Professional Documents
Culture Documents
Toxicology (Picu Course)
Toxicology (Picu Course)
Time of ingestion
Medications in the household
Amount ingested
Onset of symptoms
Intentionality
Underlying medical conditions
Approach to the Poisoned Patient
Physical Examination
Vital Signs
Pupillary exam (miosis, mydriasis)
Skin (dry, cyanotic)
Lungs (crackles, wheezing)
Cardiac (tachycardia, bradycardia)
Abdomen (decreased bowel sounds,
tenderness)
Neurologic (altered mental status, seizure)
Approach to the Poisoned Patient
Initial Management
Airway
Breathing
Circulation
Disability
Exposure
Approach to the Poisoned Patient
Diagnostic Evaluation
CBCD AXR
Electrolytes Serum Tox
ABG Urine Tox
LFTs ASA level
CXR Tylenol level
ECG Serum OSM
Useful Toxin Levels
Set time point Serial levels
Acetaminophen Salicylates
Carbon Monoxide Carbamazepine
Ethanol Digoxin
Ethylene glycol Phenobarbital
Heavy metals Phenytoin
Iron
Theophylline
Methanol
Methemoglobin
Valproate
Radiopaque drugs
Bezoars/Bags
Calcium carbonate
Chloral hydrate
Enteric-coated tablets
Heavy metals
Iodine
Fe
Phenothiazines
Potassium compounds
Anion Gap (AG)
Cyanide Toluene
Toxins associated with decreased AG
Lithium
Bromide
Osmolal Gap (OG)
Serum OSM: 2[Na] + [Glc]/18 + [BUN]/2.6
Methanol
Ethanol
Ethylene glycol
Acetone
Isopropanol
Toxidromes
(Toxicologic Syndromes)
-a constellation of signs and
symptoms associated with a
specific group of toxins
Toxidromes
Opiates
Miosis
Respiratory depression
Hypotension
Sedation
Decreased GI motility
Urinary retention
Toxidromes
Opiates
Salivation
Lacrimation
Urination
Defecation
Gastrointestinal Distress
Emesis
Toxidromes
Cholinergics-Nicotinic Effects
Muscle Fasciculations
Weakness
Paralysis
Toxidromes
Anticholinergics
“Red as a beet”- Flushed skin
“Hot as a hare”-Hyperthermia
“Mad as a hatter”-Psychosis
“Dry as a bone”-Dry skin, urinary
retention
Tachycardia
Mydriasis
Toxidromes
Sympathomimetics
Hypertension
Tachycardia
Psychomotor Agitation
Hyperthermia
Diaphoresis
Mydriasis
Gastric Decontamination
Ipecac
Gastric Lavage
Activated Charcoal
Whole Bowel Irrigation
Ipecac
NO!!!!
Had been previously been recommended
for administration at home immediately
following ingestion
No longer recommended in the AAP policy
statement - Poison Treatment in the Home
(Pediatrics Vol. 112 No. 5, November 2003)
Why Not Ipecac?
Variable percentage of removal of toxic medication
In adult volunteers:
51-83% removal (5 minutes after ingestion)
2-59% removal (30 minutes after ingestion)
May cause persistent vomiting, lethargy, and
diarrhea
Vomiting may preclude later administration of oral
antidotes
Why Not Ipecac?
Anticholinergics Physostigmine
Atropine
(muscarinic effects)
Anticholinesterases/
Cholinergics Pralidoxime
(nicotinic effects)
-controversial in
carbamate
ingestions
Toxins and their Antidotes
Benzodiazepines Flumazenil
Botulism Botulinum antitoxin
Beta-blockers Glucagon
Calcium channel blockers Calcium
Carbon monoxide Hyperbaric O2, O2
Cyanide, Nitrites Sodium thiosulfate
Toxins and their Antidotes
Digoxin Digibind aka Digoxin Fab antibodies
Ethylene Glycol Ethanol
Heparin Protamine
Iron Deferoxamine
Isoniazid Pyridoxine
Toxins and their Antidotes
Lead EDTA, BAL, DMSA
Methanol Ethanol
Opioids Naloxone
Hemodialysis
Charcoal hemoperfusion
Alkalinization/Urinary Ion Trapping
Effective for drugs that are excreted
renally
The drugs must be either weak acids or
weak bases e.g. ASA and Phenobarbital
HA H+ +A-
pKa
At a Urine pH < pKa At a Urine pH > pKa
Non-ionized form Ionized form
*Not excreted in urine *Excreted in urine
Hemodialysis
Theophylline
Phenobarbital
Carbamazepine
Phenytoin
Salicylates
Complications of Hemoperfusion
Thrombocytopenia
Hypocalcemia
Leukopenia
Rigors
A 15 year old girl presents to the ED four hours
after taking 20 extra-strength (500 mg/tablet)
Tylenol tablets. The ingestion was prompted by a
fight with her boyfriend earlier that day. She has
a history of an attempted suicide in the past.
She is awake and alert with stable vital signs.
She complains of nausea and has had one
episode of vomiting. Physical exam is normal.
Baseline labs show normal electrolytes, with
normal LFTs, normal coags and a Tylenol level of
120 microgram/ml.
What would you do?
A. Call psychiatry to evaluate the patient. No
medical intervention is required.
B. Administer 1g/kg of activated charcoal
with sorbitol every 6 hours and 17 doses of
oral N-acetylcysteine.
C. Administer one dose of activated charcoal
with sorbitol followed by intravenous
N-acetylcysteine for 21 hours.
D. Gastric lavage in an attempt to recover pill
fragments.
Acetaminophen Poisoning
Electrophile
ABG: 7.10/22/100/97%
What’s the Diagnosis?
A. Metabolic disorder
B. Congenital heart disease
C. Sepsis
D. Congenital adrenal hyperplasia
E. Met hemoglobinemia
Met Hgb
Hgb in which the Fe ++ has been oxidized
to the Fe +++
Cannot carry oxygen
Impairs oxygen release to tissues
May lead to inadequate oxygen delivery to
meet the metabolic needs of the tissues
-------> SHOCK
Met Hgb
Clinicalsuspicion-exposure to
offending agent
Chocolate brown colored blood
Cyanosis
Presence of a saturation gap
Saturation Gap
Difference between pulse oximeter
saturation, saturation on the ABG, and
saturation obtained by co-oximetry
ABG: PaO2 is measured; saturation is
calculated
Pulse oximetry measures absorbance at
two wavelengths-assumes oxyhgb or
deoxyhgb
Co-oximetry