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Managing Drug Overdoses and Poisonings

Iris Sheinhait

CORE PRINCIPLES

CHAPTER CASES

GENERAL MANAGEMENT

The most important aspect of patient management is to support airway, breathing, and circulation (the “ABCs”). There is no “cookbook” method to treat all poisoned patients, so it is important to treat the patient, not the poison or the laboratory values. The assessment and treatment of the potentially poisoned patient can be separated into seven functions: (a) gather history of exposure, (b) evaluate clinical presentation (ie, “toxidromes”), (c) evaluate clinical laboratory patient data, (d) remove the toxic source (eg, irrigate eyes,

Case 5-4 (Questions 1, 3, 5, 6)

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decontaminate exposed skin), (e) consider antidotes and specific treatment, (f) enhance systemic clearance, and (g) monitor patient outcome.

GASTROINTESTINAL DECONTAMINATION

The most appropriate method for gastrointestinal (GI) tract decontamination is unclear because sound comparative data for different methods of GI decontamination are not available. Lavage, emesis, and cathartics are rarely performed because there is no evidence that they improve patient outcome. Activated charcoal is generally safe to use, but it should not be administered if the benefit is not greater than the risk. Whole-bowel irrigation using a polyethylene glycol– balanced electrolyte solution can successfully remove substances (iron, lithium, sustained-release dosage forms) from the entire GI tract in a period of several hours.

Case 5-3 (Questions 6, 7)

Case 5-4 (Questions 11, 12, 16)

Case 5-5 (Question 3)

ANTIDOTES

An antidote is a drug that reverses the toxicity of another substance. Some antidotes displace drugs from receptor sites (eg, naloxone for opioids, flumazenil for benzodiazepines), and some can inhibit the formation of toxic metabolites (eg, N-acetylcysteine [NAC]

Case 5-4 (Questions 2, 4)

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for acetaminophen, fomepizole for ethylene glycol and methanol).

TOXICOLOGY LABORATORY SCREENING

Urine drug screens can be useful in a patient with coma of unknown etiology, when the presented history is inconsistent with clinical findings, or when more than one drug might have been ingested. Qualitative screening is intended to identify unknown substances involved in the toxic exposure. A benzodiazepine screen can detect oxazepam, a common benzodiazepine metabolite, but it will not detect alprazolam and lorazepam because they are not metabolized to oxazepam. Opioid screens may not detect synthetic opioids such as fentanyl and methadone. Quantitative testing determines how much of a known drug is present and can help determine the severity of toxicity and the need for aggressive interventions (eg, hemodialysis in ethylene glycol, methanol, and salicylate).

Case 5-4 (Questions 1, 7, 8)

TOXIDROMES

A toxidrome is a consistent constellation of signs and symptoms associated with some specific classes of drugs. The most common toxidromes are those associated with anticholinergic activity, increased sympathetic activity, and

Case 5-4 (Questions 1, 2, 5)

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central nervous system (CNS) stimulation or depression. Anticholinergic drugs increase heart rate and body temperature, decrease GI motility, dilate pupils, and produce drowsiness or delirium. Sympathomimetic drugs increase CNS activity, heart rate, body temperature, and blood pressure. Opioids, sedatives, hypnotics, and antidepressants depress the CNS, but the specific class of CNS depressants often cannot be easily identified.

SALICYLATES

Acute ingestion of 150 to 300 mg/kg aspirin causes mild-to-moderate intoxication, >300 mg/kg indicates severe poisoning, and >500 mg/kg is potentially lethal. Symptoms of intoxication include vomiting, tinnitus, delirium, tachypnea, metabolic acidosis, respiratory alkalosis, hypokalemia, irritability, hallucinations, stupor, coma, hyperthermia, coagulopathy, and seizures. Salicylate intoxication mimics other medical conditions and can be easily missed. Patients with a chronic salicylate exposure, acidosis, or CNS symptoms, and those who are elderly are at high risk and should be considered for early dialysis.

Case 5-1 (Questions 1–3)

Case 5-2 (Questions 1–6)

IRON

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Acute elemental iron ingestions of <20 mg/kg are usually nontoxic; doses of 20 to 60 mg/kg result in mild-to-moderate toxicity, and doses of >60 mg/kg are potentially fatal. Symptoms of toxicity include nausea, vomiting, diarrhea, abdominal pain, hematemesis, bloody stools, CNS depression, hypotension, and shock. Patients with severe iron poisoning do not exhibit the second stage of the so-called recovery but continue to deteriorate.

Case 5-3 (Questions 1–14)

TRICYCLIC ANTIDEPRESSANTS

Severe toxicity has been associated with doses of 15 to 25 mg/kg. Symptoms include tachycardia with prolongation of the PR, QTc, and QRS intervals; ST and T-wave changes; acidosis; seizures; coma; hypotension; and acute respiratory distress syndrome. A QRS segment >100 milliseconds is commonly seen in severe tricyclic antidepressant overdoses.

Case 5-4 (Questions 9–17)

ACETAMINOPHEN

Toxicity is associated with acute ingestions >150 mg/kg or >7.5 g total in adults. Symptoms in patients with toxicity include vomiting, anorexia, abdominal pain, malaise, and progression to characteristic centrilobular hepatic necrosis.

Case 5-5 (Questions 1–15)

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