OVERDOSE: THE BAND

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OVERDOSE THE BAND

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Mr. RR, 36yo Male

• Brought in by EMS/CPS
• Found in appt building foyer asleep
• with friend who escaped
• Not arousable, no I.D.
• Smells fruity
• GCS 3 but non-purposefull movements of all
  limbs present
• No signs of trauma, OPA accepted

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TOXICOLOGY I

• MANAGEMENT OF O.D. AND DECONTAMINATION ISSUES
• KEVIN HANRAHAN DR. DAVID JOHNSON

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OUTLINE

• GENERAL CONCEPTS
• RESUSCITATION
• HISTORY
• TOXICOLOGY PHYSICAL
• TOXIDROMES
• INVESTIGATIONS
• GENERAL DECONTAMINATION

• G.I. DECONTAMINATION
• -ORAL REMOVAL
• -BINDING
• -MECHANICAL
• FLUSHING
• ENHANCED ELIMINATION
• ANTIDOTES
• DISPOSITION

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Nontoxic Ingestions

• Only one substance in exposure
• Substance absolutely defined
• No hazards on product label
• Unintentional
• Route known
• Approximate amount known
• Asymptomatic with easy follow-up

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Setting

• Occupational-eg. xylene
• Recreational
• Medical
• environmental

I wonder what this xylene would taste like
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Portals of Entry

• Ingestion,most common historically(76)
• Inhalation(8)
• Cutaneous/mucous membrane(6)
• Injection-meds
• -drugs of abuse
• Insufflation

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PADIS 03/04
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PREVALENCE

• 2 Million toxic exposure in U.S.-2000
• 3rd leading cause of death
• Mortality from acute poisoning lt1
• Peds account for 80
• 10 admitted, usually accidental
• Adults-20,rarely accidental,90 admitted to
  hospital
• Accounts for 1 admission,10 ICU

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PADIS APRIL 04/MAR 05 AGE DISTRIBUTION
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CIRCUMSTANCES- PADIS 03/04
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PADIS O3/04 OUTCOMES
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PADIS 03/04
SUBSTANCE KIDS ADULT
OTC pain fever meds 15.4 21.3
Household cleaning prod 11.4 7.4
Cosmetics personal care 11.1 ----
Mental health meds ----- 11.2
Alcohols ----- 9.8
Anti anx sedatives ?? ----- 9.1
Fumes/gases/vapors ----- 8.3
Plants 6.6 ----
Foreign bodies 5.1 -----
Pesticides 3.6 4.4
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RESUSCITATION

• Occurs simultaneously with Dx
• Important as support may be only Tx for most
  overdoses
• Vitals, all 6 critical in toxicology
• T/BP/HR/RR/SAT/BS
• Airway-patent protected?
• -intubate for GCSlt9
• Breathing-vitals and auscultate
• Circulation-vitals,establish IV,EKG

15
RESUSCITATION contd

• Decidestable/unstable
• ?heavy hitter eg TCA, Bblocker etc
• Antidote-rarely takes precedence over ABC
  (cyanide toxicity)
• Coma Cocktail-hypoxia
• -wernickes
• -opioid intox.
• -hypoglycemia

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HEAVY HITTERS

• Largest number of deaths in 2000 in U.S.
• -analgesics
• -antidepressants
• -sedative/hypnotics/antipsychotics
• -stimulants
• -street drugs
• -CV drugs
• -alcohols

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RESUSCITATION contd

• Seizures
• -BZD.,phenobarb, not dilantin
• Hypotension
• -isotonic fluids,bicarb,hi dose levo/dop
• Vent. Arhythmia
• -bicarb bolus,lidocaine,BB in chloral hydrate
• -see ACLS for specific toxins

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COMA COCKTAIL

• Cheap
• Minimal risk
• Simple
• Oxygen as per need
• D50W,50g,adult
• 4ml/k D25W or 10ml/k D10W
• Pediatrics

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THIAMINE

• Not necessary in kids
• 100mg IV/IM qdaily
• ?before D50W?
• Previously thought to prevent Wernickes
  encephalopathy

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WHERES THE EVIDENCE ?
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Thiamine/Glucose

• Originally came from 5 case reports of Wernickes
  precipitated or made worse by glucose before
  thiamine
• All 5 had severe nutritional deficiencies,
  several comorbid illnesses and received glucose
  for several days before thiamine was administered
• Therefore dont delay glucose in ED for thiamine
• Hack,JB,JAMA 1988

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NALOXONE (NARCAN)

• 0.1-2.0MG IV/IM, /- restraints
• 20-60 min. response time
• 2nd dose 2/3 of first
• Observe 2-3h
• Triad of dec. LOC,miosis,resp dep.
• Resp status only reliable way to determine effect
  of narcan.
• Other drugs affect LOC and some opioids can cause
  mydriasis

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NALOXONE

• 730 pts prehospital tapes/sheets reviewed in AMS
  pts. for response to Narcan and clinical
  presentation.
• RRlt12,pinpoint pupils,circumstantial evidence of
  opiate abuse all predictive of response
• Use of these criteria would decrease Narcan use
  by75-90 without missing any responders
• Hoffman,JR,Annals of Emergency Med., 1991

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FLUMAZENIL AS PART OF THE COMA COCKTAIL?

• Retrospective analysis of 35 consecutive comatose
  pts
• Divided into low and non-low risk for sz. based
  on clinical and ECG(proconvulsive ODs)
• Only 4 were assessed as low risk
• High risk of sz. In non-low risk group
• Low risk might benefit but very small minority of
  pts.
• Gueye,PN,Annals of Emergency Medicine, 1996
• Flum. May also precip. Arrythmia in TCA

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TOXICOLOGICAL HISTORY

• MOST IMPORTANT DIAGNOSTIC TEST
• of pts/type of exp/ amounts,dose/route/intent
• all ODs are liars
• Corroborate with MD/pharmacist/EMS/witnesses
• Info on environmentempty bottles,
• odours,material,hobbies,notes
• AMPLE

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Toxic Features

• History
• -suicide, prev. O.D. or abuse
• -psychiatric or polypharmacy
• Physical
• -arrest,bronchospasm,dysrythm nyd
• - thermia/tension
• -AMS,sz.,rigidity,dsytonia,rotary nystagmus
• Investigation
• -anion/osmolar gap, K-Na-gluc
• -renal/hepatic failure,rhabdo,aspiration

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TOXICOLOGICAL PHYSICAL

• Expose, look for hidden substances
• Waist bands,skin folds,groin
• Watch for sharps

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NEEDLE COLLECTION
Bright yellow disposal boxes in easily accessible
locations encourage IV drug users to safely
discard used syringes. The project collected
22,245 needles in 2001.
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GENERAL APPEARANCE

• LOCagitation,obtundation,confus.
• Skincyanosis,flushing,diaphoresis
• dryness,
• Injuries,injections,bullae,bruising
• (may be from trauma,dec LOC longterm or
  coagulopathy)

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ODOURS

• Almonds
• Eggs
• Fish
• Garlic
• Fresh hay
• Geraniums
• Swimming pool
• Mothball
• Violets
• Wintergreeen
• peanuts

• Cyanide
• Hydrogen sulf
• Sinc sulfide
• Org phosporous
• Phosgene
• Lewisite
• Chlorine gas
• Camphor,naptha
• Turpentine
• Methyl salicylate
• vacor

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SKIN FINDINGS
Cyanosis Deoxyhemoglobin or methemoglobin
Yellowing Carotene veg.,cigs,picric acid, Dinitrophenol
flushing Antichol,scombroid,rectal F.B, Disulfiram,niacin,nitratres
Gray Metallic silver or gold
Eschar Anthrax,radioactive,brown recluse spider,
Bullae Barbs,chemotherapies
Red skin Cholinerg,vanco,CO,boric acid
Nail lines Arsenic,chemotherapy
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CNS

• LOC/cognition
• Tone
• Reflexes
• Coordination
• Ambulation

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Toxins Causing Seizures

• Amphetamines
• Antihistamines/
• anticholinergics
• Caffeine/theoph
• Antipsychotics
• Carbamates
• CO
• Cocaine
• Hypoglycemics
• Chlorambucil
• Propranolol
• salicylates

• Cyclic antidepress
• Ethylene glycol
• Isoniazid
• Lead
• Lidocaine
• Lithium
• Methanol
• Organophosphates
• Phencyclidine
• Withdrawal from ETOH/sedatives

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Toxins Affecting Tone
Dystonic reactions Dsykinesias Rigidity
Haldol Anticholinergic Black widow
Metoclopramide Cocaine Malign hyperth
Olanzapine Phencyclidine Neur malig syn
Phenothiazines Risperidone Strychnine
Risperidone Fentanyl
phencyclidine
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Toxins Causing AMS
DEPRESSED AGITATED DELIRIUM
Sympatholytics Sympathomimetics ETOH/drug withdrawal
Adrenergics bl Adrenergic ag Anticholinergics
Antiarrhythmic Amphet Antihist
Antihypertens Caffeine CO
Antipsychotics Cocaine Cimetidine
Cholinergics Ergots Heavy metals
Bethanechol MAOIs Lithium
Carbamates Theophylline Salicylates
Nicotine Anticholiner
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DEPRESSED AGITATED DELIRIUM
Organophos antihistamine
Physostigmine Antiparkinson
Pilocarpine Antipsychotic
Sedat/hypnot Antispasmodic
Alchohols Cyclic antidepr
Barbs Cyclobezaprine
BZD Drug withdraw
Gamma Hydrox B-blockers
Ethchlorvynol Clonidine
Narcotics Ethanol
Analgesics Opioids
Antidiarheal Sed/hypnotic


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DEPRESSED AGITATED DELIRIUM
Cyanide Marijuana
Hydrogen sulfide Mescaline
Hypoglycemic LSD
lithium
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EYES

• Pupils size, reactivity,equality
• Dysconjugate gaze
• lacrimation

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Toxins Affecting Pupil Size
Miosis Mydriasis
Barbiturates Amphetamines
Carbamates Anticholinergics
Clonidine Antihistamines
Ethanol Cocaine
Isopropyl alcohol Cyclic antidepressant
Organophosphates Dopamine
Opioids Glutethimide
Phencyclidine LSD
Phenothiazines MAOIs
Physostigmine Phencyclidine
Pilocarpine demerol
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MOUTH (with suction)

• Retained contents or pills
• Gag
• Dryness/salivation

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Lungs

• Air entry
• oxygenation
• wheezing
• bronchorhea

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TOXINS CAUSING HYPOVENTILLATION

• Alcohols
• Barbs
• Botulinum
• Cyclic antidepress
• Neuromuscular
• blockade

• Opioids
• Sedative/hypnot
• Snake bite
• Strychnine
• tetanus

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HEART/PULSES

• Rate
• Rhythm
• Regularity
• Peripheral pulses/perfusion

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TOXINS AFFECTING PULSE

• Tachycardia
• Common -TCA
• -CO
• -anticholinerg
• eg. Gravol
• -adrenergic
• eg. cocaine

• Bradycardia
• Common
• -opioids
• -cholinergics
• -BBlockers

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ABDOMEN

• Bowel sounds
• Rigidity
• Urinary retention
• tenderness

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TOXIDROMES

• Physiological groups
• Based on VS,general appearance,
• skin,eyes,mm,etc.
• Also basic labs

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DO THE BASIC FINDINGS MATCH WITH A POISON ?

• Basis for toxidrome
• Eg. Autonomic syndromes

sympathetic
parasympathetic
Adrenergic symptoms,eg. cocaine
Cholinergic,eg organophospates
Anticholinergic,eg. gravol
No bowel sounds,dry skin,blurry vis,fever etc
Tahycardia,htn, diaphoresis, mydriasis,etc
S.L.U.D.G.E
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Autonomic Nervous System
NIC
NIC
NIC
NE
MUSC
S
NMJ
PS
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Toxidrome Agent Findings
Opioids Heroine Dec. loc,miosis,dec.RR
Sympatho Cocaine Agitation,mydriasis,diaphoresis,tachy,etc
Cholinergic Organoph S.L.U.D.G.E.
Antichol Atropine Dry,red,AMS,hyper-t etc
Salicylates ASA AMS,resp alk,met acid et
Hypoglyc Insulin AMS,diaph,tachy,etc
Serotonin SSRI AMS,inc tone,hyper-t
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Toxins Affecting Temperature

• Hypothermia
• -TCA,Li,Phenothiazin
• -alcohol,barbs,opium
• -hypoglycemics
• colchicine,akee fruit
• -AMS in winter

• Hyperthermia
• -LSD,cocaine,PCP,
• amphetamines
• -antichol,antihist
• -TCA,MAOI,SSRI
• phenothiazines
• -ASA
• -malign hyper/NMS

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TOXINS AFFECTING BREATHING

• Hypoventilation-eg alcohols,BZD.,
• opioids
• Bronchospasm- eg cocaine, BB,
• aspiration from AMS

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INVESTIGATIONS

• PROGRESSIVE TESTING
• CBCD,CHEM 7,ABG,LFT
• osmolality
• EKG
• CXR
• FLAT PLATE XR
• SPECIFIC DRUG LEVELS
• Tox. Screens

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Anion Gap Acidosis Toxins

• Acetominophen
• Amiloride
• Ascorbic acid
• CO
• Colchicine
• Nipride
• Dapsone
• Epi
• Ethanol
• Ethylene glycol
• Formaldehyde
• Hydrogen sulfide
• Iron
• isoniazid

• Ketamine
• Metformin
• Methanol
• Niacin
• NSAIDS
• Papaverine
• Paraldehyde
• Phenformin
• Propofol
• Salicylates
• Terbutaline
• Tetracycline
• Toluene
• verapamil

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OSMOLAR GAP VARIABILITY

• NORMAL OSMOLAR GAP 8-10
• Distribution curve puts real normal between -?1
  and 10-11
• Therefore gap of 10 in someone whos resting
  gap is 2 may contain error of 8
• Methanol toxic gt6.2mmol/l

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Toxins with Inc. Osmolal gap

• Ethanol
• Ethylene glycol glycoaldehyde
• Glycine
• IV immunoglobulin
• Isopropanol
• 2(NA)Glucbun/-1.25(etoh)

• Mannitol
• Methanol/fromaldehyde
• Propylene glycol
• Radiocontrast
• Hypermagnesemia
• sorbitol

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EKG

• EKG findings in TCAsinus tach,inc. QRS/QTc
  intervals, inc PR interval
• RAD in the T40ms frontal QRS plane
• I neg/AVR pos, in T40ms
• Due to quinidine like effect on RBBB in TCA
• 8.6 times more likely in TCA OD
• 83sens, 63 spec
• Wolfe, TR, Ann of Emerg Med, 1989

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EKG
EKG IN TCA
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ACLS Rx of Toxic Dysrythmias

• Stimulant/Sympathomimetics
• -consider BZD,Ablockers,Lidocaine
• NaHCo3, not Bblockers
• CCBs
• -consider mixed A/B agonists,
• pacer, Ca,insulin euglycemia
• Bblockers
• -consider pacer,mixed A/B agonists,
• glucagon/insulin euglycemia
• ACLS Handbook of Emerg Card Care 2000

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RADIOLOGY

• CXR if prompted by Hx, Px or specific other
  findings like hypoxia
• Flat plat may be considerred for FB or ingestions
  of radiopaque toxins
• eg iron
• CT scan for AMS
• r/o HI and ICP
• if indicated

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TOX SCREENS

• Marijuana/opioids/cocaine/amphetamine/TCA/barbs/BZ
  D/phencyclidine
• Usually does not affect assessment or outcome
  acutely
• False amphet-propranolol,cpz etc
• TCA-flexeril,mellaril,etc
• False -opioid-demerol,heroin
• amphet-MDMA,
• benzo-rohypnol

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TOX SCREENS contd

• Slow to return
• Most ODs treated with support alone
• Chronic ingestion eg. Marijuana may confuse issue
• Less frequent intoxicants not quickly available
• May be helpful in persistant sick without obvious
  etiology
• In kids may be helpful for neglect/abuse
  situations

62
APAP/ASA/ETOH

• Frequent co-ingestants
• Relatively quick
• May help sort out multiple ingestion scenario
• May help psych. with ongoing assessment

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GENERAL DECONTAMINATION

Its great the fire department provides us with
these sprinklers on hot days
64
GROSS DECONTAMINATION

• Remove patient from substance
• Remove substance from patient
• Undress(including jewelry,watches biohazard)
• Wash, head to toe
• In mass casualty done in field or in isolation
  area outside ambulance bays in most hospitals
• Staff need full PPE

65
GROSS DECONTAMINATION

Colonoscopy booth
66
EYES

• Copious (usually 2L) irrigation
• Normal saline best but tap will do
• 0.5 tetracaine, lid retractors helpful
• 1ml tetracaine in 100ml saline

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EYE IRRIGATION
68
EYES contd

• Alkali exposure may require 1-2h of irrigation
  given deep penetration
• NS ph 5.6
• After equilibration (10min)
• Tear film phlt8

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GI DECONTAMINATION

• Oral removal-emesis
• -lavage
• Binding
• Mechanical flushing

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EMESIS

• Derived from emetine and cephaline (plants)
• Works centrally on chemotactic trigger zone and
  stomach
• Dose 30ml (15ml in 1-12) with sips

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IPECAC contd

• Can repeat once
• 90 vomit in 20m
• 97 2nd dose
• Ave. 3-5 vomits
• Done in 2h
• If 30m 18-52
• If 60m 31-36

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IPECAC CONTRAINDICATIONS

• AMS or drugs that can cause rapid(lt60mins) AMS
  (TCA,eucalyptus,strychnine)
• Active or prior vomiting
• Caustic/corrosive ingestion
• gtpulmonary than GI toxicity (hydrocarbons)
• Ingestion which can cause sz.
• Debilitated/elderly or medical made worse by
  vomiting

73
IPECAC COMPLICATIONS

• Boerhaves syndrome
• Malory-Weiss tears
• Intractable vomitting
• Inability to give oral treatments

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IPECAC INDICATIONS

• Very limited in hospital setting
• Rare-larger pills than orogastric tube in recent
  ingestion(lt60min) that cant be absorbed by
  charcoal on a Tuesday when the moon is full!
• At home if remote, recent and no contraindications

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IPECAC INDICATIONS cont

• syrup of Ipecac should not be administered
  routinely in the management of poisoned
  patientsThere is no evidence from clinical
  studies that ipecac improves the outcome of
  poisoned patients and its routine administration
  in the ED should be abandonned
• AACT Position paper, Journal of Toxicology, 2004
• AMERICAN ACADEMY OF CLINICAL TOXICOLOGY (AACT)

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OROGASTRIC LAVAGE

• LL decubitus position
• 36-40F(adult),22-24F(kids)
• Chin to xyphoid measurement
• Room temp tap water untill clear
• Instillation of charcoal before removing if
  indicated

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OG LAVAGE CONTRAINDICATIONS

• Pills too big
• Non-toxic ingestion
• Non-life threatening ingestion
• GI hem, perf or recent Sx
• Airway not assured
• Material lung dangergtGI tract (hydrocarbon,corrosi
  ve)

78
OG LAVAGE COMPLICATIONS

• Tracheal lavage
• Aspiration, tension pneumo, charcoal empyema
• Atrial/ventricular ectopy
• Esoph, trach or gastric trauma or perforation
• Desaturation, laryngospasm
• Tube knot formation
• fluid/lyte imbalance

79
OG LAVAGE EVIDENCE

• Prospective study of 808 pts with presumed OD
• Odd/even day gastric emptying(GE) with either
  ipecac or lavage based on LOC. Others got
  charcoal
• GE did not alter LOS,length of intubation,ICU
  LOS,
• GE increased ICU admits for asp. Pneum
• Merigian, KS, Amer. J. of Emerg. Med. 1990

80
GE EVIDENCE contd

• PRCT of 876 pts with OD
• Odd/even day randomization for GE/AC or just AC
• GE was lavage or ipecac
• No difference in outcome regardless of time to
  presentation
• Pond,SM,Medical J. of Australia,1995

81
AACT INDICATIONS

• Not routinely recommended
• Not if greater than 60mins
• Not if not life threatenning
• Must have assured airway
• No definite evidence that it improves outcome and
  may cause morbidity

82
CHARCOAL (GUT TOXIN ADSORPTION)(GI DIALYSIS)
83
ACTIVATED CHARCOAL(AC)

• Pyrolysis of carbanaceous material
• Steam cleaned to increase the surface area
  (activated)
• Adsorbs (holds to surface) toxins in the gut
  lumen
• Improves gut/blood gradient (GI dialysis) for
  previously absorbed
• Binds substances excreted in bile interrupting
  enterohepatic circ.

84
Toxins Not Adsorbed by AC

• Alcohols
• Hydrocarbons
• Organophosphates
• Carbamates
• acids

• Potassium
• DDT
• Alkali
• Iron
• lithium

85
AC contd

• Decreased benefit with time as toxin travels
  beyond pylorus
• At 30 min mean bioavailability decreased by 70
• At 60 min by 37
• No good studies that show clinical benefit of
  single dose AC (AACT)

86
AC BENEFITS

• Decontaminating gut non-invasively
• Rapid administration
• Safe in adults and kids
• Can be administered with juice, water or by OG
• 1g/kg or 50g in most adults
• /- cathartic with first dose

87
AC EVIDENCE

• RCT with 1479 pts. randomized to AC supportive
  measures or support alone
• Measured clinical deterioration, LOS in ED or
  hospital, complications and length of intubation
• Trial done over 24 mos., lge urban center
• Merigian,KS, Amer. J. of Therapeutics, 2002

88
AC EVIDENCE contd

• No sig. difference in length of intubation,LOS
  for hospital and complication rate
• Longer ED stay (6.2vs5.3h) and more vomiting
  (23vs13)in AC group
• No benefit of AC over support alone
• Merigian, KS, Am.J.Therepeutics, 2002

89
AC CONTRAINDICATIONS

• Perforation or abnormal GI tract
• If emergency endoscopy planned e.g. caustics
• Unprotected airway
• Increased risk from aspiration (eg Hydrocarbons)

90
AC COMPLICATIONS

• Aspiration
• Impaction with abnormal motility
• Vomiting
• Corneal abrasions

91
AC INDICATIONS

• Ingestion of any drug known to be adsorbed by
  charcoal with toxic ingestion
• Does not work for lithium, iron, lead
• Unknown ingestion with protected airway
• Lack of good clinical data for or against
• Therefore
• Not routine (AACT)
• Best within 1 hour (AACT)
• No evidence it improves outcome (AACT)

92
MULTIPLE DOSE CHARCOAL

• .25-.5G/kg on subsequent doses
• Q1-4h
• Only first dose has cathartic
• Indications-large ingestions
• -substances that form
• bezoars or are injurious
• -slow release toxins
• -enterohepatic/enteric
• circul. substances

93
Multi-dosable AC

• Amytrityline
• Amoxapine
• Baclofen?
• BZDs?
• Buproprion?
• Carbamazepine
• Chlordecone
• Dapsone
• Dig
• Disopyramide
• Glutethimide
• Maprotiline
• Theophylline
• sotalol

• Meprobamate
• Methyprylon
• Nadolol
• Nortriptyline
• Phencyclidine
• Phenobarb
• Phenylbutazone
• Phenytoin
• Pyroxicam
• Propoxyphene
• Quinine
• Salicylates?

94
MULTI-DOSE AC contd

• Contraindicated in non-life-threatening
  ingestions and toxins which slow GI motility as
  these increase risk of aspiration from gastric
  distention and impaction of charcoal
• No specific AACT position statement

95
CATHARTICS

96
CATHARTICS

• Sorbitol 70 (1g/kg) or 250ml of 10 mag citrate
  (4ml/kg in kids)
• Studies consistently show decreased transit time
  for charcoal
• Krenzolok,EP,Ann Em Med, 1985
• Harchelroad,F,J.Clin. Tox., 1989
• Cathartic alone not effective
• Minton,NA, J Clin Tox.,1995
• Al-Shareef,AH,Hum Exp Tox.,1990
• Peak plasma concentrations decrease with
  cathartics
• Picchioni, AL, J Toxicol Clin Toxicol, 1982
• Goldberg, MJ, Clin Pharmacol Ther, 1987

97
Cathartics Indications

• Same as single dose charcoal
• Ingestions unknown or known to be adsorbed by
  charcoal with protected airway
• AACT-not alone, not endorsed routinely with or
  w/o charcoal, single dose if used

98
Cathartics complications

• Nausea, vomitting, abdo cramps
• Volume depletion, electrolyte disturb
• Hypermagnesemia in renal impaired if magnesium
  product
• Hypernatremia if Na product

99
Cathartics Contraindications

• Ingestions that cause diarhea
• Kids lt1 or very old
• Mag citrate in renal failure
• Obstruction, no BS, abdo trauma,recent abdo
  Sx,perf.
• corrosive ingestion
• Heart block
• Hypotense,vol. deplete, lyte imbal.

100
WHOLE BOWEL IRRIGATION (WBI)

• Electrolyte/osmotic balanced polyethylene glycol
  (Golytely)
• Mechanically forces ingested toxins through the
  bowel
• 2L/h (adult), 50-250ml/h(peds)
• Until clear rectal fluid

101
WBI Indications-AACT 1997

• No controlled clinical studies showing improved
  outcomes but some volunteer studies
• Not routine
• Consider in slow release or enteric coated toxic
  ingestions
• Theoretic potential in iron and other
  non-adsorbables(Li,lead,zinc)
• Theoretic in delayed presentation, large amounts,
  drug packers(Farmer, JW, J Clin Gastro, 2003)

102
WBI complications

• Nausea, vomiting, cramps,bloating
• Pulmonary aspiration
• Rectal irritation
• Increased nursing care !!

103
WBI Contraindications

• Diarhea or substances that cause it
• Absent bowel sounds
• Intractable vomiting
• Obstruction, ileus,perforation,hem
• Hemodynamic instability
• Compromised airway

104
ENHANCED ELIMINATION

• Urinary-diuresis
• -alkalinization
• -acidification
• Dialysis
• Hemoperfusion
• hemofiltration

105
DIURESIS

• Not been well studied
• Consists of achieving 3-6ml/k/h u/o
• Isotonic fluids and diuretics
• Not recommended
• Causes electrolyte imbalance,pulmonary
  edema,raised ICP
• Also doesnt work

106
Urinary Alkalinization

• Helpful in some ingestions
• Weak acids held within renal tubule and excreted
  with bicarb
• 3 amps (150 ml) of bicarb in 850 D5W at 250/h
• Goal urine pH 7.5-8.0
• Must have normal K so add 40 meq kcl to bag
  after initially correcting hypokal.

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URINARY ALKALINIZATION
Tissues Plasma Urine
pH 6.8 HA H A- pH 7.4 HA H A- pH 8.0 (alkalinized) HA H A-
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GOAL PH
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Alkalinizable Toxins

• ASA
• Uranium
• Quinolones
• Primidone
• Phenobarb
• methotrexate

• 2,4 dichorphenoxy-acetic acid
• Flouride
• Isoniazid
• methobarbitol

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Urinary Alk. Complications

• Dec. K
• Volume overload (CHF)
• pH shifts

111
Urinary Alk. Containdication

• Cant tolerate fluid or Na load
• Hypokalemia
• Renal failure
• Toxin known not to respond

112
Acidification of Urine

• Virtually never used
• Potential for myoglobinuric renal tubular injury
• Systemic acidosis additive
• Arginine/lysine hydrochloride or ammonium
  chloride
• ? Use in amphetamine/phencyclidine

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DIALYSIS

I am sure happy to be here today
114
Dialysis

• Removes both the toxin and its metabolites
• Removes toxins that cant be adsorbed by charcoal
• Less effective with lge mol wgt, protein bound,
  large vol. dist.

115
Hemodialysis Indications

• Dialysable toxin that is life threatenning
• Peritoneal dialysis rarely used

116
Dialysis Contraindications

• Hemodynamic instability
• Small children (exchange transfusion better)
• Poor vascular access
• Profound bleeding diathesis

117
Dialysis Complications

• Fluid shifts
• Electrolyte imbalance
• Bleeding at access site
• Infection
• Intracranial hemorhage

118
Hemoperfusion

• Charcoal filter in dialysis machine
• Works better for large molecule size and protein
  bound if adsorbable
• Needs small volume of distribution
• Must not be highly tissue bound
• Rarely used

119
Hemoperfusion Complications

• Cartridge saturation
• Thrombocytopenia (plt dec by 30)
• Hypoglycemia, hypocalcemia
• Access complications
• Hypothermia (pump not heated)
• Charcoal embolization

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Hemoperfusion contd

• Works
• Phenobarb,phenytoin,theophylline,
  carbamazepine,paraquat,
• glutethimide
• Doesnt Work
• Heavy metals,ethanol,methanol,CO,
• cocaine

121
Hemofiltration

• Removes toxins by convection through a highly
  porous membrane
• Works well with toxins with large volume of
  distribution, extensive tissue binding
• Works well for large molecular wgt substances
• Not well studied

122
ANTIDOTES

• Increases the mean lethal dose of a toxin or
  favorably affects the effect of the toxin
• Specific indications
• Beyond the scope of this lecture

123
ANTIDOTES eg.
Drug/Poison Antidote
Acetominophen N-acetylcysteine
Antichonergics Physostigmine
Anticholinesterases Atropine
Benzodiazepines Flumazenil
Black Widow Bite Equine Antivenin
Carbon Monoxide Oxygen
Coral Snake Bite Antivenin
Cyanide Amyl Nitrate,etc
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Antidotes contd
Digoxin Digibind
Ethylene glycol Ethanol/fomepizole
Heavy metals Dimercaprol,EDTA
Hypoglycemics Dextrose
Iron Deferoxamine
Isoniazid Pyridoxine
Methanol Ethanol,fomepizole
Methemoglobinemia Methylene blue
Opioids Naloxone
Organophospates Atropine,pralodox.
Rattlesnake bite antivenin
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INDICATIONS FOR THE ICU

• PaCo2 gt45 (Brett, AS, Arch Int Med,1987)
• Intubation need
• Seizures
• Arrhythmias
• Prolonged QRS gt.12s
• SBP lt80
• 2nd or 3rd degree AV block
• GCS lt12 (unresponsive to verbal)
• Dialysis
• Staffing (babysitting suicidal)
• Hypo/Hyperthermia
• Naloxone drip

126
EXCELLENT REVIEW ARTICLE

• Babak, M, Jerrold, BL, Patrick, M,
• Adult Toxicology in Critical Care
• Chest, 2003123577-592.

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??? QUESTIONS ???