resuscitation of the poisoned patient
DESCRIPTION
RESUSCITATION OF THE POISONED PATIENT. Dr Andy McClelland Dept. of Emergency Medicine Auckland Hospital. COMMON POISONINGS. Substance abuse - ‘recreational’ Alcohol's, narcotics, sedatives, stimulants, hallucinogens Intentional overdose Suicide / Parasuicide Accidental - PowerPoint PPT PresentationTRANSCRIPT
RESUSCITATION OF THE
POISONED PATIENT
Dr Andy McClellandDept. of Emergency Medicine
Auckland Hospital
5 YR TOXICOLOGY 2003 2
COMMON POISONINGS1. Substance abuse - ‘recreational’
Alcohol's, narcotics, sedatives, stimulants, hallucinogens
2. Intentional overdoseSuicide / Parasuicide
3. AccidentalMislabelled containers / paediatric age
group
4. Toxic exposuresGases , sprays, house fires
5 YR TOXICOLOGY 2003 3
A journey into the unknown?
5 YR TOXICOLOGY 2003 4
EVALUATION
1. Recognition of poisoning
2. Identification of the poison
3. Prediction of toxicity
4. Assessment of severity
5 YR TOXICOLOGY 2003 5
MANAGEMENT5. Supportive care
6. Prevention of poison absorption
7. Administration of antidotes
8. Enhancement of elimination
9. Prevention of re-exposure
10.Treat associated conditions/injuries
11.Disposition of the patient
“ The surest poison is time.”
Ralph Waldo Emerson (1803-1882)
5 YR TOXICOLOGY 2003 7
Suspect overdose / poisoning in any patient with
• altered level of consciousness
• unexplained signs & symptoms
5 YR TOXICOLOGY 2003 8
CLINICAL COURSE
•Non-toxic ingestion
•Acute toxicity
•Delayed toxicity
5 YR TOXICOLOGY 2003 9
INITIAL PATIENT MANAGEMENT
1. Condition upon arrival
2. Likely course of the poisoning
3. Other injuries / medical conditions
4. Patient compliance
5 YR TOXICOLOGY 2003 10
INITIAL PATIENT MANAGEMENT- if unwell
‘Team approach’
5 YR TOXICOLOGY 2003 11
INITIAL PATIENT MANAGEMENT- if unwell
Initial stabilisation
i. Triage
ii. Position patient
iii. A, B, C, D
iv. Blood glucose, Temperature
v. Monitor – SaO2, ECG, BP, LOC
5 YR TOXICOLOGY 2003 12
INITIAL PATIENT MANAGEMENT- if unwellAirway
• Adequacy, protection Breathing
• Always 0XYGEN; intubation/ventilation
Circulation • Large bore IV’s• Low BP due to decreased vascular
tone will respond to IV fluids /inotropes
5 YR TOXICOLOGY 2003 13
INITIAL PATIENT MANAGEMENT- if unwell
• Correct
• Hypoxia• Fluid balance• Electrolyte abnormalities• Acid / base abnormalities
5 YR TOXICOLOGY 2003 14
INITIAL PATIENT MANAGEMENT- if unwell
‘Coma cocktail’
50 mls 50% dextrose
naloxone 2 mg thiamine 100 mg
5 YR TOXICOLOGY 2003 15
POISONS INFORMATION
Ask a senior colleague!
5 YR TOXICOLOGY 2003 16
POISONS INFORMATION
• Text books– Ellenhorn– Haddad– Goldfrank
• On-line resources– Substance database (National Poisons Centre)– Poisindex– Toxindex
5 YR TOXICOLOGY 2003 17
AVOID INJURY TO STAFF
1. Barrier precautions where applicable
2. External decontamination
3. Adequate ventilation
4. Avert / control violent behaviour
5. Exclude at risk staff
5 YR TOXICOLOGY 2003 18
EVALUATION 1
•History
•Toxidromes
5 YR TOXICOLOGY 2003 19
EVALUATION 2- History
• Circumstances of discovery • Mental illness / suicide attempts• Reason for overdose
• Recreational• Self harm• Depression
• Additional injuries• Past medical history• Social history / family history
5 YR TOXICOLOGY 2003 20
EVALUATION 3- prediction of toxicity
1. The substances ingested
2. The quantities ingested
3. The time since ingestion
4. Any treatment to date
5. Concurrent medical conditions
5 YR TOXICOLOGY 2003 21
EVALUATION 4 - History
• Intoxicated patients can be unreliable historians
• 70% of intentional overdoses involve more than 1 substance
• Always consider substances which patients may not think are harmful
examples: aspirin, paracetamol, antihistamines
5 YR TOXICOLOGY 2003 22
EVALUATION 5- assessment of severity
• Vital signs• Physical examination
– Eyes• Pupillary size, nystagmus
– Neurological• Focal deficit is rare in overdose patients
– Skin– Odors
• Toxidromes
5 YR TOXICOLOGY 2003 23
EVALUATION 6- toxidromes1. Anticholingeric2. Cholingeric3. Sympathomimetic4. Narcotic5. Sympatholytic6. Extrapyramidal movement disorders7. Haemoglobinopathies8. Metal fume fever
5 YR TOXICOLOGY 2003 24
EVALUATION 7- Diagnostic testing 1
• ECG• Blood tests
– Paracetamol level for all patients– Arterial blood gas if unwell– U + E, glucose, anion gap, osmolar gap– FBE– Drug levels
• Urine drug screens
5 YR TOXICOLOGY 2003 25
EVALUATION 7-Diagnostic testing 2:
• Harrisons text
5 YR TOXICOLOGY 2003 26
EVALUATION 8- Diagnostic testing 3Consider specific tests
• CXR for pulmonary aspiration / oedema
• LFT’s / coagulation for liver damage
• Creatinine kinase for rhabdomyolysis
• Cervical spine XR / CT head for injury
• AXR for radio-opaque substances
PREVENTION OF POISON ABSORPTION
‘Decontamination’
Note - staff may be at risk
5 YR TOXICOLOGY 2003 28
DECONTAMINATION 1• Skin
• Remove contaminated clothing / wash skin
• Gastrointestinal Activated charcoal (in 1st hour post
ingestion)x Emesis (‘ipecac’ ) – rarely usedx Gastric lavage – rarely used Cathartics / whole bowel irrigation
• Eyes
5 YR TOXICOLOGY 2003 29
DECONTAMINATION 2- activated charcoal
• 1 gram / kg• Does not absorb
– Lithium– Heavy metals - iron– Alcohols/Solvents/
hydrocarbons– Caustics/strong acids– Cyanide– Pesticides
• Recovers 60% of poison if administered within the first hour
5 YR TOXICOLOGY 2003 30
DECONTAMINATION 3- cathartics
• Reduced gastrointestinal transit time => reduced time for drug absorption
• Osmotic agents – sorbitol, mannitol, MgSO4
• Contraindications – ileus / bowel obstruction– electrolyte imbalance
• Indication = debatible
5 YR TOXICOLOGY 2003 31
DECONTAMINATION 4-whole bowel irrigation
• May be useful for concretions &sustained-release preparations
• Polyethylene-glycol solution
• Administer at 1000 mls/hour until effluent is clear
• Rarely done but may be life saving if SR overdose
5 YR TOXICOLOGY 2003 32
ANTIDOTES
• Useful in < 5% of overdoses
• Know which antidotes are stocked
• Know how to get advice
5 YR TOXICOLOGY 2003 33
ANTIDOTES – some examples
Poison1. Paracetamol2. Narcotics3. Oral anticoagulants4. Carbon monoxide5. Organophosphates6. Betablockers7. Ca channel blockers8. Iron 9. Digoxin10. Methanol, ethylene glycol11. Cyanide
Antidote1. N-acetyl cysteine2. Naloxone3. FFP, Vitamin K4. oxygen5. Atropine, oximes6. Glucagon, insulin/glucose7. Calcium8. Desferrioxamine9. Digoxin Fab fragments10. ethanol, fomepizole11. Vit. B12, E-L kit,
Kelocyanor
5 YR TOXICOLOGY 2003 34
ENHANCEMENT OF ELIMINATION
1. Diuresis2. Multiple-dose activated charcoal3. Urinary pH manipulation
- salicylate4. Haemodialysis
- small molecules, low protein binding - e.g. salicylate, Lithium
5. Charcoal haemoperfusion- theophylline/barbiturates/carbamazepine
5 YR TOXICOLOGY 2003 35
TREAT ASSOCIATED CONDITIONS
• Trauma
• Chronic illness
• Environmental
5 YR TOXICOLOGY 2003 36
MONITORING
• Clinical observation– i.e. neurological assessments
• Pulse oximetry
• ECG monitoring– Minimum 6 hours if cardio-active drug– >24 hours if delayed release
preparation
5 YR TOXICOLOGY 2003 37
DISPOSAL 1
• Discharge
• Admission
5 YR TOXICOLOGY 2003 38
DISPOSAL 2• DischargePrerequisites:
1.Medical fitness
2.‘Safety check’
Formal assessment of suicide
and self-harm risk
5 YR TOXICOLOGY 2003 39
DISPOSAL• Admission 4
•Critical Care unit
5 YR TOXICOLOGY 2003 40
DISPOSAL 5• Admission
•Psychiatric unit
5 YR TOXICOLOGY 2003 41
DISPOSAL 6• Admission
•General Medical unit
5 YR TOXICOLOGY 2003 42
DISCHARGE ADVICE• COUNSELLING
– Community and alcohol counselling contacts for recreational drug abuse
• EDUCATION– Care-giver education for accidental
ingestion's• LEGAL
– OSH contact for work-related toxic exposures
5 YR TOXICOLOGY 2003 43
SUMMARY 1• Consider poisoning in any patient with
– ALOC– Unexplained signs and symptoms of any
nature
• Supportive care is the primary objective– TSS ‘Think simple stupid’
–A–B–C
5 YR TOXICOLOGY 2003 44
SUMMARY 2
• Evaluation of the patient
– Is thorough history taking from all sources
– Is occasionally aided by ‘toxidrome’ recognition
– Do not rely on toxicology screening tests
5 YR TOXICOLOGY 2003 45
SUMMARY 3• Management of the patient
– Depends on your assessment of A B C D
– Treating the patient not the poison
– Initiating clinically indicated treatment early
– Asking advice early
5 YR TOXICOLOGY 2003 46
Any questions?