Introduction to

Toxicology

Medical Toxicology....

Is a board-accredited specialty requiring at

least two years of training after residency in
either emergency medicine, pediatrics,
internal medicine or preventative medicine.
Deals with the diagnosis, management
and prevention of poisoning and other
adverse health effects due to medications,
occupational and environmental toxins, and
biological agents

This lecture will condense this

information into two parts:

The approach to the poisoned patient

Case scenarios

Part I: Approach to the poisoned

patient.

Attempts to identify the poison should not delay

care.
Initial management of the poisoned patient begins
with the ABCs.
ACLS algorithms apply in toxicology with only a
few exceptions.
Once these are stable, begin considering how to
minimize bioavailability. Then you may begin
your history and physical.

History: find out all of this

information:

The question words:

Which drug(s) were taken?
When was it taken?
How much was taken?
How was it taken?
Why was it taken?
Was anything else taken? (Consider co-ingestants:
other things which may be in this persons
medicine cabinet.)

History continued....

Patients who overdose or use illicit drugs

may be unreliable.
Gather info from paramedics, family,
friends, the PCP, old medical records, pill
bottles the patient has on them, their
occupational environment or by having
people return to the scene where the
incident took place.

History continued....
Obtain a clinical history from
family/friends or paramedics:
- patients behavior prior to arrival
- changing vital signs
- seizures

Physical Examination:

Vital Signs: You MUST obtain a full set of

vital signs, including blood glucose.
Vital signs are the key to your initial
management of the patient....

Vital signs: Pulse

Bradycardia
(P.A.C.E.D.)
Propanolol, poppies
Anticholinesterases
Clonidine, CCBs
Ethanol
Digoxin

Tachycardia
(F.A.S.T.)
Freebase
Anticholinergics/
Antihistamines
Amphetamines
Sympathomimetics
Solvents
Theophylline

Vital signs: Temperature

Hypothermia
(C.O.O.L.S.)
Carbon monoxide
Opiates
Oral hypoglycemics
Liquor
Sedatives/Hypnotics

Hyperthermia
(N.A.S.A.)
N.M.S., Nicotine
Antihistamines
Salicylates
Sympathomimetics
Anticholinergics
Antihistamines

Vital signs: Blood pressure

Hypotension
(C.R.A.S.H.)
Clonidine, CCBs
Reserpine
Antihypertensives
Antidepressants
Aminophylline
Sedative/Hypnotics
Heroin (opiates)

Hypertension
(C.T.S.C.A.N.)
Cocaine
Thyroid supplements
Sympathomimetics
Caffeine
Anticholinergics
Amphetamines
Nicotine

Vital signs: Respiration rate

Hypoventilation
(S.L.O.W.)
Sedative/Hypnotics
Liquor
Opiates
Weed (marijuana)

Hyperventilation
(P.A.N.T.)
PCP
Pneumonitis
Noncardiogenic
pulmonary edema
Toxic met. acidosis

Physical: Neurologic exam

Mental status
(AEIOU TIPS)
Alcohol
Endocrine/Epilepsy
Intoxication
Oxygen
Uremia
Trauma/Tumor
Infection
Psychological
Shock/Strokes

Seizures
(OTIS CAMPBELL)
Organophosphates
Tricyclics
INH/Insulin
Sympathomimetics
Camphor/Cocaine
Amphetamines
Methylxanthines
PCP
Benzo withdrawal
Ethanol
Lead, Lithium
Lidocaine, Lindane

Physical exam: Pupils

Miosis
(C.O.P.S.)
Cholinergics
Clonidine
Opiates
Organophosphates
Pontine bleed
Phenothiazines
Sedatives/Hypnotics

Mydriasis
(A.A.A.S)
Antihistamines
Antidepressants
Anticholiergics
(Atropine)
Sympathomimetics
(Cocaine)

Physical: Dermatological exam

Diaphoresis
Red Skin
Blue Skin
(S.O.A.P.)
CO
Cyanosis
Sympathomimetics
Boric Acid
MetHb
Organophosphates
Anticholinergics
ASA
PCP
Blistering
Barbituates, CO, Sedative hypnotics, snake/spider bites

Odors...
Bitter almonds:
Mothballs:
Garlic:
Peanuts:
Carrots:
Rotten eggs:
Wintergreen:
Gasoline:
Fruity:
Pears:

Cyanide
Camphor
Organophosphates, Arsenic
Rodenticide
Water hemlock
Sulfur dioxide, HS
Methyl salicylates
Hydrocarbons
DKA, Isopropanol
Chloral hydrate

Epidemiology of Toxicology...
The majority of poisonings were
unintentional.... But, the majority of
deaths secondary to poisoning were
intentional.
Most poisonings are by ingestion and most
poisonings occur at home.

Epidemiology continued...
The most commonly reported poison?
Analgesics!
The least commonly reported?
Alcohol!
Which is associated with the most deaths?
Analgesics!
Which is associated with the least deaths?
Hydrocarbons!
The number one poisonous killer?
Carbon monoxide!

Lab tests/Diagnostics...
EKG. Why?
To look for conduction delays and ischemia.
(sympathomimetics, B-blockers, TCAs, digoxin,
CCBs, CO)
CMP. Why?
To calculate anion gap and osmolality. (CAT MUD
PILES and ME DIE mnemonics)
Tylenol and Aspirin levels. Why?
Because of the frequency of abuse and co-ingestion.

Lab tests/diagnostics continued...

Serum volatiles (this tells you quantitative amounts
of alcohols). Why? When?
With AMS of unknown etiology, for legal purposes,
for unexplained osmolar gaps.
Drug screens. Why? When?
With urine: Screening purposes only. (This rarely
changes your management)
With blood: For quantitative information regarding
specific ingestants.

Imaging...
Chest XR:
(Pulmonary Edema)
(M.O.P.S.)
Meprobamate
Methadone
Opiates
Phenobarbital
Propoxyphene
Salicylates

KUB:
(C.O.I.N.S.)
Chloral hydrate
Cocaine packets
Opiate packets
Iron (Heavy metals)
Neuroleptics
Sustained release/
enteric coated tabs.

Management...
Coma cocktail (Dextrose, Narcan,
Thiamine)
- Check blood sugars (the sixth vital sign)
- Narcan has side effects too!
- Thiamine for the malnourished
Flumazenil is reserved for people who we
overdose with benzos!

Management (GI decontamination)

Syrup of ipecac: Is not used
Gastric lavage:
- Used with moderate to severe
overdoses within an hour of ingestion.
-There is a highly variable outcome
with this intervention.
-Lavage is contraindicated with ingestion of
corrosives.

GI decontamination continued...

Activated charcoal:
- Purported to be superior to lavage
- Used in toxic ingestions within an hour of
the ingestion.
- Dosed as 1g/kg or 10:1 ratio of charcoal to
poison
- Given as single dose or multiple dose

Multiple dose

Not adsorbed

(A.B.C.D.)
Antimalarials
Aminophylline
ASA (?)
Barbiturates
B-Blockers (?)
Carbamazepine
Dapsone
Dilantin (?)

(C.H.A.R.C.O.A.L.)
Caustics/Corrosives
Heavy metals
Alcohols
Rapid onset cyanide
Chlorine/Iodine
Other insolubles (tabs)
Aliphatics
Laxatives

GI decontamination...
Cathartics:
- Given with charcoal to enhance
elimination
- Unproven efficacy when used alone.
Whole bowel irrigation:
- May be effective for things not adsorbed
by charcoal
- Used for body stuffers/packers

Decontamination via enhanced

elimination...
Hemodialysis:
(I.S.T.U.M.B.L.E.)
Isopropanol
Salicylates
Theophylline
Uremia
Methanol
Barbiturates
Lithium
Ethylene glycol

Urine Alkalinization:
ASA, Phenobarbital
(Alkalinizing the urine with
NaHCO3 to trap ions of weakly
acidic agents to promote
excretion).
Titrate NaHCO3 to maintain
urinary pH of 7.5-8.0.

Management (Antidotes)...
Toxin
Antidote
Acetaminophen
N-acetylcysteine
Anticholinergics
Physostigmine
Arsenic/Lead
BAL chelation
B-Blockers
Glucagon
Benzos Flumazenil
CO O2, HBO
Cyanide Nitrites
Digoxin Digibind
Ethylene glycol/Methanol
Fomepizole/Ethanol
Iron
Deferoxamine
INH
B6/Pyridoxine
Lead/Mercury
Succimer/DMSA
Methemoglobinia Methylene blue
Opioids Naloxone
Organophosphates Atropine
TCAs
Sodium bicarbonate

Pitfalls...

Ingestion of multiple agents is common

Dangerous drug combinations
Drugs masking the effects of other drugs
All altered mental status is not tox.
Consider trauma (head bleeds) and
metabolic causes (DKA, Thyroid, etc)

Pearls...

Always begin with airway, breathing,

circulation. The poisoned patient is not
exempt from this mantra.
ACLS protocols generally apply to
poisoned patients.
Treat the patient, not the poison. Observe
vital signs and provide supportive care
constantly.

Part II: Case studies

Case 1:
Mr. Smith, a 28 year old male presents in police custody
complaining of chest pain. He has no other past medical
history. No history of cardiac disease.
Patient further states that his chest pain began tonight about one
to two hours after he was arrested by police. No history of
trauma.
Social history=Smokes 1 pack/day. Occasional EtOH.
Family History= No cardiac deaths.
Mr. Smith

Physical exam...

General: Patient very agitated, clutching his chest.

Vitals: P 140, BP 220/130 RR-28 Temp- 103.2F
Eyes: Pupils 7mm, equal, EOMI
Lungs: Clear Bilaterally
Heart: Regular rate and rhythm, 2+/6 systolic
murmur
Abd: Soft, Non-Tender, BS+
Neuro: No focal deficits.
Skin: Diaphoretic

Differential diagnosis???

Sympathomimetics (cocaine? amphetamines?)

Anticholinergics?
Thyroid disease?
Solvents?
Antihistamines?
Undiagnosed hypertension?
Acute MI?
Malingering? (Why did his symptoms begin an
hour after the arrest? Why not immediately?

What do you want to order?

EKG? (grossly abnormal vital signs)

CMP?
TSH?
UTox?
Serum volatiles?
Imaging?
Cardiac enzymes?

EKG:

How should this persons cocaine

related chest pain be managed?
1.
2.
3.

4.

Benzodiazepines- First line therapy (in high

doses)
Nitroglycerin- for control of ischemic pain and
HTN
Labetalol- alpha/beta blocker (the use of
propranolol will leave the alpha portion
unopposed theoretically exacerbating cocaine's
toxicity). Alternatively, phentolamine could be
used.
Nitroprusside- for refractory HTN

This person ingested bags of cocaine. What

is the best method of GI decontamination?
Ipecac
Whole Bowel Irrigation
Cathartics
Activated Charcoal
Dialysis
Urine alkalinization
Gastric lavage

Should other services be involved?

If so, whom?

Tox!
Surgery (Why?)
Cardiology (Why?)

The outcome....

The patient's chest pain and hypertension eventually resolve

with large doses of nitroglycerin and benzodiazepines.
The patient is administered activated charcoal and
polyethylene glycol solution by the ED physician.
Because of the ST segment elevations, the cardiologist elects
to give thrombolytics.
Since thrombolytics were "on board" the general surgeon
refuses to take the patient to the OR for exploratory
laparotomy and removal of the cocaine packets.
The patient is transferred to the ICU, where he eventually
recovers and is discharged with a 10% ejection fraction.

Case 2

The patient is a 18 year old male presenting to the

ED by paramedics after found at home
unresponsive, face down in bed. According to
friends, the patient had consumed two beers and
a glass of wine earlier that day following a period
of depression. The patient was orally intubated in
the field by paramedics after no response to D50
and naloxone administration.

Physical exam:

General: Patient responsive only to deep painful

stimuli
Vitals: BP 150/70, HR=92, RR=24, T=95.4F
Lungs: CTA, BS Equal, (Intubated)
CV: RRR, no murmur
Abd: Soft, Non-Tender, No Trauma, No Masses
Rectal: Normal Tone, HemeNeuro: DTR's Hyporeflexive, Withdraws to
Painful Stimuli

Differential diagnosis??

Alcohol intoxication?
Carbon monoxide?
Sedatives/Hypnotics? (benzos?
barbiturates? muscle relaxants?)
Tylenol?
Trauma?
Large doses of narcotics?

What do you want to order?

CBC?
CMP?
Serum osmolality?
Serum volatiles?
Urine toxicology screen for drugs of abuse?
EKG?

Results:

CBC: WBC 29K HCT=45

Lytes: Na=145 Cl=105 K=5.2 HCO3=5
BUN/Cr: 28/1.8 Glucose 180
Osm: 370 (Measured)
ETOH: 46
Calcium 7.0
Toxicology Screen: Pending
Toxic Alcohols: Pending
What is his anion gap? What is his osmolar gap?
AG: 20. Osmolar gap: 370 (2(Na) + Glu/18 +BUN/2.8
+ETOH/4.6) = 50! (50 is greater than 10, so..... )

Results continued...

EKG shows NSR. No interval changes. No

ST, T or Q wave changes. Normal axis.
Normal R wave progression
CXR: Shows normal sized heart and
mediastinum. No effusions or infiltrates.
No acute disease. ETT in proper position.

How do you want to manage this

patient?
Supportive care only
Gastric lavage
Hemodialysis
Is there a potential antidote for this?
YES! Fomepizole!
We dont have any fomepizole. But we do
have ethanol!

Outcome...

With a strong clinical suspicion for toxic alcohol ingestion, an

ethanol drip is ordered, but due to pharmacy delay, the
patient is orally loaded with 85 proof whiskey obtained from
another patient in the ER waiting room.
Urine is positive for calcium oxalate crystals. Dialysis is
initiated by the renal service, after which an ethylene glycol
level of 310 mg/dl returns 12 hours later.
The patient recovers with mild renal insufficiency, and is
subsequently followed-up by the psychiatric service for his
depression.

References...
1. Erickson TB et al. Toxicology Update: A Rational Approach to
Managing the Poisoned Patient. Emerg Med Pract. 2001;
3(8): 1-28
2. Tuckler, Victor. Introduction to Toxicology handout
3. Rivers, Carol S. Preparing for the Written Board Exam in
Emergency Medicine. 5th Ed. Volume II. PP 735-738
4. Case studies in Toxicology available at:
http://www.uic.edu/com/er/toxikon/cases/allcase.htm
5.

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