Tips an tricks in approaching to poison patients

..

1.

2.

3.

(movement disorders)

rhabdomyolysis, hyperthermia, pulmonary aspiration, lactic
acidosis hyperkalemia

4.

fulminant hepatitis, noncardiogenic pulmonary edema cellular hypoxia

aerobic metabolism

5.

(basic life support)

(airway) (breathing)
(circulation)

1. (airway): (endotracheal

tube)
succinylcholine

vecuronium

a.

butyrylcholinesterase (pseudocholinesterase)

succinylcholine
succinylcholine
succinylcholine

b. hyperkalemia

hyperkalemia cardiac glycosides
hydrofluoric

c. rhabdomyolysis
sympathomimetics

2. (breathing): ventilating bag

salicylate

metabolic acidosis

respiratory alkalosis
minute

ventilation relative respiratory

acidosis

salicylate

3. (circulation):

(external cardiac massage)

(
)

( )

metabolic

acidosis

Toxidrome (toxic syndrome)

(1)

1.

toxidrome

(1)

2.

( 2)

3.

a. (qualitative test)


benzodiazepines, cocaine, amphetamines
opiates
b.

(quantitative test)

(i)

serum
paracetamol iron urine paraquat test

(ii) toxidrome

serum salicylate, theophylline, lithium, digoxin,

ethylene glycol, methemoglobin, carboxyhemoglobin,

iron, methanol cholinesterase activity ( 3)

1. :


(Gastrointestinal decontamination)

1. (Gastric lavage)
a. :

i. endotracheal tube

ii.

iii. nasogastric tube

iv.
syringe

v. activated charcoal 50 g. (1g/kg)

vi. 200-300 ml nasogastric
tube

2,000 ml

b. :
60

c. : gastric lavage
i.


(endotracheal tube)

ii.
sustain-released tablets (
; )

iii.

hydrocarbon

d. :

i.

ii.
iii.
2. (Single dose activated charcoal
administration)

a. :

i. activated charcoal 50 g. (1 g/kg) 500

ml ( 10 ml/ charcoal 1 g)

ii. charcoal nasogastric tube

b. :

2-4

c.
i.


(endotracheal tube)

ii.

hydrocarbon

d. :

3. (Whole bowel irrigation)

a. :

i. polyethyleneglycol
in balanced electrolyte

ii. nasogastric tube 2

/ 35 ml/ kg/

iii.

b.

i. sustain-released tablets

ii.

c.

i.
(endotracheal tube)

ii. (ileus)
d.

i.

ii.
:

15% Fuller earth 1,000 mL

7% Bentonite 2,000 mL
activated charcoal

2. :

(
)

1. Phenol

1.1 5

70% isopropanol (rubbing alcohol)

1.2 5

70% isopropanol (rubbing alcohol)

polyethylene glycol
(Colyte)

2. Hydrofluoric acid calcium

gluconate solution (10% calcium gluconate 50 mL NSS 500 mL)

() calcium

gluconate gel solution (10% calcium gluconate 10 mL gel 60

mL)

(enhancement
of elimination, 4)

(latent period)

superwarfarin

1: Toxidrome

Toxidrome

toxidrome
Alpha-

Hypertension,

Pseudoephedr

adrenergic

(reflex) bradycardia,

ine,

mydriasis,

phenylpropan

Phentolamine,
sodium nitroprusside
atropine

diaphoresis

olamine

Sympathom Hypertension,

Amphetamine

imetic

, cocaine

tachycardia,

bradycardia
hypertension
Phentolamine, sodium

hyperthermia,

nitroprusside beta-

agitation and

adrenergic antagonist

confusion, tremor,

intravenous propanolol

mydriasis,

beta-adrenergic

diaphoresis,

decreased bowel

hyperthermia

movement
Sympatholy Alteration of

Opiate and

Airway protection and

tic

consciousness,

opioids,

bradypnea,

Imidazolines

bradycardia-apnea,

(Clonidine,

miosis, hypotension,

tetrahydrazoli

decreased bowel

ne,

vasopressor

sounds

oxymetazolin

hypotension

ventilatory support
Naloxone for depressed
respiratory rate
Volume replacement and

e)
Cholinergic

Hypertension and

Organophasp

Cholinesterase activity

(nicotinic + tachycardia (early),

hates,

Atropine and pralidoxime

muscarinic)

hypotension and

carbamates,

bradycardia (late),

physostigmin

coma, diaphoresis,

increased secretion
(bronchial, saliva,
tear), diarrhea,
bronchospasm,
increased peristalsis,
muscle fasciculation
& weakness,
alteration of
consciousness

10

Anticholine

Hypertension,

Atropine,

rgic

tachycardia,

scopolamine,

hyperthermia,

benztropine,

ECG

agitation and

antihistamine,

physostigmine

confusion, dry

tricyclic

sodium channel blockade ECG

mucosa, mydriasis,

antidepressant

toxidrome

dry skin, decreased

agitation
benzodiazepine

hyperthermia

bowel movement
and urine retention
Wide-anion

: A MUDPILE: Alcoholic

gap

ketoacidosis, Aspirin (

metabolic

salicylates), Methanol, Uremia,

acidosis

Diabetic ketoacidosis, Phenformin

retinal arteries and veins

metformin

( cyanide)

, Isoniazid

eye ground

isoniazid poisoning, Lactic acidosis

Salicylate level, osmol gap

[hypoxia, shock, systemic

(methanol ethylene

asphyzxiants-cyanide, carbon

glycol), urine oxalate crystal

monoxinde], Ethylene glycol

(ethylene glycol), paired

arterial & venous blood gas
(cyanide), carboxyhemoglobin
Empirical treatment: pyridoxine
5 g intravenous 5
(
isoniazid)

2: Electrocardiographic toxidromes
ECG

ECG sign

Digitalis

T wave changes

Digoxin,

Toxidrome
therapeutic
effects

(flatting, iversion,

digitoxin

biphasic), U wave

11

 ST segment
depression
QT interval shorting
PR interval
prolongation

Digitalis
toxicity

Ectopic rhythms/

Digoxin,

Lidocaine, phenytoin,

Triggered

digitoxin,

digoxin-specific

automaticity

oleander, toad

immunoglobulin

- Atrial tachycardia

venom

with
block
Nonparoxysmal
junctional
tachycardia
-

Prematur
e ventricular
contraction

Ventricu
lar tachycardia,
flutter, fibrillation

Bidirecti
onal ventricular
tachycarida

Sinoatrial arrest
AV block (with/
without ectopic
rhythms)

Betaadrenergic
blocker,

Bradyarrhythmias

Beta-adrenergic

AV Blocks

blocker, calcium

Glucagon, calcium

channel blocker

Calcium

12

channel
blocker
Lithium

T wave flattening

Lithium

Hemodialysis if indicated

and inversion, U

Seizure

wave both at

Coma

therapeutic and

Impaired renal

toxic levels

function

Sinus node
dysfunction
(bradycardia,
junctional escape
rhythm)

Sodium
channel

blockade

Sinus tachycardia

Tricyclic

NaHCO3, NaCl (bolus)

Widening of the

antidepressant,

Indications:

QRS interval

antipsychotics

1. R in aVR > 3 mv.

(especially

2. R/S in aVR > 0.7

of the terminal 40-

thioridazine and

3. QRS interval >

msec frontal plane

mesoridazine),

QRS vector

diphenhydramine,

(prominent R in

cocaine,

tachycardia,

aVR)

carbamazepine,

ventricular

propanolol,

fibrillation

Rightward deviation

Prolonged QT
interval

120 msec
4. Ventricular

propoxyphene,

Physostigmine is

quinine, Class 1a

contraindicated.

and 1 c
antidysrhythmics

Hydrofluoric Prolonged QRS and

acid

QT intervals

3:

13

Serum

1.

paracetamol
level

2.

paracetamol

Matthew-Rumack Nomogram

liver enzyme

treatment line

paracetamol

paracetamol
`paracetamol

Serum iron
level

1.

iron

2.

acute hemorrhagic

gastroenteritis

serum iron 500 mcg/dL

serum iron350
mcg/dL intravenous
deferroxamine

Urine

paraquat

paraquat test

moderate toxicity (

(urine

dithionite

immunosuppressive therapy

test)

2-24

paraquat

Serum
salicylate
level

1.

salicylate

2.

Therapeutic range = 10-20 mg/dL

chronic salicylate

salicylate

intoxication

tinnitus,

therapeutic range

pulmonary edema wide anion

gap metabolic acidosis

Serum
theophylline
level

1.

theophylline

2.

theophylline

Therapeutic range = 10-20 mg/L

chronic theophylline
intoxication
35-40 mg/L

sympathomimietic toxidrome,
seizures, hypokalemia,
hypophosphatemia

14

hyperglycemia
Serum
lithium level

1.

lithium

2.

lithium

Therapeutic range = 0.4-1.2 mEq/L

chronic lithium
intoxication

therapeutic range
tremor rigidity ECG signs
Serum
osmolarity

1.

methanol,

ethylene glycol
2.

osmol gap
osmol gap (measured osm-

wide anion gap

metabolic acidosis

calculated osm)
calculated osm = 2[Na] +
[glucose]/2.8 +
[BUN/2.8]
normal osmol gap = -2 10
mosm/L
methanol ethylene glycol
osmol gap

Methemoglo

Central cyanosis

bin

oxygen therapy

oxygen -

Carboxyhem

oxygen

oglobin

carbon monoxide

Cholinesteras cholinergic toxidrome

e activity

Cholinesterase activity < 50%

Serum

digoxin level hyperkalemia

ecg toxidrome

Therapeutic range digoxin =

0.5-2 ng/mL
chronic digoxin
intoxication
therapeutic range

4: Enhancement of elimination

15

Enhanceme

nt of

elimination
Multiple-

activated

ileus,

activitaed

(0.5-1g/kg) 2-

dapsone,

obstruction

dose

charcoal

charcoal 20-30 g.
3

Carbamazepine,
quinidine,

intestinal

phenobarbital,
phenytoin,

theophylline

valproic
acid
Uninary

7.5% sodium

alikalinizati bicarbonate 50mL

on

Phenobarbital

renal failure

salicylate

volme

sodium bicarbonate

alkalosis,

D5W 1000

150-200mL/

7.5%

overload,

150mL

hypokalemia

hypomagnesemi

pH
7.5
Hemodialys hemodialysis

is

Ethylene glycol,

Hypotension

lithium,

16

methanol,
phenobarbital
potassium,
salicylate,

theophylline
valproic
acid

1.

Part 8: advanced challenges in resuscitation. Section 2: toxicology in ECC.

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2.

Position paper: whole bowel irrigation. J Toxicol Clin Toxicol

2004;42(6):843-54.
3.

Accornero F, Pellanda A, Ruffini C, Bonelli S, Latini R. Prolonged

cardiopulmonary resuscitation during acute disopyramide poisoning. Vet Hum

Toxicol 1993;35(3):231-2.
4.

Bartlett D. Dermal exposure to hydrofluoric acid causing significant

systemic toxicity. J Emerg Nurs 2004;30(4):371-3.

5.

Bosse GM, Matyunas NJ. Delayed toxidromes. J Emerg Med

1999;17(4):679-90.
6.

Brancato DJ. Recognizing potential toxicity of phenol. Vet Hum Toxicol

1982;24(1):29-30.
7.

Caravati EM. Acute hydrofluoric acid exposure. Am J Emerg Med

1988;6(2):143-50.
8.

Chyka PA, Seger D, Krenzelok EP, Vale JA. Position paper: Single-dose

activated charcoal. Clin Toxicol (Phila) 2005;43(2):61-87.

9.

Flanagan RJ. The poisoned patient: the role of the laboratory. Br J Biomed

Sci 1995;52(3):202-13.
10.

Huggins RM, Kennedy WK, Melroy MJ, Tollerton DG. Cardiac arrest

from succinylcholine-induced hyperkalemia. Am J Health Syst Pharm

2003;60(7):694-7.
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11.

Matsuno K. The treatment of hydrofluoric acid burns. Occup Med (Lond)

1996;46(4):313-7.
12.

Miller B, Craddock L, Hoffenberg S, Heinz S, Lefkowitz D, Callender

ML, et al. Pilot study of intravenous magnesium sulfate in refractory cardiac

arrest: safety data and recommendations for future studies. Resuscitation
1995;30(1):3-14.
13.

Olczak S. Tricyclic antidepressant poisoning and prolonged external cardiac

massage during asystole. Br Med J (Clin Res Ed) 1981;283(6305):1548-9.

14.

Olson KR, Pentel PR, Kelley MT. Physical assessment and differential

diagnosis of the poisoned patient. Med Toxicol 1987;2(1):52-81.

15.

Orr DA, Bramble MG. Tricyclic antidepressant poisoning and prolonged

external cardiac massage during asystole. Br Med J (Clin Res Ed)

1981;283(6299):1107-8.
16.

Orzel JA. Tricyclic antidepressant poisoning and prolonged external cardiac

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17.

Perez Guillermo F, Martinez Pretel CM, Tarin Royo F, Pena Macias MJ,

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1988;61(2):233-6.
18.

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19.

Selden BS, Burke TJ. Complete maternal and fetal recovery after

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20.

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succinylcholine administration in undiagnosed acute organophosphate poisoning.

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21.

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24.

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19