acute poisoning major c j porter ramc army medical directorate emergency medicine registrar bristol...
TRANSCRIPT
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ACUTE POISONINGACUTE POISONING
Major C J Porter RAMCArmy Medical Directorate
Emergency Medicine Registrar
Bristol Royal Infirmary
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Outline of lectureOutline of lecture
• Epidemiology
• Toxidromes
• History, examination and detective work
• General management
• Specific management
• Antidotes
• Scenarios
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EPIDEMIOLOGYEPIDEMIOLOGY
• 4000 UK deaths per year (1/3 CO)
• Most deaths outside hospital
• 100,000 Hospital admissions (12%)
• Not just overdoses: Illicit drugs, Alcohol
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• Self poisoning:• F>M • 1/3 >one drug• Taken with alcohol: F: 40% M: 60%
• Repeated self-poisoning: 11% of admissions
EPIDEMIOLOGYEPIDEMIOLOGY
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SUICIDESUICIDE
• 2% of male deaths• 1% of female deaths
• Method:• Female: Poisoning 40%• Male: Gas / Hanging / Suffocation
• Self-harm parasuicide:• 1% dead after 12 months• 3-5% dead after 5-10 years
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ToxidromesToxidromes
• Patterns of signs and symptoms
• Useful to help in diagnosis and treatment of unknown poisons
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OpiatesOpiates
• Respiratory depression
• Cardiovascular depression
• Reduced level consciousness
• Pinpoint pupils
• Pulmonary oedema
• Hypothermia
• (Rapid response to Naloxone)
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Common causesCommon causes
• Opiates – heroin, morphine etc
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Sympathomimetics /Sympathomimetics / StimulantsStimulants
• Agitation/delusions/paranoia• Fight/Flight response• Tachycardia• Hypertension• Arrhythmias• Dilated pupils• Seizures• Hyperpyrexia
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Common causesCommon causes
• Cocaine
• Amphetamines
• Decongestants
• Ecstasy
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AnticholinergicAnticholinergic
• Tachycardia• Arrhythmias• Pupils: mid-point or dilated / divergent• Confusion / drowsiness / coma• Seizures• Dry flushed skin• Urine retention• Hypertonia, Hyper-reflexia, Myotonic jerks
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Anticholinergic signsAnticholinergic signs
• Hot as a hare
• Blind as a bat
• Dry as a bone
• Red as a beet
• Mad as a hatter
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Common causesCommon causes
• Antidepressants-Tricyclics
• Antihistamines
• Atropine
• Antipsychotics
• Antispasmodics
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Serotonin SyndromeSerotonin Syndrome
• Similar to anticholinergic syndrome– loss of consciousness: uncommon– sweating and tremor: common
• Agitation• Delirium• Hypertonia / myoclonus• Tachycardia• Tachypnoea
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Common CausesCommon Causes
• SSRIs
• MAOIs (Hyperpyrexia / Hypertensive crisis)
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CholinergicCholinergic
• Brady/tachycardia
• Confusion/reduced GCS
• Pinpoint pupils
• Seizures
• Weakness
• SLUDGE
• Pulmonary oedema
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SLUDGESLUDGE
• S sweating salivation
• L lacrymation
• U urinary frequency urgency
• D diarrhoea
• G gastrointestinal discomfort
• E eyes pinpoint
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Common causesCommon causes
• Organophosphates
• Physostigmine
• Some mushrooms
• Nerve agents
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Salicylism: AspirinSalicylism: Aspirin
• Impaired hearing
• Tinnitus
• Sweating
• Warm skin
• Hyperventilation
• Cinchonism: Quinine (salicylism + blindness)
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MANAGEMENTMANAGEMENT
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Management OverviewManagement Overview• History & assessment of vital signs
• ANY concerns: move patient to RESUS
AA BB CC DDDEFGDEFG
• Supportive care (O2, IV Fluids)• Prevent absorption• Increase elimination• Antidotes• PSYCHOLOGICAL ASSESSMENT
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HistoryHistory
• What?
• When?
• How much? (mg/kg)
• What else?
• Why?
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Collateral historyCollateral history
• Paramedics
• Family / friends
• Notes
• Look in pockets – carefully!!!
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Detective workDetective work
• BNF
• Toxbase
• Tablet identification aids: TICTAC
• Poisons advice: NPIS
• Plant identification books
• National teratology information service
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Initial examinationInitial examination
• Treat problems as you find them!!
• Airway
• Breathing
• Circulation
• Disability – GCS/AVPU and Pupils
• DON’T EVER FORGET GLUCOSE
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ObservationsObservations
• Saturations and respiratory rate
• Pulse and blood pressure
• GCS
• Pupils
• Temperature
• GLUCOSE
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InvestigationsInvestigations• All Patients
– Glucose– U&E– Paracetamol & Salicylate
• As indicated– LFT– Co-ag / INR– CK– ABG / VBG– ECG– CXR
• Urine toxicology screen
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Reduce absorptionReduce absorption
• Emesis – No role
• Activated charcoal within 1 hour
• Gastric lavage – rarely
• Whole bowel irrigation - rarely
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Increase eliminationIncrease elimination
• Urinary alkalinisation
• Multi-dose Activated Charcoal
• Haemodialysis
• Haemoperfusion
• Plasma exchange• Forced alkaline diuresis (no longer recommended)
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ParacetamolParacetamol
• Very common: 40% poisons admissions
• Often asymptomatic
• Can be lethal – 200-300 deaths/year
• Check blood level at 4 hours
• Two treatment lines normal and high risk
• Given IV N-acetylcysteine
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Paracetamol metabolismParacetamol metabolism
• Metabolised by glucuronidation (60%),
Sulphation (35%) and oxidation (10%)
• Cytochrome p450 produces NAPQI
• NAPQI toxic causes hepatocellular necrosis – irreversible binding
• NAPQI detoxified by conjugation with glutathione
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Prescott NomogramPrescott Nomogram
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High RiskHigh Risk
• Increased oxidation– Chronic alcohol use– Drugs
• Reduces glutathione stores– Malnutrition– Eating disorders– Chronic liver disease
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N-acetylcysteineN-acetylcysteine
• Most effective within 8 hours
• Precursor for glutathione production
• Can cause anaphylactoid reactions
• Consider starting before paracetamol result if:– Presenting > 8 hrs & >150mg/kg taken– Staggered overdose
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To treat or not to treat?To treat or not to treat?
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Patient 1Patient 1
• 20 year old woman who takes a handful of paracetamol tablets
• No drug history• No alcohol use• Fit and well• Blood level is 80mg/l
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No need to treatNo need to treat
• Patient is not high risk• Level at 4 hours is below even the high risk
line
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Patient 2Patient 2
• 70 year old man• Takes 20
paracetamol 6 hours before presenting
• Alcoholic• No drug history• Blood level 100mg/l
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TreatTreat
• Patient is high risk• Level is above the high risk line• Delayed presentation means need to act fast
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Patient 3Patient 3
• 17 year old epileptic• 25 codydramol 2
hours before attendance
• Taking carbamazepine
• Blood level at 4 hours is 120mg/l
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TreatTreat
• High risk patient• Level above the high risk line
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Patient 4Patient 4
• 35 year old man who presents after taking 24 paracetamol over a period of 24 hours
• No drug history• Fit and well• Blood level 20mg/l
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TreatTreat
• Staggered overdoses are difficult• Poisons advice is to give IV acetylcysteine• Levels are not that helpful• Need to monitor Liver function, clotting and
renal function• May need discussing with Liver Unit if
abnormal
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PARACETAMOLPARACETAMOL
DEADLY PITFALLSDEADLY PITFALLS• The Prescott Nomogram High Risk Line• Staggered Overdoses• Management of late presentation• Recheck U&E, LFT, INR after N-acetylcysteine
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TricyclicsTricyclics
• Antidepressants
• Dangerous: US 60-70% fatal ODs
• UK commonest fatal OD per prescription
• 10% unconscious patient will fit– Treat fits with diazepam/lorazepam
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Tricyclic effectsTricyclic effects
• Anticholinergic toxidrome
• The 3 C’s– Coma– Convulsion– Cardiac
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Tricyclics cardiac effectsTricyclics cardiac effects
• Quinidine effects lead to arrhythmias• ECG
– Sinus tachycardia– Broad QRS: RBBB– Prolonged QT interval– Right axis deviation
• Severe poisoning – VT, bradycardia, heart block• QRS > 160mS = ↑↑risk of seizures and cardiac
toxicity
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TricyclicsTricyclics
• ABG– Hypoxaemia– Metabolic acidosis– Respiratory acidosis
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TricyclicsTricyclics
• Management:
– EARLY ITU REFERRAL
– SODIUM BICARBONATE• If hypotension resistant to fluid challenge• Dysrhythmias• Convulsions
– Consider IV Magnesium for resistant dysrhythmia
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SalicylateSalicylate
• Salicylism
• Dehydration
• Confusion /coma
• Seizures
• Haemetemesis
• Hypoglycaemia
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SalicylateSalicylate
• Metabolic and acid-base disturbance
• Complex
• Respiratory alkalosis – direct stimulation to over breathe
• Metabolic acidosis- acid, impaired normal metabolism, production of lactic acid
• Check ABG / VBG
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SalicylateSalicylate
• Severity of ingested dose:• >150 mg/kg: mild• >250 mg/kg: moderate• >500 mg/kg: severe
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Salicylate managementSalicylate management
• Tailor treatment to symptoms• Fluids• Reduce absorption:
• Activated charcoal• Gastric lavage (>500 mg/kg and <1 hour)
• Increase elimination:• Urinary alkalinisation
• Cooling• Glucose if hypoglycaemic
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Salicylate managementSalicylate management
• <350mg/L: oral fluids
• >350mg/L: urinary alkalinisation
• >700mg/L: haemodialysis
• DISCUSS WITH NPIS
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SalicylateSalicylate
DEADLY PITFALLDEADLY PITFALL
• Salicylate levels can continue to rise following admission (10% of cases)– Repeat levels every until peaked
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OpiatesOpiates
• Common
• Act on μ-receptors
• Reversible with Naloxone
• Naloxone pure opioid antagonist
• Naloxone• Short half life: may need repeated doses
• Give IV +/- IM & may need IVI
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AntidotesAntidotes
• Opiates – naloxone• Paracetamol – acetylcysteine/methionine• Beta-blockers – glucagon• Insulin – glucose• Iron – desferrioxamine• Carbon monoxide – oxygen• Methanol - ethanol• (Benzodiazepines – flumazenil)
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Scenario 1Scenario 1
• 20 year old IVDU found by ambulance crew unconscious
• Needle lying by side
• Resp rate 6, Sats 94% on air
• 60bpm BP 100/55
• Responds to pain
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What next?What next?
• A – Give naloxone
• B – Check airway
• C – Take history
• D – Give flumazenil
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Check airwayCheck airway
• Check airway patent
• Give oxygen
• Call for senior help
• Check glucose
• Give naloxone IM and IV
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Scenario 2Scenario 2
• 30 year old woman
• Taken some white tablets 4 hours earlier
• Feels completely well
• Felt depressed after argument with partner
• Usually fit and well
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What next?What next?
• A – Start N-Acetylcysteine
• B – Discharge as she is obviously well
• C – Find out what the tablets are
• D –Take blood for paracetamol levels
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Take bloodsTake bloods
• Early treatment is essential in paracetamol overdose
• Need to know what her levels are as soon as possible
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Scenario 3Scenario 3
• 45 year old man works in local aquarium
• Put right hand into tank and got stung by a lion fish
• Respiratory rate 16 sats 100% on air
• Pulse 100 bpm 160/80
• Fully conscious
• Extreme pain in hand
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Lion fishLion fish
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What next?What next?
• A – Panic you know nothing about lion fish!
• B – Look on Toxbase
• C – Ring local zoo
• D – Ask a senior who also knows nothing about Lion fish!
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ToxbaseToxbase
• Patient needs cardiovascular monitoring• Analgesia• Hand in water as hot as can tolerate• Lion fish toxin is heat labile• Carefully remove spines if present
• Few hours later patient feels much better goes home
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SummarySummary
• Common• Approach using:
A B C DA B C DDEFGDEFG
• Consider the toxidromes• Early senior help / Early ITU referral• Supportive Care• Antidotes• Psychological assessment
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QuestionsQuestions
?