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1 Toxicology, Alcohol & Drug Abuse 2008

1 Toxicology, Alcohol & Drug Abuse 2008. 2 Types of Toxicological Emergencies w Unintentional Dosage errors Idiosyncratic reactions Childhood poisoning

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1

Toxicology,Alcohol & Drug Abuse

2008

2

Types of Toxicological Emergencies

Unintentional• Dosage errors• Idiosyncratic reactions• Childhood poisoning• Environmental exposure• Occupational exposure• Neglect and exposure

3

Intentional poisoning/overdose• Chemical warfare

• Assault/homicide

• Suicide attempts

4

Use of poison control centers Oregon Poison Control

1-800-452-7165 Evaluation of the poisoned patient

5

Scene Size-up

Where are you? Who’s around you? Is there any potential danger? Any evidence of pill bottles, used

needles, etc.

6

History

• Provides a working diagnosis; notoriously unreliable

• What - samples• How much• How• When• Why• What else

7

Physical exam Vitals

• Airway• Stridor

• Snoring

• Vomitus

• Gag reflex

• Risk of aspiration

8

• Breathing evaluation• Baseline RR

• Quality of respirations

–Shallow; need early ventilatory support

–Deep; underlying hypoxemia or metabolic acidosis

• Early - noncardiogenic pulmonary edema

• Later - ARDS

9

• Circulation• Baseline pulse rate and BP

–Hypotension common–Hypertension occasionally; serious ie

CVA

• ECG monitoring–Tachyarrhythmias common; not

usually serious perfusion problem–Bradyarrhythmias uncommon; more

serious underlying metabolic problem

10

Temperature• Baseline temp.

• Hypothermia and hyperthermia frequently accompany poisons

11

Neuro complications• Altered level of consciousness

(AMS) frequent• Seizures one of most common• Mild drowsiness• Agitation• Hallucinations• Confused, combative• Coma• Medullary depression• Cardiopulmonary depression• Death

12

Underlying disease states• Asthma, COPD etc. increased risk for resp.

compromise

• Underlying cardiac disease increased risk for severe arrhythmias.

13

Supportive care

• Prevent or limit respiratory, cardiac, neurologic complications

• Oxygen,

• IV

• ECG

14

Respiratory complications• Airway protection• ET or NT intubation• Bronchodilator therapy prn• Positive pressure ventilation prn

15

Cardiovascular complications

• Appropriate antiarrhythmics

• Atropine

• Pacing

• Fluid challenge for hypotension

• Vasodilators for hypertension

16

Neurologic complications

• Anticonvulsants; diazepam/versed prn

• Chemical restraints only compounds

intoxication and may precipitate

catastrophic cardiopulmonary

complications

17

Routes of absorption

• Ingestion

• Inhalation

• Injection

• Absorption

18

Ingestion

Most common route• Assessment findings

• What?• When?• Quantity?• Alcohol?• Self-treatment?• Psychiatric care?• Weight?

19

Physical examination

• Skin

• Eyes

• Mouth

• Chest

• Circulation

• Abdomen

20

General management considerations

• Prevent Aspiration • Intubation/RSI?

• Fluids & Drugs• GI decontamination

• Syrup of Ipecac–Reduces absorption by @ 30%–Interferes with activated charcoal

• Gastric lavage–36-40 Fr. orogastric tube–After 1-2 hrs post ingestion

questionable

21

• Activated charcoal

• Agent of choice

• Adsorbs molecules of chemicals on its surface

• Reduces absorption by @ 50%

• Dose 1 g/kg

22

Cathartics• Sorbitol, mag sulfate, mag citrate• Speed up motility• Studies show they don’t positively

affect patient outcome• Liquid stools• Dehydration, electrolyte imbalances

occur• Administration of activated charcoal

20-30 min. prior to gastric lavage doubles effectiveness

23

How do people poison themselves?

24

They Inhale it

• Paint, other hydrocarbons• Carbon monoxide• Ammonia• Chlorine• Freon• Toxic vapors, fumes, aerosols• Mace, mustard gas

                                                          

                                        

25

What do they look like? Primarily respiratory

• Tachypnea, cough, hoarseness, stridor, dyspnea, retractions, wheezing, chest pain or tightness, rales, rhonchi

Cardiac:• Dysrhythmias

CNS• Dizziness, H/A, confusion, seizures,

hallucinations, coma

Carbon Monoxide

Inadvertant• Faulty furnace• Indoor heating source

Purposeful• Suicide

Poisonous Gases

Oxygen robbing Chlorine Warfare

• Chlorine• Mustard gas• Bromine

28

29

Now what?

Be safe! Remove patient from environment Exam Provide supportive care Contact Poison Control and follow

directions

30

They inject it

• IV drug abuse – more later

• Venomous bites and stings• Bees, hornets, yellow jackets, wasps,

ants (only females)

• Spiders, ticks, other arachnids; scorpions

• Snakes

• Marine animals; jelly fish, stingrays, anemones, coral, fish

31

Ticks/Lyme Disease

Frequently requires Antibiotics (Amoxicillin, Zithromax)

Tick generally must be attached for 24-48 hours

32

Results in immediate & delayed reactions• Immediate reaction

• Rash• Fever• Malaise• Fatigue• H/A• Muscle & joint aches• Sore throat• Sinus infection

33

Delayed reaction• Chronic malaise/fatigue• Muscle pain/joint pain with/without arthritis• Neuropathy• Tremor• Bell’s palsy• Meningitis• Vision problems (double vision, photophobia)• Vestibular problems• Seizures• Cardiac symptoms• N/V• Immune suppression

34

Hymenoptera (Bee stings, Wasp stings, Ants)• Bumblebees, Sweat bees, Honeybees;

Hornets, Yellow jackets; Fire ants, Harvester ants

• Type of reaction• Local; • Toxic; 10 or more stings

– N/V/D, light-headedness, syncope, H/A, fever, drowsiness, muscle spasms, edema, seizures

– Sx subside w/in 48 hrs

35

Systemic/anaphylactic:• The shorter the onset, more severe the

reaction• Initial sx: itching eyes, facial flushing,

generalized urticaria, dry cough• Sx intensify; chest or throat constriction,

wheezing, dyspnea, cyanosis, abdominal cramps, N/V/D, vertigo, chills, fever, shock, loss of consciousness

• Reaction can be fatal in 30 min.

Bees and Bugs

36

Delayed reaction• Serum-sickness-like sx; fever, malaise, H/A,

urticaria, lymphadenopathy appears 10-14 days later.

Dx: difficult• Honeybees; leaves it’s stinger with venom sac

attached• Yellow Jackets: nest in ground • Wasps: under eaves or windowsills • Southern US Fire Ants; groupings of 3-4

stings and pustules

Bees and Bugs

37

Tx:• Scrape honeybees stinger out; don’t

squeeze; remove quickly

• Wash sting sites with soap and water

• Ice packs

• Benadryl, Prednisone

• Epinephrine 1:1000 0.3 - 0.5 mg sq IF SYSTEMIC

Bees and Bugs

38

Brown Recluse Spiders (Fiddleback spider) Southern, midwestern states

• Tennessee, Arkansas, Oklahoma, Texas, Hawaii, California

• 15mm long. 6 eyes in a circle• Lives in dark, dry locations• Violin-shaped markings on back

39

Does it hurt?

Usually painless Bites occur at night Local reaction

• Initially, small erythematous macule surrounded by a white ring

• Over next 8 hours, localized pain, redness, swelling

• Tissue necrosis over days > weeks

Chills, fever, N/V, joint pain, DIC Tx: Diphenhydramine; supportive

40

41

Black Widow spiders

Live in all parts of continental US Found in woodpiles or brush Female spider bites

• Orange hourglass on black abdomen

42

Does it hurt? Immediate localized pain, redness, swelling. Progressive muscle spasms of all large muscle

groups can occur N/V, sweating, seizures, paralysis, decreased

level of consciousness. Management: Supportive care;

• Consider Diazepam• 2 – 10 mg IVP

• or Calcium gluconate• 0.1 – 0.2 mg/kg of 10% solution.

• Monitor B/P• Antivenin is available

43

Scorpion stings All species can sting, =

localized pain Only bark scorpion has

caused fatalities• Mostly in Arizona,

California, Nevada, New Mexico, Texas.

• Move mostly at night• Venom stored in bulb at

end of tail

44

Does it hurt? Venom acts on nervous system

• Burning, tingling effect • Gradually progresses to numbness.

Systemic effects • Slurred speech, restlessness• Hyperactivity in 80% of children• Muscle twitching, seizures• Salivation, abdominal cramping, N/V

Management: Supportive• Apply constricting band above wound site –

watch band – occludes lymphatic flow only• Avoid analgesics; may increase toxicity

45

Snakebite• 8000 bites/yr - mortality is

@ 50/yr• N. Carolina has highest %• Peak months July, August

6am - 9 pm

46

Pit Vipers

Cottonmouth, rattlesnake, copperhead• Indentation 1/2-way between eye and

nostril• Hollow, retractable fangs• Vertical pupils• Triangular head

47

Venom contains enzymes that may destroy proteins, other tissue components; destroys RBCs, affects blood clotting

Death from shock possible in 30 minutes • Most occur 6-30 hours

Pit Vipers (cont.)

48

S/S: Fang marks, swelling and pain• Weakness, dizziness, faintness• Sweating/chills• Thirst, N/V, Diarrhea, • Tachycardia, hypotension• Bloody urine

Tx: Keep pt. Supine• Immobilize limb• Maintain extremity in neutral position• DO NOT apply constricting bands, Ice, etc.

Pit Vipers (cont.)

49

Coral snakes Distinct pattern of red

and black bands wider than interspaced yellow rings

“Red on yellow, kill a fellow”/coral snake

“Red on black, venom lack”/harmless snake

•Venom•Affects coagulation•Affects endothelium of vessels•Paralyzes activity of white blood cells•Neurotoxins A & B affect nervous system; esp. cardiorespiratory centers

50

May be NO effects for 12-24 hours

• Localized numbness, weakness, drowsiness

• Ataxia, slurred speech, excessive salivation

• Paralysis of tongue, larynx

• Drooping eyelids, double vision, dilated pupils

• Abdominal pain, N/V

• Hypotension, Respiratory failure

• Seizures

Coral Snakes (cont.)

51

Size of victim important; condition of victim will seriously affect outcome

Location very important; bites on head and trunk 2-3x more dangerous; bites on upper extremities more serious than lower.

Coral Snakes (cont.)

52

Tx:• Wash wound with copious amounts of water• Apply compression bandage, keep extremity

at level of heart• Immmobilize limb• Transport for antivenin• Do NOT apply ice, cold pack, freon sprays,

or incise wound

Coral Snakes (cont.)

53

Marine Animal Injection Jellyfish, Coral, Sea urchins, Sting rays Secondary infections S/S: intense local pain, swelling

• Weakness, N/V• Dyspnea, tachycardia• Hypotension, shock

Tx: Supportive care• Consider a constricting band between heart, & wound;

occlude lymphatic flow only• Heat or hot water• Meat tenderizer

54

Poisoning By Absorption

Surface absorption

• Poisonous plants; ivy, sumac, oak

• Organophosphates

55

Now What? Management considerations

• Remove patient from environment• Wear protective clothing• Remove pt. clothing• Initiate supportive measures• Contact poison control• Soap and water• Decontaminate eyes with 15-30 min. Water

flush• Supportive care

56

Cholinergics

Pesticides (organophosphates, carbamates)

Nerve agents (sarin, Soman)

57

Findings• SLUDGE• Headache, Dizziness, Weakness, Nausea• Bradycardia, wheezing, bronchoconstriction,

myosis, coma, convulsions, diaphoresis

Management• Decontamination• Airway and ventilation

• Aggressive airway management

• Circulation

Cholinergics (cont.)

58

• Pharmacological• Atropine 2 – 5 mg IV q 15-30 min. until vitals

improve• Pralidoxime chloride (2-PAM)• Diazepam 2 – 10 mg IV for seizure control• Activated charcoal – if ingested & gag reflex

intact

• Transport considerations• Protect self • Notify receiving hospital• May require decontamination outside ED

Cholinergics (cont.)

59

Caustic substances Acids, alkalis

• 12,000 exposures/yr• 150 major complications/deaths

• Plumbing liquids• Cause tissue coagulation, necrosis• S/S - Acids: pH <2

• Eschar at burn site• Local burns to mouth, throat• Esophagus usually not damaged• Stomach lining injured• Immediate, severe pain• Acidemia

60

Alkali's: pH > 12.5• Induce liquefaction necrosis• Pain often delayed• Cause perforation, bleeding,

inflammation of central chest structures• W/in 2-3 days, complete loss of

protective mucosal tissue• S/S:

• Facial burns, pain in lips, tongue, throat, gums

• Drooling, trouble swallowing• Hoarseness, stridor, SOB• shock

61

Tx:• Aggressive, rapid

• Prevent injury to rescuers

• Airway management critical

• Cricothyrotomy

• Don’t use activated charcoal

• Rapid transport

62

Hydrofluoric Acid

Used to etch glass Extremely toxic Penetrates deeply into tissues; inactivated only

by contact with calcium; settles in tissues as salt• Causes total disruption of cell functioning, bone

destruction S/S: burning at site of contact, SOB, confusion,

palpitations, muscle cramps Tx: Supportive: Immerse affected limb in ice

water with Mag. Sulfate or calcium salts

63

Hydrocarbons Organic compounds;

• Kerosene, turpentine, mineral oil, chloroform, etc.• Lighter fluid, paint, glue, lubricants, solvents,

aerosol propellants.

S/S:• Burns, wheezing, dyspnea, slurred speech, ataxia,

obtundation• Foot and wrist drop with numbness, tingling• Cardiac dysrhythmias

Tx: Rarely serious – call poison control

64

Tricyclic antidepressants Narrow therapeutic index

• Amitrriptyline, Elavil, amoxapine, clomipramine, doxepin, imipramine, nortriptyline

S/S: dry mouth, blurred vision, urinary retention, constipation, confusion, hallucinations, hyperthermia, respiratory depression, seizures, tachycardia, hypotension, heart block, wide QRS, Torsades de pointes

Tx: Sodium Bicarbonate, 1 mEq/kg

65

MAO Inhibitors

Atapryl, Eldepryl Relatively unpopular

• Narrow therapeutic index• Serious interactions with red wine, cheese

Symptoms may not appear for up to 6 hours• Headache, agitation, restlessness, tremor• Nausea, palpitations, tachycardia, hypertension,

hyperthermia, bradycardia, hypotension, coma, death

No antidote available; tx life-threatening sx.

66

Hallucinogens

LSD, PCP, peyote, mushrooms, jimson weed, mescaline• “Psychedelic” - visual or tactile

PCP• Ketamine still used• Powdered or solution; added to tobacco or

marijuana• Onset in 2-5 min.; Peak effect in 15 min.• Elimination half-life about 7 h - 3 days.

67

LSD• Blotter acid, sugar cubes, gelatin• Sx in 1/2 - 1 hr; peak in 2 hrs (paranoia may

occur), acute psychosis may persist for days

68

• Morning Glory• Mescaline/Peyote

cactus• 6-12 buttons required

to produce hallucinogenic effects

• N/V, blurred vision, hypertension, tachycardia

• Effects peak at 2 hrs, last for 6-12 hrs

• Religious ceremonies• Tx with rest and

reassurance

69

Mushrooms; psilocybin or ibotenic acid- magic mushrooms

• Common in US; pacific NW, texas, florida,

hawaii

• Religious ceremonies since aztec

• Eaten raw, brewed in soup or tea, or dried

• GI discomfort in 15-30 min. N/V

• Effects last from 4-12 hrs

70

Nutmeg; common in foods and herbal remedies• Myristicin is major

component• 10-50 g of fresh nutmeg

(2-9 whole nutmegs)• Sx in 3-6 hrs; N/V,

abdominal pain• Cold extremities with

weak pulses shallow respirations; sx resolve in 24 hr with supportive care

71

Designer amphetamines• Adam, Eve, Ecstasy

• Effects are drug and dose dependent

• Severe psychomotor agitation

• Disorders of thought process

• Hypertension, seizures, DIC, ARDS, death

• Management supportive

72

Marijuana• Cannabis sativa; marijuana and

hashish• Medicinal qualities in china > 4000

years ago• Today; glaucoma and chronic pain• Most commonly used illicit substance

after alcohol and tobacco• THC levels peak about 8 min after

inhalation, and 45 min. after ingestion. Effects last 2-6 hrs.

73

74

Narcotics Heroin, methadone,

morphine, codeine, meperidine, hydromorphone (Dilaudid), hydrocodone (Percodan)• Street heroin cut with

quinine, lactose, sucrose, mannitol, talc, procaine, baking soda.

• Effects include drowsiness, euphoria, miosis, decreased respiration, N/V, respiratory arrest

                           

75

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Withdrawal

• Piloerection, lacrimation, yawning,

rhinorrhea, sweating, nasal stuffiness,

myalgia, vomiting, abdominal

cramping, diarrhea, irritable,

hyperactive, confused

77

Narcotic overdose• Cardinal findings; pinpoint pupils,

hypoventilation Tx: Airway, ventilation, circulation Naloxone, 0.4-2.0 mg/0.01 mg/kg in

child, SQ, IM, IV, ET; effective in 1-2 min. • Naloxone acts as antagonist at opiate

receptor sites• Overdose often mixed• Serum half-life of Narcan is 1 hr with

action duration of 2-3 hr. (methadone half-life 72 hr).

78

Complications of narcotic abuse

• Skin ulcers or lesions

• nonpitting edema of extremities

• Infection

• Abscesses, Cellulitis, Thrombophlebitis

• Endocarditis

• Malaria (1929)

• Tetanus (1876) esp. female, subcu

injectors

79

• Hepatic complications; most common• GI complications

• Ilius• Fecal impaction

• CNS complications• Meningitis• Spinal abscess

80

Cocaine Most common cause of drug related

deaths• Plant alkaloid found in coca plant. Leaves

are crushed with a hydrocarbon solvent followed by extraction of alkaloid with sulfuric acid

• Smoked, snorted, or injected• Crack is almost pure cocaine vaporizes at

high temp.• Absorbed from all sites; mucous

membranes, GI tract, respiratory tree.

81

Cocaine

Smoked, injected, snorted, swallowed Intensity & duration depends on route 1997 – 1.5 million Americans use Drug most frequently involved in ED visits Often used with Valium, Ativan, Heroin as

upper/downer combo Adolescents combine Cocaine, Marijuana,

Alcohol

               

82

Short-term effects

Pleasure Increased alertness Paranoia Vasoconstriction Myocardial damage Dysrhythmias Death

83

Long term effects Severe

depression Loss of energy Damage to

• Heart• Lung• Brain• Kidneys

84

85

86

• Intranasal admin peak effect in 1/2 hr• GI peak effect in 90 min.• IV and inhalation peak at 30 seconds to 2

min.• Tachycardia, hypertension, hyperthermia,

agitation, seizures are common.

Cocaine (cont.)

87

AMI common; onset immediate > 24 hr.• Coronary artery spasm, thrombosis, atrial and

ventricular arrhythmias, aortic rupture, CHF, QRS widening

Spontaneous pneumothorax and pneumomediastinum possible 2ndary to deep breath holding

CVA OB risks Renal failure

Cocaine (cont.)

88

Topical cocaine

Management• Sedation, control of hyperthermia and

seizures, fluids.

Cocaine (cont.)

89

Amphetamines & Amphetaminie-like Drugs

• Benzedrine• Dexedrine• Ritalin• Midol• Vicks inhaler• Bronkaid tabs• Alka-Seltzer plus, Allerest, Contac, Dexatrim,

Dimetapp, Novahistine tabs, Extra-strength Sinutab, Triaminic

• Actifed, Drixoral, Novahistine, Sudafed

90

• First synthesized in 1887, but not commercially available until 1932

• Similar to epinephrine, norepinephrine Effects:

• Restlessness, hyperactivity, repetitive behavior, anorexia, sleep reduction

• Rapidly absorbed from GI tract; peak levels within 1 hr.

Amphetamines (cont.)

91

Toxicity:

• Diaphoresis, extreme restlessness,

repetitive and bizarre behavior, coma,

intracranial hemorrhage, flushing,

tachycardia, hypertension, arrhythmias, MI,

N/V/D

• Abrupt withdrawal rarely life-threatening.

Depression, increased appetite, cramps,

N/D, HA.

• Care supportive

Amphetamines (cont.)

92

Methamphetamines

                       

80% children in foster care are Meth related

100

Barbiturates

• First introduced as sedative in 1903. Currently used to treat seizures, induction of anesthesia, treatment of ICP

• Methohexital• Phenobarbital• Secobarbital• Primadone

101

Barb. intoxication mimics alcohol intoxication. Rule of thumb; 10x hypnotic dose can produce severe toxicity.

Treatment: ET, gastric lavage, IV, diuresis, Hemodialysis

Barbiturates (cont.)

102

Benzodiazepines Commonly used for anxiety,

insomnia, seizures, Alcohol withdrawal, conscious sedation, general anesthesia.

• Xanax• Librium• Klonopin• Tranxene• Valium• Dalmane• Ativan• Versed• Halcion

103

Predominantly CNS effects, well

absorbed from GI tract. IM injection is

unpredictable

Benzodiazepines (cont.)

104

Most serious toxicity occurs in ingestion of other agents or parenteral administration.

CNS effects;• Drowsiness, dizziness, slurred speech, confusion,

ataxia, intellectual impairment. Managment:

• Dextrose, thiamine, naloxone• Do not induce vomiting• Give activated charcoal• Gastric lavage• Monitor closely

Benzodiazepines (cont.)

105

Cyanide

Potent cellular toxin; as little as 50 mg may cause death.• Extract of bitter almonds/cherry laurel leaves,

extracts of apricot, cherry, peach pits• Silver polish• Prolonged exposure to IV nitroprusside• Burning of synthetics and wool, silk, vinyl,

polyurethane

Several hours exposure (<50 ppm) can cause sx

Recovery is rapid after removal.

106

Exposure to 100 ppm may be fatal in 30 min.

Sx: • Severe dyspnea, • Loss of consc., Seizures, • Arrhythmias, • HA, • Drowsiness, • Paralysis, • Pulmonary edema,

Bright red retinal vessels, smell of bitter almonds important clues.

Tx: amyl nitrite for inhalation, 10 ml of 3% solution of sodium nitrite for IV infusion.; Give 300 mg, followed by 12.5 g of sodium thiosulfate.

107

Drug abuse• Epidemiology

• Incidence

• Morbidity/mortality

• Risk factors

• Prevention

• Psychological issues

• Psycho-social issues

108

Pathophysiology of long term drug abuse• End-organ damage

• Brain, liver, heart

• Malnutrition

• Habituation/dependence/addiction

• Tolerance

• Withdrawal syndromes

Drug abuse (cont.)

109

Alcoholism - Ethanol• Incidence

• Morbidity/mortality– 42% traffic fatalities, 69% drownings, 23%

suicides

– 100,000+ deaths/yr

• Risk factors

• Prevention

• Psychological issues

• Psycho-social issues

110

End-organ damage• Brain

• Liver

• Heart

• Bone

• Pancreas

Alcoholism (cont.)

111

Alcoholism –Clinical Manifestations

Altered Immunity Anorexia Dysrhythmias Coma Irritability and disorientation Muscle cramps Poor wound healing Seizures Tremor and ataxia

112

Malnutrition Withdrawal syndrome Wernicke’s encephalopathy (disorder

of the brain)

Alcoholism (cont.)

113

Alcoholism –Body System Disturbances

Fluid and electrolyte from diuresis

GI disorders (bleeds, esophageal varices)

Liver (cirrhosis)

Pancreatitis

Cardiac and skeletal muscle myopathy

Immune suppression

Trauma (suppressed clotting factors)

114

Prehospital concerns

Delirium Tremens (DT’s)• Treat symptomatically

• Valium/Versed• Rehydration

115

Wernicke-Korsakoff’s syndrome

• Personality; psychosis, polyneuritis,

disorientation, muttering delirium,

insomnia, illusions, hallucinations

• Classic triad; ataxia, ophthalmoplegia

(nystagmus and 6th nerve palsy), and

altered mental status; also, hypothermia,

coma, hypotension

116

Methanol

• Antifreeze, paint solvent, Sterno, gasoline additives

• Life-threat even with small amount; 30 ml of 100% methanol lethal;

• Converted in liver to formaldehyde to formate = cellular hypoxia.

• S/S: visual sx-photophobia, blurred vision, dilated pupils; CNS depression; abd. Pn; N/V; metabolic acidosis. Onset 1 hr - 72 hrs

117

Ethylene Glycol

• Colorless, oderless, sweet-tasting, nonvolatile liquid

• Detergents, paints, pharmaceuticals, polishes, antifreeze, lysol spray, coolants

• Toxicity due primarily to accumulation of toxic metabolites.

• CNS sx 1-12 hr later: Ataxia, nystagmus, seizures, hallucination, coma

118

Cardiopulmonary sx 12-72 hrs later: Tachycardia, tachypnea, mild HTN, pneumonia, pulmonary edema, cardiac failure

Renal failure w/in 24-72 hrs Tx: Gastric lavage, Alcohol, calcium

chloride

Ethylene Glycol (cont.)

119

Salicylates - aspirin (acetylsalicylic acid)

• Oil of Wintergreen (methyl salicylate)• Darvon, Percodan, Fiorinal

Directly stimulates respiratory centers

in brainstem, = respiratory alkalosis.

Causes mobilization of glycogen

stores and inhibits gluconeogenesis,

= hyperglycemia, normoglycemia,

hypoglycemia

120

S/S: • GI irritation, Upper GI bleeding, persistant

vomiting• Mixed respiratory and metabolic acidosis

• Confusion, lethargy, convulsions,

respiratory arrest, coma, brain death,

cardiac toxicity, significant hyperthermia,

pulmonary edema

Salicylates - ASA

121

Toxic doses• Peak serum levels in 18-24 hrs, although

toxic levels within 6 hours.• Therapeutic levels, salicylate mainly

cleared by hepatic metabolism• Toxic levels, renal excretion is major

route of elimination • 150-300 mg/kg = mild-moderate toxicity;

hyperpnea, vomiting, diaphoresis, tinnitus, acid/base disturbances

Salicylates - ASA

122

Tx: • Activated charcoal

• IV fluids

• D50

• Hemodialysis

Salicylates - ASA

123

Acetaminophen poisoning (APAP)• Tylenol, Datril

• Poisoning may result in fatal hepatic necrosis

• Therapeutic dose 15 mg/kg q 4-6h (children)

max daily dose 80 mg/kg

• 325-1000 mg q 4 h (adults) max daily dose 4 g

• Eliminated primarily by hepatic metabolism

• Mechanism of toxicity unclear; a highly reactive

metabolite is thought to cause hepatic necrosis

by binding to protein macromolecules

124

Toxic doses• 140 mg/kg in children• 7/5 g in adults

Toxicity:• Stage I: 1/2 - 24 h

• N/V, Anorexia, malaise, pallor, diaphoresis• Stage II: 24-48 h

• Transient clinical improvement• RUQ pain with liver enlargement, tenderness• Pancreatitis• Oliguria

Acetaminophen poisoning (APAP)

125

Toxicity: • Stage III: 72-96 h

• GI sx reappear, persist, or worsen• Jaundice• SGOT, SG

• Stage IV: 4 d - 2 weeks• Resolution or progressive hepatic failure

Acetaminophen poisoning (APAP)

Overdose guidelines Alcohol – thiamine, D50W

Cocaine – Benzodiazepines• Beta blockers absolutely contraindicated

Narcotics/opiates – naloxone

Amphetamines – benzodiazepines, haldol

Hallucinogens – benzodiazepines, haldol

Benzodiazepines – flumazenil

Barbiturates – forced diuresis, alkalinization

of urine 126

127

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Bye-Bye now~