MANAGEMENT OF ACUTE POISONING

Kent R. Olson, MD
Medical Director California Poison Control System San Francisco Division

Lessons from history

A young princess ate part of an apple given to her by a wicked witch She was found comatose and unresponsive, as if in a deep sleep Airway positioning and mouth to mouth ventilation were performed, and she recovered fully

Lesson:
Best antidote is good supportive care

(Loves first kiss)

Case 1:
Young woman found unconscious, several empty pill bottles nearby Unresponsive to painful stimuli Shallow breathing

Initial management: ABCDs

Airway Breathing Circulation Dextrose, drugs, decontamination

Airway issues
Risks:
Floppy tongue can obstruct airway Loss of protective reflexes may permit pulmonary aspiration of gastric contents

Major cause of morbidity in poisoned patients

Assessing the airway

Gag reflex
Indirect measure May be misleading Can stimulate vomiting

Alternatives

Breathing
Assess visually pCO2 reflects ventilation - ABG useful pulse oximetry provides convenient, noninvasive evaluation of O2 saturation

Pitfalls
pO2 measures dissolved oxygen
can be normal despite abnormal hemoglobin states, eg COHgb, MetHgb

Pulse oximetry also fails to detect CO poisoning

Interventions
Endotracheal intubation
Protects airway Allows for mechanical ventilation

Reverse coma?
Naloxone: note T = 60 min Flumazenil?

Dont forget GLUCOSE

A stroke is never a stroke until its had 50 of D50 Dr. Larry Tierney, 1976 Give Thiamine 100 mg IM or in IV

Case, continued
The patient has no gag reflex, and does not resist intubation. She remains unconscious and on a ventilator overnight Awakens and extubated the next day Dx: mixed sedative drug overdose

Case 2
47 year old man calls 911, suicidal BP 70/50, HR 50/min Junctional rhythm Hx: uses an antihypertensive

Circulation = plumbing
Pump working? Enough volume (is it primed)? Adequate resistance (no leaks)?

Management of Hypotension
Hypovolemia?
IV fluid challenge

Pump?
Dopamine

Inadequate vascular resistance?

Norepinephrine, phenylephrine

Antihypertensives
Diuretics Beta blockers Calcium channel blockers ACE Inhibitors Centrally acting agents Vasodilators

Calcium channel blockers

Bad ODs!! Low Toxic:Therapeutic ratio High mortality

Decreased Automaticity & Conduction

Negative Inotropic Effects

Dilated Vascular Smooth Muscle

HR AV Block

CO

SVR

SHOCK

Calcium antagonists - treatment

Calcium: most effective
High doses may be needed

Glucagon variable results Insulin plus glucose? (experimental)

Case 3:
An 18 month old takes some of his grandmothers sleeping pills Brought to the ER after a seizure HR 150/min Pupils dilated, skin flushed, mucous membranes dry

Common causes of seizures

Amphetamines/cocaine Tricyclic and other antidepressants Isoniazid (INH) Diphenhydramine Alcohol withdrawal Many others . . .

30 minutes later, the ECG shows:

Tricyclic antidepressants
Anticholinergic syndrome Seizures Cardiotoxicity

TCA overdose treatment

(similar tox possible w/ massive diphenhydramine)

Stop the seizures

Benzodiazepines, phenobarbital

Treat cardiotoxicity
Sodium bicarbonate 1 mEq/kg IV IV fluids Dopamine and/or NE

Case 4: now were cookin

24 year old man with Hx depression Agitated, confused BP 110/70 HR 120 RR 20 T 40.4 C Muscle tone increased, LE clonus Tox screen negative for cocaine, amphetamines

Drug-induced Hyperthermia
Heat Stroke Malignant Hyperthermia Neuroleptic Malignant Syndrome Serotonin Syndrome

Drug-induced heat stoke

Altered judgment leads to excessive sun/heat exposure Anticholinergic drugs prevent sweating Excessive muscle hyperactivity from seizures, or from extreme agitation

Malignant hyperthermia
Rare, familial myopathy Triggered by general anesthesia
Succinylcholine Inhalational agents (eg, Halothane)

Muscle rigidity, hypermetabolic state Treatment: dantrolene

Neuroleptic Malignant Syndrome

Patient on dopamine-blocking drugs
Haloperidol classic cause Also with newer agents (eg, clozapine)

Rigidity (lead-pipe) Autonomic instability Hyperthermia

Serotonin Syndrome
Current hot diagnosis Serotonin-enhancing Rx
SSRIs in OD or multiple combos MAOI + serotonin-ergic drug

Hypertonicity/clonus (esp. lower extr.) Autonomic instability Hyperthermia

Hyperthermia treatment
Act quickly!
Remove clothing spray and fan Sedation and anticonvulsants PRN Neuromuscular paralysis if T >40 C Dantrolene if NM paralysis ineffective Consider bromocriptine, cyproheptadine

Gut decontamination after OD

Goal: reduce systemic absorption
Induce vomiting? Pump the stomach? Activated charcoal

Ipecac-induced emesis
Easy to perform, but not very effective Contraindicated:
Comatose/convulsing Ingested corrosive or hydrocarbon

Bottom line: nobody uses it anymore

Pumping the stomach

Cooperation not required MD sense of control Punitive value?

Gastric lavage
May stimulate gagging, vomiting Risky if airway reflexes dulled Lack of proven efficacy Bottom line: used only rarely

Activated charcoal
Finely divided powdered material
Huge surface area

Binds most drugs/poisons

Exceptions: Lithium Iron

Activated charcoal
More effective than SI, GL First choice for most ODs

Whole bowel irrigation

Mechanical flush Balanced salt solution with PEG
No net fluid gain/loss

Good for:
Iron Lithium Sustained-release pills, foreign bodies

Antidotes:
The best antidote is supportive care Examples of antidotes:
Digoxin-specific antibodies Atropine & 2-PAM N-acetylcysteine Vitamin B-6 (pyridoxine)

Call the Poison Center

1-800-222-1222 - 24 hours
Immediate consultation by clinical pharmacists Back-up by MD toxicologists Identify pills, discuss diagnosis & Rx

I dont think we should go up there, especially without a paddle