pre0003-lapostolle frederic · urgences - samu 93, uf recherche hôpital avicenne & université...

16
20/09/2018 1 Frédéric Lapostolle Urgences - SAMU 93, UF Recherche Hôpital Avicenne & Université Paris 13, Bobigny Disclosures Speaker Astra-Zeneca, Bayer, BMS, Boehringer-Ingelheim, Daiichy-Sankyo, Lilly, Medtronic, Merck-Serono, Mundipharma, Novartis, Pfizer, Teleflex, The Medicine Company Investigator Astra-Zeneca, Merck-Serono, Mundipharma, Novartis, Teleflex Frédéric Lapostolle Urgences - SAMU 93, UF Recherche Hôpital Avicenne & Université Paris 13, Bobigny Frédéric Lapostolle Urgences - SAMU 93, UF Recherche Hôpital Avicenne & Université Paris 13, Bobigny 1

Upload: others

Post on 19-Aug-2020

5 views

Category:

Documents


0 download

TRANSCRIPT

Page 1: Pre0003-Lapostolle Frederic · Urgences - SAMU 93, UF Recherche Hôpital Avicenne & Université Paris 13, Bobigny Frédéric Lapostolle Urgences - SAMU 93, UF Recherche Hôpital Avicenne

20/09/2018

1

Frédéric LapostolleUrgences - SAMU 93, UF RechercheHôpital Avicenne & Université Paris 13, Bobigny

Disclosures SpeakerAstra-Zeneca, Bayer, BMS, Boehringer-Ingelheim, Daiichy-Sankyo, Lilly,Medtronic, Merck-Serono, Mundipharma, Novartis, Pfizer, Teleflex, TheMedicine Company

Investigator

Astra-Zeneca, Merck-Serono, Mundipharma, Novartis, Teleflex

Frédéric LapostolleUrgences - SAMU 93, UF RechercheHôpital Avicenne & Université Paris 13, Bobigny

Frédéric LapostolleUrgences - SAMU 93, UF RechercheHôpital Avicenne & Université Paris 13, Bobigny

1

Page 2: Pre0003-Lapostolle Frederic · Urgences - SAMU 93, UF Recherche Hôpital Avicenne & Université Paris 13, Bobigny Frédéric Lapostolle Urgences - SAMU 93, UF Recherche Hôpital Avicenne

20/09/2018

2

1

Human Toxicity Excerpts:/SIGNS AND SYMPTOMS/ Ingestion of five or more grams of nutmeg causes acute nutmeg poisoning, whichincludes giddiness, hallucinations, and feelings of depersonalization. Symptoms usually appear three to six hours after ingestion of 1‐3 whole nutmegs or 5‐15 gm of the grated spice. Recovery usually occurs within24 hours. Nevertheless, duration of action may extendbeyond several days and even include death. /Nutmeg/[Green RC, Jr; JAMA 171 (10): 1342‐4 (1959); Painter JC et al; Clin Toxicol 4 (1): 1‐4 (1971)] **PEER REVIEWED** 

Human Toxicity Excerpts:/SIGNS AND SYMPTOMS/ Ingestion of five or more grams of nutmeg causes acute nutmeg poisoning, whichincludes giddiness, hallucinations, and feelings of depersonalization. Symptoms usually appear three to six hours after ingestion of 1‐3 whole nutmegs or 5‐15 gm of the grated spice. Recovery usually occurs within24 hours. Nevertheless, duration of action may extendbeyond several days and even include death. /Nutmeg/[Green RC, Jr; JAMA 171 (10): 1342‐4 (1959); Painter JC et al; Clin Toxicol 4 (1): 1‐4 (1971)] **PEER REVIEWED** 

Page 3: Pre0003-Lapostolle Frederic · Urgences - SAMU 93, UF Recherche Hôpital Avicenne & Université Paris 13, Bobigny Frédéric Lapostolle Urgences - SAMU 93, UF Recherche Hôpital Avicenne

20/09/2018

3

1

Page 4: Pre0003-Lapostolle Frederic · Urgences - SAMU 93, UF Recherche Hôpital Avicenne & Université Paris 13, Bobigny Frédéric Lapostolle Urgences - SAMU 93, UF Recherche Hôpital Avicenne

20/09/2018

4

2 2

Boyer, NEJM, 2005 Boyer, NEJM, 2005

Serotoninsyndrome

Page 5: Pre0003-Lapostolle Frederic · Urgences - SAMU 93, UF Recherche Hôpital Avicenne & Université Paris 13, Bobigny Frédéric Lapostolle Urgences - SAMU 93, UF Recherche Hôpital Avicenne

20/09/2018

5

2

Coma

Bradypnea

Myosis

Page 6: Pre0003-Lapostolle Frederic · Urgences - SAMU 93, UF Recherche Hôpital Avicenne & Université Paris 13, Bobigny Frédéric Lapostolle Urgences - SAMU 93, UF Recherche Hôpital Avicenne

20/09/2018

6

Diagnostic strategy Diagnostic strategy

Diagnostic strategy Diagnostic strategy

Page 7: Pre0003-Lapostolle Frederic · Urgences - SAMU 93, UF Recherche Hôpital Avicenne & Université Paris 13, Bobigny Frédéric Lapostolle Urgences - SAMU 93, UF Recherche Hôpital Avicenne

20/09/2018

7

Diagnostic strategy Diagnostic strategy

Diagnostic strategy

It’s not a poisoning

There is another toxic (to identify)

There is a complication (to identify) Myosis

Normal blood

pressure

Normal heartrate

Normal EKG

Myosis

Normal blood

pressure

Normal heartrate

Normal EKG

Rhabdomyolysis

Aspiration

Interaction with diagnostic, severity and outcome

Rhabdomyolysis Aspiration

Page 8: Pre0003-Lapostolle Frederic · Urgences - SAMU 93, UF Recherche Hôpital Avicenne & Université Paris 13, Bobigny Frédéric Lapostolle Urgences - SAMU 93, UF Recherche Hôpital Avicenne

20/09/2018

8

Myosis

Normal blood

pressure

Normal heartrate

Normal EKG 2

Congruence =

Security

Congruence =

Security

2

2 3

Page 9: Pre0003-Lapostolle Frederic · Urgences - SAMU 93, UF Recherche Hôpital Avicenne & Université Paris 13, Bobigny Frédéric Lapostolle Urgences - SAMU 93, UF Recherche Hôpital Avicenne

20/09/2018

9

3 ‘’Result likely to influence treatment’’Proudfoot, Critical Care Toxicology, 2005

3 ‘’Result likely to influence treatment’’Proudfoot, Critical Care Toxicology, 2005

3Acetaminophen

Carboxyhemoglobin

Digoxin

Ethylene glycol

Iron

Lithium

Isopropanol

Methanol

Methemoglobin

Phenobarbital

Salicylates

Theophylline

Proudfoot, Critical Care Toxicology, 2005

3Acetaminophen

Carboxyhemoglobin

Digoxin

Ethylene glycol

Iron

Lithium

Isopropanol

Methanol

Methemoglobin

Phenobarbital

Salicylates

Theophylline

Proudfoot, Critical Care Toxicology, 2005

Brent, NEJM, 2009 Brent, NEJM, 2009 Finkle, Acid-base and Electrolyte disorders, 2002

Page 10: Pre0003-Lapostolle Frederic · Urgences - SAMU 93, UF Recherche Hôpital Avicenne & Université Paris 13, Bobigny Frédéric Lapostolle Urgences - SAMU 93, UF Recherche Hôpital Avicenne

20/09/2018

10

Equimolar “curative” neutralization AsystoleVentricular dysrhythmiaHeart rate < 40/min after intravenous atropineSerum potassium > 5.0 mmol/L

Semi-equimolar “prophylactic” neutralization Age>55Cardiac diseaseHeart rate <60/min after atropineSecond or third degree block Serum potassium > 4.5mmol/L

Lapostolle, Crit Care Toxicology, 2005

4

4

Supportive treatment

Decontamination / drug removal

Antidote treatment

Page 11: Pre0003-Lapostolle Frederic · Urgences - SAMU 93, UF Recherche Hôpital Avicenne & Université Paris 13, Bobigny Frédéric Lapostolle Urgences - SAMU 93, UF Recherche Hôpital Avicenne

20/09/2018

11

Clinical Toxicol, 2005 Clinical Toxicol, 2005

Clinical Toxicol, 2005 Clinical Toxicol, 2004

Page 12: Pre0003-Lapostolle Frederic · Urgences - SAMU 93, UF Recherche Hôpital Avicenne & Université Paris 13, Bobigny Frédéric Lapostolle Urgences - SAMU 93, UF Recherche Hôpital Avicenne

20/09/2018

12

Clinical Toxicol, 2004

Antidotes

Antidotes with alternative treatment

Antidotes with alternative treatment Antidotes with alternative treatment

Antidote without alternative treatment

Page 13: Pre0003-Lapostolle Frederic · Urgences - SAMU 93, UF Recherche Hôpital Avicenne & Université Paris 13, Bobigny Frédéric Lapostolle Urgences - SAMU 93, UF Recherche Hôpital Avicenne

20/09/2018

13

Simmons, Drug Alcohol Depend, 2017

Page 14: Pre0003-Lapostolle Frederic · Urgences - SAMU 93, UF Recherche Hôpital Avicenne & Université Paris 13, Bobigny Frédéric Lapostolle Urgences - SAMU 93, UF Recherche Hôpital Avicenne

20/09/2018

14

Dart, Ann Emerg Med, 2017

Dart, Ann Emerg Med, 2017California Health and Human Services Agency Department of Public Health. Hospital Administrative Penalties

Page 15: Pre0003-Lapostolle Frederic · Urgences - SAMU 93, UF Recherche Hôpital Avicenne & Université Paris 13, Bobigny Frédéric Lapostolle Urgences - SAMU 93, UF Recherche Hôpital Avicenne

20/09/2018

15

Make exceptional treatment available

4 4

Make exceptional treatment available

www.saitonjamais.be

www.saitonjamais.be

1&2The doubt kills

www.saitonjamais.be

1&2The doubt kills

3

Toxicologic screening is not useful

Page 16: Pre0003-Lapostolle Frederic · Urgences - SAMU 93, UF Recherche Hôpital Avicenne & Université Paris 13, Bobigny Frédéric Lapostolle Urgences - SAMU 93, UF Recherche Hôpital Avicenne

20/09/2018

16

www.saitonjamais.be

1&2The doubt kills

3

3Make exceptional treatment available

Toxicologic screening is not useful

www.saitonjamais.be