Clinical Toxicology
Clinical Toxicology
Clinical Toxicology
Presentation overview
Epidemiology of poisoning General approach to the poisoned patient Update on poison treatment methods Most common errors in Medical Toxicology Specific Poisoning
Medical Toxicology
Predominately comprised of physicians from the specialties of: Emergency Medicine Internal Medicine Pediatrics Occupational Medicine Critical care
Clinical Toxicology
Significant role for scientists, analytical chemists, industrial hygienists, nurses and pharmacists Poison center management and specialists Poison prevention (industrial and home directed education) Industrial/ occupational toxicology
Epidemiology of Poisoning
Approximately 1,500 cases of fatal poisoning are reported to the American Association of Poison Control Centers each year Settings include workplace, home and recreational 2 to 3 million people poisoned annually, most ingestions managed by poison centers Accidental poisoning occurs mainly in children Half of poisoning fatalities are intentional
Analgesic agents Cosmetics/ personal care products Household cleaning products Sedative hypnotics/ antipsychotics Foreign bodies/ toys Cough/ cold OTC preparations Topical preparations Pesticides
6
Systematic Treatment and Diagnostic Actions in Parallel Goal is rapid stabilization, categorization of poison class, initiation of general treatment then specific treatment when available
1. Stabilization 2. Rapid Patient Evaluation (Physical, Lab) 3. Prevention of further toxin absorption 4. Enhancement of toxin elimination 5. Specific antidote 6. Supportive therapy
History is often absent or unreliable Information from any source usually helpful Physical exam is very important
10
Odor
Bitter almonds Eggs Mothballs Wintergreen Garlic
Poison
cyanide hydrogen sulfide, mercaptans naphthalene, camphor methylsalicylate As, org- phosphates, DMSO, Thallium
12
Toxic Syndromes
13
Clinical appearance: diaphoresis (sweating), piloerection, mydriasis and hyperreflexia. In severe cases, seizures, hypotension (later effect) and dysrhythmias may occur.
14
15
SLUDGE
Clinical appearance: altered mental status coma, miosis, diminished bowel sounds, needle tracks, pulmonary edema, hyporeflexia.
17
Case Example
A 29-year-old male is brought to the emergency department by friends who report he has had several generalized seizures in the last 30 minutes. The patient is awake, hyper-alert and unwilling to provide a history. BP= 200/110. P=140/ min, RR = 22min, T=38.1C Skin is cool. Pupils are dilated and reactive. CV reveals tachycardia only. Abdomen reveals present bowel sounds, nontender. Neurologic exam reveals a resting tremor, brisk (3/4) reflexes and nonfocal exam.
18
Toxic Syndrome
19
Important clues are usually found in routine labs NEVER DELAY THERAPY WHILE WAITING FOR LAB DATA
20
Anion Gap
Valuable information from a routine lab test Calculated from serum electrolytes Anion Gap = [Na] ([HCO3 ] + [CI]) Normal anion gap = 12 2mEq/L
21
AT MUD PILES
A ALCOHOL (ETHANOL KETOACIDOSIS) T TOLUENE M METHANOL U UREMIA D DIABETIC KETOACIDOSIS P I L E S PARALDEHYDE IRON, ISONIAZID LACTIC ACID ETHYLENE GLYCOL SALICYLATE
22
pH pCO2 pO2
23
Osmolar Gap
Difference between measured and calculated serum osmolality Seen in the presence of low molecular weight toxins
normal = 0-10 mOsm Calc Ser Osm = 2 [Na] + [ Glucose/ 18] + [BUN]/ 2.8
24
Na = 140 mEq/L Glucose = 100 mg/ dl Blood urea nitrogen (BUN) = 12mg / dl Serum Osmolarity (measured) = 330 mOsm OSM GAP = 330 mOSM [[2x140] + [100/18] + [12/2.8]] OSM GAP = 330 - [280 + 5.6 + 4.3] =330-290 OSM GAP = 40 mOsm (elevated)
25
26
Radiology Evaluation
27
Radiology Evaluation
CHIPES
C chloral hydrate, chloroform, CCI4 H heavy metals I iron P phenothiazines E enteric coated S sustained release
28
29
Emesis with syrup of ipecac Gastric lavage Activated charcoal Whole bowel irrigation
30
Induction of Emesis
Syrup of Ipecac Former standard of home use, now use is rare and considered controversial in 2006 Largely replaced by activated charcoal or no treatment Contraindications: Children less than 6 months old Seizures or absent gag reflex Ingestion of corrosives, hydrocarbons or sedating drugs if past 30 minutes post ingestion
31
Induction of Emesis
Bottom line:
32
Case Example
The parents of a 3-year-old male weighing 13 kg call the Arizona poison control center to report that their child just ingested several prescription of iron tablets. The poison control specialist determines the prescription was filled 3 days ago, the bottle contained 100 ferrous sulfate tablets, each containing 65 mg of elemental iron. The mother (patient) used 4 tablets, 62 tablets remain in the bottle. The ingestion occurred approximately 10 minutes ago. The child is assymptomatic. The family lives in a remote area, the closest health care facility is 3 to 4 hours away.
33
Case Example
Dose estimation: 100 4 = 96 -62 = 32 Fe tablets missing 34 Fe tablets x 65 mg Fe/tablets = 2,210 mg elemental Fe 2,210 mg Fe/13 kg = 170 mg Fe/ kg
Refer to hospital if > 20-30 mg Fe/ kg High likelihood of severe toxicity if > 50 mg/ kg ingested
34
Gastric Lavage
Former ER standard, now very limited role Accomplished with an orogastric tube Airway protection important Contraindications:
Ingestion of corrosives Possibly ingestion of hydrocarbons
35
Activated Charcoal
Recommended for almost all ingestion Inadequate dosage is the most common error Initial dose with cathartic
36
Activated Charcoal
Not effective for: Li, Fe and other metals K+ , I and other halides Corrosives
37
Procedure:
use PEG ELS solution 1.5 2 L/ hr in adults (0.5 L/hr children) oral administration or via NG tube 6 hrs or clear effluent
38
Uses: Body packers (best evidence) Oral OD with sustained release compounds Oral OD with agents not absorbed by activated charcoal
39
Contraindications: Hemodynamic instability Diarrhea or anticipated diarrhea GI obstruction, perforation or hemorrhage Unprotected or comprised airway
40
41
Alteration of Urine pH
ONLY ALKALINIZATION
Ion trapping 2 amps NaHCO3 in D5W at 70 to 150 cc/hr Target: urine pH 7.5 to 8.5 Uses: salicylate OD (best evidence)
American Association of Poison Control Centers and the European Association of Poisons Centers and Clinical Toxicologists 2004 Position Paper on Urinary Alkalinization recommends this procedure for moderately severe salicylate poisoning for patient not meeting criteria for hemodialysis
42
High water solubility Low volume of distribution Low molecular weight Low protein binding
43
45
46
Hemoperfusion
Cartridge availability limited (medical centers): Uses: Severe theophylline Amanita toxin Paraquat Meprobamate
47
0.5 1.0 gm/ kg every 2-4 hours by mouth / NG Interrupts enterohepatic circulation Gut dialysis Enhances the clerance of several drugs including: Carbamazepine Dapsone Digoxin Digitoxin - Nadolol - Phenobarbital - Salicylates - Theophylline
48
Available for relatively few poisons Includes: Antibody fragments Chelating Agents Pharmacologic Antidotes Biochemical Antidotes
49
Naxone: reverses narcotic effects Sodium bicarbonate: tricyclic antidepressants Methylene blue: methemoglobin forming toxins Glucagon, atropine, isoproterenol: reverses bradycardia causing toxins Alpha and beta adrenergic blockers (not pure beta only): reverses sympathomimetic agents hypertensive effects
50
Methanol Metabolism
52
53
Vitamin K for warfarin induced bleeding Vitamin B6 for isoniazid induced seizures Atropine and pralidoxime for cholinesterase inhibitors Reduced folates and thymidine for methotrexate induced leukopenia
54
Deferoxamine for Fe Dimercaptosuccinic acid, Dimercaprol, CaEDTA, penicillamine for Pb DMSA, DMPS, N- acetylpenicillamine, BAL for Hg
55
IV N-acetylcysteine (NAC) acetaminophen Fomepizole ethylene glycol and methanol Glucagon or insulin glucose Ca/ beta blockers Octreotide oral hypoglycemic agents
57
L carnitine valproate liver toxicity Physostigmine gammo hydroxybutyric acid and pure anticholinergics Crotalid polyvalent immune Fab crotalid envenomation Hydroxocobalamin cyanide chelator (approved 12/06)
58
6. Supportive Care
Close monitoring for late toxic effects Vigilance for hospital acquired disease Nosocomial infections Aspiration pneumonia Latrogenic fluid / electrolyte abnormalities Psychiatric consultation for intentional ODs
59
Update highlights
GI decontamination: Ipecac now less commonly used Gastric lavage seldom used Whole bowel irrigation Expanded use of activated charcoal Toxin elimination: Hemodialysis >> Hemoperfusion Expanded use of multiple dose activated charcoal
60
SUMMARY
A systematic approach has proven to be the most efficacious way to treat critically ill poisoned patients. Categorization of the poisoned patients clinical appearance into a toxic syndrome allows the clinician to initiate effective treatment without knowing the specific poison involved. More research is needed to develop new and more effective treatments for poisoning.
62
We Innovate Healthcare
63