1. Connie Y. Yu, MD SUNY Stony Brook Department of Emergency Medicine CLINICAL PEARLS: CASE OF THE POLY- POISONED PATIENT

4. HPI 60 y/o female BIB ambulance at 300AM p/w acute intentional drug ingestion ~100AM in a suicide attempt. Upon EMS arrival, pt found conscious, but acutely nauseous and vomiting. Ingestants: “Handful” of Percocets (5/325) x20 tabs Toprol XL 100mg x12 tab Digoxin 0.25mg x12 tab

5. HPI (continued) PMH: NHL and colon cancer s/p chemotherapy and hemicolectomy, Afib s/p ablation, PE, HTN, chronic back pain, depression Meds: Digoxin 0.25mg daily Toprol XL 100mg daily Percocet 5/325 tab prn pain MTV Allergies: NKA Social: tobacco 25 pk yr, EtOH occ, no drugs

6. PE VS: T36.6 BP 161/73 HR 35-40 RR 8-10 SpO2 96% on RA Ht 163cmWt 78.5 kg General: arousable, listless Skin: warm, moist, pale HEENT:normal conjunctiva, 2mm bilateral and sluggish pupils, dry mucus membranes Neck: supple CVS: NS1/S2, bradycardic, 2+ pulses Resp: CTAB, no wheezing, bradypneic Abd: soft, NTND, hypoactive BS Neuro: AAOx3, normal motor/sensory, no clonus Psych: flat mood & affect, suicidal

7. EKG!

8. Labs 300AM: 13.23K > 13.2/41.9 < 265K PTT 26.5 139 / 106 / 17 < 162 PT 11.2 INR 1.1 4.4 / 24 / 0.8 lactic acid 1.5 Mg 2 P 3.6 Ca 4.9 VBG: 7.3/45/109/22 T bili 0.5 TP 7 AST 127 D. Bili <0.2 Alb 4.1 ALT 94 acetaminophen80 mcg/ml digoxin10.2 ng/ml ETOH<10 mg/dl salicylates <0.5 mg/dl serum osm303 mOsm/kg Urinalysis unremarkable, + large ketones, trace proteins, glucose 150 Utox +oxycodone

9. Treatment 1.Supportive management 2.Toxicologic emergencies: - NARCAN 0.2mg IVP - NAC IV over 21 hr protocol LD 150 mg/kg over 1hr 50 mg/kg/hr over 4 hr 100 mg/kg/hr over 16 hr - Digibind 400mg IV (10 vials) - Pacer pads

10. Repeat Labs 700AM: 140 / 109 / 15 < 140 5.6/ 20 / 0.5 T bili 0.5 TP 7 AST 814 D. Bili <0.2 Alb 4.1 ALT 645 acetaminophen49 mcg/ml digitalis5.4 ng/ml

11. Disposition Admitted to the MICU for further telemetry and hemodynamic monitoring, NAC treatment, supportive care, close follow up with NY Poison Control Psychiatry evaluation for SI/attempt

12. So… Let’s Rewind and Review Our Poly Poisoned Patient

13. To Drink or Not to Drink?

15. Digoxin MOA Pharmacology Indications for use Therapeutic range

16. Digoxin Toxicity

17. EKG findings AtrialDysrhythmiasVentricularAV Node PAC PAT with block Regular Afib/flutter PVC VT/Bidrectional VF

18. Acute Digoxin Toxicity Indications for DS-Fab: K > 5.5 meq/L in acute poisoning Arrhythmias Hemodynamic instability [digoxin] > 10 ng/ml, >6hr after ingestion Acute ingestion >10 mg Attention to electrolyte imbalances Treatment: DS-Fab (Digibind) Unknown: 10-20 vials IV # vials = mg/0.5 x 80% # vials = [digoxin] x wt/100 Atropine 0.5-1 mg IV

19. Clinical Pearls Acute vs. chronic ingestions Be alert to multi-drug ingestions Vital signs and clinical presentation trump your labs Early identification and treatment, have your supplies ready! Check and correct your electrolytes Care for your elders and “special” patients As always, maintain a broad differential for the bradycardic, hypotensive patient!