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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2669_Библиотеки_им_академика_М_И_Перельмана
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Management
• ABC, IV access, Continuous Cardiac Monitors, O2, Foley
• C-collar if unwitnessed LOC
• Consider – Dextrose, oxygen, naloxone, thiamine
• Tox specific treatment (see next s li d e )
– Decrease Absorption
– Increase Elimination
– Antidotes
• Call Poison Control (ALWAYS!)
– And Psychiatry if intentional overdose, once pt is stable and talking
– And Addictions medicine if applicable
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Decontamination/Elimination
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BONUS
Read on own
Decontamination
Method Single Dose Activated Charcoal (SDAC) (50-100g) Whole Bowel Irrigation
PEG 500ml + 1-2L/hr
Indications Suitable toxin +
1-2hrs since ingestion
>2hrs with drug that delays gastric emptying, massive ingestion, lethal drug
if ingestion large, deadly, long-
acting
i.e. buproprion, lithium, salicylates
Contraindications High aspiration risk (reduced LOC, not protecting airway, seizures, vomiting)
Poorly absorbed toxins
• Metals (Fe, Pb, Li)
• Alcohols
• Salts (K, Na, Mg)
• Hydrocarbons
High risk aspiration
GI: Ileus, obstruction, perforation,
bleeding
Gastric lavage not used for decontamination
Elimination
Method Dialysis Multidose-activated charcoal (12.5g q1h)
Indications Dialysable drug (small, charged, not protein bound, small
volume of distribution)
EXTRIP – list of dialysable drugs
i.e. Toxic alcohols, ASA, Lithium, Acetaminophen,
metformin, CCBs, BBs
Drug cleared by enterohepatic circulation
- Phenobarbitol, carbamazepine theophylline,
caffeine, phenytoin, ASA, quinine, dapsone
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Common antidotes
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BONUS
Read on own
Drug Antidote
Acetaminophen NAC
ASA HCO3
BB / CCB High-Dose Euglycemic Insulin, glucagon, calcium, intralipid
Benzos Flumazenil
[caution – lasts up to an hour and if multiple drug ingestions or
withdrawal seizure will make managing seizures a challenge!]
Cyanide Hydroxycobalamin, sodium thiosulfate,
Iron Deferoxamine
Isoniazid Pyridoxine
Local anesthetics Intralipid
Lipid soluble drugs (Atenolol, Buproprion, CCBs, Amitriptyline) Intralipid
Methemobloginemia Methylene blue
Organophosphates Atropine, pralidoxime
TCA HCO3, intralipid
Toxic alcohols (ethylene glycos, methanol) Fomepizole, thiamine, folate
Valproate L-carnitine
Sulfonylurea Octreotide
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TCA Overdose
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Signs and Symptoms
• CVS
– Hypotension
– Arrhythmias
• Sinus tach
• VF/VT as QRS
widens
• CNS
– Dec LOC, agitation,
psychosis, delirium
– Seizures
Anticholinergic Toxicity
RED as a beet
DRY as a bone
urinary retention
MAD as a hatter
sedation, confusion,
delirium, hallucination
BLIND as a bat (mydriasis)
dilated pupils that
DON’T respond to light
HOT as a desert
hyperthermic
STUFFED as a turnip
absent bowel sounds
SEIZURES (since acts on GABA)
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Labs
• TCA serum levels are not helpful
– Urine tox can detect TCA use, but beware of false positives
(carbamazepine, diphenhydramine, cyclopenzaprine, quetiapine)
• Would expect to see a respiratory acidosis from decrease LOC
• ECG is very helpful
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Diagnosis is made based on:
1. History of ingestion or TCA use
2. Physical findings of anticholinergic toxidrome
3. Characteristic ECG findings (see next slide)
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• QRS >100
– >100-26% get seizures
– >160-50% get
arrhythmia
• Tall R in AVR
• Deep slurred S in 1
and AVL
• R/S ratio >0.7 AVR
• Type 1 Brugada
(RBBB, downslope ST
depression V1-V3)
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Treatment
• ABCs, IV, O2, Monitors, Foley, Acute care area, Poison control
• Decontamination
– Can consider activated charcoal (1g/kg, max 50g) if present within 1-
2hours unless they have a decreased LOC, gut perforation, bowel
obstruction
• No increased elimination
• No antidote
• DO NOT use Physostigmine to counteract anticholinergic toxicity
(will worsen cardiac instability, increases risk of cardiac arrest)
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Symptom Specific Management
• LOC
– GCS 8, intubate
– Agitation: benzodiazepines (Ativan or diazepam at 5 – 10 min intervals)
– Seizures
• Start with Ativan or diazepam, add midazolam infusion if refractory
• Then propofol infusion if refractory
• Then Barbiturates
• DO NOT USE PHENYTOINà Enhances Cardiac Toxicity
• Hypotension
– NS or Na Bicarb bolus (up to 30ml/kg)
– Norepi or phenylephrine if refractory
– Consider hypertonic saline boluses 100 mg IV if refractory despite vasopressors
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Treatment of Arrhythmias
• Wide complex (ventricular) tachy OR prolonged QRS > 100
– Na Bicarb 1-2mEq/kg IV àif QRS narrows start infusion (3amps in a bag of
D5W) at 250ml/h
– If fails, give magnesium sulfate
– If fails, lidocaine (class IB) 1.5mg/kg bolus then 1-4mg/min
• Class IA, 1C, and III anti-arrhythmic are C/I
– If fail and unstableà lipid emulsion, VA ECMO
• Sodium Bicarb
– Indication
• QRS>100, ventricular arrhythmia, or hypotension
– Goal pH 7.50-7.55
– Bolus 1-2 amps then run as an infusion at 250ml/h
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Toxic Alcohols
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Ethylene Glycol
Methanol
Found in
Antifreeze, wiper fluid, cleaners, fuels, moonshine, solvents, hand sanitizer
S&S
-
Decreased LOC
-
Frank hematuria, flank pain, oliguria
-
HypoCa
-
Decreased LOC
-
Retinal injury leading to blindness
PE
-
Cranial Nerve palsies
-
Teta ny
-
Afferent pupillary defect
-
Mydriasis (dilation)
-
Retinal sheen
-
Hyperemia of the optic disc
Labs
-
Classically high AG and OG *see next slide
-
Lytes, Creatinine and Urine R&M
-
ECG (Watch QTc for ethylene glycol-à hypoCaàProlonged QT)
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