1. The Poisoned Patient Core Clerkship in Emergency Medicine University of Colorado at Denver Health Sciences Center

2. Objectives Apply general emergency medicine management principles to the poisoned patient Apply general emergency medicine management principles to the poisoned patient Review basic pharmacology and toxicology of common poisons Review basic pharmacology and toxicology of common poisons Utilize clues from the history, physical exam, and diagnostics to identify the poisons involved Utilize clues from the history, physical exam, and diagnostics to identify the poisons involved

3. First principle in poisoning management Sick or not sick? Sick or not sick? Poisoned patients can present with a broad spectrum of illness Poisoned patients can present with a broad spectrum of illness If sick, start treatment If sick, start treatment Resuscitation is always the first step- remember your ABCs Resuscitation is always the first step- remember your ABCs

4. General principles of emergency management Resuscitation/Stabilization Resuscitation/Stabilization Evaluation Evaluation Rule out the life-threats Rule out the life-threats Identify what you can Identify what you can Symptomatic care/monitoring Symptomatic care/monitoring Prevention of deterioration Prevention of deterioration Treat symptoms Treat symptoms Antidotes Antidotes

5. Case – Altered Mental Status

6. EMS Report “This is a 57 yo male. We were called to his house by his son, who found him confused. The son is on the way here. “This is a 57 yo male. We were called to his house by his son, who found him confused. The son is on the way here. “On our arrival, we found a somnolent male who is not able to answer questions, is mildly diaphoretic, and had BP 135/75, HR 100, RR 32, and oxygen sat of 99% on room air. We have a 16 gauge IV in the left AC. D- stick was 95. “On our arrival, we found a somnolent male who is not able to answer questions, is mildly diaphoretic, and had BP 135/75, HR 100, RR 32, and oxygen sat of 99% on room air. We have a 16 gauge IV in the left AC. D- stick was 95. “Any questions for us before we leave?” “Any questions for us before we leave?”

7. EMS Report House was clean, no signs of an assault, etc. House was clean, no signs of an assault, etc. No drug paraphernalia around No drug paraphernalia around No medicalert bracelet or necklace No medicalert bracelet or necklace No open pill bottles near patient No open pill bottles near patient Patient was found 5 ft from the bottom of a staircase Patient was found 5 ft from the bottom of a staircase

8. The patient’s son arrives… What would you like to ask his son?

9. His son tells you… He talked to his dad yesterday, seemed normal He talked to his dad yesterday, seemed normal No significant PMH No significant PMH PSHX: gallbladder taken out about 10 years ago PSHX: gallbladder taken out about 10 years ago No medications except for something he occasionally takes for a “stomach flu bug” No medications except for something he occasionally takes for a “stomach flu bug” SH: smoker : 40 pack/year hx, occasional social drinker SH: smoker : 40 pack/year hx, occasional social drinker Wife died of cancer about a month ago—dad took her death “very hard” Wife died of cancer about a month ago—dad took her death “very hard”

10. Physical Exam Vitals – Vitals – T 38.2; BP 134/78; Pulse 102; RR 30; SaO2 98% on RA Gen: Confused, drowsy Gen: Confused, drowsy Skin: moist and flushed, no lesions, no cyanosis Pupils: mid position (not constricted or dilated) and reactive CV: tachy RR, no murmur/rubs/gallops Lungs: CTA bilaterally Bowel sounds: present No evidence of trauma, neck is not stiff Neuro: otherwise nonfocal

11. Sick or not sick?

12. Sick or not sick Sick but stable Sick but stable No immediate airway, breathing or circulation interventions required No immediate airway, breathing or circulation interventions required But altered mental status may be due to a life- threatening condition that requires prompt intervention But altered mental status may be due to a life- threatening condition that requires prompt intervention

13. What’s our differential diagnosis for this patient?

14. Broad Differential Diagnoses Neurologic Neurologic Malignant Malignant Endocrine Endocrine Infection Infection Trauma Trauma Toxicologic Toxicologic

15. Altered Mental Status Four life-threatening causes that require immediate treatment Four life-threatening causes that require immediate treatment Hypoxia (ruled out by normal pulse ox) Hypoxia (ruled out by normal pulse ox) Hypotension/severe hypertension (ruled out by normal BP) Hypotension/severe hypertension (ruled out by normal BP) Herniation of the brainstem (ruled out by non-focal neurological exam) Herniation of the brainstem (ruled out by non-focal neurological exam) Hypoglycemia (needs to be evaluated in every patient with altered mental status) Hypoglycemia (needs to be evaluated in every patient with altered mental status)

16. Get the best history possible Often unreliable or unobtainable from patient Rely on EMS, bystanders, family members and other physicians Psychiatric files Obtain bottles/medications from home Any missing pills, amount, time of ingestion Environmental setting Check pockets, bags, belongings

17. Physical Exam Thorough exam looking for clues: Thorough exam looking for clues: Toxidromes- constellation of signs and symptoms of a particular poison Toxidromes- constellation of signs and symptoms of a particular poison In the ED we always look for the “classic” presentation In the ED we always look for the “classic” presentation Also look for signs of non-toxicologic causes: Also look for signs of non-toxicologic causes: Evidence of trauma, infection, metabolic or neurological causes, etc.

18. Common Toxidromes Common Toxidromes Sympathomimetics Sympathomimetics Anti-cholinergics Anti-cholinergics Cholinergics Cholinergics Sedatives Sedatives Opiates Opiates

19. Sympathomimetics Cocaine, Amphetamines, PCP Hypertension Tachycardia Diaphoresis Mydriasis Agitation Does this sound like our guy?

20. Anticholinergics Antihistamines, some plants, side effect of many drugs Tachycardia Hyperthermia Dry skin Mydriasis Decreased bowel sounds Urinary retention Delirium, agitation Hot as a hare, Dry as a bone, Red as a beet, Mad as a hatter, Blind as a bat. Does this sound like our guy? Does this sound like our guy?

21. Cholinergics Organophosphates, Carbamates, Nerve agents Effects both muscarinic and nicotinic receptors Muscarinic effects S- SALIVATION, SEIZURE L- LACRIMATION U- URINATION G- GI DISTRESS (diarrhea & vomiting) B- BRONCHORRHEA A- ABDOMINAL CRAMPS M- MIOSIS

22. Cholinergics Nicotinic effects - MTWThF M-Mydriasis T-Tachycardia W-Weakness TH-Hyperthermia F-Fasciculations Does this sound like our guy?

23. Opiates Opiates, Clonidine Miosis Hypotension Bradypnea Bradycardia Hypothermia CNS Depression Does this look like our guy?

24. Sedatives Benzodiazepines, GHB “Coma with normal vital signs” CNS Depression Normotensive Mild bradypnea or normal RR Does this look like our guy?

25. Toxins and Vital Signs Hyperthermia - aspirin, cocaine, anticholinergics Hypothermia - opioids, sedatives Hypertension - stimulants, tricyclics, antihistamines Hypotension - blood pressure medications, opioids Tachycardia - stimulants, vasodilators, anticholinergics Bradycardia - beta-blockers, Ca Ch blockers, clonidine, digoxin Tachypnea- aspirin, amphetamines, CO Bradypnea- narcotics, clonidine, ETOH

26. Assessment The history suggests an overdose, but we don’t know what The history suggests an overdose, but we don’t know what The physical exam is non-specific The physical exam is non-specific No common toxidrome to suggest a diagnosis No common toxidrome to suggest a diagnosis Nothing to strongly suggest another cause Nothing to strongly suggest another cause Time to gather more data…. Time to gather more data….

27. Diagnostic Testing What diagnostics might be helpful in this case?

28. Diagnostics General lab testing General lab testing Serum chemistry, blood gas to identify metabolic abnormalities Serum chemistry, blood gas to identify metabolic abnormalities CBC, UA, CSF analysis to identify infection CBC, UA, CSF analysis to identify infection Drug/alcohol screen to identify common drugs of abuse Drug/alcohol screen to identify common drugs of abuse Specific lab testing Specific lab testing Some poisons require specific testing Some poisons require specific testing

29. Labs Na 135 K 3.5 Cl100 HCO3 15 Glucose 120 BUN 25 Cr 1.0 ABG 7.50/15/90/16/-12 EtOH undetectable Urine drug screen negative for drugs of abuse ECG – sinus tachycardia Head CT – negative CXR - normal

30. What is your assessment now? What is the acid/base disturbance? What is the acid/base disturbance? What is the differential for this acid/base disturbance? What is the differential for this acid/base disturbance? Is this consistent with a common overdose? Is this consistent with a common overdose? How can we assess this problem? How can we assess this problem? Was the ECG, head CT, and CXR helpful? Was the ECG, head CT, and CXR helpful?

31. Salicylism (Aspirin Poisoning) Respiratory alkalosis Respiratory alkalosis Direct stimulation of respiratory Direct stimulation of respiratory centers centers Tachypnea Tachypnea Metabolic acidosis Metabolic acidosis Aspirin is salicylic acid Aspirin is salicylic acid Causes lactic acidosis by uncoupling oxidative phosphorylation Causes lactic acidosis by uncoupling oxidative phosphorylation Causes ketosis by stimulating lipid metabolism Causes ketosis by stimulating lipid metabolism Confusion/cerebral edema Confusion/cerebral edema

32. Evaluation In most poisonings, symptoms do not correlate well with serum drug levels, so levels are not useful In most poisonings, symptoms do not correlate well with serum drug levels, so levels are not useful Acute salicylate ingestion is one case where symptoms DO correlate with levels Acute salicylate ingestion is one case where symptoms DO correlate with levels Therapeutic is up to 30 mg/dl Therapeutic is up to 30 mg/dl This patient’s level was 75 mg/dl This patient’s level was 75 mg/dl

33. Poisoning Management Supportive and symptomatic care are required for all poisonings Supportive and symptomatic care are required for all poisonings

34. Treating Common Poisoning Symptoms SymptomTreatment NoneObservation HypoglycemiaGlucose Somnolence/comaIntubation Agitation/seizures Sedatives (benzodiazepines) Hypotension Fluids/adrenergic pressors Cardiac arrhythmia Sodium bicarbonate, calcium, anti-dysrhythmics, pacing Vomiting Anti-emetics, IVF

35. Poisoning Management Antidotal therapies are needed for only a few poisons. (Consult your EM book for detailed listings.) Antidotal therapies are needed for only a few poisons. (Consult your EM book for detailed listings.) Consider GI decontamination Consider GI decontamination Removal of drug or decrease absorption from GI tract Removal of drug or decrease absorption from GI tract

36. GI Decontamination Ipecac syrup Ipecac syrup No longer recommended for poisonings No longer recommended for poisonings Activated charcoal Activated charcoal Binds to most medications and potentially decreases GI absorption Binds to most medications and potentially decreases GI absorption Potentially useful within 1 hour of ingestion but no evidence of improved clinical outcomes Potentially useful within 1 hour of ingestion but no evidence of improved clinical outcomes Aspiration is uncommon unless given by an NG tube or in patient with altered mental status Aspiration is uncommon unless given by an NG tube or in patient with altered mental status

37. GI Decontamination Gastric Lavage Gastric Lavage Insertion of large orogastric tube into the stomach and lavaging with several liters of fluid Insertion of large orogastric tube into the stomach and lavaging with several liters of fluid Potentially useful in life threatening ingestions < 1 hour Potentially useful in life threatening ingestions < 1 hour Aspiration occurs in around 5% of patients Aspiration occurs in around 5% of patients

38. Borrowed from Vik Bebarta, “One Pill Can Kill”

39. GI Decontamination Whole Bowel Irrigation Whole Bowel Irrigation Decreases GI transit time using PEG Decreases GI transit time using PEG Useful in life threatening ingestions when other methods not helpful Useful in life threatening ingestions when other methods not helpful

41. GI Decontamination Would GI decontamination be useful in this patient? Would GI decontamination be useful in this patient? Do you think that this patient has more drug in the GI tract? Do you think that this patient has more drug in the GI tract?

42. GI Decontamination He has a high salicylate level He has a high salicylate level He has been “confused for a couple of hours” He has been “confused for a couple of hours” Probably not much drug left in the GI tract Probably not much drug left in the GI tract

43. Specific Treatments Very few poisons require specific treatments such as: Dialysis Dialysis Diuresis Diuresis Chelation Chelation Cardiac pacing Cardiac pacing

44. Salicylism - Treatment Salicylate poisoning has a specific treatment Salicylate poisoning has a specific treatment Alkaline diuresis – increase in urine pH favors movement of salicylate ion into urine Alkaline diuresis – increase in urine pH favors movement of salicylate ion into urine Dialysis for severe cases Dialysis for severe cases Is this patient sick enough to get dialysis?

45. Non-Toxic Ingestions (Small amounts) Household bleach Household bleach Cigarettes (<3) Cigarettes (<3) Cosmetics Cosmetics Glues/paste Glues/paste Hydrogen peroxide (medicinal) Hydrogen peroxide (medicinal) Matches Matches Paint (indoor, latex) Paint (indoor, latex) Shampoos, lotions Rat poison Detergents Chalk Laxatives Ink Antibiotics Antacids

46. Summary Always start with the ABCs Always start with the ABCs Target your history and physical for clues to the diagnosis Target your history and physical for clues to the diagnosis Labs and other testing may be useful Labs and other testing may be useful Most poisons only require supportive care Most poisons only require supportive care If you have questions call the Rocky Mountain Poison Center If you have questions call the Rocky Mountain Poison Center