toxicological emergencies

Toxicological EmergenciesToxicological Emergencies

Dr. Shahid Aziz MBBS, MRCP (UK), MCEM (London)Dr. Shahid Aziz MBBS, MRCP (UK), MCEM (London)Assistant professor and consultant emergency medicine, Assistant professor and consultant emergency medicine,

DEMDEMKing Khalid University HospitalKing Khalid University Hospital

ObjectivesObjectives

History and Physical ExaminationHistory and Physical ExaminationToxicology ScreeningToxicology ScreeningThree gaps are important in Three gaps are important in toxicologytoxicologyTreatmentTreatmentICU AdmissionICU Admission

History and Physical Examination

No reliable history in patients with profoundly altered metal status

Focused treatment decisions quite difficult.

Multiple substances

Difficulties

Separating patients who have Separating patients who have suspected poisoning into broad suspected poisoning into broad

categories that are based on vital categories that are based on vital signs, eye findings, mental status, and signs, eye findings, mental status, and muscle tone, that helps to determine muscle tone, that helps to determine drug or toxin class i.e.drug or toxin class i.e.“toxidromes.”


Diagnosing toxicity from vital signs

Bradycardia (PACED)

Propranolol (beta-blockers), poppies (opiates), propoxyphene, physostigmine

Anticholinesterase drugs, antiarrhythmics

Clonidine, calcium channel blockers

Ethanol or other alcohols

Digoxin, digitalis

Tachycardia (FAST)

Free base or other forms of cocaine, freon

Anticholinergics, antihistamines, antipsychotics, amphetamines, alcohol withdrawal

Sympathomimetics (cocaine, caffeine, amphetamines, PCP), solvent abuse, strychnine

Theophylline, TCAs, thyroid hormones

Carbon monoxide

Opioids

Oral hypoglycemics, insulin

Liquor (alcohols)

Sedative-hypnotics

Hypothermia (COOLS)

Neuroleptic malignant syndrome, nicotine

Antihistamines, alcohol withdrawal

Salicylates, sympathomimetics, serotonin syndrome

Anticholinergics, antidepressants, antipsychotics

Hyperthermia (NASA)

Clonidine, calcium channel blockers

Rodenticides (containing arsenic, cyanide)

Antidepressants, aminophylline, antihypertensives

Sedative-hypnotics

Heroin or other opiates

Hypotension (CRASH)

Cocaine

Thyroid supplements

Sympathomimetics

Caffeine

Anticholinergics, amphetamines

Nicotine

Hypertension (CT SCAN)

Rapid respiration (PANT)

PCP(phencyclidine), paraquat, pneumonitis (chemical), phosgene

ASA and other salicylates

Noncardiogenic pulmonary edema, nerve agents

Toxin-induced metabolic acidosis

Slow respiration (SLOW)

Sedative-hypnotics (barbiturates, benzodiazepines)

Liquor (alcohols)

Opioids

Weed (marijuana)

COMA L: Lead, lithiumE: Ethanol, ethylene glycol, ethchlorvynolT: Tricyclic antidepressants, thallium, tolueneH: Heroin, hemlock, hepatic encephalopathy, heavy metals, hydrogen sulfide, hypoglycemicsA: Arsenic, antidepressants, anticonvulsants, antipsychotics, antihistaminesR: Rohypnol (sedative hypnotics), risperidoneG: GHBI: Isoniazid, insulinC: Carbon monoxide, cyanide, clonidine

Agents that cause seizures (OTIS CAMPBELL)

Organophosphates, oral hypoglycemicsTricyclic antidepressantsIsoniazid, insulinSympathomimetics, strychnine, salicylatesCamphor, cocaine, carbon monoxide, cyanide, Amphetamines, anticholinergicsMethylxanthines (theophylline, caffeine), methanolPhencyclidine (PCP), propranololBenzodiazepine withdrawal,bupropion, GHB Ethanol withdrawal, ethylene glycolLithium, lidocaine Lead, lindane

Agents that affect pupil size

Miosis (COPS)

Cholinergics, clonidine, carbamates

Opiates, organophosphates

Phenothiazines (antipsychotics), pilocarpine)

Sedative-hypnotics

Mydriasis (SAW)

Sympathomimetics

Anticholinergics

Withdrawal

Agents that cause skin signs

Diaphoretic skin (SOAP) SympathomimeticsOrganophosphatesAcetylsalicylic acid or other salicylatesPhencyclidineDry Skin Antihistamines, anticholinergicsBullae Barbiturates and other sedative-hypnotics,Bites: Snakes and spidersAcneiform rash BromidesChlorinated aromatic hydrocarbons (dioxin)

Flushed or red appearance Anticholinergics, niacinBoric acidCarbon monoxide (rare)Cyanide (rare)Cyanosis ErgotamineNitratesNitritesAniline dyesPhenazopyridineDapsoneAny agent causing hypoxemia, hypotension, or methemoglobinemia.

Agents causing an elevated anion gap (METAL ACID GAP)

Methanol, metformin, massive overdosesEthylene glycolTolueneAlcoholic ketoacidosisLactic acidosisAcetaminophen (large overdoses)Cyanide, carbon monoxide, colchicineIsoniazid, iron, ibuprofenDiabetic ketoacidosisGeneralized seizure-producing toxinsAcetylsalicylic acid or other salicylatesParaldehyde, phenformin

Drugs causing pneumonitis or pulmonary edema (MOPS)

Meprobamate, methadone

Opioids

Phenobarbital, propoxyphene, paraquat, phosgene

Salicylates

Common toxidromes

Cholinergic (Examples: organophosphates, carbamates, pilocarpine)

(DUMBELLS )Diarrhea, diaphoresisUrinationMiosisBradycardia, bronchosecretionsEmesisLacrimationLethargicSalivation

Monday: Miosis

Tuesday: Tachycardia

Wednesday: Weakness

Thursday: Tremors

Friday: Fasciculations

Saturday: Seizures

Sunday: Somnolent

Nicotinic (recalled by the days of the week)

Anticholinergic (Examples: antihistamines, cyclic antidepressants, atropine, benztropine, phenothiazines, scopolamine)

Hyperthermia (HOT as a hare)

Flushed (RED as a beet)

Dry skin (DRY as a bone)

Dilated pupils (BLIND as a bat)

Delirium, hallucinations (MAD as a hatter)

Tachycardia

Urinary urgency and retention

Mydriasis

Tachycardia

Hypertension

Hyperthermia

Seizures

Sympathomimetic (Examples: cocaine, amphetamines, ephedrine, phencyclidine, pseudoephedrine)

Miosis

Bradycardia

Hypotension

Hypoventilation

Coma

Opioid (Examples: heroin, morphine, codeine, methadone, fentanyl, oxycodone, hydrocodone)

Agents responsive to multiple doses of activated charcoal

Substances adsorbable by activated charcoal (ABCD)

Antimalarials (quinine), aminophylline (theophylline)Barbiturates (phenobarbital)CarbamazepineDapsone

Substances not adsorbable by activated charcoal (PHAILS)

Pesticides, potassiumHydrocarbonsAcids, alkali, alcoholsIron, insecticidesLithiumSolvents

AntidoteIndication (agent)

n-acetylcysteineEthanol/fomepizole (4-MP)Oxygen/hyperbaricsNaloxone/nalmefenePhysostigmineAtropine/pralidoxime (2-PAM)Methylene blueNitritesDeferoxamineDimercaprol (BAL)Succimer (DMSA)Fab fragmentsGlucagonSodium bicarbonateCalcium/insulin/dextroseDextrose, glucagon, octreotide

AcetaminophenMethanol/ethylene glycolCarbon monoxideOpioidsAnticholinergicsOrganophosphatesMethemoglobinemiaCyanideIronArsenicLead, mercuryDigoxin, colchicine, crotalidsBeta-blockersTricyclic antidepressantsCalcium channel antagonistsOral hypoglycemics

Table -- Antidotes and their indications

Toxins accessible to hemodialysis (UNSTABLE)

Uremia

No response to conventional therapy

Salicylates

Theophylline

Alcohols (isopropanol, methanol)

Boric acid, barbiturates

Lithium

Ethylene glycol

Theophylline

Barbiturates

Carbamazepine

Paraquat

Glutethimide

Enhanced elimination by charcoal hemoperfusion


ToxidromeToxidrome Treat

ovital signsvital signsoocular findingsocular findingsomental statusmental statusomuscle tonemuscle tone

determine drugdetermine drug or toxin classor toxin class

Yes

No

Initially, a rapid survey for ABCs & life-threatening natureInitially, a rapid survey for ABCs & life-threatening nature

Then, a more focused examination for Then, a more focused examination for

Physical examinationPhysical examination

A rapid but careful physical A rapid but careful physical examination of the patient is examination of the patient is

performed in stagesperformed in stages..

Signs of traumaSigns of trauma Neurologic findingsNeurologic findings Skin changesSkin changes OdorsOdors EyesEyes


Patients may present with Patients may present with hypotension or hypertensionhypotension or hypertension bradyarrhythmias or tachyarrhythmias. bradyarrhythmias or tachyarrhythmias.

The pathogenesis of hypotension varies and The pathogenesis of hypotension varies and may include may include

Physical examinationPhysical examination

HypovolemiaHypovolemia Myocardial depressionMyocardial depression Cardiac arrhythmiasCardiac arrhythmias Systemic vasodilation. Systemic vasodilation.


Urine Drug ScreensUrine Drug Screens

Detect only natural opiatesDetect only natural opiates

Do not detect synthetic or semisynthetic Do not detect synthetic or semisynthetic productsproducts

o OxycodoneOxycodoneo HydrocodoneHydrocodoneo FenanylFenanylo PropoxyphenePropoxypheneo MeperidineMeperidineo methadone. methadone.

o morphineo codeineo heroin

Laboratories InvestigationLaboratories Investigation

Most hospital laboratories have the capability Most hospital laboratories have the capability to rapidly identify and quantify to rapidly identify and quantify onlyonly a small a small

fraction of the substances commonly fraction of the substances commonly encountered in clinical practice. encountered in clinical practice.

Toxicology ScreeningToxicology Screening

Check acetaminophen levels in all Check acetaminophen levels in all cases of suspected intoxicationcases of suspected intoxication

Supportive serum toxicology assays

AcetaminophenLithiumSalicylateValproic acidCarbamazepineCo-oximetry (carboxyhemoglobin, methemoglobin)

Data from Wu AH, McKay C, Broussard LA, et al. National Academy of Clinical Biochemistry Laboratory Medicine practice guidelines: recommendations for the use of laboratory tests to support poisoned patients who present to the emergency department. Clin Chem 2003;49:357–79.

SkeltonSkelton H.,H., DannDann L.M.,L.M., et al.et al. Drug screening of patients who deliberately harm Drug screening of patients who deliberately harm themselves admitted to the emergency department.themselves admitted to the emergency department. Ther Drug Monit Ther Drug Monit (1998) (1998) 2020 : pp : pp 98-103. 98-103.

DigoxinPhenobarbitalIronEthanolMethanolEthylene glycolTheophylline

GENERAL TREATMENTGENERAL TREATMENT

ABCsABCs.. Protection of the Protection of the cervical spinecervical spine (unless trauma (unless trauma

has been excluded). has been excluded). A rapid assessment of the need A rapid assessment of the need of of endotracheal endotracheal

intubation intubation Attention to any abnormalities of the Attention to any abnormalities of the vital signsvital signs.. Discontinuing the offending Any Any life-threateninglife-threatening abnormalities abnormalities A A 12-lead EKG12-lead EKG is obtained along with continuous is obtained along with continuous

cardiac monitoring.cardiac monitoring. ABG ABG

Initial supportive measuresInitial supportive measures

Endotracheal intubation is indicatedEndotracheal intubation is indicated

when there is concern regarding airway when there is concern regarding airway protection and clinical deterioration protection and clinical deterioration

acute respiratory failure. acute respiratory failure.

the need for high levels of the need for high levels of supplemental oxygensupplemental oxygen

It decreases (but does not eliminate) the risk of aspiration It decreases (but does not eliminate) the risk of aspiration (which is approximately 11% in the comatose patient with drug (which is approximately 11% in the comatose patient with drug

overdose).overdose).

Initial supportive Initial supportive measuresmeasures Rapid IV normal saline solution Rapid IV normal saline solution

infusion is indicated in most instances. infusion is indicated in most instances. Vasopressors may be required for Vasopressors may be required for

refractory hypotension. refractory hypotension. The vasopressor of choice depends on The vasopressor of choice depends on

the type of intoxication the type of intoxication Hypertension-induced (reflex) Hypertension-induced (reflex)

bradycardia generally should not be bradycardia generally should not be treated.treated.

Initial supportive measuresInitial supportive measures

Dexrtrose, flumazenil, naloxone, thiamine. Dexrtrose, flumazenil, naloxone, thiamine.

Coma CocktailComa Cocktail

..

There is no evidence that dextrose should be There is no evidence that dextrose should be withheld until thiamine is administered.withheld until thiamine is administered.

Initial supportive measuresInitial supportive measuresComa CocktailComa Cocktail

Reuler JB, Girard DE, Cooney TG. Wernicke's Reuler JB, Girard DE, Cooney TG. Wernicke's encephalopathy. N Engl J Med 1985; 312:1035encephalopathy. N Engl J Med 1985; 312:1035––10391039

rapidly reverses coma, respiratory rapidly reverses coma, respiratory depression, and hypotension induced by depression, and hypotension induced by opioids. opioids.

An initial dose of 0.2 to 0.4 mg is An initial dose of 0.2 to 0.4 mg is administered IV (or endotracheally). administered IV (or endotracheally).

If there is no response after 2 to 3 min, If there is no response after 2 to 3 min, repeated up to 10 mg as required. repeated up to 10 mg as required.

lack of response to 10 mg of naloxone lack of response to 10 mg of naloxone generally excludes opioid toxicity. generally excludes opioid toxicity.


NaloxoneNaloxone

a higher dose may precipitate a higher dose may precipitate large cardiovascular changes in large cardiovascular changes in opioid dependent patients.opioid dependent patients.

Observe forObserve for

acute pulmonary edema opioid withdrawal seizures


NaloxoneNaloxone

Its use in undifferentiated ED patients is not Its use in undifferentiated ED patients is not recommended recommended

Withdrawal seizures in mixed overdoses or in Withdrawal seizures in mixed overdoses or in patients with long-term use of benzodiazepines. patients with long-term use of benzodiazepines.

HoffmanHoffman R.S.,R.S., GoldfrankGoldfrank L.R.,L.R., The poisoned patient with The poisoned patient with altered consciousness: controversies in the use of a coma altered consciousness: controversies in the use of a coma cocktail.cocktail. JAMA JAMA (1995) 274 : pp 562 (1995) 274 : pp 562

SpiveySpivey W.H.,W.H., Flumazenil and seizures: analysis of 43 cases. Flumazenil and seizures: analysis of 43 cases. Clin Ther Clin Ther (1991) 14 : pp 292-305. (1991) 14 : pp 292-305.


FlumazenilFlumazenil

Case reports have cautioned clinicians Case reports have cautioned clinicians of the risk of precipitating seizures with of the risk of precipitating seizures with flumazenil when there is a suspicion of flumazenil when there is a suspicion of benzodiazepine plus benzodiazepine plus TCATCA overdose overdose

0.2 mg of IV flumazenil over 30 s 0.2 mg of IV flumazenil over 30 s followed by another 0.3-mg dose if followed by another 0.3-mg dose if necessary.necessary.

Doses beyond 3 mg generally do not Doses beyond 3 mg generally do not provide additional benefit. provide additional benefit.


Flumazenil

Patients must be able to maintain their Patients must be able to maintain their airways or be intubated. airways or be intubated.

Should not be performed on patients who Should not be performed on patients who have ingested medications that may cause have ingested medications that may cause seizures or abrupt central nervous system seizures or abrupt central nervous system deterioration.deterioration.

GASTRIC LAVAGEGASTRIC LAVAGE DecontaminationDecontamination

There is no clear definition of There is no clear definition of when to end the procedurewhen to end the procedure..


One study using radiographic markers One study using radiographic markers suggested that GL may actually propel suggested that GL may actually propel gastric contents past the pylorus, moving gastric contents past the pylorus, moving the poison into the small intestine, where the poison into the small intestine, where most of the drug will be absorbedmost of the drug will be absorbed

SaettaSaetta J.P.,J.P., MarchMarch S.,S., GauntGaunt M.E.,M.E., et al.et al. Gastric emptying Gastric emptying procedures in the self-poisoned patient: are we forcing procedures in the self-poisoned patient: are we forcing contents beyond the pylorus?.contents beyond the pylorus?. J R Soc Med (1991) J R Soc Med (1991) 8484 : pp : pp 274-276. 274-276.


three clinical trials have failed to three clinical trials have failed to demonstrate improved outcomes when GL is demonstrate improved outcomes when GL is added to AC for the management of added to AC for the management of undifferentiated symptomatic poisoning undifferentiated symptomatic poisoning patients. patients.


KuligKulig K.,K., Bar-OrBar-Or D.,D., CantrillCantrill S.V.,S.V., et al.et al. Management of acutely poisoned Management of acutely poisoned patients without gastric emptying.patients without gastric emptying. Ann Emerg Med Ann Emerg Med (1985) 14 : pp 562-(1985) 14 : pp 562-567. 567. Pond Pond S.M.,S.M., Lewis-DriverLewis-Driver D.J.,D.J., WilliamsWilliams G.M.,G.M., et al.et al. Gastric emptying in Gastric emptying in acute overdose: a prospective randomised trial.acute overdose: a prospective randomised trial. Med J Aust Med J Aust (1995) 163 : (1995) 163 : pp 345-349.pp 345-349.

SaettaSaetta J.P.,J.P., MarchMarch S.,S., GauntGaunt M.E.,M.E., et al.et al. Gastric emptying procedures in Gastric emptying procedures in the self-poisoned patient: are we forcing contents beyond the pylorus?.the self-poisoned patient: are we forcing contents beyond the pylorus?. J J R Soc Med (1991) 84 : pp 274-276R Soc Med (1991) 84 : pp 274-276

GI tract perforationGI tract perforation hypoxiahypoxia aspiration. aspiration. esophageal perforationesophageal perforation Arterial oxygen tension dropped Arterial oxygen tension dropped

17% during GL17% during GL pneumothoraxpneumothorax

Complications associated with GL includeComplications associated with GL include


Based on the available data, the American Academy of Clinical Toxicology does not recommend gastric lavage unless a patient has ingested a potentially life-threatening amount of a poison and the procedure can be undertaken within 60 minutes of ingestion


Current consensus recommendations are that adult overdose patients receive 25 to 100 g

The efficacy of charcoal is time dependent. A recent consensus statement suggests

that charcoal should be administered within 60 minutes of ingestion

ACTIVATEDACTIVATED CHARCOALCHARCOAL DecontaminationDecontamination

LaineLaine K.,K., KivistoKivisto K.T.,K.T., NeuvonenNeuvonen P.J.,P.J., Effect of delayed administration Effect of delayed administration of activated charcoal on the absorption of conventional and slow-of activated charcoal on the absorption of conventional and slow-release verapamil.release verapamil. J Toxicol Clin Toxicol J Toxicol Clin Toxicol (1997) 35: pp 263-268(1997) 35: pp 263-268

CLINICAL EFFICACY OF ACTIVATED CHARCOAL CLINICAL EFFICACY OF ACTIVATED CHARCOAL A study evaluated AC versus supportive care A study evaluated AC versus supportive care

alone in asymptomatic pt.alone in asymptomatic pt. 231 patients were assigned to observation 231 patients were assigned to observation

and 220 were assigned to AC. and 220 were assigned to AC.

No patient in either group deteriorated, No patient in either group deteriorated, suggesting that AC provided no benefit in the suggesting that AC provided no benefit in the management of asymptomatic poisoning management of asymptomatic poisoning patients. patients.


MerigianMerigian K.S.,K.S., WoodardWoodard M.,M., HedgesHedges J.R.,J.R., et al.et al. Prospective evaluation of gastric emptying in the self-Prospective evaluation of gastric emptying in the self-poisoned patient.poisoned patient. Am J Emerg Med (1990) 8 : pp 479-483. Am J Emerg Med (1990) 8 : pp 479-483.

a large study was published comparing AC a large study was published comparing AC with supportive care for symptomatic and with supportive care for symptomatic and asymptomatic overdose patients. asymptomatic overdose patients.

This study is described as a randomized This study is described as a randomized controlled trial (RCT) where 1479 patients controlled trial (RCT) where 1479 patients were assigned on an alternating-day basis to were assigned on an alternating-day basis to either AC or supportive care. either AC or supportive care.


MerigianMerigian K.S.,K.S., BlahoBlaho K.E.,K.E., Single-dose oral activated Single-dose oral activated charcoal in the treatment of the self- poisoned patient: a charcoal in the treatment of the self- poisoned patient: a prospective, randomized, controlled trial.prospective, randomized, controlled trial. Am J Ther (2002) 9 Am J Ther (2002) 9 : pp 301-308. : pp 301-308.

One additional RCT with Preliminary One additional RCT with Preliminary results suggest that the patients who results suggest that the patients who were given AC had a trend toward were given AC had a trend toward longer ED stay and no change in longer ED stay and no change in mortality mortality


CooperCooper G.M.,G.M., Le CouteurLe Couteur D.G.,D.G., RichardsonRichardson D.,D., et al.et al. A A randomised controlled trial of activated charcoal for the randomised controlled trial of activated charcoal for the routine management of oral drug overdose.routine management of oral drug overdose. J Toxicol Clin J Toxicol Clin Toxicol Toxicol (2002) 40 : pp 313-. (2002) 40 : pp 313-.

The major complications of AC are The major complications of AC are

VomitingVomiting intestinal obstructionintestinal obstruction aspiration. aspiration.


Clinical benefits remain unproved Clinical benefits remain unproved

American Academy of Clinical Toxicology and American Academy of Clinical Toxicology and European Association of Poison Centers and European Association of Poison Centers and Toxicologist.Toxicologist. Position paper: single-dose Position paper: single-dose activated charcoal.activated charcoal. J Toxicol Clin Toxicol J Toxicol Clin Toxicol (2005) (2005) 4343 : pp 61-87 : pp 61-87


ComplicationComplication


pneumoniapneumoniabronchiolitis obliteransbronchiolitis obliteransARDSARDSdeath.death.

Alcohols

Hydrocarbons

Organophosphates

Carbamates

Acids

Potassium

Dichloro diphenyl trichloroethane )DDT(

Alkali

Iron

Lithium

Toxins and Drugs Not Adsorbed by Activated Charcoal


Three methodsThree methods (1) dialysis (usually hemodialysis (1) dialysis (usually hemodialysis

rather than peritoneal dialysis)rather than peritoneal dialysis) (2) hemoperfusion(2) hemoperfusion (3) hemofiltration. (3) hemofiltration.

ExtracorporealExtracorporeal Removal of ToxinsRemoval of Toxins

Toxins Characteristics Toxins Characteristics

low molecular weight (< 500 d)low molecular weight (< 500 d) water solublewater soluble low protein binding (< 70 to 80%)low protein binding (< 70 to 80%) small volume of distribution (< 1 L/kg). small volume of distribution (< 1 L/kg).

It can especially be effective in correcting concomitant It can especially be effective in correcting concomitant electrolyte abnormality and metabolic acidosis. electrolyte abnormality and metabolic acidosis.

I,e:I,e: methanol, methanol, ethylene glycol, ethylene glycol, boric acid, boric acid, SalicylatesSalicylates lithium. lithium.

HemodialysisHemodialysis

Hemoperfusion is defined as direct contact of blood Hemoperfusion is defined as direct contact of blood with an adsorbent system with an adsorbent system

drug clearance is not limited by low water solubility, drug clearance is not limited by low water solubility, high molecular weight, or increased protein binding, high molecular weight, or increased protein binding, but on the ability of the adsorbent to bind to the but on the ability of the adsorbent to bind to the drug/toxin. drug/toxin.

toxin needs to be present in the central compartment toxin needs to be present in the central compartment for hemoperfusion to be effective. for hemoperfusion to be effective.

used to enhance elimination of used to enhance elimination of theophylline, theophylline, phenobarbital, phenytoin, carbamazepine, paraquat.phenobarbital, phenytoin, carbamazepine, paraquat.

HemoperfusionHemoperfusion

application of this technique has not been vigorously studied application of this technique has not been vigorously studied in poisoned patientsin poisoned patients

there are increasing numbers of case reports of there are increasing numbers of case reports of extracorporeal intoxicant removal by either the continuous extracorporeal intoxicant removal by either the continuous arteriovenous or venovenous hemofiltration methodsarteriovenous or venovenous hemofiltration methods

Hemofiltration is potentially useful for removal of substances Hemofiltration is potentially useful for removal of substances with a large volume of distribution, slow intercompartmental with a large volume of distribution, slow intercompartmental transfer, or extensive tissue binding. transfer, or extensive tissue binding.

combined digoxin-Fab fragment complexes, or combined digoxin-Fab fragment complexes, or desferoxamine complexes with iron or with aluminum.desferoxamine complexes with iron or with aluminum.

HemofiltrationHemofiltration

Criteria for Admission of the Poisoned Patient to the ICU

•Respiratory depression )PaCO2 > 45 mm Hg(•Emergency intubation •Cardiac arrhythmia •Seizures •SBP < 80 mm Hg •Unresponsiveness to verbal stimuli •Glasgow coma scale score < 12 •Need for emergency dialysis, hemoperfusion, or ECMO •Increasing metabolic acidosis •Pulmonary edema induced by toxins )including inhalation( or drugs

ICU Admission Initial supportive measuresInitial supportive measures

•Hypothermia or hyperthermia including neuroleptic malignant syndrome •Tricyclic or phenothiazine overdose manifesting anticholinergic signs, neurologic abnormalities, QRS duration > 0.12 s, or QT > 0.5 s •Body packers and stuffers •Emergency surgical intervention•Administration of pralidoxime in organophosphate toxicity•Antivenom administration •continuous infusion of naloxone •Hypokalemia secondary to digitalis overdose (or need for digoxin-immune antibody Fab fragments)

Criteria for Admission of the Poisoned Patient to the ICU


In this retrospective study, if a poisoned patient did In this retrospective study, if a poisoned patient did not exhibit any of the eight characteristics, no ICU not exhibit any of the eight characteristics, no ICU interventions (intubation, vasopressors or interventions (intubation, vasopressors or antiarrhythmics, and dialysis or hemoperfusion) antiarrhythmics, and dialysis or hemoperfusion) were required.were required.

(1) PaCO2 > 45 mm Hg, (1) PaCO2 > 45 mm Hg, (2) need for intubation, (2) need for intubation, (3) toxin-induced seizures, (3) toxin-induced seizures, (4) cardiac arrhythmias, (4) cardiac arrhythmias, (5) QRS ≥ 0.12 s, (5) QRS ≥ 0.12 s, (6) sBP < 80 mm Hg, (6) sBP < 80 mm Hg, (7) 2(7) 2ndnd or 3 or 3rdrd degree AV block, degree AV block, (8) unresponsiveness to verbal stimuli. (8) unresponsiveness to verbal stimuli.


• Brett AS, Rothschild N, Gray R, et al. Predicting the clinical course in intentional drug Brett AS, Rothschild N, Gray R, et al. Predicting the clinical course in intentional drug overdose: implications for the use of the intensive care unit. Arch Intern Med 1987; overdose: implications for the use of the intensive care unit. Arch Intern Med 1987; 147:133147:133––137137•Mokhlesi B, Leikin JB, Murray P, et al. Adult toxicology in critical care: part I: general approach to the intoxicated patient. Chest 2003;123(2):577-92.

toxicological emergencies

Documents

insulin sympathomimetics

cyanide antidepressants

rohypnol sedative hypnotics

alcohol withdrawal salicylates

freon anticholinergics

ghb ethanol withdrawal

forms of cocaine

alcohols digoxin