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Approach to Poisonings

Approach to Poisonings. Robert J. Vinci, MD. Background. 2 – 5 Million exposures per year 4% require hospitalization 96% minor or no effects. Background. 93% involve a single substance 67 % patients < 20 years of age 53% children < 6 years of age 25% children < 2 years of age

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Approach to Poisonings

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  1. Approach to Poisonings Robert J. Vinci, MD

  2. Background • 2 – 5 Million exposures per year • 4% require hospitalization • 96% minor or no effects

  3. Background • 93% involve a single substance • 67 % patients < 20 years of age • 53% children < 6 years of age • 25% children < 2 years of age • Bimodal Pediatric age distribution • Household products vs. pharmaceuticals

  4. Fatalities • Cleaning substances • Analgesics • Antidepressants • Heavy metals, especially iron • Street drugs • Cardiovascular drugs • Alcohols

  5. How do Children Present? • Vague History • Change in mental status • Suspicion of Ingestion • Open bottles • Pills on floor • Missing medications • Directly Observed

  6. Initial Evaluation • History • When • How Much • Symptoms • Meds in the Home • Any other possible exposures • Observations from EMS personnel

  7. Initial Evaluation • History • Seizures • GI symptoms • Hallucinations • Toxidromes

  8. Initial Evaluation • Physical Examination • ABC’s – Rapid deterioration • Review vital signs for clues • Mental Status • Pupils • Nystagmus • Skin Color/Skin Warmth

  9. Initial Evaluation • Laboratory Studies • Pulse Oximetry • EKG • Electrolytes/Blood Sugar • ABG’s • Toxic Screen/Drug Levels • Serum osmolality/osmolal gap

  10. Increased Anion Gap Acidosis • Methanol • Ethylene Glycol • Salicylates • Iron, INH, Ibuprofen • Drugs producing hypotension and lactic acidosis (many serious ingestions)

  11. Increased Osmolal Gap • Osmolal Gap = Osm (calc) – Osm (meas.) • Osmolal Calc. = 2 x Na + Gluc + BUN 18 2.6 • Increased Osmolal Gap • Ethanol • Methanol • Ethylene Glycol • Acetone

  12. Radiographic Studies • CHIPES • C = Chloral Hydrate • H = Heavy Metals, especially Iron • I = Iodinated compounds (thyroxin) • P = Psychotropic, Packers • E = Enteric Coated Medications • S = Salicylates, Sustained Release

  13. Hyperthermia, agitation, mydriasis, hypertensive hyperthermic Coma, Seizures, arrhythmia Coma, respiratory depression, myosis Hallucinations, mydriasis, hot dry skin, urinary retention, tachycardia Sympathomimetics Tricyclics Opiods Anticholinergics Toxidromes

  14. Serum Toxic Screens • Aspirin • Salicylates • Alcohols • Tricyclics

  15. Urine Toxic Screens • Benzodiazepines • Barbiturates • Opiates • PCP • Marijuana

  16. General Management • Supportive Care • Oxygen • Intravenous glucose • Careful monitoring for potential side effects

  17. Specific Management • Gastric Emptying • Decrease Absorption • Enhance Elimination • Specific Antidotes

  18. Gastric Emptying • Syrup of Ipecac • Stimulates Gastric Receptors linked to the CNS vomiting center • Emesis within 20 minutes • 80% after a single dose • 99% after two doses • Vomiting persists for 1 – 2 hours and may delay use of oral antidotes and treatments

  19. Syrup of IpecacShould it be Used? • Adverse Effects • Uncontrolled vomiting/ Mallory Weiss Tear • Sedation • Fatal aspiration • 30% recovered < one hour of ingestion. Minimal toxin recovered after 90 minutes • No true evidence it improves outcome • Not studied well with delayed gastric emptying or decreased peristalsis

  20. When to Consider Ipecac • Alert, conscious children > 6 months of age • Ingestion of potentially toxic amount of poisoning • Within 60 minutes of ingestion • Perhaps at home or in pre-hospital setting • Limited value in the hospital setting

  21. Syrup of IpecacContraindications to Use • Substance that produces rapid change in mental status • Calcium channel blocker, digitalis, beta-blocker (worsen bradycardia of vomiting) • Corrosives • Mental Status changes/Decreased Gag • Coagulopathy • Infants less than 6 months of age

  22. IpecacAdverse Effects • Protracted vomiting, sedation or diarrhea • Forceful vomiting (Mallory-Weiss tears, pneumomediastinum, bradycardia) • Sedation or seizures leading to aspiration • Cardiomyopathy with chronic abuse • May delay oral therapy, especially charcoal

  23. Gastric Lavage • Need Presence of gag – now and during the procedure • Left Lateral Decubitus/Trendenburg • Large Bore Single Lumen tube • After confirming position of tube, 10 – 15 ml/kg aliquots of saline until clear • Removes < 30 % of what is ingested (similar to ipecac) • Similar contraindications to ipecac

  24. Gastric LavageContraindications • Corrosives • Uncooperative child • History of GI surgery/pathology

  25. Gastric LavageTechnique • Confirm presence of gag reflex • Left lateral decubitus position with head lower than feet • Largest possible tube • Lavage with aliquots of 10 ml/kg until clear

  26. Charcoal - Adsorbent • Binding surface areas of 3000 m2/gm • Maintains attachment through covalent bonding • If treatment occurs within one hour as much as 75% of toxin is adsorbed • Dose is 10:1 ratio, however a fixed dose of 1 gram/kg is recommended • May mix with flavoring to hide taste • ?Use with NG tube????

  27. Use of Charcoal • 1 gm/kg of body weight • Often pre-mixed as aqueous solution or with a cathartic such as sorbitol • May flavor with cola, chocolate syrup in order to make it more palatable • More effective than ipecac or gastric lavage • Greatest benefit if used within one hour of ingestion

  28. Charcoal “Contraindications” • Hydrocarbons • Alcohols • Heavy Metals (Iron) • Minerals • Corrosives (makes endoscopy difficult) • GI perforation

  29. Multiple Dose Activated Charcoal • Drugs which decrease gastrointestinal mobility • Enterohepatic circulation • Gastric Dialysis • Give 0.5 mg/kg of charcoal without sorbitol every 4 – 6 hours

  30. Adverse Effects of Charcoal • Aspiration • Diarrhea, if used with sorbitol • Fluid loss and electrolyte abnormality

  31. Cathartics • Osmotic Agents used to treat ingestions • Increase Gastric Motility • In pediatric patients the use of cathartics should be limited to the first dose of charcoal

  32. Magnesium Citrate • 4 ml/kg of 6% suspension • Larger doses do not improve efficacy • Magnesium does get absorbed

  33. Sorbitol • The most efficient osmotic agent • 1 – 2 grams/kg • Not recommended in children < 1 year • May cause hypernatremic dehydration and cardiovascular collapse

  34. Whole-Bowel Irrigation • Polyethylene glycol-electrolyte solution • There is no absorption • Large volumes infused (500 – 1000 ml per hour) until effluent is clear • Treatment of choice for agents which are not well absorbed by charcoal

  35. Indications • Enteric coated pills • Sustained release tablets • Illicit drug packets • Drug concretions • Ingestions of substances poorly bound by charcoal

  36. Opiate Overdose Acetominophen Salicylates Digoxin Iron INH Ethylene Glycol Tricyclics Narcan N-acetylcysteine Alkalinization Fab Antibodies Deferoxamine Pyridoxine Fomepazole Sodium Bicarbonate Common Antidotes

  37. Approach to Patients • Avoid the use of ipecac • Gastric lavage has not been shown to be effective • In general, activated charcoal is the sole intervention necessary to treat serious poisonings. This may be used with or without a cathartic

  38. Poison Control Centers • 1-800-222-1222 • 617-232-2120 • May be helpful in identification of toxins based on symptoms alone

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