Project: Ghana Emergency Medicine Collaborative Document Title: Basics of Toxicology Author(s): Patrick Carter, MD, University of Michigan Medical School License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License:We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact with any questions, corrections, or clarification regarding the use of content. 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To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Basics of Toxicology Medical Student Lecture Series Emergency Medicine revised 6/2009 3 Objectives Describe the role of GI decontamination Describe the role of GI decontamination Recognize common toxidromes Recognize common toxidromes Recognize substances for which specific antidotes exist Recognize substances for which specific antidotes exist Initiate ED management of a patient with an overdose Initiate ED management of a patient with an overdose 4 The undifferentiated patient A patient is dropped off at the ED door. He is minimally responsive. His friends say they think he took something and drive off A patient is dropped off at the ED door. He is minimally responsive. His friends say they think he took something and drive off Where do we start? Where do we start? 5 Approach to (possible) Tox patient Simultaneous treatment & diagnosis Simultaneous treatment & diagnosis Immediate action: Immediate action: ABC(D), IV / O2 / monitor ABC(D), IV / O2 / monitor Thinking: Thinking: Is this a tox problem? Is this a tox problem? If yes, are there complicating factors? If yes, are there complicating factors? Got drunk and fell down, now with head injury? Got drunk and fell down, now with head injury? Resources to get a history? Resources to get a history? 6 Approach to (likely) Tox patient Youve considered a differential and you think it is a toxicologic issue Youve considered a differential and you think it is a toxicologic issue Immediate action: Immediate action: Supportive therapy (airway etc) Supportive therapy (airway etc) Decontamination Decontamination Thinking: Thinking: Toxidrome present? Toxidrome present? What more information do I need? What more information do I need? Definitive Management Definitive Management Is there an antidote or specific treatment? Is there an antidote or specific treatment? 7 Overdose History Time of ingestion Time of ingestion Talk to witnesses Talk to witnesses Get pill bottles & count! Get pill bottles & count! Assume common co-ingestants Assume common co-ingestants Alcohol Alcohol Acetaminophen Acetaminophen Aspirin Aspirin Jmh649, Wikimedia CommonsWikimedia Commons 8 Decontamination GI exposure GI exposure Most common route (75% of toxic exposures) Most common route (75% of toxic exposures) Prevent absorption Prevent absorption Topical exposures Topical exposures Remove clothing Remove clothing Wash skin Wash skin Enhance elimination Enhance elimination Whole bowel irrigation Whole bowel irrigation Sorbitol Sorbitol Diuresis / ion trapping Diuresis / ion trapping Hemodialysis Hemodialysis 9 GI Decontamination ***Activated Charcoal*** ***Activated Charcoal*** Absorbs up to 60% of ingestant Absorbs up to 60% of ingestant 1 gm/kg +/- Sorbitol 1 gm/kg +/- Sorbitol Maximal effect if given early ( 30 mg/dl at 6 hrs - toxic Done nomogram Done nomogram Historical interest only Historical interest only Serum level not predictive of degree of toxicity Serum level not predictive of degree of toxicity 47 Salicylates - Treatment Increased elimination in urine Urine alkalinization Urine alkalinization 3 amps of bicarb in 1 L of D5W 3 amps of bicarb in 1 L of D5W Hemodialysis indicated if Hemodialysis indicated if Coma, seizure Coma, seizure Renal, hepatic, or pulmonary failure Renal, hepatic, or pulmonary failure Pulmonary edema Pulmonary edema Severe acid-base imbalance Severe acid-base imbalance Deterioration in condition Deterioration in condition 48 Tricyclic Antidepressants 49 Tricyclic antidepressants Depression, sleep, & pain disorders Depression, sleep, & pain disorders Less common due to SSRI prevalence Less common due to SSRI prevalence High toxicity in overdose High toxicity in overdose 50 Tricyclic antidepressants Anticholinergic toxidrome plus Anticholinergic toxidrome plus Cardiac Dysrhythmias Cardiac Dysrhythmias Quinidine-like (Ia) effects on Na channels Quinidine-like (Ia) effects on Na channels Sinus tach, Vfib, Vtach Sinus tach, Vfib, Vtach Seizures Seizures 51 Tricyclic antidepressants Screening EKG Widened QRS Widened QRS > 100ms sz & dysrhythmia risk > 100ms sz & dysrhythmia risk R wave in aVR and S waves in I, aVL R wave in aVR and S waves in I, aVL Prolonged QTc Prolonged QTc 52 Electrocardiographic changes associated with tricyclic antidepressant overdose. The QRS complex is prolonged with delayed right ventricular activation and intraventricular conduction delay, which results in rightward shift in the terminal 40 msec frontal plane QRS vector. In qualitative terms, this shift manifests as a deep, slurred S wave in leads I and AVL, and an R wave in lead AVR (blue arrows). Source Undetermined 53 Tricyclic antidepressants - Tx ABCs ABCs Bicarbonate drip Bicarbonate drip Reduces cardiac effects Reduces cardiac effects Control seizures Control seizures Benzodiazepines Benzodiazepines Phenobarbital Phenobarbital Avoid phenytoin risk of dysrhythmias Avoid phenytoin risk of dysrhythmias 54 Case 3: 27 yo F brought in by family. Confused and vomiting. She took some Tylenol this morning (about 4 hours ago) 27 yo F brought in by family. Confused and vomiting. She took some Tylenol this morning (about 4 hours ago) P125 BP135/65 T99.4 Warm, dry skin. Oriented x 2. Sometimes nonsensical answers. +gag reflex. Dilated pupils. P125 BP135/65 T99.4 Warm, dry skin. Oriented x 2. Sometimes nonsensical answers. +gag reflex. Dilated pupils. What do you need to know? What do you need to know? Does this fit with a Tylenol OD? Does this fit with a Tylenol OD? 55 Case 3 Gary Seidman, FlickrFlickr 56 Case 3 What are your initial orders? What are your initial orders? Hint: ABC, IV, O2, monitor Hint: ABC, IV, O2, monitor What labs / tests do you want? What labs / tests do you want? Medications? Medications? 57 Case 3 Acetaminophen level 375 mg/dl Acetaminophen level 375 mg/dl What next? What next? 58 Case 4 32 yo M brought in because of violent behavior 32 yo M brought in because of violent behavior Agitated and combative Agitated and combative P125 BP 160/95 T99.4 P125 BP 160/95 T99.4 Warm & sweaty. Dilated pupils. Exam otherwise non-focal Warm & sweaty. Dilated pupils. Exam otherwise non-focal Differential? Differential? 59 Case 4 UDS cocaine positive UDS cocaine positive Treatment? Treatment? 60 Slides & content for this lecture developed by Stacey Noel, MD With revisions by Colin Greineder, MD & Laura Hopson, MD 61