South Carolina AHEC Emergency & Disaster Medicine Summit

August 15 & 16, 2008

Practical Approach to Toxicology

Jeff Brosius B.S., NREMTP, FP-C

Objectives
Discuss treatment priorities when treating toxic ingestions Compare/contrast clinical differences of varied toxins Describe clinical implications of toxic ingestions Apply toxic ingestion care to prehospital arena.

ABCs of Toxicology
Airway Breathing Circulation Diagnosis Decontaminate Enhance Removal

South Carolina AHEC Emergency & Disaster Medicine Summit

August 15 & 16, 2008

ABCs
Airway as needed, best option available. Breathing: Rate, depth, with oxygen Circulation: Pulse rate, rhythm, and blood pressure. Diagnosis: This is the challenge!

Diagnosis: Pupils
Constricted SCOPE-B
Sedatives/hypnotics Cholinergics Opiates PCP Ethanol Barbiturates

Diagnosis: Pupils
Dilated
Sympathomimetics
Cocaine Meth Stimulants

Diagnosis: Odors
Garlic
Arsenic Organophosphates Thallium

Anticholinergics
Nerve agents Benadryl

Pears
Chloral Hydrate Paraldehyde

Diagnosis: Odors
Acetone
Cyanide Isopropyl alcohol

Diagnosis: Odors
Mothballs
Naphthalene Paradichlorbenzene

Almonds
Cyanide (burning carpet, apple seeds, cherry pits, peach pits)

Carrots
Water hemlock

Wintergreen
Methylsalicylate

South Carolina AHEC Emergency & Disaster Medicine Summit

August 15 & 16, 2008

Diagnosis: Lab Values

Anion Gap: Na Cl - CO2 Elevated Anion Gap is evidence of organic acids. Normal is 8-12 mEq/L

Diagnosis: Lab Values

Elevated Anion Gap: AT MUD PILES
Alcohol Tolulene Methanol Uremia Diabetes Paraldehyde Iron Lactic Acidosis Ethylene Glycol Salicylates

Diagnosis: Lab Values

Tox Screen Options
Blood/Plasma/Serum
Best option for selected substances: APAP, ASA, Co, CBZ, Dig, EtOH, Fe, Li, Phenobarb, Theoph. Do not use for comprehensive screen.

Decontamination
Universal Antidote
Burned toast Milk of Magnesia Strong Hot Tea Grandmothers still know best, despite advances in medicine.

Urine (UDS)
Best option for abused drugs: amphetamines, barbs, benzos, cocaine, opiates, PCP, THC.

Decontamination: Emesis
Indications
Not many! Iron Lithium Potassium

Decontamination: Lavage
Indications
Remove ingested material Administration of Charcoal Administration of cathartics

Contraindications
Altered mentation Rapid Progression of condition TCA, Cocaine, camphor, etc. Corrosives Petroleums Hydrocarbons

Contraindications
Obtunded Comatose Convulsions Corrosives

South Carolina AHEC Emergency & Disaster Medicine Summit

August 15 & 16, 2008

Decontamination: Charcoal
Indications
Any ingested poison except:
Alcohols Alkalis Acids Iron Potassium Lithium Phenobarb

Decontamination: Other Options

Repeat doses of Charcoal
Some anti-convulsants Salicylates Theo

Contraindications
Bowel obstruction Corrosives

Cathartics
Mag Citrate (4mL/kg)

Whole Bowel Irrigation **

Enhanced Elimination
Necessary? Accessibility of Poison? Efficiency?

Enhanced Elimination: Methods

Urinary removal Hemodialysis Peritoneal Dialysis Multi-dose charcoal Whole Bowel Irrigation

Enhanced Elimination: Antidotes

Very few specific antidotes exist for toxic ingestions Time is a significant factor Effectiveness of antidote depends on dose given and serum levels of toxic substance

Acetaminophen
History of Event Symptoms

South Carolina AHEC Emergency & Disaster Medicine Summit

August 15 & 16, 2008

Acetaminophen
Labs
Acetaminophen Level (Baseline, then q4h) AST, ALT, PT Bilirubin, Ammonia LFTs

Acetaminophen: Treatment
N-acetylcysteine (Muco-Myst) 150mg/kg in first hour 50mg/kg in next 4 hours Antiemetics as needed. Repeat Labs q 4-8 hours to follow LFT and PT values.

Alcohols and Glycols

Methanol/Ethylene Glycol is converted to various organic acids by alcohol dehydrogenase. These acids create a metabolic acidosis, with the resultant complications. Treatment is designed to prevent or treat that acidosis.

Alcohols and Glycols

History Symptoms Labs: Glucose, Anion Gap, Osmolar Gap, Methanol/Ethylene

Alcohols and Glycols: Treatment

Glucose! Supportive symptomatic care Ethanol Blockade/Dialysis EtOH

Alcohols and Glycols: Treatment

Ethanol Blockade
Indicated for Osmolar gap > 20mg/dL

Dialysis
Indicated for Osmolar gap > 50 mg/dL

Osmolar Gap = Measured Osm Calculated Osm.

South Carolina AHEC Emergency & Disaster Medicine Summit

August 15 & 16, 2008

Cardiac Prescription Meds

Three Major types
Receptor antagonists (-blockers, Ca++ blockers) Alpha-agonists (clonidine, cardura) Sodium/Potassium Pump Inhibitors (digitalis, etc.)

Cardiac Prescription Meds

History Symptoms Labs: Chem, Coags, CBC, Tox Screen.

Cardiac Prescription Meds: ECG

Receptor Antagonists
-Blockers alter conduction Ca++ Channel blockers decrease contractility and vessel tone Both will cause bradycardia and hypotension WARNING: Beware of SR or LA or XL preparations.

Receptor Antagonists: Treatment

IV, ECG, Oxygen, fluids PRN with caution. Glucagon: 0.1 mg/kg IV for -Blockers Calcium Chloride 2-4 mg/kg IV *SLOWLY * for Calcium Channel Blockers. Activated Charcoal

Alpha Agonists
Decrease sympathetic flow by action on central inhibitory receptors Transient hypotension Bradycardia Respiratory Depression

South Carolina AHEC Emergency & Disaster Medicine Summit

August 15 & 16, 2008

Alpha Agonists: Treatment

IV, ECG, Oxygen, fluids PRN with caution Delayed symptoms. Supportive care is usually effective. 24 hour ICU admission.

Digitalis
History Symptoms Labs: Dig level, Chemistry Panel (K+)

Digitalis ECG

Digitalis: Treatment
Hyperkalemia Treatment First!
D50, Insulin, Bicarb, Calcium, Albuterol, Kayexelate, etc.

Charcoal FAB/Digibind for refractory hyperkalemia or lethal ECG rhythms.

Salicylates
History Symptoms Labs: Tox, Gases, Coags, Chemistry Tox Screen

Salicylates
Serum levels peak at 2-6 hours from ingestion Symptomatic: >50mg/dL; Fatal: >100 mg/dL Also reported at 200-500 mg/kg

South Carolina AHEC Emergency & Disaster Medicine Summit

August 15 & 16, 2008

Salicylates: Treatment
Temperature control. Fluids for dehydration, glucose as needed. Correct coagulopathy with Vitamin K. Bicarb as needed to keep urine pH above 7.5 Consider dialysis. Charcoal.

Tricyclic Antidepressants
History Symptoms Labs: usually not needed or helpful.

Tricyclic Antidepressants: ECG

Tricyclic Antidepressants: Treatment

Arrhythmia Treatment NO IPECAC! Charcoal (via NG) Bicarb 1-2 mEq/kg IV for wide QRS, acidosis, or refractory hypotension. Airway/ventilatory support may be needed: Be prepared.

Mnemonics
Hyperthermia: NASA Nicotine Antihistamines Salicylates. Sympathomimetics Anticholinergics, Antidepressants Hypothermia: COOLS Carbon Monoxide Opiates Oral Hypoglycemics (Insulin too!) Liquor (EtOH) Sedative-hypnotics

Mnemonics
Tachycardia: FAST Freebase Anticholinergics, Amphetamines Sympathomimetics Theophylline Bradycardia: PACED Propranolol Anticholinesterase Clonidine, CCBs Ethanol Digoxin

South Carolina AHEC Emergency & Disaster Medicine Summit

August 15 & 16, 2008

Mnemonics
Tachypnea: PANT PCP, Paraquat Aspirin, Salicylates Noncardiac Pulm. Edema Toxic induced acidosis Bradypnea: SLOW Sedative-hypnotics Liquor Opiates Weed (THC)

Mnemonics
HTN: CT SCAN Cocaine Thyroid, Theophylline Sympathomimetics Caffeine Anticholinergics Nicotine Hypotension: CRASH Clonidine, CCBs Resperdine Antidepressants Sedative-hypnotics Heroin (opiates)

Seizures: OTIS CAMPBELL

Organophosphates Tricyclics Insulin Sympathomimetics Camphor, Cocaine Amphetamines Methylxanthines PCP Benzo (withdrawal) EtOH (withdrawal) Lithium, Lidocaine Lead, Lindane

Mnemonics

Non-Toxics
EMS is frequently called for Toxic Ingestions of various substances. The items in the following list are generally not toxic substances. A thorough exam and history is still needed, to rule out any other symptoms or pathology.

Non-Toxics
Antibiotics Baby Oil Bleach Cigarettes Cologne Contraceptive pills Cosmetics Detergent Glue Hydrogen Peroxide Laxatives Paint Shampoo Vitamins

!! hanks T
E-mail: reno316@hotmail.com