INITIAL EVALUATION

OF THE PATIENT: VITAL

SIGNS AND TOXIC
SYNDROMES
OBJECTIVES:
INTRODUCTION
New York Hospital (1865)
Vital signs
pulse rate, respiratory rate, and temperature were
incorporated into the bedside chart
20th century
Blood pressure determination became routine as well
as Additional components of the standard emergency
assessment, such as oxygen saturation by pulse
oximetry, capillary blood glucose, and pain severity
VITAL SIGNS
frequently provide valuable physiologic clues to
the toxicologic etiology and severity of an illness.
a valuable parameter, which are used to assess
and monitor a patients response to supportive
treatment and antidotal therapy.
 NORMAL VITAL SIGNS BY AGE

The normal rectal temperature is defined as 95F to 100.4F (35C38C) for

all ages. For children 1 year of age or younger, these values are the mean
values for the 50th percentile. For older children, these values represent the
90th percentile at a specific age for the 50th percentile of weight in that age
group.
NORMAL VITAL SIGNS
May not accurately stated
Published normal values may have little relevance to
an acutely ill or anxious patient in the emergency
setting, yet that is precisely the environment in
which we must define abnormal vital signs and
address them accordingly.
THE HUMAN BODY AS A TARGET OF
XENOBITIOCS

Many xenobiotics affect the autonomic nervous

system
Affects the vital signs via the sympathetic
pathway, the parasympathetic pathway, or both.
Example:
The value of serial monitoring of the vital signs is
demonstrated by the patient who presents with an
anticholinergic overdose who is then given the
antidote, physostigmine ( tachycardia becomes
bradycardia).
TOXIDROMES
Coined by Mofenson and Greensher
from the words toxic syndromes

describe the groups of signs and symptoms that

consistently result from particular toxins.
usually best described by a combination of the
vital signs and clinically apparent end-organ
manifestations.
TOXIDROMES
the signs that prove most clinically useful are
those involving the central nervous system (CNS;
mental status), ophthalmic system (pupil size),
gastrointestinal system (peristalsis),
dermatologic system (skin dryness versus
diaphoresis), mucous membranes (moistness
versus dryness), and genitourinary system
(urinary retention versus incontinence).
SAMPLE OF TOXIDROMES
BLOOD PRESSURE
Xenobiotics cause hypotension by four major
mechanisms:
1. decreased peripheral vascular resistance
2. decreased myocardial contractility
3. Dysrhythmias
4. depletion of intravascular volume
BLOOD PRESSURE
Hypertension from xenobiotics may be caused by:
1. CNS sympathetic overactivity
2. increased myocardial contractility
3. increased peripheral vascular resistance
4. a combination of these
BLOOD PRESSURE
Blood pressure and pulse rate may vary
significantly as a result of:
1. changes in receptor responsiveness
2. degree of physical fitness
3. degree of atherosclerosis.
COMMON XENOBIOTICS THAT AFFECT THE
BLOOD PRESSURE
PULSE RATE
net result of a balance between sympathetic
(adrenergic) and parasympathetic (muscarinic
and nicotinic) tone.
PULSE RATE
Carotid artery
is usually easily palpable, for reasons of both safety
and reliability
Brachial artery
preferred in infants and in adults older than 60
years.
PULSE RATE
The normal heart rate for adults was defined by
consensus more than 50 years ago as a regular
rate greater than 60 beats/min and less than 100
beats/min.
PULSE RATE
No single vital sign abnormality can definitively
establish a toxicologic diagnosis.
Pulse rate: difference between sympathomimetic and
anticholinergic.
PULSE RATE
Tachycardia both present in sympathomimetic
and anticholinergic toxicities.
Sympathomimetic
Tachycardia is accompanied by diaphoresis or
increased bowel sounds
Anticholinergic
Tachycardia is accompanied by decreased sweating,
absent bowel sounds, and urinary retention
COMMON XENOBIOTICS THAT AFFECT THE
PULSE
RESPIRATIONS

Establishment of an airway and evaluation of

respiratory status are the initial priorities in
patient stabilization.
Usual assessment of respiration includes:
Rate
Depth
Pattern
RESPIRATIONS

Very few investigators have actually measured

the respiratory rate in large populations of
normal people, let alone in emergency
department patients.
Published studies suggest normal respiratory
rates are 16 to 24 breaths/ min in adults with
more rapid rates that are inversely related to age
in children.
RESPIRATIONS

Hyperventilation
may mean tachypnea (an increase in ventilatory
rate), hyperpnea (an increase in tidal volume), or
both.
RESPIRATIONS
Possibility of erroneous diagnosis
When hyperventilation results solely or
predominantly from hyperpnea, the clinicians may
miss this important finding entirely, instead
erroneously describing such a hyperventilating
patient as normally ventilating or even
hypoventilatingif bradypnea is also present.
The ventilatory status of the patient must be viewed
in the context of the patients physiologic condition.
RESPIRATIONS

Hyperventilation may result from the direct

effect of a CNS stimulant.
Example: Direct effect of salicylates on the
brainstem characteristically produces
hyperventilation by tachypnea, but it also produces
hyperpnea, with or without tachypnea.
COMMON XENOBIOTICS THAT AFFECT
RESPIRATION
TEMPERATURE
The core temperature or deep internal
temperature (T) is relatively stable (98.6
1.08F; 37 0.6C) under normal physiologic
circumstances.
Hypothermia (T <95F; <35C) and hyperthermia
(T >100.4F; >38C) are common manifestations
of toxicity.
TEMPERATURE
The risks of inaccuracy are substantial when an
oral temperature is taken in a tachypneic
patient.
An axillary temperature or a temporal artery
temperature is taken in any patient (especially
those found outdoors), or a tympanic temperature
is taken in a patient with cerumen impaction.
TEMPERATURE
Rectal temperatures using a nonglass probe is
essential for safe and accurate temperature
determinations in agitated individuals and is
considered the standard method of temperature
determination in this text.
TEMPERATURE
Life-threatening hyperthermia (T >106F;
>41.1C) from any cause may lead to extensive
rhabdomyolysis, myoglobinuric renal failure, and
direct liver and brain injury and must therefore
be identified and corrected immediately.
TEMPERATURE
Hyperthermia may result from a distinct
neurologic response to a signal demanding
thermal upregulation.
This signal can be from:
internal generation of heat beyond the capacity of the
body to cool, such as occurs in association with
agitation or mitochondrial uncoupling
from an externally imposed physical or
environmental factor, such as the environmental
conditions causing heat stroke
the excessive swaddling in clothing causing
hyperthermia in infants.
TEMPERATURE
Fever, or pyrexia, is hyperthermia due to an
elevation in the hypothalamic thermoregulatory
set-point.
Core temperatures higher than 106F (41.1C)
are extremely rare unless normal feedback
mechanisms are overwhelmed.
TEMPERATURE
Hyperthermia is usually attributed to:
environmental heat stroke
extreme psychomotor agitation
xenobiotic-related temperature disturbances such as
malignant hyperthermia, the serotonin syndrome, or
the neuroleptic malignant syndrome.
TEMPERATURE
Hypothermia is probably less of an immediate
threat to life than hyperthermia, but it requires
rapid appreciation, accurate diagnosis, and
skilled management.
TEMPERATURE
A hypothermic patient should never be declared
dead without both an extensive assessment and a
full resuscitative effort of adequate duration,
taking into consideration the difficulties in
resuscitating cold but living patients.
This is true whenever the body temperature
remains less than 95F (35C)
COMMON XENOBIOTICS
THAT AFFECT TEMPERATURE
End of
Lecture
PRINCIPLES OF MANAGING
THE ACUTELY POISONED
OR OVERDOSED PATIENT
INTRODUCTION
A clinical approach should be directed to
poisoned or overdosed patients that emphasizes
treating the patient rather than treating the
poison.
 Basic guide
to the
management
of poisoned
patients
INTRODUCTION

Initial therapeutic interventions in toxicologic

management should be evidence-based
Providing more rational individualized early
treatment for toxicologic emergencies involves a
closer examination of the actual risks and
benefits of various gastrointestinal (GI) emptying
interventions.
INTRODUCTION
On individualized treatment..
Absence of clear evidence-based support of efficacy
have led to a significant reduction in the routine use
of activated charcoal (AC)
Almost complete elimination of syrup of ipecac-
induced emesis or orogastric lavage and cathartic-
induced intestinal evacuation.
INTRODUCTION
The American Academy of Pediatricians (AAP,
2004)
abandoned its recommendations for the use of syrup
of ipecac in the home.
efficacy of orogastric lavage, even when indicated by
the nature or type of ingestion, is limited by the
amount of time elapsed since the ingestion.
value of whole-bowel irrigation (WBI) with
polyethylene glycol electrolyte solution (PEG-ELS)
appears to be much more specific and limited than
originally thought
some of the limitations and (uncommon) adverse
effects of AC are now more widely recognized.
INTRODUCTION
Review on interventions to eliminate absorbed
xenobiotics
Multiple-dose activated charcoal (MDAC) is useful for
select but not all xenobiotics.
Ion trapping in the urine is only beneficial,
achievable, and relatively safe when the urine can be
maximally alkalinized after a significant salicylate,
phenobarbital, or chlorpropamide poisoning.
The roles of hemodialysis, hemoperfusion, and other
extracorporeal techniques are now much more
specifically defined.
MANAGING ACUTELY POISONED
OR OVERDOSED PATIENTS
The history may be incomplete, unreliable, or
unobtainable
Multiple xenobiotics may be involved; and even
when a xenobiotic etiology is identified, it may
not be easy to determine whether the problem is
an overdose, an allergic or idiosyncratic reaction,
or a drugdrug interaction.
It is sometimes difficult or impossible to
differentiate between adverse effects of a correct
dose of medication and the consequences of a
deliberate or unintentional overdose.
MANAGING ACUTELY POISONED
OR OVERDOSED PATIENTS
As a result..
The patients presenting signs and symptoms may
force an intervention at a time when there is almost
no information available about the etiology of the
patients condition , and as a result, therapeutics
must be thoughtfully chosen empirically to treat or
diagnose a condition without exacerbating the
situation.
 CLINICAL AND LABORATORY FINDINGS IN
POISONING AND OVERDOSE

a Anticholinergics, including antihistamines, atropine, cyclic antidepressants, and scopolamine.

b Sympathomimetics, including adrenergic agonists, amphetamines, cocaine, and ephedrine.
c Cholinergics, including muscarinic mushrooms; organic phosphorus compounds and carbamates, including select
Alzheimers disease drugs and physostigmine; and pilocarpine and other direct-acting xenobiotics.

HMG-CoA, 3-hydroxy-3-methyl-glutaryl-CoA); LSD, lysergic acid diethylamide; MAOI, monoamine oxidase inhibitor.
 CLINICAL AND LABORATORY FINDINGS IN
POISONING AND OVERDOSE

a Anticholinergics, including antihistamines, atropine, cyclic antidepressants, and scopolamine.

b Sympathomimetics, including adrenergic agonists, amphetamines, cocaine, and ephedrine.
c Cholinergics, including muscarinic mushrooms; organic phosphorus compounds and carbamates, including select
Alzheimers disease drugs and physostigmine; and pilocarpine and other direct-acting xenobiotics.

HMG-CoA, 3-hydroxy-3-methyl-glutaryl-CoA); LSD, lysergic acid diethylamide; MAOI, monoamine oxidase inhibitor.
INITIAL MANAGEMENT OF PATIENTS
WITH A SUSPECTED EXPOSURE
Patient potentially exposed to a xenobiotic begins
with the recognition and treatment of life-
threatening conditions, including :
airway compromise
breathing difficulties
circulatory problems such as hemodynamic
instability and serious dysrhythmias.
INITIAL MANAGEMENT OF PATIENTS
WITH A SUSPECTED EXPOSURE
After the ABCs (airway, breathing, and
circulation) have been addressed, the patients
level of consciousness should be assessed because
this helps determine the techniques to be used
for further management of the exposure.
MANAGEMENT OF PATIENTS WITH
ALTERED MENTAL STATUS
Altered mental status (AMS)
defined as the deviation of a patients sensorium from
normal.
commonly construed as a depression in the patients
level of consciousness, a patient with agitation,
delirium, psychosis, and other deviations from
normal
MANAGEMENT OF PATIENTS WITH
ALTERED MENTAL STATUS
After admission and airway patency is
established or secured, an initial bedside
assessment should be made which includes:
Adequacy of breathing
Pulse
Body temperature
Blood pressure
Blood tests
Other parameters like presence of seizures and
hypoglycemia
MANAGEMENT OF PATIENTS WITH
ALTERED MENTAL STATUS
Adequacy of breathing
If it is not possible to assess the depth and rate of
ventilation, then at least the presence or absence of
regular breathing should be determined.
In this setting, any irregular or slow breathing
pattern should be considered a possible sign of the
incipient apnea, requiring
ventilation with 100% oxygen by
bagvalvemask followed as soon
as possible by endotracheal
intubation and mechanical
ventilation.
MANAGEMENT OF PATIENTS WITH
ALTERED MENTAL STATUS
Arterial blood gas (ABG) analysis
define the adequacy not only of oxygenation (PO2, O2
saturation) and ventilation (PCO2 ) but may also
alert the physician to possible toxic-metabolic
etiologies of coma characterized by acidbase
disturbances (pH, PCO2).
MANAGEMENT OF PATIENTS WITH
ALTERED MENTAL STATUS
After the patients respiratory status has been
assessed and managed appropriately, the
strength, rate, and regularity of the pulse should
be evaluated, the blood pressure determined, and
a rectal temperature obtained.
Both a 12-lead electrocardiogram (ECG) and
continuous rhythm monitoring are essential.
Monitoring will alert the clinician to dysrhythmias
that are related to toxic exposures either directly or
indirectly via hypoxemia or electrolyte imbalance.
MANAGEMENT OF PATIENTS WITH
ALTERED MENTAL STATUS

For example, a 12-lead ECG demonstrating QRS

widening and a right axis deviation might
indicate a life-threatening exposure to a cyclic
antidepressant or another xenobiotic with sodium
channelblocking properties.
MANAGEMENT OF PATIENTS WITH
ALTERED MENTAL STATUS
Extremes of core body temperature must be
addressed early in the evaluation and treatment
of a comatose patient. Life-threatening
hyperthermia (temperature >105F; >40.5C) is
usually appreciated when the patient is touched
(although the widespread use of gloves as part of
universal precautions has made this less
apparent than previously).
MANAGEMENT OF PATIENTS WITH
ALTERED MENTAL STATUS
Most individuals with severe hyperthermia,
regardless of the etiology, should have their
temperatures immediately reduced to about
101.5F (38.7C) by sedation if they are agitated
or displaying muscle rigidity and by ice water
immersion
MANAGEMENT OF PATIENTS WITH
ALTERED MENTAL STATUS
For a hypotensive patient with clear lungs and
an unknown overdose, a fluid challenge with IV
0.9% sodium chloride or lactated Ringers
solution may be started. If the patient remains
hypotensive or cannot tolerate fluids, a
vasopressor or an inotropic agent may be
indicated, as may more invasive monitoring.
MANAGEMENT OF PATIENTS WITH
ALTERED MENTAL STATUS
At the time that the IV catheter is inserted, blood
samples for glucose, electrolytes, blood urea
nitrogen (BUN), a complete blood count (CBC),
and any indicated toxicologic analysis can be
obtained.
MANAGEMENT OF PATIENTS WITH
ALTERED MENTAL STATUS
A pregnancy test should be obtained in any
woman with childbearing potential. If the patient
has an AMS, there may be a temptation to send
blood and urine specimens to identify any central
nervous system (CNS) depressants or so-called
drugs of abuse along with other medications
MANAGEMENT OF PATIENTS WITH
ALTERED MENTAL STATUS
For the potentially suicidal patient, an
acetaminophen concentration should be routinely
requested, along with tests affecting the
management of any specific xenobiotic, such as
carbon monoxide, lithium, theophylline, iron,
salicylates, and digoxin (or other cardioactive
steroids), as suggested by the patients history,
physical examination, or bedside diagnostic tests.
MANAGEMENT OF PATIENTS WITH
ALTERED MENTAL STATUS
Xenobiotic-related seizures may broadly be
divided into three categories:
those that respond to standard anticonvulsant
treatment (typically using a benzodiazepine)
those that either require specific antidotes to control
seizure activity or that do not respond consistently to
standard anticonvulsant treatment, such as
isoniazid-induced seizures requiring pyridoxine
administration
those that may appear to respond to initial treatment
with cessation of tonicclonic activity but that leave
the patient exposed to the underlying, unidentified
toxin or to continued electrical seizure activity in the
brain, as is the case with carbon monoxide poisoning
and hypoglycemia.
MANAGEMENT OF PATIENTS WITH
ALTERED MENTAL STATUS
Within the first 5 minutes of managing a patient with
an AMS, four therapeutic interventions should be
considered, and if indicated, administered:
1. High-flow oxygen (810 L/min) to treat a variety of
xenobioticinduced hypoxic conditions
2. Hypertonic dextrose: 0.51.0 g/kg of D 50W for an adult
or a more dilute dextrose solution (D10W or D 25W) for a
child; the dextrose is administered as an IV bolus to
diagnose and treat or exclude hypoglycemia
3. Thiamine (100 mg IV for an adult; usually unnecessary
for a child) to prevent or treat Wernicke encephalopathy
4. Naloxone (0.05 mg IV with upward titration) for an adult
or child with opioid-induced respiratory compromise