1. The Approach to the Poisoned Patient
Toxicology Skills Workshop
Regions Hospital Emergency Medicine Program

2. Initial Approach to the Patient with a Toxic Ingestion
Develop a Systematic Approach
Look for Toxidromes (“Talkingdromes”)
Attention to ABCs and need for Antidote
Know the Indications for Decontamination Procedures
Enhance when possible and appropriate

3. Initial Management of Severe OD - ABCDE
A – Antidote
B – Basics ; ABCs
C – Change catabolism
D – Distribute differently; Decontamination
E – Enhance elimination
In the patient with an ingestion, remember the basics (Airway, Breathing, Circulation), but also start thinking early about antidote and eliminating the toxin if indicated. Time matters.

4. Initial Management; A = Antidote
Toxin/Drug
Oxygen
CO, CN, H2S
Naloxone
Narcotics/Opiates
NAC
APAP, Carbon tet
Atropine, Pralidoxime
Organophosphates
Calcium
HF, Fl, Oxalates
DMSA
As, Lead, Hg
Sodium Bicarbonate
TCA

5. A = Antidote Antidotes Toxin/Drug Ethanol, 4MP EG, (methanol)
Digoxin-specific Fab
Digoxin
Glucose
Insulin
Hydroxocobalamin* CN
Physostigmine
Anticholinergics, central
Pyridoxine
INH, hydrazines
Glucagon
Beta-blockers

6. Basics - ABCs Airway Breathing Circulation Do the DONT Dextrose Oxygen
Naloxone
Thiamine

7. Reduce Adsorption Vomiting (Ipecac) Activated Charcoal Gastric Lavage
Never used in 21st century
Generally not indicated or used in an ED setting
Contraindicated in patients < 6 mos old, caustic ingestions, actual or potential loss of airway reflexes, need to give oral antidote
Activated Charcoal
Most effective if given within one hour
Caution in the patient with altered mental status (need a protected airway)
Not effective for hydrocarbons, metals (Lead, Iron, Lithium)
Gastric Lavage
Rarely used
Consider in large, potentially life threatening ingestions not amenable to activated charcoal

8. E = Enhance Elimination
Hemodialysis
STUMBLE(D) - Dialysis
Salicylates
Theophylline
Uremia
Methanol
Barbiturates, Bromide
Lithium
Ethylene Glycol
Depakote (high levels)
Pneumonic for which toxins are able to be removed via dialysis

9. The Patient with a Toxic Ingestion – H & P
Focused History and Brief Tox Exam
History: what-when-how much
Reliability factor, relatives, paramedics
Exam
Vital signs
Mental status
Pupillary response
Skin changes, Odors/other prominent features. M A T E R S
Medication
Amount
Time
Taken
Emesis
Reason
Signs/symptoms
Remember to focus on the time of ingestion, how much (ask paramedics or family for pill bottles, count pills if necessary), ask about vomiting. Pay attention on your physical to vital signs, mental status and Pupillary response as this may clue you in to a toxidrome.

10. History & Mini Tox Exam Exam Vital signs Pulse up or down or normal
BP up or down or normal
Temp up or down or normal
Resp up or down or normal

11. Vital Signs Toxicity – Pulse
Bradycardia (PACED)
Propranolol or other Beta blockers, Poppies (opiates)
Anticholinesterase drugs
Clonidine, CCBs, Ciguatera
Ethanol or other alcohols, Ergotamine
Digoxin

12. Vital Signs Toxicity – Pulse
Tachycardia (FAST)
Free base or other forms of cocaine
Anticholinergics, antihistamines, amphetamines
Sympathomimetics (ephedrine, amphetamines), Solvent abuse
Theophylline, Thyroid hormone
Anticholinergic medications: antidepressants like doxepin, amitriptyline…
furosemide digoxin
nifedipine disopyramide

13. Vital Signs Toxicity – Temperature
Hypothermia (COOLS)
Carbon monoxide, Clonidine
Opiates
Oral hypoglycemics, Insulin
Liquor
Sedative-hypnotics

14. Vital Signs Toxicity – Temperature
Hyperthermia (NASA)
Nicotine, Neuroleptic malignant syndrome
Antihistamines
Salicylates, Sympathomimetics
Anticholinergics, Antidepressants

15. Vital Signs Toxicity – BP
Hypotension (CRASH)
Clonidine, CCBs (and B-blockers)
Reserpine or other antihypertensives
Antidepressants, Aminophylline, Alcohol
Sedative-hypnotics
Heroin or other opiates

16. Vital Signs Toxicity - BP
Hypertension (CT SCAN)
Cocaine
Thyroid supplements
Sympathomimetics
Caffeine
Anticholinergics, Amphetamines
Nicotine

17. Vital Signs Toxicity - Respirations
Rapid Respiration (PANT)
PCP, Paraquat, Pneumonitis (chemical)
ASA and other salicylates, Amphetamines
Non-cardiogenic pulmonary edema
Toxin-induced metabolic acidosis
Paraquat is used in pesticides

18. Vital Signs Toxicity - Respirations
Slow Respirations (SLOW)
Sedative-hypnoptics, Strychnine, Snakes
Liquor
Opiates, OPs
Weed (marijuana)
Other causes: Nicotine, Clonidine, Chlorinated HC

19. Exam – Mental Status
Seizures?
Hallucinations?
CNS depressed?

20. Agents that Cause Seizures
WITH LA COPS
Withdrawals (alcohol, benzos)
INH, Insulin, Inderal
Tricyclics, theophylline
Hypoglycemics; Hemlock, water; Haldol
Lithium, Lidocaine, Lead, Lindane
Anticholinergics, Antiseizure
Hemlock is a plant

21. Agents that Cause Seizures
WITH LA COPS
Cocaine, Camphor, CN, CO, Cholinergics
Organophosphates
PCP, PPA, propoxyphene
Sympathomimetics, Salicylates, Strychnine
Phenylpropanolamine (PPA) is another one of the Ephedra alkaloids similar to ephedrine, epinephrine, methamphetamine, and amphetamines
Strychnine is used in pesticides

22. Agents that Affect Pupil Size
Miosis (COPS)
Cholinergics, Clonidine
Opiates, organophosphates
Phenothiazines, pilocarpine
Sedative-hypnotics, SAH
MydriASis (A3S)
Antihistamines, Antidepressants, Atropine
Sympathomimetics

23. Skin Changes Sympathomimetics Organophosphates ASA or salicylates
Diaphoretic (SOAP)
Sympathomimetics
Organophosphates
ASA or salicylates
Phencyclidine (PCP)

24. Skin Changes Dry Skin Bullous Lesions Antihistamines, Anticholinergics
Barbiturates and other sedative- hypnotics
Carbon monoxide
Tricyclics (personal case series)

25. Skin Changes
Flushed
CO (rare)
Anticholinergics
Boric acid
CN (rare)

26. Skin Changes Cyanosis Phenazopyridine Aniline dyes Nitrates Nitrites
Ergotamine
Dapsone
Any agent hypoxia, hypotension
MetHb

27. Exam - Diagnostic Odors
Bitter Almonds
Carrots
Fruity
Garlic
Gasoline
-Cyanide -Cicutoxin (water hemlock) -DKA, Isopropanol -OP, As, DMSO, selenium, thallium, phosphorus -Petroleum distillates

28. Diagnostic Odors Mothballs Pears Pungent aromatic Oil of wintergreen
Rotten eggs
-Naphthlene, camphor -Chloral hydrate -Ethchlorvynol -Methylsalicylate -Sulfur dioxide, hydrogen sulfide
Ethchlorvynol is a sedative and hypnotic medication developed by Pfizer in the 1950s.[2] In the United States Abbott Laboratories used to sell it under the tradename Placidyl. During their heyday, they were known on the street as "jelly-bellies". Since Abbott and Banner Pharmacaps, which manufactured the generic version, discontinued production in 1999, ethchlorvynol has no longer been available in the United States

29. Laboratory Evaluation of the Tox Patient
Toxicology Screens
Urine Stat
Urine vs Serum
Acetaminophen level
Routine Tests
CBC
BMP
Anion Gap
ABGs

30. Levels - Timing
*Clinical Symptoms may dictate treatment, not level.

31. Suggestive Findings in the Poisoned Patient: Anion Gap
A MUD PILE CAT
ASA
Methanol
Uremia
DKA
Paraldehyde, Phenformin
INH, Iron, Ibuprofen
Lactic acidosis
Ethylene Glycol
If you find an elevated anion gap on your lab workup – consider these potential poisonings

32. Suggestive Findings in the Poisoned Patient: Anion Gap
A MUD PILE CAT
CO, CN, Caffeine
AKA
Theophylline, Toluene
Others
Benzyl alcohol
Metaldehyde
Formaldehyde
H2S

33. Suggestive Findings in the Poisoned Patient: Anion Gap
Decreased Anion Gap
Bromide
Lithium
Hypermagnesemia
Hypercalcemia

34. Osmolar Gap Calculated Significant if >10
2(Na)+[Glu/18] + [BUN/2.8] + EtOH(mg/dL)/4.6
Osm Gap = measured - calculated
Significant if >10
Really significant if >19
Remember normal osmolar gap does not rule out toxic alcohol ingestion

35. Suggestive Findings in the Poisoned Patient: Osmolar Gap
Increased Osmolar Gap
MAD GAS
Mannitol
Alcohols (met, EG, Iso, eth)
Dyes, Diuretics, DMSO
Glycerol
Acetone
Sorbitol

36. Toxidromes: Case #1
A 40 year old man collapsed at work while moving his car. He has a hx of depression. He had recently attended his mother’s funeral the day before.
He was found slumped over the steering wheel of his car, lethargic and incoherent. A co- worker left the patient and went to call medics. He was intubated and transferred to Regions Hospital.

37. Toxidromes: Case #1 Examination Labs were unremarkable
BP 130/88, P90, R-vent, T 1012
Pupils 6mm unreactive but equal.
Skin warm, red, dry
Absent bowel sounds
Labs were unremarkable
ABG:pH 7.50, 32, 140
EKG - QRS 102, occasional PVC

38. Toxidromes: Case #1 Is there a Toxidrome? A. Opioid B. Anticholinergic
C. Delayed Exercise Syndrome
D. Cholinergic poisoning
Is there an antidote?
B. Altered Mental Status, Mydriasis, Hot, Red skin, Dry skin = Anticholinergic Syndrome
Antidote - physostigmine

39. Toxidromes: Case #1
Is there a Toxidrome?
A. Opioid
B. Anticholinergic
Altered Mental Status, Mydriasis, Hot, Red skin, Dry skin = Anticholinergic Syndrome
C. Delayed Exercise Syndrome
D. Cholinergic poisoning
Is there an antidote?
Antidote - physostigmine
B. Altered Mental Status, Mydriasis, Hot, Red skin, Dry skin = Anticholinergic Syndrome
Antidote - physostigmine

40. The Talkingdromes
Anticholinergic (antihistamines, cyclic antidepressants, Jimson weed)
Hot as a hare (hyperthermia)
Red as a beet (flushed)
Dry as a bone (dry skin, urinary retention)
Blind as a bat (mydriasis)
Mad as a hatter (hallucinations, delirium, myoclonic jerking)

41. The Talkingdromes Also with anticholinergic How do you treat it?
Mydriasis
Tachycardia
Hypertension
Hyperthermia
Seizures
How do you treat it?
Supportive care
TCAs – Sodium Bicarb for widened QRS
Benzodiazepenes for agitation, seizures
Consider physostigmine for pure anticholinergic overdoses (contraindicated in TCA overdose or with dysrhythmias or seizure)

42. Toxidromes: Case #2
A 19 year old male presents after from a party after his friends noted he was “acting funny.” He was “out of control” and not making sense, so they decided to bring him into the Emergency Room.
The patient is agitated on arrival

43. Toxidromes: Case #2 Examination Labs were unremarkable
BP 180/114, P120, R20, T 101
The patient is agitated and appears to be hallucinating
Pupils 6mm sluggish but equal.
Skin warm, red, very diaphoretic
Labs were unremarkable
EKG – sinus tachycardia

44. Toxidromes: Case #2 Is there a Toxidrome? Opioid Anticholinergic
Sympathomimetic
Cholinergic
C - Sympathomimetic

45. Toxidromes: Case #2 Is there a Toxidrome? Opioid Anticholinergic
Sympathomimetic (symptoms can be like anticholinergic except you see diaphoresis)
Cholinergic
C - Sympathomimetic

46. Talkingdromes (Toxidromes)
Sympathomimetics (cocaine, amphetamines, ephedrine)
Mydriasis
Tachycardia
Hypertension
Hyperthermia
Seizures
Diaphoresis
Treatment
Supportive care
Benzodiazepines as needed

47. Toxidromes: Case #3
A 40 y/o female is brought by medics. A family member called after a suicide note was found and the patient was found unresponsive.
On medic arrival the patient was noted to be very somnolent. She was transported to Regions Hospital.

48. Toxidromes: Case #3 Examination Labs were unremarkable
BP 100/65, P50, R6, T 98.6
The patient is arousable only to sternal rub.
Pupils 2mm sluggish but equal.
Skin cool, dry
Labs were unremarkable
EKG – sinus bradycardia

49. Toxidromes: Case #3 Is there a Toxidrome? Opioid Anticholinergic
Sympathomimetic
Cholinergic
Is there an antidote?
A – opioid
Treatment - naloxone

50. Toxidromes: Case #3 Is there a Toxidrome?
Opioid (key is respiratory depression with miosis
Anticholinergic
Sympathomimetic
Cholinergic
Is there an antidote?
Naloxone/Narcan. Can give 0.4mg - 2mg as first dose
A – opioid
Treatment - naloxone

51. Talkingdromes (Toxidromes)
Narcotic (heroin, methadone, other opioids)
Miosis
Bradycardia
Hypotension
Hypoventilation
Coma/CNS depression
Treatment
Naloxone

52. The Imitators – Opioid-like
Clonidine
Hypotension usually more profound
May require HIGH dose naloxone to see any effect
Tetrahydrozaline
Periodic apnea in kids
Kids should be admitted if symptomatic in ED
Tetrahydrozoline, a derivative of imidazoline, is found in over-the-counter eye drops and nasal sprays. Other derivatives include naphazoline, oxymetazoline, and xylometazoline.

53. Toxidromes: Case #4
A 50 y/o male is brought in after being found in his garage. According to paramedics, there were several containers of liquids in glass jars near the patient. They also noted a large amount of emesis. He was noted to have altered mental status and some respiratory distress prior to arrival. He was intubated prior to arrival and transported to Regions Hospital.

54. Toxidromes: Case #4 Examination Labs were unremarkable
BP 110/65, P50, R - intubated, T 98.6
The patient is obtunded, intubated
Pupils 2mm sluggish but equal.
There are copious secretions in the patient’s mouth and in the endotracheal tube
Incontinent of both urine and stool
Skin is cool, diaphretic
Labs were unremarkable
EKG – sinus bradycardia

55. Toxidromes: Case #4 Is there a Toxidrome? Serotonin Syndrome
Anticholinergic
Sympathomimetic
Cholinergic
Is there an antidote?
D - cholinergic
Treatment – 2PAM, atropine (lots)

56. Toxidromes: Case #4 Is there a Toxidrome? Serotonin Syndrome
Anticholinergic
Sympathomimetic
Cholinergic
Is there an antidote?
Atropine given until secretions are improve (no max dose)
2PAM/ Pralidoxime
D - cholinergic
Treatment – 2PAM, atropine (lots)

57. Toxidromes: SLUDGE Treatments: Pralidoxime (2PAM), Atropine
Cholinergic (DUMBBELS or SLUG BAM)
Salivation
Lacrimation
Urination
GI complaints (nausea, vomiting, diarrhea)
Bradycardia, Bronchoconstriction
Bronchorrea
Abdominal cramping
Miosis, Muscle fasciculations
Treatments: Pralidoxime (2PAM), Atropine

58. More Talkingdromes

59. Talkingdromes (Toxidromes)
Salicylates (ASPIRIN)Harris
Altered MS (lethargy to coma)
Sweating
Pulmonary edema
Increased ventilation, temp, heart rate
Ringing in ears
Irritable
Nausea and vomiting

60. Talkingdromes (Toxidromes)
Serotonin Syndrome
VS: T, HR, BP (unstable)
MS: Agitation, coma
Pupils: Mydriasis
Skin: Diaphoresis
Other: LE rigidity, myoclonus, hyperreflexia, seizure
Hunter Criteria for diagnosis of Serotonin syndrome
CNS: AMS/confusion
Autonomic instability: Brady/Tachycardia, HTN, hypotension
Muscle involement: Nystagmus, clonus, hyperreflexia

61. Serotonin Syndrome MAOI and other drug Idiosyncratic reaction
Alteration in MS
Autonomic instability
Neuromuscular abnormality
Treatment is supportive
Symptoms resolve hrs
Lactic acidosis, rhabdo, hyperthermia

62. Serotonin Syndrome Specific drugs SSRIs (i.e., Prozac)
Dextromethorphan
Demerol
Ecstasy (MDMA): hallucinogenic amphetamine
Cocaine
L-tryptophan

63. Acetaminophen Toxicity - Metabolism
Metabolized in the liver primarily to nontoxic glucoronide and sulfide conjugates, however small amount is converted via cytochrome P450 to potentially toxic NAPQI
Normally, NAPQI is conjugated with glutathione to nontoxic metabolites
In significant overdose, glutathione stores are depleted
NAPQI destroys hepatocytes leading to liver failure

64. Acetaminophen Toxicity – Clinical Presentation
First few hours
Non-specific signs and symptoms
Nausea, vomiting, pallor, diaphoresis
Even severely poisoned patients may remain symptomatic
18 – 24 hours
Asymptomatic phase
No laboratory evidence of hepatotoxicity
After 24 – 36 hours
Aminotransferases begin to rise
Signs and symptoms of hepatotoxicity
N, V, RUQ pain, hepatic enlargement, jaundice
72 – 96 hours
Peak hepatotoxicity
Although massive liver necrosis can occur, recovery is the rule and usually complete if the patient survives

65. Acetaminophen Level Levels are important
Check levels in all cases of suspected overdose or polydrug overdose
Antidotal therapy is most effective if started within 8 – 10 hours
Signs and symptoms are delayed for 18 – 36 hours
Rumack-Matthew nomogram
Used to predict the severity of toicity and need for antidotal therapy
4 hour level
Levels above the line require antidotal therapy

66. Acetaminophen Toxicity - Antidote
N-acetylcysteine (NAC)
Glutathione precursor and glutathione substitute
Increases substrate supply for the non-toxic sulfate conjugation pathway
Available as oral and IV form
Extremely effective if initiated within 8 hours
Standard of care to treat patients up to 24 hours

67. Summary - Systematic Approach
ABCs - Antidotes
Decontaminate - Special Treatments?
Toxidromes?
Investigate - look closely
REASSESS, MONITOR, SUPPORT

68. The End…Questions?