poisoning and ingestions Flashcards
initial mgmt when presented with a poisoned pt?
- Gross decontamination beforehand
- ABC, VS
- Cont. Cardiac monitoring, ECG
- IV access - Large bore or central line
- HoTN: IV crystalloid bolus - Bedside glucose
- ABG
- Mental status, Pupil size, Skin check
Toxin-induced QRS interval prolongation can be seen with what medications?
Antidepressants, antipsychotics, antihistamines, organophosphate insecticides
SVT can be caused by what meds?
Sympathomimetics, Anticholinergics
V Tach can be caused by what meds?
Sympathomimetics, TCA
bradycardia can be caused by what meds?
cholinergics, opioids, sedative-hypnotics
initial tx for AMS
coma cocktail
- dextrose
- naloxone (Narcan)
- thiamine
initial tx for seizures
poisoned pt
- IV lorazepam - Double the dose if no improvement within a few mins
- seizure persists - IV phenobarbital, intubate
- Isoniazid-induced - pyridoxine
What medication is ineffective for stopping seizures caused by most poisonings?
Phenytoin
how/what to obtain a brief hx about the poisoned pt?
- Pt may be unreliable - correlate with pt’s sx
- Get hx from others - EMS, police, family, friends, etc
- Inquire about exposures
- Other ill contacts - CO, foods, chemical and biological warfare agents
The ____, ____, and ____ help classify the pt into either a state of physiologic excitation or depression
mental status, VS, and pupillary examination
- signs of physicologic excitation?
- what meds can cause this?
- CNS stimulation, mydriasis
- Tachycardia, inc BP, RR and temp
- Etiologic toxidromes: anticholinergic, sympathomimetic, serotonin syndrome, hallucinogens
- signs of physiological depression?
- what meds can cause this?
- AMS, miosis, Low BP, RR and temp
- Etiologic toxidromes: sedative-hypnotic agents, opiates, cholinergics
what meds can cause Mydriasis?
- anticholinergics
- sympathomimetics
dilated pupils
what meds can cause Miosis?
- cholinergics
- opioids
small pupils
what meds can cause Nystagmus?
Ethanol, phenytoin, ketamine, PCP
what med can cause Excessive lacrimation
cholinergics
- what meds can cause hypersalivation?
- excessive dryness?
- cholingerics
- anticholingergics
possible findings of abominal exam from a poisoned pt?
signs and their meds
- bowel sounds - diminished in anticholinergic and opiates
- enlarged bladder - anticholinergic
- abdominal tenderness or rigidity - ASA, anticholinergic
what meds can affect muscle tone and tremor or fasciculation
cholinergics,serotonin
general w/u for poisoned pt?
- Abd XR
- CXR
- Tox screen
- Concentrations of common coingestants
- UA
When is a tox screening not needed?
- non-intentional ingestion and asx OR
- clinical findings consistent with MHx
individual tox screening may be needed to determine specific tx for what 2 meds?
lithium, digoxin
what 3 specific concentrations should always obtain in any person with unknown ingestion
APAP, ethanol, and salicylate
Calcium oxalate crystals may be present with what type of poisoning
ethylene glycol (antifreeze)
preferred method of gastric decontamination?
Activated Charcoal (AC) 1g/kg
- absorbs toxins in stomach
- not able to bind metals, corrosives or alcs
indication for activated charcoal?
- if ingestion < 1 hr prior to arrival
- can be used after 1 hour if toxins that slow GI transit (anticholinergics) and those that form bezoars (salicylate)
CI for activated charcoal?
unable to protect airway
- removes non-absorbed toxins
- High risk of aspiration - avoid unless pt is intubated or airway protective reflexes are intact
which type of gastric decontamination?
lavage
indications for gastric lavage?
- ingestion has occurred < 1 hr prior to presentation
- no antidote
- toxin has a poor response to supportive care
how to perform gastric lavage?
- Insert 36F-40F orogastric tube
- LLD w/ HOB tilted down
- 200 ml of warm tap water instilled into stomach and removed via gravity or suction
what gastric decontamination is indicated for:
- ingestion of chemicals poorly adsorbed to charcoal (lithium, iron, lead)
- ingestion of drug-filled packets
Whole bowel irrigation
how to perform Whole bowel irrigation?
Instil a electrolyte polyethylene glycol soln (GoLYTELY) to flush out entire intestinal tract
- via NG tube, 1–2 L/h (400–500 mL/min in children)
- Continue until rectal effluent is clear (3–5< hr)
CI of whole bowel irrigation
absent bowel sounds or suspected ileus or obstruction
indications, CI, and caution of multi-dose activated charcoal?
- carbamazepine, dapsone, phenobarbital, quinine, and theophylline
- unprotected airway, absent BS
- ingestions resulting in reduced GI motility
what method of enchanced elimination ionizes acidotic toxins preventing resorption back across the renal tubule
Urinary alkalinization
indications and caution for Urinary alkalinization
- moderate-severe salicylate toxicity
- hypokalemia will reduce the alkalinity of the urine
how to perform urinary alkalinization?
- Give IV NaHCO3 +/- KCl
- monitor serum K and HCO3 q 2-4 h
- Serum K goal 4-4.5 mEq/L range - assess urine pH q 15-30 min
- pH goal 7.5-8.5
which type of Extracorporeal removal is more effective at clearing highly protein-bound drugs and lipid-soluble drugs?
hemodialysis
when to use hemoperfusion as a choice for enhanced elimination?
for clearing water-soluble low molecular wt substances
4 indications for antidotes?
- exposure to toxin where a antidote exists
- severity of toxicity warrants use
- benefits outweigh its associated risk
- no CIs