poisoning 2004
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POISONING 2004
Kent R. Olson, MD, FACEPMedical Director, SF Division
California Poison Control System
Case 1: Metabolic Acidosis
20 year old woman found in her parked car, comatose (GCS 8)3 empty bottles of Tylenol BP 100/50 HR 140-160 RR 38Na 150 K 3.5 Cl 124 HCO3 6pH 6.98 pCO2 12 pO2 198
“MUDPILES”
MethanolUremiaDKAPhenformin, ParaldehydeINHLactateEthylene glycol, EthanolSalicylate
Lactic Acidosis
Many possible causes:Hypoxia-ischemiaCyanide poisoningCarbon monoxide poisoningMetforminINH . . . and many others
Order a serum lactate level
“SALAD”
Gives you a quick “what to order”:
Salicylate (order a stat [ASA])Alcohols (toxic alcohols – order Osm)Lactate (order a state [Lactate])Anuria (BUN, Cr)DKA (check glucose)
If the [Lactate] = normal
Then, you have fewer things to consider, e.g.:
Toxic alcoholsMethanol = formic acidosisEthylene glycol = glycolic acidosis
KetoacidosisMostly beta-hydroxybutyrate
Case, continued . . .
Salicylate negativeBUN/Cr = 5/1.1Glucose 400 mg/dLLactate 18 mmol/LCOHgb not detectedOsmolality not sent
“MUDPILES”
MethanolUremiaDKAPhenformin, ParaldehydeINHLactateEthylene glycol, EthanolSalicylate
What was it?
Serum acetaminophen = 917 mg/L !!
She was treated with NAC, IV NaHCO3 (repeat pH 7.29), insulinNext day AST, ALT began to rise
Peak measured ALT 5318Bili to 2.8, INR 3.1
Acetaminophen overdose
Acidosis, coma uncommon without fulminant liver failure as prior causeOccasional cases of early coma, severe acidosis with very high drug levels - despite absent liver failure
Mnemonics . . just remember:
“Today’s clinical pearl
may end up as tomorrow’s fecalith.”. . .John Wallace, MD c.1979
1
10
100
1000
0 5 10 15 20 25
APAP(mg/L)
Possibly Toxic
Probably Toxic
hrs
Serum APAP level
Note: co-ingestion of Nyquil plus up to 44 g Tylenol ERRef: Bizovi K et al: J Toxicol Clin Toxicol 1995; 33:510
Serum acetaminophen (APAP) levels afteringestion of “Tylenol Extended Relief”
New drug: Acetadote™
IV formulation of N-acetylcysteineFDA approved January 2004Not yet on the marketDose? The UK-European protocol:
150 mg/kg in 200 mL D5W over 15 min +50 mg/kg in 500 mL D5W over 4 hours +100 mg/kg in 1 L, over 16 hrs
Duration of NAC treatment?
Current US oral NAC protocol = 72 hrAcetadote IV = 20 hrOnset of rising AST, ALT ~ 24-30 hr
We recommend Rx (or at least observation) until ~36 hrs after the ingestion to r/o liver damage
Case 2: Little Blue Lady
80 year old woman just returned from transeophageal echocardiogramPerioral cyanosis and blue nail bedsOtherwise asymptomaticPulse oximetry 87% - did not improve with high-flow oxygen
Arterial blood gases:
pH = 7.43 pCO2 = 36 pO2 = 266
Methemoglobinemia
Fe2+ in heme is oxidized to Fe3+
Unable to carry oxygen Many causes: (oxidants)
Benzocaine spray (in Hurricaine™)DapsonePhenazopyridineNitrites (eg, amyl nitrite)
Another crappy hemoglobin
67 year old man found unresponsive and covered with vomitusBarbeque was heating the trailerCOHgb 33%Intubated, hypotensive on LevophedCandidate for HBO?
Carbon monoxide poisoning
CO poisoning, continued . . .
Can cause coma, seizures, deathSurvivors may have varying degrees of neurological sequelae
Persistent coma, vegetative state, etcSubtle mood and memory disorders
Incidence up to 30-40%
Controversy over treatment
Hyperbaric oxygen (2.5 ATM)
versus
Normobaric oxygen ?
Literature is inconclusive
Most reports are uncontrolled case seriesOnly two RCTs
Australian study: no differenceWeaver study: small benefit with HBO
Weaver recommends HBO if:
COHgb > 25%History of loss of consciousnessMetabolic acidosisAge > 50 yearsCerebellar findings on neuro exam
Another CO case:
55 year old man found unconscious on his yachtHe had gone downstairs 10 min earlier to check on a burning odorPulled out to fresh air, awake in 10 minutesIn ER 2.5 hrs later, COHgb 14.4%alert and normal neuro exam
Child with a Seizure
14 month old boy had a seizure at home. No prior Hx of seizures.Had been playing with Effexor bottleSecond seizure on arrival in ERBP 138/87 HR 150 RR 28 T nlPupils dilated
Common causes of seizures
Tricyclic antidepressantsNewer antidepressants (SSRIs)
especially bupropion (Wellbutrin™)Amphetamines/cocaineINHDiphenhydramineTramadol (Ultram™)
Toxicology screen showed:
Positive for methamphetamineNot tested for venlafaxine (Effexor™)
Potential false (+) for amphetamines:Ephedrine, MDMA, pseudoephedrine, etcBupropion, Labetalol, Ranitidine, Sertraline, Selegiline, Trazodone,others . . .
Final case:
22 year old man ingested 60 lithium tablets (300 mg)Asymptomatic 1 hour later in ER
How to decontaminate the stomach?
Gut decontamination
Goal: limit systemic absorptionPossible methods:
Induced emesisGastric lavageActivated charcoalCathartics/whole bowel irrigation
Induced emesis
Don’t use:Salt waterFinger gag
Ipecac?Soapy water?
Ipecac syrup
Easy to perform, butNOT very effectiveRisks:
Pulmonary aspirationWretching, GI injuryDelay in administering charcoal
Bottom line: OUTDATED
“Pumping the stomach”
NOT very effectiveRisks:
AspirationGI traumaDelay to administering AC
Bottom line: RARELY used
Activated charcoal
Finely divided powderHuge surface areaDrugs and poisons areadsorbed to surfaceDoes NOT bind:
IronLithium
Activated charcoal . . .
More effective than ipecac, lavageFirst choice for most drugs & poisons
Whole Bowel Irrigation
Mechanical flushGoLytely or COLYTE
Balanced salt solutionNonabsorbable PEGNo net fluid loss or gain
Good for:Lithium, iron, foreign bodies
1-800-222-1222
New national toll-free hotline #Dial from anywhere in the USAConnects to regional poison center
24-hr consultationPharmDs with physician back-up
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