R3 SARUNPAKORN PERMPATDECHAKUL

3RD YEAR RESIDENT, EMERGENCY DEPARTMENT, CMU

HOW TO APPROACH THE PATIENTS
ARE THEY THE POISONED PATIENTS?
RESUSCITATION

• Cardiac arrest: Follows ACLS guideline

• Antidotes: a few indicate before
• Altermental status: Glucose, Thiamine(not require before
dextrose), supplement O2, Naloxone (COMA cocktail safe
but may not cost effective in deveping countries)
RESUSCITATION

• Cardiac arrythmia: antiarrythmic drugs not first-line

• Seizure: no role for phenytoin, 1st BZD (except INH), 2nd
Propofol and barbiturates
• Agitation: BZD
• Hyperthermia: >39 C require active cooling
TOXIDROME
TOXIDROME

• Anticholinergic
• Cholinergic
• Opioid
• Sympathomimetics
• Sedative-hypnotics
DECONTAMINATION
DECONTAMINATION

• Respiratory: Evacuate from the site

• Ocular: local anesthetic, irrigation 1-2 L per eye (20 mins),
Check pH 7.2-7.4
• Skin: water with soap, DON’T use neutralizing solution
GI DECONTAMINATION

• Toxic ingestion?
• Benefit?
• Risk?
GI DECONTAMINATION

• Syrup of Ipecac
• Gatric lavage
• Activated charcoal
• Whole bowel irrigation
GASTRIC LAVAGE
Indication
• Rarely indicated
• Consider for recent (<1 h) ingestion of life-threatening amount of a
toxin for which there is no effective treatment once absorbed
Contraindications
• Corrosive/hydrocarbon
• Supportive care/antidote likely to lead to recovery
• Unprotected airway
• Unstable
GASTRIC LAVAGE
Complication
• Aspiration pneumonia/hypoxia
• Water intoxication
• Hypothermia
• Larygospasm
• Mechanical injury to GI tract
• Delay other definitive care
ACTIVATED CHARCOAL
Indication
• Recent ingestion (<1 hour) of a toxic substance known to be
absorbed by AC
• Potential benefit > 1 hour cannot be excluded

• DOSE: Adults 50 g., Children 1 g./kg.

ACTIVATED CHARCOAL

Substances not well absorbed by AC “CHAMPS”

• Caustics
• Hydrocarbons
• Alcohols
• Metals (As, Fe)
• Pb (Lead)
• Salts (Na, K Mg, Li)
ACTIVATED CHARCOAL

Contraindications
• Nontoxic ingestion
• Toxin not adsorbed by activated charcoal
• Recovery will occur without administration of activated charcoal
• Unprotected airway
• Corrosive ingestion
• Possibility of upper GI perforation
ACTIVATED CHARCOAL

Complications
• Vomiting
• Aspiration of the activated charcoal
• Impaired absorption of orally administered antidotes
WHOLE BOWEL IRRIGATION

Polyethylene glycol-electrolyte solution (PEG-ES)

A recommended dosing schedule based on expert opinion is:
•Children 9 months to 6 years—500 mL/h
•Children 6–12 years—1000 mL/h
•Adolescents and adults—1500–2000 mL/h
Endpoint: clear effluent, clear content
WHOLE BOWEL IRRIGATION

Indications
• Iron ingestion >60 milligrams/kg with opacities on abdominal
radiograph
• Life-threatening ingestion of diltiazem or verapamil
• Body packers or stuffers
• Slow-release potassium ingestion
• Lead ingestion (including paint flakes containing lead) Symptomatic
arsenic trioxide ingestion Life-threatening ingestions of lithium
WHOLE BOWEL IRRIGATION

Contraindications
• Unprotected airway
• GI perforation, obstruction or ileus, hemorrhage Intractable
vomiting
• Cardiovascular instability
WHOLE BOWEL IRRIGATION

Complications
• Nausea, vomiting
• Pulmonary aspiration
• Time consuming; possible delay instituting other definitive
care
ENHANCE ELIMINATION
ENHANCE ELIMINATION

• Ion trapping = Urine alkalinization

• MDAC
• Extracorporeal removal: Hemodialysis, Hemoperfusion
URINE ALKALINIZATION

Indications
• Salicylate
• Phenobarbital
• Chlorophenoxy herbicides
(2,4-Dichlorophenoxyacetic acid)
• Chlorpropamide
URINE ALKALINIZATION

Contraindications
• Preexisting fluid overload
• Renal impairment
• Uncorrected hypokalemia
URINE ALKALINIZATION

Complication
• Hypokalemia
• Volume overload
• Alkalemia
• Hypocalcemia (mild)
MULTIPLE DOSE ACTIVATED CHARCOAL (MDAC)

Toxin
• Enterohepatic/enteroenteric circulation
• Release slowly into the gut lumen
• Form bezoars in the GI tract
Dosage
• Initial dose: 50gm (1gm/kg children)
• Repeat dose: 25gm (0.5gm/kg children) every 2 hours (depend on
toxins/drugs)
MULTIPLE DOSE ACTIVATED CHARCOAL (MDAC)

Mnemonic : “These People Drink Charcoal Quickly”

• Theophylline
• Phenobarbital
• Dapsone
• Carbamazepine
• Quinine
MULTIPLE DOSE ACTIVATED CHARCOAL (MDAC)

Contraindications
• Unprotected airway
• Bowel obstruction
• Caution in ingestions resulting in reduced GI motility
MULTIPLE DOSE ACTIVATED CHARCOAL (MDAC)

Complication
• Vomiting
• Pulmonary aspiration
• Constipation
• Charcoal bezoar, bowel obstruction/perforation
HEMODIALYSIS

Substances amenable to dialysis must have

• Low protein binding
• Small Vd (<1L/kg)
• High water solubility
• Low molecular weight (MW < 500Da)
HEMODIALYSIS
Mnemonic : I STUMBLE
• Isopropanol
• Salicylates
• Theophylline
• Uremia (Valproic acid)
• Methanol/Metformin
• Barbiturates
• Lithium
• Ethylene glycol
HEMOPERFUSION
Toxin requirement
• Low Vd
• Low endogenous clearance
• Bound by activated charcoal
Indication
• Theophylline (high-flux HD is an alternative)
• Carbamazepine (MDAC or high-efficiency HD also effective)
• Paraquat (theoretical benefit if instituted early)
HEMODIALYSIS/HEMOPERFUSION

Contraindications
• Hemodynamic instability
• Poor vascular access
• Infants (generally)
• Significant coagulopathy
HEMODIALYSIS/HEMOPERFUSION
Complications
• Fluid/metabolic disruption
• Removal of antidotes
• Limited availability
• Limited by hypotension
• Infection/bleeding at catheter site
• ICH secondary to anticoagulant
SYMPATHOMIMETICS
 Sympathomimetics stimulate release or decrease
reuptake of neurotransmitters (serotonin,
norepinephrine, dopamine, epinephrine)

Cause euphoria and increased energy

FOUNDATIONS
Excessive use can lead tachycardia,
hypertension, mydriasis, diaphoresis,
hyperthermia, hyperreflexia and agitation

Can lead seizure, coma, and death

The primary goals of clinical intervention are to

decrease sympathetic by sedating the patient
COCAINE
 • Cocoa leaf (Erythroxylon)

COCAINE • Regular use of cocaine accelerates

vascular pathology including coronary
artery arteriosclerosis
FORMS AND ROUTE
• Freebase
• Smoke
• Onset : instant
• Duration : 5-10 min.

• Coke - water-soluble (hydrochloride salt)

• Absorb stress all mucosal surfaces : oral, nail, GI and vaginal
epithelium
• Snort
• Onset 3-5 min.
• Duration 15-30 min.

• IV injection
• Onset : instant
• Duration : 20-60 min.
FORMS AND ROUTE
• Crack - alkaline presentation
• Smoke
• Onset : instant
• Duration 5-10 min.

• When cocaine is insufflated

nasally, the delayed and
prolonged effect is a result of
vasoconstrictive properties
PATHOPHYSIOLOGY
Decreases the clearance of dopamine, epinephrine,
norepinephrine, and serotonin from synapses
Both CNS stimulant and local anesthetic

Autonomic stimulation

• NE - vasoconstriction by alfa1-adrenergic
receptors
• E - increases myocardial contractility and heart
rate by Beta1-adrenergic receptors

Propagates peripheral catecholamine release

PATHOPHYSIOLOGY
Euphoria associated with enhanced alertness

Local anesthetic by Na channels blocking

• Can cause wide QRS complex
• Can block K channels and cause QT prolongation

Cocaine exert direct toxic effect on myocardium resulting negative

isotropy and wide-complex dysrhythmias
INVESTIGATION

Urine - Benzoylecgonine
AMPHETAMINE
AND ITS
DERIVATIVES
 Alpha-methylphenethylamine

• compose a broad class of structurally

similar derivatives of phenylethylamine

AMPHETAMINE • The derivative methamphetamine, also

AND ITS known as “ice,” is abused by ingestion,
DERIVATIVES IV injection, inhalation, or nasal
insufflation

• More than 50 such “designer”

amphetamines have been created
 • Structurally distant from cocaine

• Were discovered while trying to develop a

nasal decongestant

• Amphetamines enhance the release and

AMPHETAMINE block the reuptake of catecholamines at
AND ITS the presynaptic terminal
DERIVATIVES
• Mortality from amphetamine toxicity is a
result of hyperthermia, dysrhythmias,
seizures, hypertension (intracranial
hemorrhage or infarction), and
encephalopathy.
 • Sympathomimetic
• Vasoconstrictive
CLINICAL
• Psychoactive
FEATURES
• Local anesthetic
 Dysrhythmias
• Sympathomimetic stimulation
• Blockade of Na,K channel
CVS : • Tachycardia : sinus tachycardia,
reentrant supraventricular tachycardia
COCAINE and atrial fibrillation and flutter
• Brugade
Myocarditis
Cardiomyopathy (including takotsubo)
 Acute coronary syndromes
• even low dose
• Coronary vasoconstriction by beta-
adrenergic blockade
• Potentiated by smoking
• More risk in preexisting coronary artery
CVS : disease
COCAINE In addition, cocaine increasing atherogenesis
throughout increased platelet aggregation,
thrombogenesis, and accelerated
atherosclerosis
All route of cocaine associated with typical
chest pain, acute coronary syndrome,
STEMI, NSTEMI
CVS :
• Valvular abnormalities(mitral, aortic)
AMPHETAMINE
 • Seizure
• Cerebral infarction
• Cerebral hemorrhage
CNS
• Spinal cord infarctions
• Cerebral vasculitis
• Intracranial abscesses
 • CRAO unilateral blind
• Bilateral blind from diffuse vascular
spasm
• Choreoathetosis “crack dancing”
(Dopamine dysregulation)
CNS • Corneal abrasions and ulcerations from
smoke and irritation “Crack eye”
• Prolong crack binge > depletion of
neurotransmitters “Cocaine washout” >
depress mental status for 24 hour
 • Common in crack cocaine
• Pulmonary hemorrhage >
pneumomediastinum, Pneumothorax,
pneumopericardium secondary to
valsava maneuver after inhalation
• Barotrauma
RS
• pneumonitis
• Asthma
• Pulmonary edema
• Bronchospasm from irritation
 • Cocaine-induced mesenteric
vasospasm
• Intestinal ischemia
• Bowel necrosis
GI • Ischemic colitis
• Splenic infarction
• GI ulceration, bleeding and perforation
• Advanced tooth decay (Meth mouth)
 • Hyponatremia due to drug-induced
ENDOCRINE secretion of vasopressin
 • Rhabdomyolysis
• Acute kidney failure
RENAL
• Renal infarction in IV cocaine
 • Uteroplacental blood flow decrease
• Spontaneous abortion
• Abortion
PREGNANCY • Abruptio placenta
• fetal prematurity
• intrauterine growth retardation
 • sympathomimetic toxidrome : agitation,
mydriasis, diaphoresis, tachycardia,
dyspnea, hypertension and hyperthermia
• Mental status : normal - severely agitated
and paranoid
DIAGNOSIS • Lethargy and coma suggests post ictal or
ICH
• Difficult to distinguish from alcohol or
sedative-hypnotic withdrawal
• Lactic acidosis from seizure and
vasoconstriction and hypo perfusion
 • Chemistry panel
• CPK
• EKG for chest pain patient
• If hyperthermia : LFT, Coagulogram
LABORATORY • AOC typically requires neuroimaging
EVALUATION • Urine cocaine : highly specific (24-72
hr.)
• Urine amphetamine may positive in
some drugs (Ex. Pseudoephedrine,
bupropion, chlorpromazine, trazodone)
 Standard protocol of poisoned patients
TREATMENT
 • IV access
• Oxygen supplement
• Monitor vital sign
TREATMENT • Treatment of complication
• Supportive care
• Adequate sedation to prevent self-harm
 • Treat hyperthermia (Goal core temp. <
TREATMENT 39 c to avoid overshoot hypothermia)
 • Aggressive IV hydration for treatment of
rhabdomyolysis
• Seizure : initial BZD and follow by the
aggressive treatment of status
TREATMENT epilepticus
• CT scan to r/o intracranial cause of
seizure
 • Benzodiazepines are the cornerstone :
lorazepam 2 mg IV, Diazepam 5 mg IV
• Antipsychotics such as haloperidol are
SEDATION not first-line : lower seizure threshold,
hyperthermia, increase QT prolongation,
ventricular dysrhythmias
 • In cocaine same as ACS
• Cocaine user with suspect ACS : ASA,
NTG
• IV calcium channel blockers (diltiazem 5 -
20 mg IV) are recommended as adjunctive
for STEMI or STD
• Betablocker is controversial : AHA not to
CHEST PAIN use with sign of acute cocaine intoxication
• CAG is recommended if STEMI despite
NTG and CCB
• Fibrinolytic may use in STEMI if no
contraindication
• Serial troponin is reasonable
 • Sinustachycardia - sedation, cooling, IV
hydration
• Use CCB to treat reentrant SVT and rate
control in AF
• Wide QRS tachycardia - NaHCO3 1-2
DYSRHYTHMIA
mEq/L IV bolus (keep serum pH < 7.55),
lidocaine in refractory wide QRS
• TdP - Mg(not for prevention), lidocaine,
overdrive pacing
 • Try sedation with BZD
• Phentolamine (2.5-5 mg IV)
• NTG
HYPERTENSION • Nicardipine
• Sodium nitroprusside
• Not use BB
 • Body stuffer
• Body packer

BODY • Both methods can result in severe

toxicity and death
STUFFERS
AND • CTWA is the best imaging modality
BODY
PACKERS • If no sign of toxicity : single dose oral
activated charcoal and whole bowel
irrigation
then CT scan
BODY • For symptomatic : sedation and
STUFFERS symptomatic care
AND • Immediate surgical consultation
BODY • No endoscopy : can rupture the packets
PACKERS
 • Cocaine withdrawal is characterized by
irritability, paranoid ideation, and
depression
• Methamphetamine withdrawal is
WITHDRAWAL characterized by drowsiness, lethargy,
hunger, tremor, and chills

• Strongest during first 48 hour

 • Excessive use of stimulants
• Manifestations : tachycardia, hypertension,
mydriasis, diaphoresis, hyperthermia, hyperreflexia
and agitation
• Can lead seizure, coma, and death
• BZD is key therapeutic intervention
KEY • Worsening hyperthermia portends imminent death
• Reduce temperature rapidly by external cooling,
CONCEPTS sedation, and paralysis (if needed)
• Short-acting antihypertensive agents as an adjusts
• Wide-complex rhythms may respond to IV
NaHCO3
• Cocaine body packers who develop toxicity need
emergent surgical intervention to limit bowel
necrosis and life-threatening sequelae
REFERENCE