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Diagnosis of Poisoning

Diagnosis of Poisoning. Kent R. Olson, MD, FACEP Medical Director California Poison Control System, San Francisco Division University of California, San Francisco. Lessons from history. A young princess ate part of an apple given to her by a wicked witch

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Diagnosis of Poisoning

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  1. Diagnosis of Poisoning • Kent R. Olson, MD, FACEP • Medical Director • California Poison Control System, • San Francisco Division • University of California, San Francisco

  2. Lessons from history • A young princess ate part of an apple given to her by a wicked witch • She presented comatose and unresponsive (as if she was in a deep sleep) • Airway positioning and mouth to mouth ventilations were performed, and she recovered

  3. Diagnosis of Poisoning • Rule #1: Take good care of the patient • ABCD’s: • Airway • Breathing • Circulation • Dextrose, Drugs & Decontamination • Rule out: • Head trauma, Meningitis, Sepsis • Metabolic disorders

  4. Diagnosis of Poisoning • Rule #2: Get a good history • Check multiple sources: • Patient • Family, Friends • Paramedics, Pharmacy • Circumstances: • What was taken? • How much? • When?

  5. Diagnosis of Poisoning • Rule #3: Do a good physical exam • Toxicologic physical exam: • Mental status • Vital signs (all of them) • Pupils • Bowel sounds • Muscle tone and activity • Skin: dry or diaphoretic? • Look for an autonomic syndrome

  6. Autonomic Syndromes SympatheticCholinergic • Blood Pressure +++/-- • Pulse Rate + +/-- • Pupils dilated pinpoint • Peristalsis -++ • Skin sweatysweaty

  7. Autonomic Syndromes SympatheticSympatholytic • Blood Pressure ++-- • Pulse Rate + -- • Pupils dilated small • Peristalsis -- • Skin sweaty-

  8. Autonomic Syndromes AnticholinergicCholinergic • Blood Pressure ++/-- • Pulse Rate ++ +/-- • Pupils dilated pinpoint • Peristalsis --++ • Skin dry sweaty

  9. Autonomic Syndromes SympatheticAnticholinergic • Blood Pressure +++ • Pulse Rate +++ • Pupils dilateddilated • Peristalsis --- • Skin sweatydry

  10. Case Study • Two adolescents are brought to the ED by their parents because of agitation. • #1: BP 150/100, HR 120, pupils dilated, jumpy, diaphoretic. • #2: BP 130/90, HR 130, pupils dilated, distended bladder, dry flushed skin.

  11. Sympathomimetic Syndrome • Common features: • Agitation, psychosis • Hypertension, tachycardia • Dilated pupils • Diaphoresis • Hyperthermia • Common causes: • Cocaine • Amphetamines (including MDMA - Ecstasy) • Phencyclidine (PCP) • Phenylpropanolamine (PPA): often causes severe hypertension with reflex bradycardia

  12. Anticholinergic Syndrome • Common features: • Dilated pupils • Dry, flushed skin • Sinus tachycardia • Ileus, urinary retention • Confusion, delirium • Common causes: • Atropine & related drugs • Plants (eg, jimson weed)& mushrooms (eg, A. muscaria) • OTC & Rx antihistamines • Tricyclic antidepressants Mad as a Hatter Red as a Beet Blind as a Bat Dry as a Bone

  13. Case Study • A 28 year old woman presents groggy and confused. Pupils 7-8 mm. Skin dry and flushed. Bowel sounds diminished. • 130/90 120/min 14/min 37.8 C • Shortly after arrival she has a grand-mal seizure. • ECG monitor: QRS 0.16 sec, wide complex tachycardia

  14. Tricyclic Antidepressant Overdose • Anticholinergic syndrome • The three “Cs”: • Coma • Convulsions • Cardiac conduction abnormalities • QRS >0.12 sec is a better predictor of toxicity than the serum drug level

  15. Common Causes of Seizures • Tricyclic antidepressants • Newer antidepressants – esp. Wellbutrin • Cocaine, Amphetamines • Diphenhydramine • Isoniazid

  16. Case Study • A 2 year old child is found unresponsive. The parents are suspected heroin users. • BP 80/50 HR 70 RR 6, shallow • Pupils 1 mm. Peristalsis decreased. Muscle tone flaccid. No sweating. • There is no response to 0.4 mg naloxone.

  17. Case (cont.) • Common causes of miosis: • Opioids • Other sympatholytic drugs • Phenothiazines • Cholinergic agents • CNS structural lesions

  18. Case (cont.) • There was no response to repeated doses of naloxone to a total of 4 mg. • There was no response to flumazenil (total dose 1.2 mg). • The parents found an opened bottle of clonidine 0.1 mg on the kitchen floor.

  19. Common Sympatholytic Agents: • Opioids • Clonidine • Benzodiazepines • Barbiturates • Ethanol

  20. Case Study • A 34 year old man drank an unidentified liquid. He vomited several times, and became weak and pale. In the ED: • BP: 150/100 HR 110 • Pupils pinpoint. Profuse diaphoresis. Vomit has a chemical odor. • He develops muscle fasciculations and has a respiratory arrest.

  21. Cholinergic Syndrome • “SLUD” • Salivation, Sweating • Lacrimation • Urination • Diarrhea, Vomiting • also:muscle weakness paralysis

  22. Diagnosis of Poisoning • Rule #4: Use the laboratory appropriately • Routine labs • Arterial blood gases • Electrolytes & anion gap • Osmolality • Toxicology testing • Tox screening • Specific stat quantitative tests

  23. Case Study • A 44 year old man was found unconscious, with a suicide note and a half-empty bottle of whiskey. • BP 110/80 HR 110 RR 32 • pH 7.47 pCO2 18 pO2 88 • Na 140 K 3.8 Cl 106 HCO3 18 • Ethanol 0.18 gm/dL

  24. Anion Gap • Na - Cl - HCO3= 8-12 mEq/L • Causes of increased gap: “SALAD” • Salicylates • Alcohols • Lactic Acidosis • Anuria • DKA

  25. Salicylate Intoxication • Typical mixed acid-base abnormality: • Respiratory alkalosis • Metabolic acidosis • Treatment: • Alkalinize urine, restore serum pH • Hemodialysis

  26. Radiopaque Drugs & Poisons • Unreliable - useful only if positive • Commonly radiopaque: • Iron • Potassium • Calcium • Sometimes visible: • Chloral hydrate • Phenothiazines • Sustained-release preparations

  27. Case • A 16 year old was brought to the ED by paramedics after an overdose of Tylenol with codeine • She had small pupils, and was very sleepy/poorly responsive • Naloxone 2 mg increased pupil size and she became combative but not fully awake

  28. Case, continued • Her mother was questioned: “. . . I didn’t say she overdosed. . . I told them I was worried about all the pain pills she was using for her headache. . .” • Rectal Temp: 102.5 F • LP: pneumococcal meningitis!

  29. Important “Rule-Outs” • “ATOMIC” • Alcohol: check ETOH; consider alcoholism • Trauma: consider CT scan • Overdose: other drugs involved? • Metabolic: Na, glucose, O2, Thyroid, etc. • Infection: consider LP • Carbon Monoxide: obtain COHgb

  30. Case Study • A 27 year old woman found obtunded with pinpoint pupils, awoke with IV naloxone, and admitted to ingestion of a few pain pills. • Does this patient need a Tox Screen? • She was treated with oral activated charcoal, observed for 4 hours, and released to psychiatry.

  31. Case (cont.) • Three days later, she returned because of nausea, abdominal pain, and lethargy. She appeared jaundiced. • AST 8,000 PT 28 sec Bilirubin 3.6 • Toxicology screen from the original visit revealed acetaminophen.

  32. Acetaminophen • Pitfalls in Diagnosis: • History: • Not volunteered by patient • Hidden ingredient in many products • No initial specific symptoms • Physical exam & laboratory: • No initial specific findings • Only reliable test: STAT acetaminophen

  33. Comprehensive Toxicology Screening • Problems: • Slow, expensive • Many drugs not included • Potential uses: • Forensic questions • Possible brain death • Quick “drugs of abuse” screens • ? Useful - for JGP • Many drugs not included – know your hosp’s limits • Should not use (+) test forensically unless confirmed

  34. Toxicology Laboratory • Quantitative testing may be useful if: • results will return quickly, and . . . • results will affect clinical management • Examples of specific useful levels: • Acetaminophen • Carbon monoxide • Digoxin • Salicylate • Valproic acid

  35. Diagnosis of Poisoning - Summary • Take good care of the patient • Get a good history • Do a good physical exam • Use the laboratory appropriately • Consult with the Poison Control Center: • 1-800-411-8080 or 1-800-222-1222

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