Diagnosis of Poisoning Kent R. Olson, MD, FACEP Medical Director California Poison Control System, San Francisco Division University of California, San

Diagnosis of PoisoningDiagnosis of PoisoningDiagnosis of PoisoningDiagnosis of Poisoning

Kent R. Olson, MD, FACEPMedical Director

California Poison Control System,

San Francisco Division

University of California, San Francisco

Kent R. Olson, MD, FACEPMedical Director

California Poison Control System,

San Francisco Division

University of California, San Francisco

Lessons from historyLessons from historyLessons from historyLessons from history

A young princess ate part of an apple given to A young princess ate part of an apple given to her by a wicked witchher by a wicked witch

She presented comatose and unresponsive She presented comatose and unresponsive (as if she was in a deep sleep)(as if she was in a deep sleep)

Airway positioning and mouth to mouth Airway positioning and mouth to mouth ventilations were performed, and she ventilations were performed, and she recoveredrecovered


Rule #1: Rule #1: Take good care of the patientTake good care of the patient

• ABCD’s:ABCD’s:• AirwayAirway• BreathingBreathing• CirculationCirculation• Dextrose, Drugs & DecontaminationDextrose, Drugs & Decontamination

• Rule out:Rule out:• Head trauma, Meningitis, SepsisHead trauma, Meningitis, Sepsis• Metabolic disordersMetabolic disorders


Rule #2: Rule #2: Get a good historyGet a good history

• Check multiple sources:Check multiple sources:• PatientPatient• Family, FriendsFamily, Friends• Paramedics, PharmacyParamedics, Pharmacy

• Circumstances:Circumstances:• What What was taken?was taken?• How much?How much?• When?When?


Rule #3: Rule #3: Do a good physical examDo a good physical exam

• Toxicologic physical exam:Toxicologic physical exam:• Mental statusMental status• Vital signs (Vital signs (all of themall of them))• PupilsPupils• Bowel soundsBowel sounds• Muscle tone and activityMuscle tone and activity• Skin: Skin: dry or diaphoretic?dry or diaphoretic?

• Look for an autonomic syndromeLook for an autonomic syndrome

Autonomic SyndromesAutonomic SyndromesAutonomic SyndromesAutonomic Syndromes

SympatheticSympatheticCholinergicCholinergic

Blood PressureBlood Pressure ++++ +/--+/--

Pulse RatePulse Rate ++ +/--+/--

PupilsPupils dilateddilated pinpointpinpoint

PeristalsisPeristalsis -- ++++

SkinSkin sweatysweaty sweatysweaty

Autonomic Syndromes Autonomic Syndromes Autonomic Syndromes Autonomic Syndromes

SympatheticSympatheticSympatholyticSympatholytic

Blood PressureBlood Pressure ++++ ----

Pulse RatePulse Rate ++ ----

PupilsPupils dilateddilated smallsmall

PeristalsisPeristalsis -- --

SkinSkin sweatysweaty --


AnticholinergicAnticholinergicCholinergicCholinergic

Blood PressureBlood Pressure ++ +/--+/--

Pulse RatePulse Rate ++++ +/--+/--

PupilsPupils dilateddilated pinpointpinpoint

PeristalsisPeristalsis ---- ++++

SkinSkin drydry sweatysweaty


SympatheticSympatheticAnticholinergicAnticholinergic

Blood PressureBlood Pressure ++++ ++

Pulse RatePulse Rate ++ ++++

PupilsPupils dilateddilated dilateddilated

PeristalsisPeristalsis -- ----

SkinSkin sweatysweaty drydry

Case StudyCase StudyCase StudyCase Study

Two adolescents are brought to the ED by Two adolescents are brought to the ED by their parents because of agitation.their parents because of agitation.

#1: BP 150/100, HR 120, pupils dilated, jumpy, #1: BP 150/100, HR 120, pupils dilated, jumpy, diaphoretic.diaphoretic.

#2: BP 130/90, HR 130, pupils dilated, #2: BP 130/90, HR 130, pupils dilated, distended bladder, dry flushed skin.distended bladder, dry flushed skin.

Sympathomimetic SyndromeSympathomimetic SyndromeSympathomimetic SyndromeSympathomimetic Syndrome

• Common features:Common features:• Agitation, psychosisAgitation, psychosis• Hypertension, tachycardiaHypertension, tachycardia• Dilated pupilsDilated pupils• DiaphoresisDiaphoresis• HyperthermiaHyperthermia

• Common causes:Common causes:• Cocaine Cocaine • Amphetamines (including MDMA - Amphetamines (including MDMA - EcstasyEcstasy))• Phencyclidine (PCP)Phencyclidine (PCP)• Phenylpropanolamine (PPA): often causes severe Phenylpropanolamine (PPA): often causes severe

hypertension with reflex hypertension with reflex bradycardiabradycardia

Anticholinergic SyndromeAnticholinergic SyndromeAnticholinergic SyndromeAnticholinergic Syndrome

• Common features:Common features:• Dilated pupilsDilated pupils• Dry, flushed skinDry, flushed skin• Sinus tachycardiaSinus tachycardia• Ileus, urinary retentionIleus, urinary retention• Confusion, deliriumConfusion, delirium

• Common causes:Common causes:• Atropine & related drugsAtropine & related drugs• Plants Plants (eg, jimson weed)(eg, jimson weed) && mushrooms mushrooms (eg, A. muscaria) (eg, A. muscaria)• OTC & Rx antihistaminesOTC & Rx antihistamines• Tricyclic antidepressantsTricyclic antidepressants

Mad as a HatterRed as a BeetBlind as a Bat Dry as a Bone

Mad as a HatterRed as a BeetBlind as a Bat Dry as a Bone


A 28 year old woman presents groggy and A 28 year old woman presents groggy and confused. Pupils 7-8 mm. Skin dry and confused. Pupils 7-8 mm. Skin dry and flushed. Bowel sounds diminished.flushed. Bowel sounds diminished.

130/90130/90 120/min120/min 14/min14/min 37.8 C37.8 C

Shortly after arrival she has a grand-mal Shortly after arrival she has a grand-mal seizure.seizure.

ECG monitor: ECG monitor: QRS 0.16 sec, wide complex QRS 0.16 sec, wide complex tachycardiatachycardia

Tricyclic Antidepressant OverdoseTricyclic Antidepressant OverdoseTricyclic Antidepressant OverdoseTricyclic Antidepressant Overdose

• Anticholinergic syndromeAnticholinergic syndrome

• The three “Cs”:The three “Cs”:• ComaComa• ConvulsionsConvulsions• Cardiac conduction abnormalitiesCardiac conduction abnormalities

• QRS >0.12 sec is a better predictor of QRS >0.12 sec is a better predictor of toxicity than the serum drug leveltoxicity than the serum drug level

Common Causes of SeizuresCommon Causes of SeizuresCommon Causes of SeizuresCommon Causes of Seizures

• Tricyclic antidepressantsTricyclic antidepressants

• Newer antidepressants – esp. Newer antidepressants – esp. WellbutrinWellbutrin

• Cocaine, AmphetaminesCocaine, Amphetamines

• DiphenhydramineDiphenhydramine

• IsoniazidIsoniazid


A 2 year old child is found unresponsive. The A 2 year old child is found unresponsive. The parents are suspected heroin users.parents are suspected heroin users.

BP 80/50BP 80/50 HR 70HR 70 RR 6, shallowRR 6, shallow

Pupils 1 mm. Peristalsis decreased. Muscle Pupils 1 mm. Peristalsis decreased. Muscle tone flaccid. No sweating.tone flaccid. No sweating.

There is no response to 0.4 mg naloxone.There is no response to 0.4 mg naloxone.

Case (cont.)Case (cont.)Case (cont.)Case (cont.)

Common causes of miosis:Common causes of miosis:• OpioidsOpioids

• Other sympatholytic drugsOther sympatholytic drugs

• PhenothiazinesPhenothiazines

• Cholinergic agentsCholinergic agents

• CNS structural lesionsCNS structural lesions


There was no response to repeated doses of There was no response to repeated doses of naloxone to a total of 4 mg.naloxone to a total of 4 mg.

There was no response to flumazenil (total There was no response to flumazenil (total dose 1.2 mg).dose 1.2 mg).

The parents found an opened bottle of The parents found an opened bottle of clonidine 0.1clonidine 0.1 mg on the kitchen floor. mg on the kitchen floor.

Common Sympatholytic Agents:Common Sympatholytic Agents:Common Sympatholytic Agents:Common Sympatholytic Agents:

• OpioidsOpioids

• ClonidineClonidine

• BenzodiazepinesBenzodiazepines

• BarbituratesBarbiturates

• EthanolEthanol

•


A 34 year old man drank an unidentified A 34 year old man drank an unidentified liquid. He vomited several times, and liquid. He vomited several times, and became weak and pale. In the ED:became weak and pale. In the ED:

BP: 150/100BP: 150/100 HR 110HR 110

Pupils pinpoint. Profuse diaphoresis. Vomit Pupils pinpoint. Profuse diaphoresis. Vomit has a chemical odor. has a chemical odor.

He develops muscle fasciculations and has a He develops muscle fasciculations and has a respiratory arrest.respiratory arrest.

Cholinergic SyndromeCholinergic SyndromeCholinergic SyndromeCholinergic Syndrome

““SLUD”SLUD”

• SSalivation, Sweatingalivation, Sweating

• LLacrimationacrimation

• UUrinationrination

• DDiarrhea, Vomitingiarrhea, Vomiting

also:also: muscle weakness paralysismuscle weakness paralysis


Rule #4: Rule #4: Use the laboratory appropriatelyUse the laboratory appropriately

• Routine labsRoutine labs• Arterial blood gasesArterial blood gases• Electrolytes & anion gapElectrolytes & anion gap• OsmolalityOsmolality

• Toxicology testingToxicology testing• Tox screeningTox screening• Specific stat quantitative testsSpecific stat quantitative tests


A 44 year old man was found unconscious, A 44 year old man was found unconscious, with a suicide note and a half-empty bottle with a suicide note and a half-empty bottle of whiskey.of whiskey.

BP 110/80BP 110/80 HR 110HR 110 RR 32RR 32

pH 7.47 pH 7.47 pCOpCO22 18 18 pOpO22 88 88

Na 140Na 140 K 3.8K 3.8 Cl 106Cl 106 HCOHCO33 18 18

Ethanol 0.18 Ethanol 0.18 gm/dLgm/dL

Anion GapAnion GapAnion GapAnion Gap

Na - Cl - HCONa - Cl - HCO33 == 8-12 8-12 mEq/LmEq/L

Causes of increased gap: “SALAD”Causes of increased gap: “SALAD”

• SSalicylatesalicylates

• AAlcoholslcohols

• LLactic Acidosisactic Acidosis

• AAnurianuria

• DDKAKA

Salicylate IntoxicationSalicylate IntoxicationSalicylate IntoxicationSalicylate Intoxication

• Typical mixed acid-base abnormality:Typical mixed acid-base abnormality:• Respiratory alkalosisRespiratory alkalosis• Metabolic acidosisMetabolic acidosis

• Treatment:Treatment:• Alkalinize urine, restore serum pHAlkalinize urine, restore serum pH• HemodialysisHemodialysis

Radiopaque Drugs & PoisonsRadiopaque Drugs & Poisons

• Unreliable - useful only if positive

• Commonly radiopaque:• IronIron• PotassiumPotassium• CalciumCalcium

• Sometimes visible:• Chloral hydrateChloral hydrate• PhenothiazinesPhenothiazines• Sustained-release Sustained-release

preparations preparations

• Unreliable - useful only if positive

• Commonly radiopaque:• IronIron• PotassiumPotassium• CalciumCalcium

• Sometimes visible:• Chloral hydrateChloral hydrate• PhenothiazinesPhenothiazines• Sustained-release Sustained-release

preparations preparations

CaseCaseCaseCase

• A 16 year old was brought to the ED by A 16 year old was brought to the ED by paramedics after an overdose of Tylenol paramedics after an overdose of Tylenol with codeinewith codeine

• She had small pupils, and was very She had small pupils, and was very sleepy/poorly responsivesleepy/poorly responsive

• Naloxone 2 mg increased pupil size and she Naloxone 2 mg increased pupil size and she became combative but not fully awakebecame combative but not fully awake

Case, continuedCase, continuedCase, continuedCase, continued

• Her mother was questioned:Her mother was questioned:

““. . . I . . . I didn’tdidn’t say she say she overdosedoverdosed. . . I told . . . I told them I was worried about all the pain them I was worried about all the pain

pills she was using for her pills she was using for her headache. . .”headache. . .”

• Rectal Temp: 102.5 FRectal Temp: 102.5 F

• LP: pneumococcal meningitis!LP: pneumococcal meningitis!

Important “Rule-Outs”Important “Rule-Outs”Important “Rule-Outs”Important “Rule-Outs”

““ATOMIC”ATOMIC”

• AAlcohol: lcohol: check ETOH; consider alcoholismcheck ETOH; consider alcoholism

• TTrauma: rauma: consider CT scanconsider CT scan

• OOverdose: verdose: other drugs involved?other drugs involved?

• MMetabolic:etabolic: Na, glucose, O Na, glucose, O22, Thyroid, etc., Thyroid, etc.

• IInfection: nfection: consider LPconsider LP

• CCarbon Monoxide: arbon Monoxide: obtain COHgbobtain COHgb


A 27 year old woman found obtunded with A 27 year old woman found obtunded with pinpoint pupils, awoke with IV naloxone, and pinpoint pupils, awoke with IV naloxone, and admitted to ingestion of a few pain pills.admitted to ingestion of a few pain pills.

Does this patient need a Tox Screen?Does this patient need a Tox Screen?

She was treated with oral activated charcoal, She was treated with oral activated charcoal, observed for 4 hours, and released to observed for 4 hours, and released to psychiatry.psychiatry.


Three days later, she returned because of Three days later, she returned because of nausea, abdominal pain, and lethargy. She nausea, abdominal pain, and lethargy. She appeared jaundiced. appeared jaundiced.

AST 8,000AST 8,000 PT 28 secPT 28 sec Bilirubin 3.6Bilirubin 3.6

Toxicology screen from the original visit Toxicology screen from the original visit revealed revealed acetaminophenacetaminophen..

AcetaminophenAcetaminophenAcetaminophenAcetaminophen

Pitfalls in Diagnosis:Pitfalls in Diagnosis:

• History:History:• Not volunteered by patientNot volunteered by patient• Hidden ingredient in many productsHidden ingredient in many products• No initial specific symptomsNo initial specific symptoms

• Physical exam & laboratory:Physical exam & laboratory:• No initial specific findingsNo initial specific findings• Only reliable test: Only reliable test: STAT acetaminophenSTAT acetaminophen

Comprehensive Toxicology ScreeningComprehensive Toxicology ScreeningComprehensive Toxicology ScreeningComprehensive Toxicology Screening

• Problems:Problems:• Slow, expensiveSlow, expensive• Many drugs not includedMany drugs not included

• Potential uses:Potential uses:• Forensic questionsForensic questions• Possible brain deathPossible brain death

• Quick “drugs of abuse” screensQuick “drugs of abuse” screens• ? Useful - for JGP ? Useful - for JGP • Many drugs not included – know your hosp’s limitsMany drugs not included – know your hosp’s limits• Should not use (+) test forensically unless confirmedShould not use (+) test forensically unless confirmed

Toxicology LaboratoryToxicology LaboratoryToxicology LaboratoryToxicology Laboratory

• Quantitative testing may be useful if:Quantitative testing may be useful if:• results will return quickly, results will return quickly, and . . .and . . . • results will affect clinical managementresults will affect clinical management

• Examples of specific useful levels:Examples of specific useful levels:• AcetaminophenAcetaminophen• Carbon monoxideCarbon monoxide• DigoxinDigoxin• SalicylateSalicylate• Valproic acidValproic acid

Diagnosis of Poisoning - SummaryDiagnosis of Poisoning - SummaryDiagnosis of Poisoning - SummaryDiagnosis of Poisoning - Summary

• Take good care of the patientTake good care of the patient

• Get a good historyGet a good history

• Do a good physical examDo a good physical exam

• Use the laboratory appropriatelyUse the laboratory appropriately

• Consult with the Poison Control Center:Consult with the Poison Control Center:

1-800-411-8080 or 1-800-222-12221-800-411-8080 or 1-800-222-1222

Documents

Diagnosis of Poisoning Kent R. Olson, MD, FACEP Medical Director California Poison Control System, San Francisco Division University of California, San