The PCC, Toxidromes, and “Deadly in a Dose”

Peds IngestionsJohn Dayton, MD FACEP

Emergency Physician, Assistant ProfessorBoard Member, Utah ACEP

Legislative Committee Member, UMA

Disclosure

Most of these slides are mine, but I also included information from the Poison Control Center’s (PCC) 2012 review book and a toxidrome presentation.

I did this for two reasons: the data goes with their Toxidrome booklets I’m handing out and their data is really good.

Goals

• Discuss scope of poisonings in Utah

• Discuss common toxidromes and common prescriptions, OTCs and supplements from each category

• Discuss initial evaluation and stabilization

• Discuss use of PCC resources and EMS resources

• Quiz time (with prizes)

Utah Poisonings from 2012 Report

Utah Poisonings from 2012 Report

Utah Poisonings from 2012 Report

Utah Poisonings from 2012 Report

Utah Poisonings from 2012 Report

Why?•Kids – 99% accidental•Teens – 42% accidental•Adults – 61% accidental

Where?•Own home – 88%•Other home – 5%•Work – 2%•Other – 5%

Utah Poisonings from 2012 Report

•Unintentional – 84%•Intentional – 11%•Adverse Reaction – 2.5%•Other (tampering, poisoning, etc) – 1%•Unknown – 0.6%

Utah Poisonings from 2012 Report

Call outcome:

• 76% of calls handled over the phone

• 90% of Peds cases managed over the phone

• 20% required treatment in health care facility

Utah Poisonings from 2012 Report

Most Common Substances

Less than 6

years

6-19 years 20+ Years

Cosmetics/

personal care

Analgesics Analgesics

Analgesics Cough and Cold Sedative/hypnotic

Cleaning

substances

Sedative/hypnotic Antidepressants

Vitamins &

Minerals

Antidepressants Bites/envenomations

Topicals Foreign bodies Cleaning substances

Utah 2008

“Deadly in a Dose”

Beta-blockers

Calcium channel blockers

Clonidine

Opioids (narcotics)

Oral hypoglycemics

Toxic alcohols

Tricyclic antidepressants

“olols”: carvedilol (coreg), labetalol, metoprolol

(toprol),timolol (timoptic eye drop)

“pines”: amlodipine (norvasc), nifedipine (procardia),

nicardipine (cardene), verapamil, diltiazem (cardizem)

Clonidine (kapvay or nexiclon) for HTND or ADHD

Lortab, percocet, tylenol 3, fentanyl, oxcodone,

oxycontin, hydrocodone, methadone, suboxone

Sulfonylurea (glyburide, blipizide), acarbose, glucovance

(glyburide/metformin)

Methanol (wood alcohol blindness and death),

isopropyl alcohol (solvent), ethylene glycol (antifreeze)

Amitriptyline (elavil), imipramine (tofranil)

“Deadly in a Dose”

Ingestions are possibly deadly for Ped patients in homes where any family members (especially grandparents) are taking meds for:

• Hypertension – beta Ca blockers (-olos)

• Diabetes – sulfonylureas (glipizide)

• Pain - narcotics

• Parkinsons – selegiline (MAO-B inhibitor), benztropine (cogentin – anticholinergic/antihistamine)

• Psychiatric problems – TCAs (elavil, Imipramine)

Poisoning Fatalities• Sedative/Hypnotics/Antipsychotics

– benzodiazepines (Valium, Xanax, Klonipin)– antipsychotics (Seroquel)

• Opioids (Oxycontin, methadone)• Antidepressants (amitriptyline, Prozac)• Cardiovascular drugs (beta blockers, calcium channel

blockers, clonidine)• Acetaminophen alone and combinations (pain and

cold meds)• Alcohols• Stimulants and street drugs

Toxidrome

• A constellation of signs and symptoms that characterize a particular toxin or a category of toxins

• Helps in “unknown” situations to narrow down possible toxins

• Vital signs and toxicology assessment essential to identify possible toxidromes

Toxidrome Card - example

Toxicology Assessment

• Signs and Symptoms– vital signs (HR, BP, R, Temp)– neurologic status– pupils– skin color/temp

• Allergies• Medications in home• Past medical history

• Circumstances Leading to Event

Toxidrome #1

• A 16-year-old girl found by parents to be confused, agitated and actively hallucinating (picking bugs off skin)

• Vital signs: HR 124 bpm, BP 135/88 mm Hg, T 100.8°F

• Pupils: 5 mm bilaterally (mydriasis)

• Skin: flushed, dry skin

• Physical exam: dry mouth, diminished bowel sounds

Anticholinergic Toxidrome

• Blind as a bat

• Dry as a bone

• Red as a beet

• Hot as a hare

• Mad as a hatter

Exam: mydriasis, dry flushed skin, hyperthermia, altered mental status, seizure, tachycardia, hypotension, urinary retention

Antidote: PhysostigmineOther Treatment: fluids

Anticholinergics

OTC: antihistamine (benadryl)

Prescriptions:

• TCAs (amatriptyline/elavil, imipramine)

• Antipsychotics (chorpromazine,

fluphenazine/prolixin, haldol)

• Parkinson meds (benztropine)

• Muscle relaxants

• Scopolamine

• Atropine

Natural: Jimson weed, deadly nightshade

Toxidrome Case #2

• 32-year-old woman found delirious and very agitated; extremely paranoid; appears to be hallucinating

• Vital signs: HR 130 bpm; BP 170/100 mm Hg; R 16/min; T 100.4°F

• Pupils 7mm (mydriasis)

• Skin: moist, diaphoretic

Stimulant (Sympathomimetic) Toxidrome

Vitals: elevated BP, HR and hyperthermia

HEENT: mydriasis

Derm: diaphoresis

Cardiac: tachycardia, SVT, Afib, Aflutter, heart blocks, chest pain

Neuro: seizures, stroke

Psych: psychosis, delirium,

bruxism (teeth grinding)

Stimulants

OTC: decongestants (pseudoephedrine), phenylephrine

Prescription: Adderall, Ritalin, Thyroid Supplements (synthroid)

Natural: ma huangIllegal: PCP, cocaine, meth

• Treatment: Benzodiazepines

Toxidrome Case #3

A 15-year-old boy found unresponsive, snoring in bed.

Vital signs: HR 50 bpm, BP 90/60 mm Hg, RR 5/min, Temp 97°F

Pupils 1-2 mm (miosis)

Neurologic: unresponsive to painful stimuli

Physical exam: decreased bowel sounds

Opioids (“Narcotics”)

Signs and Symptoms

• CNS and respiratory depression

• Miosis

• Hypotension, bradycardia, hypothermia

Antidote

• Naloxone 0.4-2 mg

Examples: heroin, morphine, oxycodone, fentanyl, hydrocodone, hydromorphone, buprenorphine (Suboxone), methadone

Toxidrome Case #4

• A 45-year-old female found unresponsive at home. She was last seen approximately 20 hours prior. She does not respond to painful stimuli.

• Vital signs: HR 60 bpm, BP 100/50 mm Hg, T 96°F, RR 10/min

• HEENT: 4 mm bilaterally, reactive to light• Skin: pressure sores• Physical exam: poor gag reflex,

decreased muscle tone and depressed reflexes

Sedative-Hypnotic Agents• Central nervous system depression

– ataxia, slurred speech, drowsiness, confusion → coma– loss of reflexes, respiratory depression, myocardial

depression• Barbiturates like phenobarbitol, pentobarbital

(nembutal) • Benzodiazepines like chordiazepoxide (librium),

diazepam (valium), alprazolam (xanax)• Combo drugs: fioricet/fiorinal (contains

butalbital), donnatol• Alcohol and narcotics• Additive/synergistic effects in combination

Sedative-Hypnotic Agents:Alcohol Derivatives

Methanol:• Found in windshield wiper fluid, anifreeze, solid fuels (sterno)• Conversion to formic acid anion gap acidosis - intoxicated, headache, CNS

depression, visual change “looking through snow field” blindess, tachycardia/ypnea, abd pain, N/V

• Hallmark: blind drunk with anion gap metabolic acidosisEthylene glycol • Found in coolants (antifreeze) • oxalic acid renal toxicity• Sx include intoxication, HA, CNS depression,

N/V, Acute Renal Failure• Oxalate crystals in urine can be seen with woods lampsIsopropyl alcohol• Found in rubbing alcohol and hand sanitizers• CNS depression, coma, N/V, hemorrhagic gastritis• Hallmark: drunk without +serum alcohol

Toxidrome #5

• A 14-year-old girl found acting strangely with complaints of nausea and vomiting and ringing in ears

• Vital signs: HR 110 bpm; BP 120/60 mm Hg; R 30/min; T 100.2°F

• Pupils 4 mm

• Skin: diaphoretic

Salicylates

Exam

• Neuro: confusion, agitation, seizures, lethargy coma

• Vitals: increased respiratory rate, HR and temp

• Skin: normal to sweaty

• GI: nausea and vomiting

• Hallmarks: tinnitis (ringing ears) or other hearing changes

OTCs, prescriptions – aspirin, shampoos, pepto-bismol, oil of wintergreen, muscle rubs

Treatment – supportive care +/- intubation, charcoal, HD

Toxidrome #6

• A 56-year-old woman with confusion, shortness of breath, vomiting and diarrhea

• Vital signs: HR 50 bpm; BP 90/palp mm Hg; R 32/min; T 98.6°F

• Pupils 2 mm

• Skin: profuse sweating, tearing and rhinorrhea

• Physical exam: hyperactive bowel sounds, muscle fasciculations

Cholinergic ToxidromeMnemonics:• DUMBELLS:

• Diarrhea

• Urination

• Miosis, muscle fasciculations & weakness

• Bronchorrhea, Bradycardia, Bronchospasm

• Emesis

• Lacrimation, Loss of muscle strength

• Salivation, Sweating

• SLUDGE: Salivation/sweating, Lacrimation, Urination, Defecation, GI distress, Emesis

• Killer Bs: Bradycardia/Bronchorhea/Bronchospasm)

Cholinergic Meds

Medications: Alzehimers meds (donepizil), Myasthenia Gravis meds (pyridostimine, edrophonium), Carbamates like soma, felbatol for seizures

Chemicals: organophosphates (farming), carbamatesinsecticides, sarin, cytocybe and inocybe mushrooms

Cholinergic Treatment

Treatment:

• atropine and 2PAM (Pralidoxime)

• supportive care

• benzos

Other Drugs to be Aware of

Tylenol – 140 mg/kg can kill the liver. Presents in 4 stages. RUQ pain with elevated LFTs and bili. Antidote is NAC.

SSRIs - fluoxetine (prozac), citalpram (celexa), paroxetine (paxil) can cause N/V, abd pain, tachycardia, CNS sedation, hyperthemia, diaphoresis, AMS, nystagmus, myoclonus, hyper-relfexia. Give supportive care, benzos for sz, cyproheptadine is the antidote for seratoninsyndrome.

Other Drugs to be Aware of

• MAOIs – Depression meds like phenlzine (nardil), trancylcypromaine (parnate), MAO blockers for Parkinsons (selegiline, rasagiline), and St John’s Wart. Will inhibit monoamine oxidase decreased inactivation of biogenic amines like epineph, norepi, seratonin excess catecholaminessympathomimetic reaction. Treat with benzos and antipyretics for agitation/rigidity/sz

• Isoniazid (INH) – Tuberculosis med causes lupus-like syndrome, reduces Vitamin B6 and can lead to seizures. Treatment is supportive, pyridoxine (Vit B6).

Drugs of Abuse

Drug Symptoms/Toxidrome Treatment

Cocaine Sympathomimetic Supportive, benzos

Amphetamines (extacy, ADD and narcolepsy meds, weight loss supplements)

sympathomimetic Supportive, benzos

Opiates Opiate Nalaxone, support respiration

PCP Sympathomimetic, rotary or vertical nystagmus, hyperthermia

Supportive, benzos, cooling, sedation as needed

GHB (used as date rape drug, ravers, body builders)

Coma with episodes of agitation, hypothermia, sudden awakening

supportive

Poison Control Centers

• Available 24-hours/day

• Specialists in poison information

• pharmacists and nurses

• extensive toxicology knowledge and resources

• Medical toxicologist available 24/7

• Outreach education materials

Role of the PCCThey take history of exposureThey make assessment based on history, circumstances, health

statusThey recommend treatment They recommend management site

• manage on site• refer to Health Care Facility

• private vehicle • EMS

They follow up on exposuresCommunication bridge during disasters

• PCC has 800 mHz radio

Tox Management

Emergency stabilization• Airway, Breathing, Circulation

“Coma cocktail”• Naloxone (0.01 mg/kg)• Amp D50• some include thiamine (100 mg IV before D50)

Activated charcoal• best if used within 1-2 hours of ingestion• Do not use if you have concern for aspiration• Does not work for metals, alcohols, hydrocarbons and

caustics

Tox Management: ABC’s

Airway: check for flaccid tongue, gag reflex, clear secretions, nasal trumpet/oral airway, position to avoid aspiration

Breathing: check sats and RR – give Os, give albuterol for brochospasm, atropine for bronchorrhea, BVM and intubate as needed to protect airway (low sats, AMS, caustic burn)

Circulation: IV access, draw labs, fluids for hypotension, EKG monitoring (bicarb for long QT)

Antidotes

Dialysis and Charcoal

EKG abnormalities by Drugs

Bradycardia – beta and calcium blockers, digitalis, clonidine

Tachycardia – anticholinergics, stimulants

QRS widening –TCAs, sympathomimetics

Ischemic changes – stimualnts(cocaine)

Digoxin – Salvidor Dali mustache

From Rapid Interpretation of EKG's copyright © 2013 COVER Publishing Co. Inc.

Quiz Time

What toxidrome will these cause?• Percocet• Jack Daniels• Soma (hint – has barbiturate)• Pepto-Bismol• PCP• Crystal Meth• Organophosphate fertilizer• Jimson Weed

Quiz Time

You pick up a lethargic child who was staying with his grandma who has diabetes. What medication do you worry about?

You pick up some ravers from SaltAir who have pacifiers in their mouth? What drug and toxidrome are you concerned about?

You are called to the home a depressed teenager who just broke up with her boyfriend. She has ringing in her ear. What med did she OD on what toxidrome does she have?

Quiz Time

You are called to an orchard where some workers are foaming at the mouth and having difficulty breathing. What was their likely exposure and what toxidrome do you see? How do you treat it?

You pick up a patient who admits a soma overdose. What kind of symptoms do you expect to see and what will his tox screen look like?

Picture Sources

Peds Ingestion – www.emsworld.comXanax pill - psychiatrist-blog.blogspot.comPCP hallucination – www.defense.govMydriasis - webeye.ophth.uiowa.eduMad Hatter - http://www.alice-in-wonderland.net/pictures/mad-hatter-pictures.htmlJimson Weed – www.commons.wikimedia.org , sowandhoe.blogspot.comPeter Pan Hallucination - theosophical.wordpress.comEcstasy Pacifier - www.michaelallenblair.comMa Huang – www.eagleherbs.comMiosis – www.tumblr.com/tagged/miosisNaloxone - http://www.tumblr.com/tagged/naloxonePressure Sore - www.snjourney.comSterno – www.zenstoves.netPesticides – animalpetdoctor.homestead.comSarin gas newspaper - www.sciencemuseum.org.ukAtropine and 2PAM - www.atsdr.cdc.govAntidote, Activated Charcoal, and Hemodialysis Charts – www.ebmedicine.netDali Mustache - From Rapid Interpretation of EKG's copyright © 2013 COVER Publishing Co. Inc