Toxicology

I'm just here for the tox

Look, listen, touch, smell, diagnostics

General approach for a possible toxic ingestion - intervene whenever necessary

ABCs and a fingerstick, Vitals, look for any toxidromes,

When taking care a patient with a possible toxic ingestion, where should we start?

patient, family, EMS, suicide notes, previous medical records (Hx of SI/TI)

In the case of toxic ingestion, the history should come from…

Miosis

Constricted, pinpoint pupils

Mydriasis

Dilated pupils

Ketones (DKA, AKA, acetone, isopropyl, EtOH)

Fruity or sweet odors can be associated with

methyl salicylates

Wintergreen odors can be associated with

cyanide

Bitter almond odors can be associated with

Sulfide compounds, disulfiram (antabuse/antabus), N-acetylcysteine (NAC)

Rotten egg odors can be associated with

organic phosphorus compounds, arsenic, thallium (rat poisons or insecticides)

Garlic odors can be associated with

cicutoxin (water hemlock)

Carrot odors can be associated with

Phosgene

Hay odors can be associated with

Naphthalene (petroleum), p-dichlorobenzene, camphor

Mothballs odors can be associated with

Fingerstick, ECG, CMP, VBG, APAP/ASA, Urine tox screen, Medication levels for lithium/seizure meds (if necessary), CBC (if worried about infection), Head CT (possible blow to the head)

Diagnostics for toxicology

Organophosphate insecticides/nerve agents, carbamate insecticides, Tobacco, Poison hemlock, broom shrub, clitocybe/inocybe mushroom

Etiology for Parasympathetic (Cholinergic) Syndrome

Inhibition of acetylcholinesterase leads to overstimulation of ACh receptors

What goes wrong in Cholinergic syndrome?

Cholinergic poisoning

If a patient presents with agitations, miosis, increased salivary and respiratory secretions, increased GI tract motility, increased sweating, Fasciculation and Paralysis - its giving…

Atropine, Benzos, Pralidoxime (organophosphates)

Treatment plan for cholinergic poisoning

Cocaine, amphetamines, PCP, catecholamines

Etiology of Sympathomimetic syndrome

Inhibition of Norepi and dopamine reuptake → excess sympathetic activation

Patho for Sympathomimetic syndrome

Sympathomimetic syndrome

If a patient presents with agitations, mydriasis, decreased salivary and respiratory secretions, increased heart rate, slightly decreased GI motility, Slightly increased sweating, hyperthermia - its giving…

Active cooling, benzos, IV fluid (if rhabdo), MAYBE beta-blockers (labetalol)

Treatment plan for Sympathomimetic Poisoning

Antihistamine (diphenhydramine - most common), antipsychotics, TCAs, Belladonna alkaloids (atropine, scopolamine, hyoscyamine), Anti-parkinsonian medications

Etiology for Antimuscarinic syndrome (AKA anticholinergic)

ACh cannot bind its site leading to disturbances in the CNS and parasympathetic NS

Patho for Anticholinergic Syndrome

Antimuscarinic syndrome

If a patient presents kinda loopy with delirium/hallucinations, non-reactive mydriasis, decreased salivary and respiratory secretions, increased heart rate, decreased GI tract motility, decreased sweating, decreased urination, and hyperthermia - its giving…

Supportive care, sedation if necessary, physostigmine

Treatment plan for antimuscarinic syndrome

Benzos, Barbiturates, EtOH, propofol, etomidate, gabapentin

Etiology for a sedative/hypnotic toxidrome

sedative/hypnotic toxidrome

If a patient presents with decreased mental status, miosis/mydriasis, decreased respiratory rate, bradycardia, and hypothermia - its giving…

Supportive care, Flumazenil (that we NEVER use in case our homies are chemically dependent)

Treatment plan for sedative/hypnotic toxidromes

sedative/hypnotic withdrawal

If a patient presents with seizures, AMS, mydriasis, increased respiratory rate, tachycardia, hyperthermia, and tremor - it’s giving…

Benzos, thiamine

Treatment plan for sedative/hypnotic withdrawal

Morphine, semisynthetic, synthetic (FENT), heroin

Etiology for Opioid syndrome

Opioid Poisoning

If a patient presents with decreased mental status, Miosis, decreased respirations, variable heart rate (probably bradycardia), decreased GI motility, and hypothermia - its giving…

Supportive Care, Naloxone (start with 0.2 mg)

Treatment for Opioid Poisoning

opioid withdrawal

If a patient presents with mydriasis, lacrimation, yawning, increased respiratory rate, tachycardia, N/V/D, and goosebumps - its giving…

Supportive (clonidine), Replacement with methadone or buprenorphine, Detox

Treatment plan for opioid withdrawal

ABCs, IV, O2, cardiac monitoring, Temp control, electrolyte replacement

Symptomatic and Supportive care for toxidromes

Drug, Dose, Patient (type and time since ingestion, estimated amount, co-ingestants, patient age and comorbidities, mental status)

GI Decontamination is based on

NEVER

When should you use ipecac?

cases with high morbidity, life threatening ingestions, protect airway, sustained release drug

When should a gastric lavage be used?

toxic dose of drug take, sustained release, patient protecting their airway or intubated, presentation under 1 hour

When should activated charcoal be used?

Potassium, Heavy metals/hydrocarbons, Alcohol, Alkalis, Acid, Iron, Inorganic salts, Lithium, Solvents

Activated charcoal fails to absorb…

Whole bowel irrigation

What can be used in the case of a potentially toxic sustained-release that cannot be absorbed by activated charcoal or body packers

lithium, valproic acid, ASA

Hemodialysis is indicated for

Severe intoxications with deteriorating condition, Normal route of elimination is impaired, ingestion of known lethal dose

Hemodialysis is used for

N-acetylcysteine if ingestion is under 8 hours, plot on the Rumack-Matthew Treatment nomogram, Check baseline APAP and treat if time of ingestion is not known

Game plan for Tylenol OD

Sodium bicarbonate (cardiac antidote)

Game plan for TCA OD

Epi or Norepi, glucagon, high dose insulin with glucose

Game plan for beta-blocker OD

Calcium chloride, Epi or Norepi, glucagon, high dose insulin with glucose

Game plan for CCB OD

Deferoxamine

Game Plan for Iron OD

Hydroxocobalamin (binds to the intracellular)

Game plan for cyanide (think after fighting a fire) OD

Atropine, pralidoxime

Game plan for organophosphate OD

Dextrose, Octeotide

Game plan for Sulfonylurea OD

Calcium

Game plan for Hydrofluoric acid (Whink rust remover - bilateral hand pain) OD

Ethanol or fomepizole

Game plan for Methanol/ethylene glycol (anti-freeze) OD

Oxygen/hyperbaric chamber (over oxygenate)

Game plan for Carbon monoxide poisoning

CroFab

Game plan for rattlesnake bite

IV fluids before pressors, don’t attribute AMS to just alcohol, risk stratify

Pearls and Pitfalls for toxicology

1-800-222-1222

Whats the number for poison control?

Xylazine (alpha 2 agonist, tranq)

If a patient presents with Central nervous system depression, ataxia, blurred vision, bradycardia, hyperglycemia, hypotension, hypothermia, miosis, premature ventricular contractions, tachycardia, and respiratory depression - its giving?

ABCs, naloxone (in the presence of concurrent opioids)

Treatment plan for Tranq

Telazol (tiletamine-zolazepam)

If a patient presents with bradycardia, hypertension, hyperkalemia, metabolic and respiratory acidosis, and obtundation, mydriasis often occurs and eyelids will remain open, combativeness, dysarthria, dysphagia, myoclonus, psychosis tremors, and nystagmus - its giving…

ABCs, bland ophthalmic ointment to the corneas, monitor temperature for a minimum of 6 hours

Treatment plan for Telazol (tiletamine-zolazepam)