General Management of the Poisoned Patient
General Management of the Poisoned Patient
Assessment
A. Treat the patient, not the poison! Above all, do no further harm.
B. General approach to the poisoned patient:
1. Assess the patient and support vital functions.
• Airway-airway-airway!
• Monitor cardiac status, vital signs, fluid intake and output, body temperature, and mental status.
Toxidromes
• Paying particular meticulous attention to the initial and repeat vital signs is of extreme importance if one is to identify a pattern of changes suggesting a particular drug or group of drugs.
• Toxidrome is a coined phrase to aid the clinician in recognizing the groups of signs and symptoms that tend to consistently result from particular toxins.
2. Patients in coma or altered mental status should receive oxygen, naloxone (Narcan), thiamine (in adults), and have glucose measured immediately or get dextrose 50%.
3. Assess the substance in question and the route of administration.
4. Prevent further absorption.
a. Drugs are absorbed, distributed, metabolized, and eliminated. The entire goal is to STOP THE ABSORPTION AND HASTEN THE ELIMINATION.
b. Swallowed Poisons:
Goal is to physically remove from the stomach.
Ipecac is favored for home use.
Not for:
• caustics;
• substances that cause mental status change (drowsy or seizures);
• cardiovascular compromise;
• use in children when greater than 30 minutes of ingestion;
• vomit until clear.
c. Lavage
• Best with a cuffed endotracheal tube.
• Position the patient on left lateral decubitus in Trendelenberg.
• Tube size 22-28 child; 36-40 adult.
• Use warm saline or water for children and give in 50-100 ml aliquots.
• 300 ml in adults.
• Until clear, not just 1,000 ml.
• Lavage return should approximate fluid given.
d. Activated Charcoal
• Ultra-fine charcoal powder adsorbs most drugs except small molecules like lithium iron and alcohols.
• 1 gram/kg for children, 50 to 100 grams for adults.
• Drugs with an affinity to charcoal; salicylates, phenobarbitol, theophylline, digoxin, and tricyclic antidepressants.
• Complications: vomiting -> aspiration.
• Messy — prejudiced against it.
e. Cathartics
• No cathartic under 1 year old.
• Sorbitol — usually found in premixed charcoal.
• Mag citrate 4 ml/kg.
• Give only once and document it.
• Bowel sounds must be present to give charcoal and cathartic.
f. Multiple-Dose Activated Charcoal
• NOT multiple-dose cathartic
• Hastens the elimination for those drugs that:
— are excreted in the bile (interrupts recirculation);
— gut dialysis;
— effective against tricyclic antidepressants, theophylline, salicylates, lead isoniazid (INH) digoxin, and phenytoin.
g. Whole Bowel Irrigation
• Relatively new concept of safe, rapid catharsis
• Indications:
— drugs not bound to charcoal;
— sustained-release products;
— iron;
— lithium;
— rising blood levels;
— acute lead ingestion.
• Procedure
— Colyte or Go-lytely orally or N/G tube
— Child 500 ml/hr
— Adult 2,000 ml/hr
• Caution: Need bowel sounds in order to use
• Have patient sit on a bedside commode.
5. Advanced therapies for hastening elimination
a. Hemodialysis
• Used when there is:
— a low volume of distribution;
— low protein binding;
— must be water-soluble.
• Indicated in small group of drugs/substances i.e., Lithium, salicylates, ethylene glycol, methanol, ethanol, and isopropyl alcohol.
• Risk of drop in blood pressure.
• Fluid and electrolyte imbalance.
b. Charcoal Hemoperfusion
• Useful for drugs bound to activated charcoal, i.e. short-acting barbiturates, Amanita mushroom poisonings, and paraquat pesticide overdose.
c. Renal Elimination: Forced Diuresis
• Drug excreted in the urine as parent compound or active metabolite. Need a low volume of distribution and low protein binding.
• Used rarely.
• Used in isonazid (INH) overdose.
• NO ACID DIURESIS in olden days used for amphetamines, phencyclidine, and strychnine.
d. Alkaline Diuresis
• Hastens the elimination and is safe.
• Used in salicylates and phenobarbitol overdoses and tricyclic antidepressants.
• Goal: Urine pH 7.5-8.
• 3 amps sodium bicarbonate in 1 liter D5W (1-2 mEq/kg)
• Keep urine flow 3-6 ml/hour.
Red Flag Toxins
What constitutes a red flag in a poisoning?
A. Something that causes a rapid clinical response that leads to a life-threatening event.
B. Something that causes toxicity, but has delay in time to form a metabolite which then leads to an irreversible state.
C. Small quantities of products or medications that are "deadly in a single dose."
D. New products or medications that have little toxicity information available.
What are some of those products or medications?
A. Rapid responders
• Beta blockers
• Oral hypoglycemic drugs (all ingestions require overnight admission. 16 to 24-hour delay in hypoglycemia)
• Lindane (found in Kwell or other pediculicide)
• Nicotine
• Clonidine (Catapres) and transdermal patches
— Antihypertensive
— Used in smoking cessation and cocaine withdrawal
— No ipecac signs and symptoms occur in 30-90 minutes
— Narcan for respiratory depression — THIS IS COMMON
— Early transient hypertension do not treat.
— Altered mental status? Need six to 12 hours of heart monitoring until Asx x 4 hours
— Mild hyperthermia
— All children are referred to health care facility
— Treatment: charcoal, Narcan IV fluids, trendel, and Dopamine PRN
— Symptoms resolve in 24-48 hours
• Clozapine (Clorzaril)
— Anti-psychotic drug.
— Causes seizures, hypotension, tachycardia, central nervous system depression, and decreased muscle tone.
— Symptomatic and supportive care; dopamine for hypotension.
— Overdose requires several days of monitoring due to delayed effects of the drug.
• Tricyclic antidepressants
• Lomotil (Diphenoxylate)
— Narcan
• Isoniazid (INH)
— In overdose seizures within one hour of ingestion (35-40mg/kg)
— Death 80-150mg/kg
— LARGE DOSES OF PYRIDOXINE used synergistically with Valium to stop seizures
• Antimalarials (Cloroquine)
— Has a quinidine-like effect on the heart and vasodilatory properties.
— Symptoms occur rapidly, and death can occur in one to two hours even with small ingestion.
— Transport by ambulance!
— Cardiovascular failure from hypotension, ventricular dysrhythmias, respiratory arrest, and pulmonary edema.
— If asymptomatic for 6-8 hours post-ingestion, they can be sent home.
• Oil of wintergreen
— 98% methyl salicylate = 1400mg ASA/ ml
• Darvon (propoxyphene)
• Camphor
• Organophosphate pesticides
• Calcium Channel Blockers
• Chloral hydrate
— Prolonged coma
B. Metabolite formers?
• Nail glue removers containing acetonitrile, which converts to cyanide; use lily cyanide kit
• Methanol-containing products (i.e., windshield washer fluid, dry gas, Sterno)
• Ethylene glycol (antifreeze)
• Acetaminophen
C. Deadly in a single dose?
• Pipeline cleaners used in barns or milking parlors
• Oil of wintergreen
• Beta blockers
• Calcium channel blockers
• Visine, Afrin (imidazoline derivatives)
• Sodium azide
— Direct-acting vasodilator
— At the cellular level, inhibits cellular respiration, producing a metabolic acidosis
— Product found in air bag inflation (gas generator) and degrades to nitrogen gas
— Preservatives in lab reagents
— Commercial Isotonic buffering solution as a preservative
— Explosive industry
— Symptoms: hypotension, headache, weakness, coma, seizures
— Symptoms occur and progress quickly
• Cloroquine
D. Miscellaneous
• Rat bait contains new and improved longer-acting anti-coagulants, i.e., Brodifacum found in "Just One Bite."
• Iron is the No. 1 cause of pediatric deaths due to poisoning.
Source: New Hampshire Poison Information Center, Lebanon, NH.
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