General Approach to the Poisoned Patient

Bruce D. Anderson, PharmD, DABAT

Director, Maryland Poison Center

Assistant Professor, University of Maryland

School of Pharmacy

The Maryland Poison Center

GOAL

•Students will be able to describe the evaluation and the most appropriate initial therapy for poisoning and overdose patients.

OBJECTIVES•Describe the usual population of poisoning victims

•Describe the roles of a poison center•Describe the nine main questions to ask when evaluating a poisoning patient

•Describe the general steps involved in the initial management of poisoning victims

Quiz!

•You are contacted about a normally healthy 18 month old who just ingested the packet of silica gel that was in the new shoe box.

•What would you recommend: management in the ED or at home?

Quiz!

• The mother of a 3 year old calls you about the child ingesting a small amount of Visine® eye drops. The exposure just happened and the child is fine. The bottle only contains 10 ml’s. How would you manage this case?

• What would you recommend: management in the ED or at home?

Quiz!A normally healthy 15 year old is helping his father build a deck. The child reaches into a wood pile and feels a sting on his hand. He looks down in time to see this spider crawling away.

What would you recommend?

Maryland Poison Center•Certified Regional Poison Center•24 hour service•410-706-7701 1-800-222-1222•Certified “SPI’s”•Poison prevention education•Professional education

MPC: Overview

•Service program of the University of Maryland School of Pharmacy

•Located here since 1972•First year of operations, received 5,600 calls

•In 2012, MPC received 62,229 calls

MPC: (continued)

•Open 24 hours/day•Staffed by pharmacists & nurses•Nationally certified Specialists in Poison Information

•Board certified Medical Director•Board certified Director•Additional consultants available

Other Functions

•Recognition and prevention of exposures through community education and outreach

•Professional education to optimize patient care

•Data collection/reporting nationally•Research to optimize patient care *

What’s the Mission?

•The mission of the Maryland Poison Center is to decrease the cost and complexity of poisoning and overdose care while maintaining and/or improving patient outcomes.

Bottom Line

•Save Lives•Save Dollars

Bottom Line (continued)

•Save lives by providing emergency triage and treatment information to all callers.

•Save dollars by managing vast majority of patients (66%) safely and inexpensively at home.

Fiscal Impact:

•Last year, 22,883 poisoning patients were safely managed at home.

•Usual charge for ED evaluation and treatment: ~ $500 - $1,000 per patient

•Estimated cost savings:$11,441,500 to $22,883,000 per year

Poisonings - Epidemiology

•Over 2.2 million human poisonings in 2012.

•Approximately 1.1 million exposures occurred in children < age 6 years.

Poisonings - Epidemiology

•~50% occur in children <6 years old.

•< 30 fatalities in children < 6 years old in 2012.

Why Pediatrics?

•Stages of child development• Imitate adult behavior;•Product may not be used or stored properly;

•Changes in the child’s environment (vacation, moving, going to a relatives house, etc).

•Siblings

Siblings

Common Substances

•Cosmetics and personal care products•Cleaning products•Drugs (analgesics, cough and cold medicines, topicals, antibiotics, etc.)

•Plants•Hydrocarbons•Pesticides

Why Pediatric Poisonings Occur

• Susceptibility of young children• stages of development• imitate adult behavior

• Potentially dangerous circumstances• lack of supervision• child is hungry/thirsty• product is in use/not stored properly• “look-alikes”

Can You Tell???

Can You Tell???

• Substance• Amount• Route(s)• Time of or since exposure

• Age/weight

• Symptoms present• Previous treatment provided

• REASON for the exposure

• Pre-existing medical conditions

Initial Assessment

• If possible, identify physical findings:•What does the patient LOOK like?

Assess the WHOLE Patient!

•Name the toxin that produces a smell of almonds.

Quiz!

•Cyanide!!!

Answer

• Any changes in urine, feces, fingernails, hair, etc?

• Assess vital signs: any changes in heart rate, blood pressure, temperature, respiratory rate?

• Changes in pupil size (e.g., miosis vs. midriasis)?

• Unusual eye movements?• New neurologic findings (hypertonia vs. hypotonia; posturing, seizures, tremor, etc.)?

Assess the WHOLE Patient!

Name the toxin that can cause the tongue to turn black?

Quiz!

Bismuth

Answer

• Every patient has a story. • The job of the clinician is to listen to that story, assess the quality of the information, relate all of the information to the physical findings and other objective information that’s available about your patient, and make reasonable assessments based on all of the information.

Assess the STORY

Do you believe the story?

•Assume that the story is INCORRECT and/or INCOMPLETE until you have objective information to support the story.

Assess the STORY

• Constellations of symptoms associated with specific toxins or groups of toxins.

• E.g., opioid toxidrome: • CNS depression• Respiratory depression• Miosis• Bradycardia

Toxidromes

Initial Assessment

•Substance•Amount•Route(s)•Time of or since exposure

•Age/weight

•Symptoms present•Previous treatment provided

•REASON for the exposure

•Pre-existing medical conditions

Consider Poisoning for:

•any abrupt, unexplained change in mental status;

•victims of fire or trauma•patients with previous psychiatric history

•patients that present with multiple symptoms

General Management

ABC’s•The vast majority of poisoning exposures can be managed supportively.

Supportive therapy (continued)

•Altered mental status:•Give naloxone 0.4 - 2.0 mg, glucose, and thiamine

•Monitor and treat seizures, fluid and electrolyte abnormalities, hypo/hyper thermia

•Eye exposures: flush!•Skin exposures: flush!• Inhalation exposures: Move to fresh air!• Injections: Mmmm…toughie• Ingestion of toxins: Consider methods to prevent absorption. Can safely dilute almost any exposure with water

General Decontamination

Don’t become a victim!

• More effective than ipecac or the combination of ipecac + charcoal.

• Contraindications: ileus, foreign bodies

• Dose: 1-2 grams/kg or 10 X the amount of the ingested substance.

• Adverse effects: aspiration pneumonia (common), gastric obstruction (RARE).

Activated Charcoal

• Iron• Lithium• Sodium• Potassium• Lead• Hydrocarbons• Acids• Bases• Cyanide

Activated Charcoal: Doesn’t Bind

• Is it acceptable to administer activated charcoal to someone who is unconscious and unresponsive?

•Yes! Need to protect airway first

Charcoal… Can You???

•Is it acceptable to administer activated charcoal to someone who is intubated and being ventilated?

•Yes!

Charcoal… Can You???

What are the situations where you CAN’T safely give charcoal???

•Substance NOT bound by charcoal•GI Obstruction

Charcoal… When Can’t You..??

•Saline cathartics (sorbitol, magnesium citrate) may be given along with charcoal to speed passage of the AC-drug complex through the GI tract.

•NOT NECESSARY•May lead to fluid and electrolyte abnormalities

Cathartics

• Little or no advantage over the use of activated charcoal alone.

• Effectiveness is limited by the size of the tube.

• 30% return (adults)

Gastric Lavage

• Use PEG-ELS to flush the GI tract.• Consider only for overdoses involving:

• Iron• Lithium• Sustained release preparations

•Contraindicated in patients with ileus

Whole Bowel Irrigation

• Multiple Dose Activated Charcoal (MDAC)

• Consider for:• dapsone• phenobarbital• phenytoin• theophylline

• DO NOT USE MULTIPLE DOSES OF CATHARTICS!

Enhancement of Elimination

• Alteration of URINE pH: acid or base• Acidification of urine no longer performed because of risk of rhabdomyolysis and renal failure

• Alkalinization: check systemic pH

Enhancement of Elimination (continued)

•Does not work for substances with large volumes of distribution

Hemodialysis/Hemoperfusion

•Advantages:• Corrects acid/base imbalances

• Corrects fluid and electrolyte imbalances

• Fairly common procedure

Hemodialysis

• Advantages:• May clear some protein bound drugs

• Disadvantages:• Not a common procedure

• Who has the cartridge?

Hemoperfusion

•HD:•phenobarbital•salicylates•alcohols• lithium

•HP•meprobamate•phenobarbital•salicylates *• theophylline

Hemodialysis/perfusion

Opioids Naloxone, nalmafene

Acetaminophen Acetylcysteine

Tricyclic Antidepressants Sodium Bicarbonate

Calcium Channel Blockers Calcium, Glucagon, Insulin/glucose

Beta Blockers Glucagon

Iron Deferoxamine

Benzodiazepines Flumazenil *

Digoxin FAB fragments

Anticholinergics Physostigmine

Antidotes

Cyanide Amyl Nitrite, Na Nitrite, sodium thiosulfate; or

Hydroxocobalamin

Carbon Monoxide Oxygen

Nitrates/nitrites Methylene blue

Carbamates,Organophosphates

Atropine, Pralidoxime (2-PAM)

Ethylene glycol, methanol Fomepizole or Ethanol

Snakes Antivenin (CroFab)

Metals BAL, EDTA, Succimer,d-penicillamine

Antidotes

Name something WAY BAD!

•What do you think? Name a substance that you believe is SO toxic, only one dose can be FATAL.

“One is Deadly”

• Camphor• Clonidine• Calcium channel

blockers• Methyl salicylate (oil of

wintergreen)• Topical imidazolines (like

Visine)• Benzocaine, lidocaine• Oral hypoglycemics

• Diphenoxylate and atropine (Lomotil)

• Olanzapine, clozapine• Hydrocarbons

(petroleum distillates)• Antifreeze (ethylene

glycol, methanol)• Caustics • Acrylic Nail Glue

Remover (acetonitrile)

Questions?