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THE MOST COMMON AND THE MOST DANGEROUS INGESTIONS
Russell E. Berger, MDCo-Director of Medical Toxicology
Emergency Physician
Cambridge Health Alliance
Instructor in Medicine
Harvard Medical School
Brief Outline-Toxidromes
-The “Tox” EKG
-Guidance on some of the most common ingestions
-Agents of Concern
-Agents of little or no concern
-Q &A
Toxidromes
A way that we can group symptoms together which helps us formulate a treatment plan.
Vital Signs
Mental Status
Pupils
Skin Findings
Neurologic Exam
Opiate Toxidrome
Vitals signs: Down
- low heart rate, low blood pressure
Mental Status: Down (asleep)
Pupils: Down(small)
Skin Finding:
- Needle tracks, usually cool and dry
Sympathomimetic
Vital signs: up:
-high heart rate, hypertensive
Mental Status: up
-agitated-VIOLENT
Pupils(up)
Skin findings(sweaty)
Anticholinergic
Vital Signs: Up
Mental Status:
-Agitated, DELIRIOUS
Pupils: Up
Skin: DRY
Serotonergic
AMS
Hyper-reflexia (clonus is most important feature.
Dysautonomia(Vital sign abnormalities, usually activated)
Sympathomimetic versus Anticholinergic
Freddy Kruger
Versus
The Cookie Monster
Tox EKG
QRS duration
QTC duration
Terminal R in aVR
If you block Sodium channels…
You prolong the QRS complex
>100ms is significant
Just read from the top of the cardiogram
If you block Potassium Channels… You prolong the QTC
>450ms is significant
Just go by what’s reported on the top of the cardiogram
Some Na Channel Blockers besides TCA’s Carbamazepine Benadryl Flecainide, Procainamide Chloroquine Propranolol Quinine Bupivicaine
Some QTC prolonging Agents
Seroquel Zofran Methadone Trazodone Citalopram Erythromycin
DRUGS
Tylenol
It is in everything.
It produces early symptoms that are easy to overlook.
Have a low threshold to test for it and a low threshold to treat in overdose.
Tylenol
We have NAC to treat this overdose.
The dosing of NAC is very confusing for people so needs to be checked carefully for accuracy.
NAC may produce a scary appearing reaction during loading. Still give it!
Opiates
One of the most worrisome emerging epidemics.
RESPIRATORY RATE is the most important reason to give Narcan.
Remember Narcan has a short half life compared with the agents it is reversing. Observe, Observe, Admit, Observe.
Give Narcan sparingly to avoid precipitating patient distress.
Don’t forget to check a tylenol level.
Detectable tylenol levels should = NAC treatment and admission (in the setting of combined opiate preps, eg percocet)
Aspirin
One of the most dangerous agents we see.
30, 60, 90 rule; chronic levels are worse than acute levels so get treated earlier.
Single levels are not adequate to medically clear a patient
Aspirin
Any change in mental status = dialysis
Seizures = death
If you are at a facility without reliable renal coverage, push to transfer the patient.
Carbon Monoxide Exposures
Flu like symptoms
Is the dog sick or not?
Duration of exposure is as important as level
While level is cooking, NRB based 100% oxygen.
Carbon Monoxide If your patient is pregnant, worry about them.
Patients will have a functional anemia.Chest painSOBDizzinessHeadache.
If in doubt, talk to a dive chamber for guidance.
Lithium
Check the level.
Is the level post-distribution---was the blood drawn >6 hours after the last dose of medication. If yes, it is reliable. If not, it may not be reliable.
Is the patient neurotoxic? Can they walk?
Substantial alteration in mental status is always a reason to dialyze (esp with co-ingestants).
Early dialysis is associated with better patient outcomes. Level is NOT everything.
Give sodium to trick the kidneys into eliminating lithium as early as you can.
Benadryl
In everything
Patient can get SUPER sick
Don’t forget your NAC (eg tylenol PM).
May act like a TCA overdose
Benadryl
Patient will be dry, delirious, and tachycardic.
They may have prolongation of their QRS complex on EKG.
They may seize and develop ventricular dysrhythmias.
Sympathomimetic Agents
Cocaine LSD Ecstacy Bath Salts PCP Ketamine
Crazy and aggressive.
Wide eyed and pouring sweat
Control with benzodiazepines/Avoid Haldol.
Keep the patient cool. Intubate and paralyze PRN.
Clonidine Very common in both pediatric and adult
populations(ADHD or withdrawal)
Sedation
Produces hypotension, bradycardia with normal potassium and glucose.
Looks like opiate---pinpoint pupils---may respond to narcan
Digoxin Hypotension, bradycardia, hyperkalemia.
More common in the elderly or in cardiac kids.
Can reverse with digibind.
Labs for digoxin will be off when you check the level again. Don’t freak out about this---go by the clinical picture.
Digoxin Consider treating the potassium itself
Avoid calcium (for now)
Concentration x Wt in Kg/100 gives you reversal dose of digibind (round up)
Pt is 80 kg, dig level is 4.0. [80]x[4]/100 = 3.2Give 4 vials
Calcium Channel BlockersHypotension, bradycardia, HYPERglycermia
The worst of the worst ingestions
High Dose insulin therapy
Intralipid
ECMO/Intra-aortic balloon pump.
Seroquel
“I take seroquel for sleep.”
Ataxia
Prolongation of the QT.
May need to be tubed 2/2 decreased mental status.
Sleeping Pills
Ambien Lyrica Gabapentin Lunesta
A lot of worry
Little true concern
Agents to not worry about Motrin(unless > 400mg/kg) Most Antibiotics SSRI’s Thyroid Hormone Laxatives Most diuretics Ace inhibitors ARBS Vitamins(except prenatals) Sleep aids Benzodiazepines
Household Items(bedroom and bathroom)
I don’t care:MakeupHousehold bleachDish soapBath soapDish detergent (Pods are different)ShampooRat poisonRaidVitamins
Household items(garage) Emergency:
-Gasoline/Kerosone
-Oil of wintergreen(salicylate)
-Antifreeze(EG)
-De-icer(Methanol)
-Button Batteries
-Wheel Cleaners(HF)
-Essential Oils(citronella)
Admit these kids
Oral sulfonylureas(glipizide, glimeperide, etc)
Long acting opiates, suboxone and methadone
TCA’s Calcium Channel Blockers Most beta blockers MAOi exposures Wellbutrin
Thank you
