1 / 46

RESUSCITATION OF THE POISONED PATIENT

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

yamal
Télécharger la présentation

RESUSCITATION OF THE POISONED PATIENT

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. RESUSCITATION OF THE POISONED PATIENT Dr Andy McClelland Dept. of Emergency Medicine Auckland Hospital

  2. COMMON POISONINGS • Substance abuse - ‘recreational’ Alcohol's, narcotics, sedatives, stimulants, hallucinogens • Intentional overdose Suicide / Parasuicide • Accidental Mislabelled containers / paediatric age group • Toxic exposures Gases , sprays, house fires 5 YR TOXICOLOGY 2003

  3. A journey into the unknown? 5 YR TOXICOLOGY 2003

  4. EVALUATION • Recognition of poisoning • Identification of the poison • Prediction of toxicity • Assessment of severity 5 YR TOXICOLOGY 2003

  5. MANAGEMENT • Supportive care • Prevention of poison absorption • Administration of antidotes • Enhancement of elimination • Prevention of re-exposure • Treat associated conditions/injuries • Disposition of the patient 5 YR TOXICOLOGY 2003

  6. “ The surest poison is time.” Ralph Waldo Emerson (1803-1882)

  7. Suspectoverdose / 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 • Condition upon arrival • Likely course of the poisoning • Other injuries / medical conditions • 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 • Triage • Position patient • A, B, C, D • Blood glucose, Temperature • Monitor – SaO2, ECG, BP, LOC 5 YR TOXICOLOGY 2003

  12. INITIAL PATIENT MANAGEMENT- if unwell Airway • 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 • Barrier precautions where applicable • External decontamination • Adequate ventilation • Avert / control violent behaviour • 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 • The substances ingested • The quantities ingested • The time since ingestion • Any treatment to date • 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- toxidromes • Anticholingeric • Cholingeric • Sympathomimetic • Narcotic • Sympatholytic • Extrapyramidal movement disorders • Haemoglobinopathies • 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 3 Consider 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 5 YR TOXICOLOGY 2003

  27. PREVENTION OF POISON ABSORPTION ‘Decontamination’ Note - staff may be at risk

  28. DECONTAMINATION 1 • Skin • Remove contaminated clothing / wash skin • Gastrointestinal • Activated charcoal (in 1st hour post ingestion) x Emesis(‘ipecac’ ) – rarely used x 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 donebut 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 5 YR TOXICOLOGY 2003

  34. ENHANCEMENT OF ELIMINATION • Diuresis • Multiple-dose activated charcoal • Urinary pH manipulation - salicylate • Haemodialysis - small molecules, low protein binding - e.g. salicylate, Lithium • 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 • Discharge Prerequisites: • Medical fitness • ‘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? 5 YR TOXICOLOGY 2003

More Related