1. The document provides guidance on the initial assessment and management of a patient presenting with poisoning in the intensive care unit. It covers the ABCDE approach - Airway, Breathing, Circulation, Disability/Neurological stabilization, and Environment/Electrolytes.
2. For airway management, the document discusses indications for intubation as well as techniques. For breathing, it addresses various toxins that can interfere with oxygenation. For circulation, it outlines cardiac monitoring and discusses specific scenarios involving drugs like digoxin, beta-blockers, calcium channel blockers, and toxins causing arrhythmias.
3. The document also provides guidance on decontamination techniques like gastric lavage,
1. The document provides guidance on the initial assessment and management of a patient presenting with poisoning in the intensive care unit. It covers the ABCDE approach - Airway, Breathing, Circulation, Disability/Neurological stabilization, and Environment/Electrolytes.
2. For airway management, the document discusses indications for intubation as well as techniques. For breathing, it addresses various toxins that can interfere with oxygenation. For circulation, it outlines cardiac monitoring and discusses specific scenarios involving drugs like digoxin, beta-blockers, calcium channel blockers, and toxins causing arrhythmias.
3. The document also provides guidance on decontamination techniques like gastric lavage,
1. The document provides guidance on the initial assessment and management of a patient presenting with poisoning in the intensive care unit. It covers the ABCDE approach - Airway, Breathing, Circulation, Disability/Neurological stabilization, and Environment/Electrolytes.
2. For airway management, the document discusses indications for intubation as well as techniques. For breathing, it addresses various toxins that can interfere with oxygenation. For circulation, it outlines cardiac monitoring and discusses specific scenarios involving drugs like digoxin, beta-blockers, calcium channel blockers, and toxins causing arrhythmias.
3. The document also provides guidance on decontamination techniques like gastric lavage,
1. The document provides guidance on the initial assessment and management of a patient presenting with poisoning in the intensive care unit. It covers the ABCDE approach - Airway, Breathing, Circulation, Disability/Neurological stabilization, and Environment/Electrolytes.
2. For airway management, the document discusses indications for intubation as well as techniques. For breathing, it addresses various toxins that can interfere with oxygenation. For circulation, it outlines cardiac monitoring and discusses specific scenarios involving drugs like digoxin, beta-blockers, calcium channel blockers, and toxins causing arrhythmias.
3. The document also provides guidance on decontamination techniques like gastric lavage,
A – The Airway • AIRWAY – Assess need for intubation. – Commonest indication is a depressed level of consciousness i.e. airway protection. – When in doubt intubate. – Exceptions • Hypoglycemia • Opoid – Do NOT give Flumazenil to suspected BZD OD. A – The Airway • Rapid Sequence Intubation – Rocuronium instead of SCh. Especially • Organophosphorous Poisoning – Toxin inactivates Choline esterases – Prolonged duration of NMB • Digoxin – Hyperkalemia • Caustic Ingestion – Awake Approach – Consider early surgical airway. B- Breathing • Toxins may interfere with oxygenation (Tissue Hypoxia) – Carbon Monoxide • False normal SpO2 values – Methemoglobinemia. • Cyanotic patient with SpO2 of 85% – Cyanide, Hydrogen Sulfide, and Sodium Azide • Cellular hypoxia with Normal SpO2 • Intubation and 100% FiO2 in these patients B- Breathing • Aspirin/ Salicylates – What the ABG could look like? • Acute Respiratory Alkalosis – Hyperventilation due to stimulation of respiratory center. • HAGMA (+ Acute resp alkalosis) – Organic acids eg. lactic acid and ketoacids. – Salicylate itself plays a minor role. • Acute Respiratory Acidosis??? – Late – Early….another poison (Resp depressant)? B- Breathing (Salicylates) • Respiratory Alkalosis as a protective mechanism. – Salicylic acid (Weak acid) as charged and uncharged molecule. – Uncharged molecule crosses cellular barriers. – Charged Uncharged (Met Acidosis) – CNS (Blood Brain Barrier) and Renal (Systemic reabsorbtion) B- Breathing (Salicylates) • Avoid Intubation if possible. • If intubation unavoidable – Try to maintain pre intubation MV (12 ml/kg at 20 RR) – Monitor PAW and ABG. – Avoid sedation till just before intubation. – Pre and Post intubation NaHCO3 C- Circulation • Continous cardiac monitioring. • May require invasive monitoring. • Vascular access. • Fluid resuscitation or Inotropes. C – Circulation 1. Asystole or V Fib. – Standard ACLS protocols 2. Hypotension – IV Crystalloids – Vasopressors – Noradrenaline – IABP, ECMO in refractory shock – May require higher doses than non poisoned patients – Antidotes. C- Circulation (Specific Scenarios) 3. Bradycardia + Hypotension (In poisoning) – Consider • Digoxin • CCB • Beta Blockers C- Circulation (Specific Scenarios) • Digoxin Toxicity • GI Symptoms: anorexia, nausea, vomiting, diarrhoea, abdominal pain • Hyperkalaemia (early sign of significant toxicity) • CNS: lethargy, confusion • CVS: Increased automaticity, AV block, repolarisation anomalies. • Resistant to standard t-reat-ment-. • Digoxin-specific Fab fragments (digibind) C- Circulation (Specific Scenarios) • Beta blocker Toxicity – Hypoglycemia, Bronchospasm – Resucitation • fluid • beta-agonists • vasopressors • atropine • pacing – Antidotes • Glucagon • High dose Insulin • Intralipid C- Circulation (Specific Scenarios) • Two beta-blockers require special consideration: • Propanolol :causes sodium channel blockade - QRS widening - treat with NaHCO3 • Sotalol :causes potassium efflux blockade - long QT - monitor for Torsade. C- Circulation (Specific Scenarios) • Calcium Channel Blockers – Hyperglycemia – Depressed consciousness is rare. – T-reat-ment- • Supportve • Calcium C- Circulation (Specific Scenarios) 4. Monomorphic Wide Complex T-achy-cardia – Most likely SVT with aberrancy – Sodium Channel blocked – Tricyclic antidepressants, antihistamines, Type IA antiarrhythmics, and cocaine. – Treatment is sodium bicarbonate • QRS < 100 msec in limb leads • pH 7.55 – Avoid Type 1 Antiarrythmics (Procainamide) C- Circulation (Specific Scenarios) 5. Polymorphic VT – Types IA, IC, and III antiarrhythmics, Pentamidine, antipsychotics, arsenicals, antifungals and antihistamines. – Treatment • MgSO4 2 gms IV over 5 mins (x2 more doses) • Overdrive pacing (Electrical or Isoproterenol ) C- Circulation (Specific Scenarios) 6. Narrow Complex Tachycardia + Hypertension – Hyperadrenergic states – Cocaine, Amphetamines, sympathomimetic drugs. – Treatment • BZD • Phentolamine • Refractory HTN : NTG, Nitroprusside – AVOID B-Blockers and antipsychotics. D- Disability and Neurostabalization • Coma cocktail. • Rule out and treat hypoglycemia. • Naloxone for reversal of respiratory depression secondary to suspected opoid OD. • No Flumazenil even if BZD OD suspected. – Withdrawal Seizures • Thiamine – Unlikely to reverse coma D- Disability and Neurostabalization • Seizures – Toxicity or Withdrawal – Drug of Choice: • Short Acting BZD • Second line : Propofol • Avoid Phenytoin – Ineffective – Propelene Glycol toxicity. – High dose pyridostigmine (5 gms IV) in Isoniazid OD – IV Sodabicarb if seizures due to Na channel blockade. E – Environment & Electrolytes • Environment – Correct hypothermia • Severe hypothermia (<30 C) • Active rewarming – Correct Hyperthermia • Severe hyperthermia (>40 C) • Ice bath, sedation, NMB • Electrolytes – Correction of electrolyte abnormalities. DECONTAMINATION Rationale for Decontamination • Proportion of the ingested drug still has not absorbed (Esp Early) • Could potentially be cleared from the gut • Reduced total dose of the drug • Reduced total toxicity • Ergo, the removal of undissolved drugs should reduce the toxicity of the overdose!! Criticism of Decontamination • Aspiration esp. in unprotected airway • Effectiveness diminishes with time. • Bowel obstruction with charcoal. • Patient outcome not affected in long term as per studies. Types of Decontamination • Surface Decontamination – Strip naked Soap and water body wash. – Irrigation of the eye. – Drugs which absorb readily though the skin include the following: • Glycerol ethers • Industrial solvents, eg. carbon tetrachloride, trichloroethylene, methylene chloride, etc. • Mercury salts • Lead salts Types of Decontamination • Gut Decontamination – Induced emesis (abandoned) – Gastric lavage (largely abandoned; only indicated within the first hour) – Whole bowel irrigation (only indicated for iron and slow release enteric coated tablets) – Activated charcoal, single or multiple doses Gastric Lavage • Technique • Indications – Should not be applied routinely if ever! – Within 1st hour of ingestion. • Contraindications – Unprotected airway – Caustic ingestion (due to risk of exacerbating any esophageal or gastric injury) – Hydrocarbon ingestion (due to high aspiration risk) – Patients at risk of GI hemorrhage or perforation (recent surgery, underlying anatomic abnormality or pathology, coagulopathy) Gastric Lavage • Complications – Aspiration pneumonia – Increased incidence of intubation vs control. – Esophageal or gastric perforation – Laryngospasm, hypoxia, dysrhythmia – Fluid or electrolyte imbalance – Push poison beyond pylorus (Making activated charcoal ineffective) Whole Bowel Irrigation • Technique – Large amounts of iso-osmotic PEG-ES administered (NG) until effluent runs clear. • Indications – Sustained-release or enteric coated drugs. – Iron tablets (Not absorbed by AC) – Illicit drug packets Whole Bowel Irrigation • Contraindications
– leus, bowel obstruction, or intestinal perforation
– Clinically significant GI hemorrhage – Hemodynamic instability (sequestration of bowel and worsening of shock) – Intractable emesis Activated Charcoal • Mechanism of Action – AC is a highly adsorbent powder made of high surface area porous organic material. Its extensive surface area surface area(2000 m2/g) is covered with a carbon based network which adsorbs chemicals within minutes of contact preventing GI absorption and hence systemic toxicity. – Highest affinity is for compounds with a molecular weight of 100– 1000 Da – Many pharmacologically active substances fall within this range Activated Charcoal • Indication – Presentation within 1 hour of injection of toxin. – Later benefit “cannot be excluded” Activated Charcoal • Contraindications – Depressed consciousness without airway protection. • Do NOT intubate just for the purpose of AC. – Late presentation – Increased risk and severity of aspiration associated with AC use (hydrocarbon ingestion) – Need for endoscopy (significant caustic ingestion) – Toxins poorly adsorbed by AC – Intestinal obstruction (absolute contraindication). Activated Charcoal • Toxins for which AC ineffective – Drugs which are absorbed too rapidly • Ethanol • Paraquat – Drugs which do not adsorb on to charcoal • Corrosive substances(strong acids and alkalis) • Iron • Lithium Activated Charcoal • Administration – Powder mixed with water (Juice, milk) to form slurry. – Commercial preparation – suspension with thickening agent like sorbitol. – Dose • Single Dose – 50 grams (20 – 100 gms) – Multi Dose Activated Charcoal • Multi Dose Activated Charcoal (MDAC) – Rationale • NOT more for more effect • Interruption of enterohepatic recirculation. • Facilitation of transluminal diffusion from body into the bowel lumen (“gut dialysis”), followed by excretion • Reduced absorption of extended or delayed release formulations. – Indications • Carbamazepine, Dapsone, Phenobarbital, Quinine, Theophylline – Dose (MDAC) • 50 grams loading then 12.5 gms/hour equivalent. Activated Charcoal • Complications – GI side effects like fullness, abdominal pain, nausea, vomiting, constipation, and diarrhea. – Aspiration. • Inadequately protected airway • In association with lavage • Improperly placed nasogastric tube • Bowel obstruction. ENHANCED ELIMINATION Forced (Alkaline) Diuresis • MOA – Altering the pH converts a lipid-soluble intact acid (HA) or base (BOH) in the tubular lumen into the charged salt. (A-/B+) – The charged particle is lipid-insoluble and cannot easily move back across the renal epithelium. This leads to a marked increase in drug excretion. Alkaline Diuresis • Indications (Toxin Properties) – Eliminated unchanged by the kidney – Distributed primarily in the ECF. – Protein-bound – Weak acids. Alkaline Diuresis • Contraindications – Renal failure, pulmonary oedema and cerebral oedema, pre-existing cardiac disease (CI to Sodabicarb). • Technique – Get a baseline electrolytes, BUN, S.Creat, glucose, systemic pH, urinary pH and serum drug concentrations. – Foleys to measure UO. – W/F Respiration Alkaline Diuresis • Technique – Goal • Urine pH > 7.50 • Serum pH 7.55 to 7.60 – Alkalinisation of Urine • IV NaHCO3 • 1-2 mEq/kg of 8.4% as bolus. • Infusion with continuous monitoring of Urine and Blood pH. • Do NOT use acetazolamide. (Acidemia) Alkaline Diuresis – Complications • Hypokalemia • Ionized hypocalcemia • Alkalemia Haemodialysis • Toxic compounds in blood diffuse through a semipermeable membrane down a concentration gradient into a dialysate. • Also treat associated electrolyte imbalance and acidosis. Methanol • Common Drugs Ethylene glycol Salicylates Theophylline Lithium Haemoperfusion • Large surface area of resin or charcoal filter enhances adsorption by presenting a larger contact surface for the filtered blood • Resin filters may also be impregnanted with drug-specific antibodies • Spectrum - Drugs adsorbed by activated charcoal. Theophylline Carbamazepine Valproic acid Procainamide. Hemodialysis/Haemoperfusion • Contraindications – Patient with active hemorrhage or coagulopathy (Require systemic anticoagulation with heparin). – Hypotensive patients. • Complications – Those with HD plus – Charcoal embolization. Exchange Transfusion/Plasmapherisis. • Rarely Used • Indications – Massive hemolysis (arsine or sodium chlorate poisoning) – Methemoglobinemia, sulfhemoglobinemia (hydrogen sulfide exposure) – Neonatal drug toxicity. Any Questions?