bradic. toxicologie

7/18/2019 Bradic. toxicologie

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“What is it that is not a poison?

All things are poison and nothing iswithout poison.

It is the dose only that makes a thing

not a poison.”

—Paracelsus (1493-1541), the Renaissance

“Father of Toxicolog,! in his Thir" #efense$

Toxicology-What Every

Emergency Physician

Should Know



Dr Michael HaDr Michael HaUniversity of Manitoba

Section of Emergency Medicine

Dr John SoalDr John SoalEmergency Medicine

Health Sciences Centre

Dr !o" SweetlandDr !o" SweetlandEmergency Medicine

Health Sciences Centre

Presenters



#ME $"%ectives

Be familiar with the initialBe familiar with the initial

management and stabilization of toxicmanagement and stabilization of toxic

ingestionsingestions

Be able to recognize overdoses byBe able to recognize overdoses by

their clinical featurestheir clinical features



#ase

3 !emale Comatose3 !emale Comatose

"u#ils mm $CS % & S#'"u#ils mm $CS % & S#' % (&)% (&)

B" *&+,, H- .' -- (B" *&+,, H- .' -- (

/hat methods of ra#id reversal are/hat methods of ra#id reversal are

available0available0

How can we decontaminate her gut0How can we decontaminate her gut0

/hat a##roach in case of life threatening/hat a##roach in case of life threatening

120120



Her EK&



'#oma #octail(

Consider in all unnown causes ofConsider in all unnown causes ofcoma and decreased 41Ccoma and decreased 41C

5 2,'/ 6 unless 7ccuchec available2,'/ 6 unless 7ccuchec available5 8hiamine 6 alcoholics only8hiamine 6 alcoholics only



'#oma #octail(

9aloxone :9arcan;9aloxone :9arcan;5 '<= 6 <' mg >?@ >M@ SC@ E88'<= 6 <' mg >?@ >M@ SC@ E88

2uration .A hours2uration .A hours

+A sage at +3 bolus + hour +A sage at +3 bolus + hour Higher doses withHigher doses with

5 "entazocine :8alwin;"entazocine :8alwin;

5 CodeineCodeine5 2i#henoxylate :4omotil;2i#henoxylate :4omotil;

5 "ro#oxy#hene :2arvon;"ro#oxy#hene :2arvon;



#ase )*ost +arcan,

3 !emale Comatose3 !emale Comatose

"u#ils"u#ils =mm=mm $CS % .' S#'$CS % .' S#' % *.) :r+a;% *.) :r+a;

B" *&+,, H- .'B" *&+,, H- .' --.=--.=

/hat methods of ra#id reversal are/hat methods of ra#id reversal are

available0available0

How can we decontaminate her gut0How can we decontaminate her gut0

/hat a##roach in case of life threatening/hat a##roach in case of life threatening

120120



Toxic &rill

7ctivated Charcoal will adsorb all the 7ctivated Charcoal will adsorb all the

following medsfollowing meds except:except:

a<a< "henobarbital"henobarbital

b<b< 8heo#hylline8heo#hylline

c<c< !errous sulfate!errous sulfated<d< ?era#amil?era#amil

e<e< SalicylatesSalicylates



& Decontamination

*ecac*ecac5 +o+o role for >#ecac in managementrole for >#ecac in management

of overdoses in the E2 settingof overdoses in the E2 setting

&astric .avage&astric .avage5 9o evidence of im#roved outcomes9o evidence of im#roved outcomes

5 Contraindicated with corrosives andContraindicated with corrosives andhydrocarbonshydrocarbons



& Decontamination

Charcoal ,'gm :.g+g;Charcoal ,'gm :.g+g;

5 !irst line decontamination method!irst line decontamination method

5

2oesnt adsorbD2oesnt adsorbDHeavy metalsHeavy metals

HydrocarbonsHydrocarbons

7cids + 7lalis 7cids + 7lalisEthanolEthanol

5 -e#eated doses for 8heo#hylline-e#eated doses for 8heo#hylline



Toxic &rill

/hole bowel irrigation is recommended/hole bowel irrigation is recommended

in all of the following ingestionsin all of the following ingestions

except:except:

a<a< 4ead #aint chi#s4ead #aint chi#s

b<b< Cocaine #acetsCocaine #acets

c<c<

Button batteriesButton batteriesd<d< HydrocarbonsHydrocarbons

e<e< SustainedArelease lithium tabletsSustainedArelease lithium tablets



& Decontamination

/hole Bowel >rrigation/hole Bowel >rrigation

5 Heavy metalsHeavy metals

5

SustainedArelease medsSustainedArelease meds5 $o4ytely$o4ytely

,'' 6 ''' ml+hr ,'' 6 ''' ml+hr

,cc+g+hr #eds,cc+g+hr #eds+A metoclo#ro#amide+A metoclo#ro#amide

=A& hours duration=A& hours duration



Enhanced Elimination

Urinary 7lalinizationUrinary 7lalinization

SalicylatesSalicylates

5

.A me+Fg bolus then 3 am#s.A me+Fg bolus then 3 am#s9aBicarb in (,'cc 2,/9aBicarb in (,'cc 2,/

5 .,' 6 ,' cc+hr .,' 6 ,' cc+hr

5

Urine #H G<,Urine #H G<,5 7dd ' 6 =' me FCl + 4 7dd ' 6 =' me FCl + 4



Enhanced Elimination

Hemodialysis and CharcoalHemodialysis and CharcoalHemo#erfusionHemo#erfusion5 Confer with a "oison ControlConfer with a "oison Control

Centre@ 8oxicologist@ 9e#hrologistCentre@ 8oxicologist@ 9e#hrologist

5 7S7@ 8oxic 7lcohols@ 4ithium 7S7@ 8oxic 7lcohols@ 4ithium

5 MB "CC (A,*.MB "CC (A,*.5 8oxicology 6 HSC "aging (A'.8oxicology 6 HSC "aging (A'.



Management Ste*s

.<.< 7BCs 7BCs

<< >mmediate consideration of IComa>mmediate consideration of IComa

CoctailJ treatmentsCoctailJ treatments

3<3< $ather information$ather information

=<=< 2econtaminate $> tract2econtaminate $> tract

/0/0 Su**ort PatientSu**ort Patient&<&< Enhanced EliminationEnhanced Elimination

<< 7ntidotes 7ntidotes



.i1e Threatening $verdose

-es#iratory 2e#ression0 Hy#oxia0-es#iratory 2e#ression0 Hy#oxia0

5 7ssist res#irations 7ssist res#irations

5

>ntubate as necessary>ntubate as necessary5 Sus#ected 1#iates or Unnown0Sus#ected 1#iates or Unnown0

"u#ils and -es#irations"u#ils and -es#irations

9aloxone mg >?9aloxone mg >?



Toxic &rill

7ll the following drugs can cause miotic 7ll the following drugs can cause miotic

#u#ils#u#ils except:except:

a<a< ClonidineClonidine

b<b< M2M7M2M7

c<c< 1rgano#hos#hates1rgano#hos#hates

d<d< HeroinHeroine<e< CodeineCodeine



Toxic &rill

7ll the following drugs can cause miotic 7ll the following drugs can cause miotic

#u#ils#u#ils except:except:


b<b< M2M7M2M7

c<c< 1rgano#hos#hates1rgano#hos#hates

d<d< HeroinHeroine<e< CodeineCodeine



The Eyes Have t

MiosisMiosis 1#iates61#iates6

5 BU8 dilated withDBU8 dilated withD

Me#eridine :2emerol;Me#eridine :2emerol; "ro#oxy#hene :2arvon;"ro#oxy#hene :2arvon; Hy#oxia@Hy#oxia@ CoAingestants@ 4omotil:mixed agent;CoAingestants@ 4omotil:mixed agent;

Cholinergics@ "henothiazinesCholinergics@ "henothiazines 7bsence of miosis doesnt rule out o#iate 7bsence of miosis doesnt rule out o#iate

ingestioningestion



The Eyes Have t

MydriasisMydriasis

5 7nticholinergics 7nticholinergics

5

Sym#athomimeticsSym#athomimetics

+ystagmus+ystagmus

5 Ethanol@ 4ithium@ "henytoin@Ethanol@ 4ithium@ "henytoin@Carbamaze#ine@ SedativeAhy#noticsCarbamaze#ine@ SedativeAhy#notics

5 ?ertical 9ystagmus A "C"?ertical 9ystagmus A "C"




Evidence of acute cardiacEvidence of acute cardiac

manifestations0manifestations0

Chest #ain0Chest #ain0

EF$ and 3Alead rhythm stri#EF$ and 3Alead rhythm stri#



.i1e Threatening $D - EK&

?ery im#ortant to do EF$@ es# in?ery im#ortant to do EF$@ es# in

8C7@ BetaA and CaABlocers8C7@ BetaA and CaABlocers

5 8C7D8C7D

8achycardia@ K-S widening8achycardia@ K-S widening

-ightward shift of terminal '<'= s-ightward shift of terminal '<'= s

of frontal #lane K-Sof frontal #lane K-S5 ie #rominent - in 7?-ie #rominent - in 7?-



T#2 EK&




/ide Com#lex 8achycardia with/ide Com#lex 8achycardia with#ulse0#ulse0

EF$ evidence of 8C7 120EF$ evidence of 8C7 1205 Sodium BicarbonateSodium Bicarbonate

.A me+g.A me+g8itrate to K-S narrowing or8itrate to K-S narrowing or

#H <,#H <,5 >f cocaine@ may also try lidocaine>f cocaine@ may also try lidocaine5 7?1>2 #rocainamide 7?1>2 #rocainamide



Toxic &rill

Bradycardia is commonly associatedBradycardia is commonly associated

with all the following overdoseswith all the following overdoses

except:except:


b<b< 2igoxin2igoxin

c<c< "ro#anolol"ro#anolol

d<d< MethadoneMethadone

e<e< 7m#hetamines 7m#hetamines




7cute coronary syndrome associated 7cute coronary syndrome associated

with Cocaine0with Cocaine0

5 9itrates9itrates

5 Benzodiaze#inesBenzodiaze#ines

5 7s#irin 7s#irin

5

"hentolamine if #ersistent severe"hentolamine if #ersistent severehy#ertensionhy#ertension




Hy#otension0Hy#otension0

5 !luids!luids

-esistant shoc0-esistant shoc0

E#ine#hrine or nore#ine#hrineE#ine#hrine or nore#ine#hrine




Hy#otension associated withDHy#otension associated withD

5 8C708C70

Bicarbonate to #H <,' 6 <,,Bicarbonate to #H <,' 6 <,,

5 CaAchannel Blocer0CaAchannel Blocer0

CaCl .A3 $ms >?CaCl .A3 $ms >?

5 CaAchannel or Beta Blocer0CaAchannel or Beta Blocer0$lucagon ,A.' mg >? bolus then$lucagon ,A.' mg >? bolus then

hourly dri#hourly dri#




Status Seizures0Status Seizures0

5 $lucose if hy#oglycemia$lucose if hy#oglycemia

5

4oraze#am '<. mg+g >?4oraze#am '<. mg+g >?

5 "henobarbital 'A3' mg+g >?"henobarbital 'A3' mg+g >?

5 7?1>2 #henytoin 7?1>2 #henytoin

5 >soniazid0>soniazid0"yridoxine , gm 7dult@ . gm "ed"yridoxine , gm 7dult@ . gm "ed




"rofound Coma0"rofound Coma0

5 Ensure airway controlEnsure airway control

5

Coma CoctailComa Coctail

5 Consider C8 scan :occult trauma;Consider C8 scan :occult trauma;




Severe Metabolic 7cidosis0Severe Metabolic 7cidosis0

5 Bicarb and loo for causeBicarb and loo for cause

8oxic 7lcohols8oxic 7lcohols

SalicylatesSalicylates

>ron>ron

4actic 7cidosis from shoc4actic 7cidosis from shoc2F72F7



Elevated 7$ Metabolic 7cidosis

)MET2. 2#D &2P,MMethanolethanol@ Metformin@ Metformin

EEthylene $lycolthylene $lycol

TTolueneoluene

22lcoholic F7lcoholic F7

..acticactic

22minogycosides@ other uremic agentsminogycosides@ other uremic agents

##yanide@ C1yanide@ C1

ron@ron@ >soniazid>soniazidDDF7F7

&&eneralized Seizureseneralized Seizures

22S7S7

PParaldehydearaldehyde



Toxic &rill

7ll of the following toxins are #ro#erly 7ll of the following toxins are #ro#erly

matched with their associated odourmatched with their associated odour

except:except:

a<a< Cyanide + Bitter almondsCyanide + Bitter almonds

b<b< Methylsalicylate + 1il of /intergreenMethylsalicylate + 1il of /intergreen

c<c< 1rgano#hos#hates + $arlic1rgano#hos#hates + $arlic

d<d< Mercury + MothballsMercury + Mothballs

e<e< Sulfur 2ioxide + -otten eggsSulfur 2ioxide + -otten eggs



2ccording to Historians3

“ “ Sir, if you were my husband, I wouldSir, if you were my husband, I would

poison your drink.” poison your drink.”

A 4ady 7stor to /inston Churchill<A 4ady 7stor to /inston Churchill<

A/inston Churchill in re#lyDA/inston Churchill in re#lyD

“ “ Madam, if you were my wife,Madam, if you were my wife,

I would drink it.” I would drink it.”



Toxidromes

2nticholinergic2nticholinergic

dry@ tachycardicdry@ tachycardic

mydriasismydriasis

Sedative-$*iateSedative-$*iate

bradycardicbradycardic

miosismiosis

Sym*athomimeticSym*athomimetic

wet@ tachycardicwet@ tachycardic

mydriasismydriasis

#holinergic#holinergic

all wet@ bradycardicall wet@ bradycardic

miosismiosis



2nticholinergic Toxidrome

2ry mouth and sin2ry mouth and sin

2elirium2elirium

5 "eculiar mumbling s#eech"eculiar mumbling s#eech

5 "icing finger movements"icing finger movements

H-@H-@ 8em#8em#

4arge "u#ils4arge "u#ils↓ Bowel soundsBowel sounds

Urinary retentionUrinary retention



Sym*athomimetic

Toxidrome 2elusional + #aranoid2elusional + #aranoid

Seizures@ or #ostictal confusionSeizures@ or #ostictal confusion

B"@B"@ H-@H-@ "u#ils"u#ils

2ia#horesis2ia#horesis

9ormal 69ormal 6 Bowel soundsBowel sounds



$*iate 4 Sedative

Toxidrome

↓

EverythingEverything

5 --@ H-@ 41C@ 8em#@ 28-@--@ H-@ 41C@ 8em#@ 28-@Bowel SoundsBowel Sounds

Usually miosis@ but several exce#tionsUsually miosis@ but several exce#tions



#holinergic Toxidrome

ConfusionConfusion ComaComa SeizuresSeizures

/eaness@ !asiculations/eaness@ !asiculations

2ia#horesis2ia#horesis

BradycardiaBradycardia Miotic #u#ilsMiotic #u#ils

>nsecticides 6>nsecticides 65 1rgano#hos#hates1rgano#hos#hates

5 CarbamatesCarbamates



#holinergic Toxidrome

II/etJ "atient@/etJ "atient@ S.5D&ES.5D&E

5 SSalivationalivation

5

..acrimationacrimation5 55rinationrination

5 DDefecation@ 2ia#horesisefecation@ 2ia#horesis

5 &&> Cram#s> Cram#s

5 EEmesismesis



Jimson Weed



Toxic &rill

Mydriasis@ tachycardia@ urinary retention@Mydriasis@ tachycardia@ urinary retention@

diminished bowel sounds@ and drydiminished bowel sounds@ and dry

mucous membranes would bemucous membranes would be

ex#ected for all the followingex#ected for all the following except:except:a<a< Limson /eedLimson /eed

b<b< 8C78C7

c<c< 2i#henydramine2i#henydramine

d<d< 7m#hetamines 7m#hetamines

e<e<

CogentinCogentin



Toxic &rill

7ll of the following ingested toxins have 7ll of the following ingested toxins have

been found to be radio#auebeen found to be radio#aue except:except:

a<a< !errous Sulfate!errous Sulfate

b<b< 7cetamino#hen 7cetamino#hen

c<c<

4ead4ead

d<d< MercuryMercury

e<e< Cocaine "acetsCocaine "acets



ron Pills on 6ray



!ody Pacer



Toxic &rill

7ll the following toxins are correctly 7ll the following toxins are correctly

matched with their res#ectivematched with their res#ective

antidoteantidote except:except:

a<a< Cyanide + Methylene BlueCyanide + Methylene Blue

b<b< >soniazid + "yridoxine>soniazid + "yridoxine

c<c< Ethylene $lycol + =AMethyl#razoleEthylene $lycol + =AMethyl#razole

d<d< Carbon monoxide + 1xygenCarbon monoxide + 1xygen

e<e< 7cetamini#hen + 9A7cetycysteine 7cetamini#hen + 9A7cetycysteine



2ntidotes 5sed in the ED

ToxinToxin 2ntidote2ntidote DoseDose

$*iates$*iates +aloxone+aloxone 7mg7mg

T#2T#2 !icar"!icar" 8-7me94g8-7me94g

#alcium#alcium!locer !locer

#alcium#alcium 8gm :8gm :

#alcium#alcium!locer !locer

&lucagon&lucagon/-8; mg/-8; mg

thenthenin1usionin1usion





!eta!eta!locer !locer

&lucagon&lucagon /-8; mg/-8; mg thenthen in1usionin1usion

#yanide#yanide +a +itrite+a +itrite 8;ml o1 <=8;ml o1 <=

#yanide#yanide +a Thiosul1ate+a Thiosul1ate /;ml o1 7/=/;ml o1 7/=

ronron De1eroxamineDe1eroxamine 8/mg4g4hr 8/mg4g4hr





ToxicToxic2lcohols2lcohols

EthanolEthanol8;ml4g 8;=8;ml4g 8;=

then ;08/then ;08/ml4g4hr ml4g4hr

ToxicToxic2lcohols2lcohols

>ome*i?ole>ome*i?ole8/mg4g :8/mg4g :

987H987H

EthyleneEthylene&lycol&lycol PyridoxinePyridoxine 8;;mg8;;mg

MethanolMethanol >olate>olate /;mg : 9@h/;mg : 9@h





2cetamino*hen2cetamino*hen +2#+2# : regime: regime

nsecticidesnsecticides 2tro*ine2tro*ine 8-7 mg4g8-7 mg4g

nsecticidesnsecticides Proto*amProto*am8-7& : then8-7& : then/;; mg 4 hr /;; mg 4 hr



Dis*osition o1 Tox Patient

>CU 7dmission>CU 7dmission

5 Unstable #atientUnstable #atient

5 "otentially lethal overdose"otentially lethal overdose

5 Cardiotoxic overdoseCardiotoxic overdose

Hos#ital 7dmissionHos#ital 7dmission5 Moderately sym#tomatic #atientModerately sym#tomatic #atient

with low fatality #otentialwith low fatality #otential




"rolonged 1bservation :. A = hours;"rolonged 1bservation :. A = hours;

or 7dmissionor 7dmission

5 1verdose with delayed onset or1verdose with delayed onset or

sustained release #re#arationsustained release #re#aration

E2 1bservation = 6 & hoursE2 1bservation = 6 & hours

5 Mild sym#toms@ low lethality 12Mild sym#toms@ low lethality 12

5 7sym#tomatic@ unnown 12 7sym#tomatic@ unnown 12




"rolonged 1bservation :. A = hours;"rolonged 1bservation :. A = hours;

or 7dmissionor 7dmission

5 1verdose with delayed onset or1verdose with delayed onset or

sustained release #re#arationsustained release #re#aration

E2 1bservation = 6 & hoursE2 1bservation = 6 & hours

5 Mild sym#toms@ low lethality 12Mild sym#toms@ low lethality 12

5 7sym#tomatic@ unnown 12 7sym#tomatic@ unnown 12

Excuses That DonAt Wor



Excuses That Don t Wor

in #ourt

,<,< “I thought the child was ! since“I thought the child was ! since

she only took one pill” she only took one pill”

Be wary ofDBe wary ofD

5 8C7s@ Methylsalicylate@ CaAblocer@8C7s@ Methylsalicylate@ CaAblocer@

Hy#oglycemic agents@ 4omotilHy#oglycemic agents@ 4omotil





in #ourt

=< I=< I"he toxicology screen was"he toxicology screen was

negati#e, so it couldn$t ha#e been annegati#e, so it couldn$t ha#e been an

o#erdose” o#erdose”

High false negative ratesHigh false negative rates

9ewer street drugs9ewer street drugs

"oor timing of 12"oor timing of 12





in #ourt

3<3< “"he guy o#erdosed on heroin and“"he guy o#erdosed on heroin and

woke right after naloxone. %e cursedwoke right after naloxone. %e cursed

at me, so I kicked him out.” at me, so I kicked him out.”

5 9aloxone may wear off before the9aloxone may wear off before the

narcotic< 1bserve<narcotic< 1bserve<

5 >f #atient wont stay 6 determine>f #atient wont stay 6 determine

com#etence and document well<com#etence and document well<





in #ourt

<< “"he patient looked great, so I“"he patient looked great, so Ithought one hour of obser#ation wasthought one hour of obser#ation was

enough.” enough.”

5 Most overdoses 6 observe = 6 &Most overdoses 6 observe = 6 &

hours<hours<

5 2angerous 12s or sustainedA2angerous 12s or sustainedA

release 6 observe = hours<release 6 observe = hours<





in #ourt

.<.< "he patient said she only took one"he patient said she only took one pill & how was I supposed to know pill & how was I supposed to know

she ingested the whole bottle'” she ingested the whole bottle'”

5 1verdosers are notoriously1verdosers are notoriously

unreliable historians<unreliable historians<

5 $et collateral<$et collateral<

5 >f in doubt 6 observe = 6 & hours<>f in doubt 6 observe = 6 & hours<



T2KE H$ME MESS2&E

Su##ortive care is the most im#ortantSu##ortive care is the most im#ortantmeasure in most serious overdosesmeasure in most serious overdoses

/hen in doubt 6 observe in the E2/hen in doubt 6 observe in the E2

/hen faced with an unfamiliar or/hen faced with an unfamiliar or

serious toxic ex#osure call a "oisonserious toxic ex#osure call a "oison

Control Centre or consult with aControl Centre or consult with a

toxicologisttoxicologist



M! Poison #ontrol #entre

Childrens Hos#ital EmergencyChildrens Hos#ital Emergency

2e#artment "oison Control 4ine2e#artment "oison Control 4ine

'=A(A,*.'=A(A,*.



eMEDiUMeMEDiUM

Bac

Emergency MedicineEmergency Medicine

in the U of Min the U of M

emergency0m"0caemergency0m"0ca



HS# EDHS# ED

Maryann #romwell

M#romwellBexchange0hsc0m"0ca

*hone3 CC-7<@1ax3 CC-77<8

De*artment o1 Emergency Medicine

Health Sciences #entre&> 7;8-;; Sher"roo Street

Winni*egF M!

G<2 8G

bradic. toxicologie

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