poisoning deaths 62%
“Recent changes in drug poisoning mortality in US by urban–rural status & drug type”
Paulozzi LJ: Pharmacoepi Drug Safety 08
Nonsuicide drug poisoning deaths 62%
 Primarily due to prescription opioids.
By 04, prescription opioids caused more deaths than either heroin or cocaine

8. From: The Health of Washington State, 2007 , WA DOH
1.5

9. Basic Approach to the poisoned patient
Stabilization
History and Physical Exam
Diagnostic tools
Measures to reduce absorption
Measures to enhance elimination
Specific antidotes
Supportive care

10. Stabilization Airway, Breathing, Circulation DON’T regimen EKG
Dextrose (or rapid finger stick glucose check)
Oxygen
Naloxone
Thiamine
EKG
intubate early if necessary
-hypotension should be treated aggressively (IV fluids/pressors)

11. History and physical History and Physical
Info from family/friends/EMS/Police
Look for signs of toxidromes
Consider GI decontamination and enhanced elimination
Call the poison center
Assistance with management
Reporting and surveillance

12. Toxicologic focus physical exam
Vital signs
Mental status – depressed or agitated?
Eyes- miosis or mydriasis
Skin/Axilla/Mucus membranes-moist or dry?

13. Toxicologic focused exam cont.
Respirations
-Increased or decreased rate/adventitious sounds?
Bowel sounds
-Present? Absent?
Neuro
-Rigidity, hypo/hyperreflexive?

14. Toxidromes
Toxidrome: Cluster of clinical sign and symptoms that can help identify a toxin and aid in the management of a poisoned patient.
Types of Toxidromes
Opioid
Sedative/hypnotic
Sympathomimetic
Anticholinergic
Cholinergic

15. Case 1
Case: 29 year old male is found lying on the floor of a bathroom of a gas station.
He is somnolent and responds only to deep stimulation
His respiratory rate is 6 with
shallow breaths
Pupils are pinpoint
Track marks are noted
What toxidrome is this?
Ask stude

16. Opoid toxidrome Opioid toxidrome Treatment The main culprits: Heroin
Miosis, usually
Respiratory depression
CNS depression
Treatment
Oxygen and airway management
Assisted ventilation
Naloxone?
Intubation
The main culprits:
Heroin
Prescription narcotics (methadone/vicodin/
oxycodone/etc.)

17. Case 2
A 39 year old female well known to EMS and ED for alcohol abuse is found sleeping in the street by police stating she took some “stix”
She is somewhat sleepy but answers questions appropriately with slurred speech.
Vitals are normal, pupils are 3mm reactive bilateral
She shows horizontal nystagmus on visual testing
What toxidrome is present?

18. Sedative/hypnotic toxidrome
CNS depression
Respiratory depression (sometimes)
Nystagmus
Normal to dilated pupils
Treatment
Largely supportive
Extreme caution with antidotes
Main culprits
-ethanol
-benzodiazpines (lorazepam/diazepam/clonazepam etc..)
-barbiturates (phenobarbital)
Flumazenil can reverse benzodiazepines, but can also cause intractable seizures and so is not used routinely. Supportive care is generally adequate.

19. Case 3 What is your initial management ? What is this toxidrome?
24 year old male is found by police wildly agitated and threatening and is not restrained by 4 large officers after kicking out the windows of a police cruiser.
His pupils are markedly dilated and he is diaphoretic and tachycardic
Between insults and threats, he complains of chest pain
What is your initial management ?
What is this toxidrome?

20. Sympathomimetic toxidrome
Agitation to aggressive behavior
Seizure
Dilated pupils
Increased pulse and respiratory rate
Rigid and febrile in severe cases
Examples:
Cocaine (crack/powder)
MDMA (ecstasy)
Methamphetamine
PCP (sherms)
Treatment
Support
Sedation (benzodiazepines!)

21. Case 4
17 year old high school senior is found mumbling and hallucinating after ingesting jimson weed seeds.
Pupils are dilated
Skin is red and dry
He has decreased bowel sounds and a full bladder

22. Anticholinergic toxidrome
Dilated pupils
Dry, flushed skin
Dry, mucous membranes
Sedation agitation and hallucinations
Urinary retention
Examples:
Benadryl
Phenergan
Jimson weed
Scopolamine
Treatment
Support
Sedation (benzos)
Mad as a hatter, dry as bone, hot as a stove, blind as a bat…

23. Case 5
35 year old migrant farm worker is found in respiratory distress and vomiting. He was spraying the fields with an unknown chemical today without a mask.
His saturation on room air is 92% and he has rales and wheezing bilaterally
Pupils are pinpoint and he is somewhat agitated
What is this toxidrome?

25. Cholinergic Toxidrome
SLUDGE
DUMBELS
Salivation
Lacrimation
Urination
Defecation
GI cramping
Emesis
Defecation
Urination
Meiosis
Bronchorrhea
Emesis
Lacrimation
Salivation

26. Cholinergic Toxidrome
Treatments
Main Culprits
Decontamination
Atropine
2-PAM
Supportive care
Organophosphate pesticides
Nerve gas

27. Putting it all together
Opoids
Anticholinergic
Cholinergic
Sympathomimetic
Pulse
Decreased
Increased BP
Variable
Resp
Temp
Bowel Sounds
Hyperactive
Normal
Skin
diaphoretic
Dry, hot
Diaphoretic
Mental Status
Depressed
Agitated
Pupils
Miosis
Mydriasis

28. Toxicology Evaluation
TG Martin, MD, MPH University of Washington
4/15/2017
Toxicology Evaluation
Serum labs
Chem 7 (look for anion gap), osmol, ABG if indicated, HCG
Quantitative levels
Tylenol, aspirin, lithium, seizure meds (dilantin, VPA, tegretol), digoxin
Urine toxicology
Send if helps with diagnosis or management
EKG
Seattle, WA USA

29.  Anion Gap Acidosis Methanol, Metformin Uremia Diabetic Ketoacidosis
Martin TG
 Anion Gap Acidosis
Methanol, Metformin
Uremia
Diabetic Ketoacidosis
Paraldehyde, Phenformin
Idiopathic, Iron, Isoniazid
Lactic Acidosis (Cyanide)
Ethylene & Other Glycols
Salicylate, Strychnine
UW-TOX

30. “Double Gap Acidosis” Screens for toxic alcohol poisoning Anion Gap
Na - (Cl + HCO3)
Normally < 10
Osmolal Gap (OG)
(2*Na) + (Gluc/18) + (BUN/2.8) + ETOH/4

31. Increased Osmolal Gap Renal Failure* Ethanol Mannitol Ethylene Glycol*
Martin TG
Increased Osmolal Gap
Renal Failure*
Mannitol
Sorbitol
Hyperlipidemia
Hyperproteinemia
Ethanol
Ethylene Glycol*
Isopropanol
Methanol*
Acetone
Ketoacidosis*
* Double Gap Acidosis
UW-TOX

32. TG Martin, MD, MPH University of Washington
4/15/2017
Main GI Decon Options
None
First, do no harm
Gastric Lavage
Activated Charcoal
Whole Bowel Irrigation
Seattle, WA USA

33. TG Martin, MD, MPH University of Washington
4/15/2017
Gastric Lavage
Indications:
Life threatening OD or pharmacobezoar
Contraindications:
Unprotected airway, hydrocarbon or caustic ingestions, esophageal pathology
Complications:
Aspiration  Hypoxia, Pneumonia
Kinked Orogastric Tube
Perforation (throat, esophagus, stomach), laryngospasm, epistaxis, great discomfort
Should be oral not nasogastric lavage
Probably the sickest patients who need it the most are at greatest risk unless intubated beforehand.
Seattle, WA USA

34. With LOC
Protect Airway -
Rapid Sequence
Intubation

35. Activated Charcoal Indications: Contraindications:
Potentially adsorbable toxic OD presenting < 1-2 hr after ingestion
Contraindications:
Unprotected airway, non adsorbable toxin (metals, caustics)
Dose: 1 gm/kg up to 50 gm
Can give charcoal through OG tube when intubated—charcoal causes significant pneumonitis (and even death) if aspirated

36. Whole Bowel Irrigation WBI
Very little literature available
Indications:
Sustained release, enteric coated, heavy metals
Contraindications:
Bowel obstruction, perforation, ileus; unprotected airway, dehydration

37. Multidose Activated Charcoal (MDAC)
Enhanced Elimination
Serial dosing of activated charcoal
Enhance elimination by interruption of entero-enteric circulation
Consider in ingestion of:
Phenobarbital
Salicylates
Theophyline
Carbamazepine
Digoxin
Phenytoin

38. Hemodialysis
Utility depends on toxin physical characteristics -size -high water solubility -low protein binding -small Vd (volume of distribution)
Salicylates
Phenobarbital
Methanol
Ethylene glycol
Lithium

39. Hyperbaric oxygen Potential benefit in carbon monoxide (CO) poisoning
Increase dissociation of CO from carboxyhemoglobin
Consider for highly symptomatic patients or pregnant patients with CO poisoning
Indications for Hyperbaric oxygen therapy (if available)
Symptomatic pt w/CO>20% (angina, dizziness, persistent headache)
Any pt w/mental status changes
Persistent impairment after 4 hr of 100% O2 mandates Hyperbaric tx
Asymptomatic pt w/CO>40% (controversial)
Pregnant pt w/CO>20%
Most effective if given w/in 6 hr of exposure

40. Common Antidotes Toxin Antidote Opioids Narcan Tylenol NAC TCA
NaBicarbonate
Digoxin
Digibind
Cyanide
Cyanide kit (hydroxycobalamin)
Carbon Monoxide
O2, Hyperbaric O2
Beta blockers
Glucagon
Calcium channel blockers
Calcium, glucagon, insulin/glucose
Cholinergics
Atropine, 2-PAM
Growing evidence supporting Intralipid infusion for lipophilic overdoses (TCA, lidocaine, B-blockers and CCB)

41. Supportive care
Continual re-assessment of patient stability (don’t forget the ABCs!)
Psychiatric care and precautions for suicidal patients
Intubate to protect airway as necessary
IV fluids for hypotension, consider pressor if needed

42. In Summary Initial stabilization
Complete history and physical (as possible)
Identify toxidromes if present
Call poison control for guidance
Utilize tests as indicated
Determine whether GI decontamination/enhanced elimination is indicated
Antidotes
Continual re-assessment/supportive care