Poisoning Unintentional Overdose Intentional

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Poisoning (Unintentional)Overdose (Intentional)

• Marie-Martine Logvinoff, M.D.

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EPIDEMIOLOGY

• 2003, it was reported more that 1.582 million
  poisoning exposures
  
• 86 unintentional
• 11 intentional
• 60 children under 12 years of age
• Only 0.18 with major effect
• 106 total fatalities (0.007)
• 6.0 therapeutic error
• 5 of pediatric admissions

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EPIDEMIOLOGY

• Sites of exposure
• Residence..92
• Work Place.3.0
• School.1.5
• Envenomation
• (bite/sting)
• Other4.3

• Modes of Exposure
• Ingestion.74
• Dermal.8.5
• Inhalation7.0
• Other parenteral5.1
• Ophthalmic

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EPIDEMIOLOGY

• Pediatric Population
• Subgroup I Children aged 1 to 5 years
• Usually a single agent exposure (non-toxic)
• Involves household products, cosmetics,
  medications
  
• 90 of episodes occur at home with parents
  present
  
• Children misuse of drugs
  
• Preschoolers Curiosity

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EPIDEMIOLOGY

• Subgroup II Adolescent
• 90 girls
• Often intentional ingestion
• Associated with emotional/psychiatric problems
• May involve multiple agents
• Usually with prescription or non prescription
  drugs

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EPIDEMIOLOGY

• Toxic exposures Associated with Most Deaths
• Category
• Analgesics
• Antidepressants
• Sedatives/hypnotics
• Stimulants/Street drugs
• Alcohols
• Cardiovascular drugs
• Cleaning substances
• Cough and cold preparation
• Hydrocarbons
• Carbon monoxide

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Identification

• Exact name of the product
• Date on container
• When purchased
• Consult current reference (Poison Center, MSDS,
  etc)
  
• CHEMTREC 800-424-9300 www.cmahq.com
• National Poison Control Number is
• 1-800-222-1222

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History Toxic Triage

• Often difficult (toddler,suicidal, abuse)
• Type of substance
• Amount (pills, liquid missing)
• Time since ingestion
• Allergies/Illnesses
• History consistent with observers
• Any exposure, think abuse

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Management

• Treat the patient
• Supportive Care
• Decontamination
• Antidote
• ABCDs assess vital signs including mental status
• Consider use of coma protocol

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Management

• Rapid physical exam toxidrome?
• Common manifestation of poisoning hypoxia, Lyte
  imbalance, CNS bleed infection (CBC, CMP,U/A,
  ABG, EKG)
  
• Serum acetaminophen, urine (HCG, drug screen),
  CPK, serum osomodality, drug levels (salicylate,
  iron, anti convulsant, toxic alcohol)
  

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Management

• D-Disability
• Level of consciousness
• Pupillary size reactivity
• (Miosis, Mydriasis, Nystagmus)
• Temperature

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Management

• D-Drugs
• Dextrose D25W 2-4 cc/kg
• Oxygen
• Naloxone 2 mg initially
• Thiamine 50-100 mg I/M or I/V
• Trial of D25, Narcan is indicated in all comatose
  patients

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Management

• D-Decontamination
• Ocular Copious saline lavage
• Skin Copious water, then soap and water
• GI Consider options (ipecac,charcoal, gastric
  lavage, bowel irrigation)

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GI Emptying

• Ipecac used for home management of mild possibly
  toxic ingestion, within 1 hour of ingestion not
  recommended by the AAP
  
• Gastric lavage early, selectively, (within 1-2
  hours contraindicated with alkali, acid,
  hydrocarbons, altered mental status
  
• Activated charcoal
• Whole bowel irrigation with PEGES (iron, late
  presentation, large amount, enteric coated
  preparation) (0.5 to 1.5 liter/hr)
  

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Activated Charcoal

• Bioavailability
• 70 at 30 min
• 30 at 60 min
• 1 gm/kg up to 1 year than 25-50gm if stable
  airway, contraindicated if no bowel sound
  
• (TCA Ca Blocker opiate)
• 1st dose premixed with sorbitol (?)
• Benefit of multiple doses (?)
• No benefit for acid, alcohol, alkali, cyanide,
  hydrocarbon, lead, lithium, iron
  

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Chest, Abdominal X-Ray

• Look for radio-opaque substances
• Choral hydrate, cocaine packets
• Heavy metals
• Iron
• Phenothiazines

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Tox Screens

• Indications for Tox Screen
• Altered mental status, coma
• Unexplained seizures
• Sudden onset of unusual behavior
• Unexplained medical complication---arrhythmias
  hypotension

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Toxidromes

• Anticholinergic
• Sympathomimetic
• Opioid
• Cholinergic (Anticholinesterase)
• Sedative Hypnotic
• Withdrawal

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Anticholinergic

• Hot as a hare, blind as a bat, dry as a bone,
  red as a beet, mad as a hatter, bloated as a
  bladder
  
• Delirium, tachycardia, flushed skin,
  hyperthermia, urinary retention, decreased bowel
  sounds
  
• Seizures and coma may occur, arrhythmia
• Antihistamines, Atropine, antispasmodics, muscle
  relaxants, tricyclic, antidepressants,
  antiparkinson meds., plants (jimson weed, amarita
  muscaria

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• TCA antidepressant, sodium channel blocking agent
  B blocker, procainamide, quinidine, lidocaine,
  carbamazepine and antiarrhythmic
  
• Three Cs and an A Rapid deterioration
• Coma, Convulsion, Cardiac Arrythmias and Acidosis
  
  
• EKG ORS?100 MILISEC
• Treatment
• Airway, O2, ECG monitoring
• 1-2 meq/kg Na bicarb, 7.5 ph
• Norepinephrine for B/P
• No phenytoin but benzodiazepine for seizure

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Sinus tachycardia with wide QRS complex and
prolonged QT interval caused by tricyclic
antidepressant overdose
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Sympathomimetic

• Diaphoresis, tachycardia, tachypnea,
  hypertension, mydriasis, restlessness, tremors,
  insomnia
  
• Dysrhythmias and seizures may occur
• Difficult to distinguish from anticholinergic
• Cocaine, amphetamines, caffeine, OTCs, plants
  (ma huang)

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Opioid / Sedative

• Classic triad Mental status depression,
  respiratory depression, pulmonary edema, pinpoint
  pupils, hypotension, hypothermia, bradycardia
  
• Morphine, heroin, fentanyl, other synthetics
• Meperidine/propoxyphene (Dilated pupil /
  seizures), Tramadol, Dextromethorphan
  
• Central alpha2 receptor agonists clonidine,
  barbiturate, benzodiazepine,ethanol ( dilated
  pupil / seizure)

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Cholinergic

• SLUDGE salivation, lacrimation, urination,
  diarrhea, GI distress, emesis
  
• Miosis, bronchorrhea, bronchoconstriction, vagal
  tone, are muscarinic effects
  
• Nicotinic fasciculations, pallor, weakness,
  hypertension, mydriasis, tachycardia
  
• CNS ataxia, headache, agitation, delirium,
  seizures
  
• Organophosphate/carbamate insecticide,
  physostigmine, edrophonium

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Toxin Elimination

• Multiple dose activated charcoal (phenobarbital,
  ASA)
  
• Chelation (lead/dimercaptsuccinic acid (DMSA)
  p.o., iron/deferoxamine)
  
• Antidotes (? Benzodiazepine / Flumazenil,
  Opiate / Naloxone, Methanol Ethyleneglycol /
  famepizole, organophosphate / atropine, Isoniazid
  / Pyridoxine, acetaminophen/ N.acetylcysteine
• Digoxin specific Fab
• Alkalinisation (TCA, Salicylate, Phenobarbital
• Exchange transfusion / Dialysis

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Metabolic Adidosis with high anion gap

• MUDPILES
• Methanol
• Uremia
• Diabetic Ketoacidosis
• Paraldehyde and Phenformin
• Iron, Isoniazid
• Lactic Acidosis (hypoxia, shock, CO, cyanide)
• Ethanol
• Salicylates

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Hypoglycemia

• Ethanol
• Salicylates
• Beta blockers / Ca blocker
• Oral hypoglycemic agents
• Insulin injections

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Acetaminophen

• Over 100,000 calls per year
• Most common hospitalization from OTCs
• Rapidly absorbed in less than 4 hours
• Toxicity less common in children (

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Acetaminophen

• Adults 94 metabolized by glucuronidation and
  sulfation. 4 metabolized by cytochrome P-450 ?
  toxic intermediate (NAPQI) conjugated with
  glutathione is harmless
• Increased gluthathione capability of children and
  pathway P 450 not significant in children
  
• If glutathione stores cellular damage
  

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Acetaminophen (APAP/Paracetamol)

• Acute ingestion (325/500 mg immediate released
  and 650 mg extended release)
  
• 7.5 g in adult or 200 mg/Kg in child
• 4 hour level 150 µg/ml (nomogram)
• If AST is elevated, follow PT, BUN, Creat
• Level at 24 hrs is not useful

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Runmack-Matthew nomogram for acetaminophen
poisoning. Semilogarithmic plot of plasma
acetaminopeh
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Acetaminophen

• Clinical Presentation
• Phase I (0.5-24 hrs) malaise, anorexia, palor,
  diaphoresis
  
• Phase II (24-72 hrs) RUQ abd. pain, elevation of
  enzymes, PT?
  
• Phase III (72-96 hrs) Coagulopathy, jaundice,
  hepatic/renal failure, encephalopathy
  
• Phase IV (7days-2weeks) Resolution

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Acetaminophen

• Treatment lavage if ingestion
• Activated charcoal.
• N-acetylcysteine (precursor of glutathione binds
  NAPQI) , oral x 48 hrs, IV form available (2
  hours after charcoal)
  
• Supportive care
• Watch for bleeding and hypoglycemia
• (Vit K)

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Salicylates

• Toxic effects
• Central stimulation of respiratory centers
• Dehydration, uncoupling of oxidative
  phosphorylation, inhibits Kreb cycle
  
• Interruption of glucose and fatty acid metab. ?
  lactic acidosis
  
• Alter platelet function

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Salicylates

• Well absorbed from GI tract prolonged in OD and
  enteric coated tabs
  
• Low VD increased CNS risk in acidosis (cannot be
  dialyzed)
  
• Toxic dose
• 150-200 mg/Kg mild
• 300-500 mg/Kg severe
• Chronic 100 mg/Kg/d for 2 days
• Level 100 mg/dl

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Salicylates

• Acute ingestion
• Nausea/Vomiting, hyperpnea, tinnitus, lethargy
• ABG mixed resp alkalosis and metab. Acidosis (5 y/o)
  
• Severe Coma, seizures, (cerebral edema)
  pulmonary edema, hypoglycemia, hyperthermia,
  hypokalemia
  

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Salicylates

• Treatment
• ABCs avoid respiratory acidosis, treat coma,
  seizures, hyperthermia, pulmonary edema as they
  occur
  
• Multiple dose of charcoal / whole bowel
  irrigation
  
• Treat acidosis with bicarb (7.4)
• Add 100 mEq NaBicarb to 1 L of 5 D / ½ NS infuse
  at 3-4 mL/Kg/h
  
• Fluids (carefully to avoid pulmonary edema)
• Alkalize the urine (7 7.5) to increase the
  clearance
  
• Needs a lot of K
• Hemodialysis (renal failure, pulmonary edema)

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Iron

• Disrupts mitochondrial function, cellular
  metabolism
  
• Elemental Fe level (eg Ferrous sulfate20)
• 300-500 micg/dLtoxic
• GI toxicity (emesis, diarrhea)
• Systemic toxicity (hepatic, hypoglycemia,
  metabolic acidosis, bleeding, shock)
  
• Late GI stenosis

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Iron/Management

• Early Recognition and Good Supportive CARE
• Decontamination
• Emesis
• Lavage
• Charcoal not effective in binding
• Whole bowel irrigation (PEGES)
• Volume expansion I/V fluids
• Correct electrolytes, acid-base disturbance
• Deferoxamine Symptomatic with levels350ug, all
  patients with levels 500 ug/dl
  
• IV 15-20 mg/Kg/hr. Follow B/P
• Close follow-up for GI complications

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Other

• Carbon Monoxide
• Carboxyhemoglobin level may be deceptive Look
  for other family members
  
• TT 100 O2 hyperbaric O2