toxicology for primary care
DESCRIPTION
Common toxidromes that may be encountered by primary care doctors, particularly military doctors.TRANSCRIPT
![Page 1: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/1.jpg)
Poisoning
AKA: Stupid sailor/marine tricks.Tina F. Edwards, MD FAAEM
LCDR MC USN
![Page 2: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/2.jpg)
Toxicology, in a nutshell
OSupportive careOSeizure, coma, death
![Page 3: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/3.jpg)
Conclusion
OQuestions? OJust Kidding!
![Page 4: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/4.jpg)
OverviewO Basics of the poisoned patientO AnticholinergicsO CholinergicsO SedativesO SympathomimeticsO Carbon MonoxideO Toxic Alcohols
![Page 5: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/5.jpg)
What is a poison?O Too much of anything can be a bad
thing.
![Page 6: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/6.jpg)
Why primary care? O Jus’ gonna send this patient to ED!O RecognizeStabilizeO YOU might be the ED
![Page 7: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/7.jpg)
BasicsO Stable or unstable?
O Abnormal Vital signsO Respiratory distressO Altered Mental Status
![Page 8: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/8.jpg)
BasicsO Nature of the syndrome?
O Mental statusO Agitated vs. SedatedO PupilsO SkinO VitalsO Mucous membranesO Odors
![Page 9: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/9.jpg)
BasicsO Emetics. Don’t. O Charcoal, maybe.O Aggressive supportive care:
O IV, monitors, fluidsO If it’s fast, slow it.O If it’s slow, speed it up.O If it’s low, raise itO If it’s high, lower it.
![Page 10: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/10.jpg)
Common Causes of Seizures
O BupropionO Tricyclic Antidepressants*O TramadolO Isoniazid*O Cocaine, amphetaminesO AntihistaminesO Venlafaxine (Effexor)
![Page 11: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/11.jpg)
WorkupO EKGO Finger stick blood
sugarO ChemistryO Blood GasO CBCO Tylenol, Aspirin, EtOHO UAO CXR,KUB
![Page 12: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/12.jpg)
TreatmentsO Got Activated Charcoal?
O 1 hour +/-O CautionsO Ineffective
O AlcoholsO MetalsO Caustic agents
![Page 13: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/13.jpg)
TreatmentsO DecontaminationO Naloxone
(Narcan)O BenzodiazepinesO DialysisO AntidotesO Sodium Bicarb
![Page 14: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/14.jpg)
So there you are minding your own
business…When...
![Page 15: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/15.jpg)
19 yr old AD Female
O Oriented x 1O AgitatedO 140, 156/92, 20,
101.2, 98%O Dry skin, MM’sO Hypoactive BS
![Page 16: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/16.jpg)
Anticholinergic Toxidrome
O BenadrylO Cough syrupO TCA’sO ScopolamineO DM
![Page 17: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/17.jpg)
Anticholinergic Toxidrome
O Flushed, dry skin, dry mucous membranes
O MydriasisO DeliriumO Hyper: -thermia, -tensionO TachycardiaO Urinary retentionO Hypoactive BS
![Page 18: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/18.jpg)
Anticholinergic Treatment
O Aggressive supportive careO Physostigmine Why?
O Can’t use if any QRS wideningO Contraindicated in asthmaO Requires continuous cardiac
monitoringO Usually won’t outlast the
anticholinergic
![Page 19: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/19.jpg)
24 yr old AD maleO C/O frequent diarrhea,
vomitingO Fatigued, mildly confusedO Acrid garlic smellO 112/62, 52, 18, 98.2,
95%O Productive coughO TearingO Frequent spittingO Muscle twitches
![Page 20: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/20.jpg)
Cholinergic Toxidrome
O MuscarinicO NicotinicO Central
O CausesO InsecticidesO PilocarpineO CarbacholO Betel nutsO Indian
TobaccoO NicotineO Black widow
![Page 21: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/21.jpg)
Cholinergic ToxidromeO Nicotinic
O TachycardiaO HypertensionO Fasciculation'sO WeaknessParalys
is
![Page 22: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/22.jpg)
Cholinergic ToxidromeO Central
O AgitationO Psychosis/
confusionO Seizure/coma/
death
![Page 23: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/23.jpg)
Cholinergic PoisoningO Muscarinic
O DiarrheaO UrinationO MiosisO BradycardiaO BronchorrheaO EmesisO Lacrimation,
salivation
![Page 24: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/24.jpg)
Cholinergic treatmentO Protect yourself!O Stabilize, then decontaminateO Atropine until dryO Pralidoxime currently recommendedO Aggressive supportive care
![Page 25: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/25.jpg)
17 yr old boyO Brought in by momO C/C “not himself”O Sedated, barely
responsiveO Disheveled O 90/58, 52, 10, 97.2,
94%O CracklesO Decreased BSO Hypotonic reflexes
![Page 26: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/26.jpg)
Opioid ToxidromeO Classic Triad
O ComaO Respiratory
DepressionO Pinpoint pupils
![Page 27: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/27.jpg)
Opioid ToxidromeO Causes
O All the usual, plus LomotilO Dextromethorphan
O But wait!
O Random fact:O Not all opioids cause miosis
O Meperidine (Demerol)O Propoxyphene (Darvon)
![Page 28: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/28.jpg)
Opioid TreatmentO NaloxoneO Aggressive supportive care
![Page 29: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/29.jpg)
19 year old AD maleO Brought in by
roommate, “Seized”O Moans, doesn’t open
eyesO 88/52, 101, 10, 95.8,
93%O PERRL, but slowed O Nystagmus
![Page 30: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/30.jpg)
Sedative Hypnotic Toxidrome
O BarbituatesO BenzodiazapinesO GHBO Zolpidem
(Ambien)O Zaleplon (Sonata)
O Confusion/comaO Respiratory
depressionO HypotensionO HypothermiaO Pupillary changes O Vesicles or bullaeO Seizures
![Page 31: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/31.jpg)
Sedative-hypnotic treatment
O Aggressive supportive careO Airway managementO Multiple-dose activated charcoalO Phenobarbital may require dialysis
![Page 32: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/32.jpg)
A note about flumazenilO Why?
O Can precipitate seizuresO Absolutely contraindicated in QRS
wideningO Doesn’t reverse Hypoventilation
![Page 33: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/33.jpg)
What to do?
![Page 34: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/34.jpg)
23 yr old AD maleO Brought in by
command, “not acting right”
O AnxiousO 180/110, 142, 18,
103.2, 100%O Flushed, sweatingO A+O x 3
![Page 35: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/35.jpg)
Sympathomimetic Toxidrome
O CocaineO MethamphetamineO Other CNS StimulantsO Withdrawal from sedative hypnotics
![Page 36: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/36.jpg)
Sympathomimetic Toxidrome
O HypertensionO TachycardiaO HyperpyrexiaO MydriasisO Anxiety or
delirium
![Page 37: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/37.jpg)
Sympathomimetic treatment
O Aggressive supportive careO BenzodiazepinesO Active cooling if needed
![Page 38: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/38.jpg)
What to do?
![Page 39: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/39.jpg)
34 yr old AD maleO Losing balance,
headache, chest pain, vomiting
O 100/72, 120, 32, 98.7, 99%
O A+O x 2O Accessory muscle
use
![Page 40: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/40.jpg)
EKG
![Page 41: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/41.jpg)
Carbon Monoxide Poisoning
O Signs/Sx highly variable, non-specificO HeadacheO DizzinessO Nausea/Vomiting/DiarrheaO ConfusionO SyncopeO SOBO Chest painO Cerebellar ataxia
![Page 42: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/42.jpg)
Mechanism CO Poisoning
O Running engine, closed spaceO MechanicsO Suicide attemptO GeneratorsO Gas heatersO Camp stoves/Charcoal grills
![Page 43: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/43.jpg)
CO Poisoning Treatment
O Oxygen, more is betterO Aggressive supportive careO Mild to moderate acidosis is helpful
O Moves curve to right
![Page 44: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/44.jpg)
23 yr old ADO Sent “I want to
die” textO A+O x 1O 102/62, 110, 12,
97.3, 97%O Covered in vomitO Slurred speechO Ataxic gait
![Page 45: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/45.jpg)
Toxic AlcoholsO Ethanol!O Ethylene GlycolO MethanolO Isopropanol/
AcetoneO Other glycols
![Page 46: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/46.jpg)
Toxic AlcoholsO Ethylene glycol – Ca oxalate
monohydrate crystalsO Methanol – Formic acidO Isopropanol – Acetone
![Page 47: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/47.jpg)
Toxic AlcoholsO All – Airway compromiseO Ethylene Glycol
O DysrhythmiasO NephrotoxicityO MeningoencephalitisO Cerebral/pulmonary edema
![Page 48: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/48.jpg)
Toxic AlcoholsO Methanol
O Visual symptoms, “snowfields”O ComaO Respiratory and circulatory failureO Parkinson-like syndrome
![Page 49: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/49.jpg)
Toxic AlcoholsO Isopropanol
O KetonemiaO CNS Depression (2 x EtOH)O GI effectsO Increased Cr w/nl BUN suggests
![Page 50: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/50.jpg)
Toxic AlcoholsO Other glycolsO Effects
O Neurologic toxicity
O Renal failureO HepatitisO PancreatitisO HemolysisO ARDS
![Page 51: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/51.jpg)
Toxic AlcoholsO Diethylene glycol
O Renal failure epidemicsO Propylene glycol
O “safer” antifreezeO Iatrogenic, IV Benzos
![Page 52: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/52.jpg)
Toxic AlcoholO Aggressive supportive care! O FomepizoleO Plain ol’ ethanolO Look for acidosis, ketones, other
clues
![Page 53: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/53.jpg)
Are you ready?
![Page 54: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/54.jpg)
24 year old maleO Found down
outside barracksO 90/54, 48, 8,
92%, 96.2O Non responsiveO PERRL
![Page 55: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/55.jpg)
18 year old AD femaleO Witnessed
seizureO 160/102, 120, 22,
102.4, 99%O Flushed, DryO Pupils dilated,
reactiveO Absent bowel
sounds
![Page 56: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/56.jpg)
22 year old AD maleO Working outsideO VomitingO 190/120, 130, 24,
104.2, 95%O DiaphoreticO Rigid, shakingO Smells of stoolO Pupils pinpoint,
reactive
![Page 57: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/57.jpg)
SourcesO Harwood-Nuss, Clinical Practice of Emergency Medicine,
5th Edition, Lippincott Williams & Wilkins, Philadelphia, PA, 2010
O Hamilton, Sanders, Strange, Trott. Emergency Medicine, An Approach to Clinical Problem Solving, 2nd Edition. Saunders. Philadelphia, PA. 2003.
O http://www.mrcophth.com/plants.htmlO http://memorize.com/toxidromes-and-antidotes/erichfO http://emedicine.medscape.com/article/812411-clinicalO Thundiyil JG, et. al, Evolving epidemiology of drug-
induced seizures reported to a Poison Control Center System. J Med Toxicol, 2007, Mar, 3(1):15-9.
![Page 58: Toxicology for primary care](https://reader038.vdocuments.net/reader038/viewer/2022102804/548f30e8b47959d9168b47b5/html5/thumbnails/58.jpg)
Questions