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The Poisoned Patient
The Overdosed & The Underdosed

by Tom Trimble, RN

Key Points:

Triage and Assessment:

--A high Index of Suspicion is necessary.

--Be alert to motivation.

--Remember, poisoning can be "accidental, suicidal, or homicidal", and occupational exposures occur, also.

--When triaging patients, be alert to clues of psychic stress and potential overdose:

affect seems flat, odd, inappropriate

seems "needy" but cannot articulate complaint or problem; seems ashamed or unworthy (cultural influences)

poor eye contact, deep breaths taken, sighing, non-verbal vocalizations, evasive responses to questions

seems "under the control" of another person, who may attempt to do all the talking, dominate or "steer" the interview: abusive situation?Munchausen’s Syndrome by proxy?

--Suspect group poisoning when more than one patient from the same grouping presents, especially with order of onset = order of ascending body mass (the Miner's Canary Effect) ± variability due to age effect or dosage/exposure.

History of this episode/Factors affecting absorption:

--Look for co-ingestants. Alcohol is often a factor in self-poisonings. Food, medication effect, and some disorders may slow absorption.

--Pin down time and span of ingestion.

--Identify as accurately as possible the exact compound(s) ingested as formulations may include multiple dosage varieties, additional agents, and Extra-Strength or extended release forms. Ask also about all over-the-counter medicines used, (or taken to feel better as a result of this illness) by brand name and product name. If need be, send someone to retrieve all possible specimens.

--Extended Release compounds may extend absorption or prolong the prodromal phase.

--Medication history may be important regarding interactions and absorption.

--Concretions of ingested substances may form bezoars in the stomach and alter absorption, or provide "a continuing source of supply."

--Weight (and height) may be useful in calculating dosage and estimating lethality.

Suicidality:

--Many self-poisoners may have seriously under-estimated the toxicity or lethality of compounds ingested. There is a prevalent false perception that if a product is sold over-the-counter (and is safe when used as directed) that it’s not dangerous.

--Extreme Suicidality:

Ingestion of frank poisons (Danger label-"Skull & Crossbones"),

or sustained ingestion over time, with co-intoxicants or dissolved in liquid form
(showing deliberation and serious attempt to achieve lethality),

or adjuvant suicidal means (asphyxiation, slashed wrists, jumping, attempted run-over, isolation to avoid discovery, plastic bag over the head, etc.) suggest extreme suicidality.

Critically appraise patient's statements for falsehood or under-reporting.
Do not hesitate to hospitalize or place in critical care.

General:

--Contacting "Poison Control" for management suggestions or identification of a toxidrome is always appropriate.

--Beware of ingestion of medicines belonging to visiting elders by children. Parents may have locked up or out of reach any known medicines or toxins, but Granny’s purse may be in reach and contain her heart medicine.

--Some poisons are radiopaque and may be seen on X-Ray exam.

Interactions:

--Avoid the "Insensitivity Trap." "How come they never do it right?"

--In manner, be matter-of-fact, pragmatic, and future-minded ("When you are recovered from this, what will you do?)"

General Management of Overdoses and Poisonings:

c.f., article linked:
"Management of the Poisoned/Overdosed Patient"
http://www.uspharmacist.com/newlook/ce/poisoning/default.htm
http://www.uspharmacist.com/newlook/ce/poisoning/default.htm

Testing for Toxicology:

The key "take-home lesson" is that toxicology testing "is as sensitive as you can be specific in requesting tests." There is no single broad-spectrum "poison-o-gram" test to be done or can give clinically useful results in the short term. Medical Examiner’s testing in autopsies (including gas chromatography) takes six-eight weeks to complete.

The more carefully you can suspect and suggest a toxic agent for testing from available sample sources by the history, clinical examination,, and differential diagnosis for the toxidrome under consideration,, the more likely that you will receive a meaningful test result. If you have a well-founded suspicion or hunch that a particular poison may be part of the picture, or that something is not quite right with the story as told, suggest that it be tested for. Go with your hunch. It may be too late later on to test and establish the diagnosis.

The so-called "U-Tox" is actually "DAU" (or Drugs of Abuse – urine) on the lab requisition in the section for urine studies. It will tell if opiates, benzodiazepines, cannibinol, amphetamines, or cocaine is in the system. It will not tell you when it was taken, and is primarily for qualitative rather than quantitative guidance.

Other toxicology panels go out of the hospital to a commercial laboratory and require 3 or more days for processing. Thus, information is not available to guide current management. Questions regarding testing availability and methods may need to be referred to the Laboratory Medicine resident, or may be suggested by Poison Control.

Tests that are useful in the majority of cases include acetaminophen and salicylate. This is so because of the vast number of over-the-counter medications containing them, poor public recognition of the ingredients of such medications or of their potential toxicity, and the likelihood of multiple source of ingestion. The tests are cheap, timely, and may catch a major intoxication not suspected which may have life-altering or life-ending results. [The lab codes for the requisition in this hospital are: AAPH and SAL, respectively.]

Levels of specific drugs may be useful: e.g., digoxin; ethanol/methanol; carbamazepine, phenobarbital, phenytoin, valproic acid; theophylline; iron; lead. Prothrombin (PT) and Partial Thromboplastin Times (PTT) {"coags") are useful when there has been an excess of Coumadin (Warfarin®).

Electrolytes, creatinine, BUN, glucose; calcium, magnesium, and phosphorus, and liver function tests --amylase, AST, ALKP, ALT, BILT (total bilirubin) are needed depending on the metabolic pathway affected.

If Carbon Monoxide poisoning is suspected, the test to send is a stat Arterial Blood Gas with Co-Oximetry checked off to obtain the COHgb result. Administer 100% Oxygen via Non-Rebreather mask while awaiting the result. Do not be deceived by the SPO2 reading of pulse oximetry (which will be false)! If clinical suspicion is high, do not await an order for the ABG but send it at the first opportunity (time and oxygen wash out the blood level)

Alcohol levels can be determined from the ordinary serum chemistry "tiger-top" SST (serum separator tube) if ordered initially; --as alcohol volatilizes when the tube is opened, the test cannot be "added-on" later. A light gray top tube can be used for ethanol testing if there will be delay before the test is run. If the poisoning is of mixed or undetermined alcohols, or there are any visual symptoms, send both ethanol and methanol levels. Medical-legal testing for alcohol at the request of law enforcement officers should be done with the kit and instructions they supply (for evidentiary reasons) and if the patient consents or will not resist (for your safety).

A clue to possible methemoglobinemia would be that venous blood drawn for the laboratory appears dark and "chocolate brown" in appearance.

From one institution's Laboratory Manual:
(Intended as a sample for the planning of intended testing. Data changes frequently and must be checked locally and contemporaneously. Do not use for reference .)

DRUG SCREENING:

Different screening tests are appropriate depending upon the clinical situation:

--Drugs of Abuse Screen - Rapid (not for Neonates)

The drugs most frequently abused, including those most likely to present as a drug-induced psychosis, are included in this screen on urine offered stat for use primarily by the Emergency Department (Editor's Note: and for medical clearance efforts during psychiatric evaluation). Cross-reactions and false positive results are uncommon, but may occur within each drug class. This assay offers presumptive identification only and does not include confirmation of the identity of the drug detected, which is available on request at an additional charge.

--Drugs of Abuse Screen - Routine Comprehensive (not for Neonates)

Establishing whether an individual is improperly taking drugs is not usually important for the immediate clinical or social management of the patient. In these cases, this very comprehensive (>400 compounds) and inexpensive Drugs of Abuse Screen on urine is sufficient, and is the test recommended for routine purposes. This Drugs of Abuse Screen also does not include confirmation of the identity of the drug detected in the urine, but the major street drugs are measured with very specific immunoassays and give a very low rate of false-positive results. This assay should NOT be used for Neonatal Screening (see below).

--Drugs of Abuse Screen - Routine Neonatal

Because the results of the drug screen in neonates are often a factor in the decision to discharge the infant home with the mother, any positive results of this assay are routinely confirmed by Gas Chromatography / Mass Spectrometry (even though a formal chain-of-custody has not been maintained for the sample).

--Drugs of Abuse Screen - Stat Limited (ETS, Emergency Toxicology Screen)

The treatment of most drug intoxications is empirical and supportive, and stat results are rarely needed. Narcan is administered on clinical grounds, not upon finding opiates in the urine; the Clinical Laboratories offer in-house assays for acetaminophen, ethanol, and salicylates. In the uncommon situation for which availability of the result within a 4-6 hr turnaround will alter patient management, the Stat Limited Drug Screen offers a more extensive spectrum of commonly abused drugs than the Rapid (in-house) screen. Confirmatory testing is available at an additional charge.

--Drugs of Abuse Screen - Stat Volatiles

The most frequent need for sendout drug testing is in questions of methanol or isopropanol ingestion, which this assay will detect in addition to acetone and ethanol.

-------------------------------------------------------------------------------

Drugs of Abuse Screen

- Rapid Urine DAU CHEM 5 mL random (E) (min. 1.5) Method: EIA This test includes:

Sensitivity

Amphetamines 1000 µg/L

Barbiturates 200 µg/L

Benzodiazepines 200 µg/L

Cocaine metabolite 300 µg/L

Opiates 2000 µg/L

THC (Cannabinoids) 50 µg/L

------------------------------------------------------

- Routine Comprehensive Urine ABUS NISD 25 mL random

(NOT FOR NEONATES - (min. 15)

see below)

Method: Enzyme Immunoassay, Gas Chromatography, High Performance Liquid Chromatography, Thin-Layer Chromatography, spot tests

Qualitative screen for >400 drugs, including:

Amphetamines:* Amphetamine, Methamphetamine

Analgesics:  Acetaminophen, Salicyclates, Norpropoxyphene, Propoxyphene

Antibacterials: Trimethoprim (as metabolites),

Antidepressants: Amitriptyline, Amoxapine, Desipramine, Doxepin, Fluoxetine, Loxapine, Maprotiline, Nortriptyline,  Phenothiazine, Protriptyline, Trazodone, Trimipramine

Antihistamines: Brompheniramine, Chlorpheniramine, Diphenhydramine, Doxylamine, Methapyrilene, Pyrilamine

Barbituates:* D- Amobarbital, Butabarbital, Butalbital, Pentobarbital, Phenobarbital, Secobarbital

Benzodiazepines:* Chlordiazepoxide, Diazepam, Flurazepam metabolites, Nordiazepam

Miscellaneous:  Cannabinoids* Glutethimide, Cimetidine , Cocaine metabolite*,  Dextromethorphan, Ephedrine , Lidocaine, Methocarbamol,  Phencyclidine (PCP)*, Phenylpropanolamine, Propranolol, Pseudoephedrine, Quinidine/Quinine, Verapamil

Narcotics: Codeine*, Heroin (as Morphine)*, Hydrocodone*, Meperidine, Methadone*, Morphine*, Pentazocine

Sedatives: Ethchlorvynol, Meprobamate, Methaqualone, Methyprylon

Volatiles: Ethanol*

Screening tests are not confirmed as positive by a second, independent method in this inexpensive panel, but the immunoassays (marked by a *) used to detect the usual illicit street drugs rarely give falsely positive results. Ethanol is confirmed and quantitated by GC.

------------------------------------------------------

- Routine Neonatal Urine NABU NISD 25 mL random (min. 15)

Method: EIA, with confirmation by This test includes:

GCMS Amphetamines Ethanol Barbiturates Methadone Benzodiazepines Opiates Cannabinoids Phencyclidine Cocaine.

------------------------------------------------------

- Stat Limited Serum MTOX SKSF Pink top

(NOT FOR NEONATES - & 10 mL

see above) STSK (min. 5)

Use iodophor skin disinfection; do not use alcohol or tincture of iodine!

+/-

Method: EIA, GC, TLC, STTX (if stat transport required)

spot tests

Urine MTOX SKSF 60 mL random & (min. 30)

STSK

+/-

STTX (if stat transport required)

Lavender top ok. The serum screen includes:

Acetaminophen* Volatiles:*

Barbiturates# Acetone

Benzodiazepines# Ethanol

Salicylates* Isopropanol

Tricyclic Anti- Methanol

depressants#

* Positive results are automatically quantified.

# Positive results for this class of drug are specifically identified and quantified only upon request and at additional cost.

Cross-reactivity from phenothiazines and diphenydramine may occur with the serum screen for tricyclic drugs (this is not a problem with the urine screen

for these compounds).The urine screen includes:

Acetaminophen Salicylates

Amphetamines Tricyclic Antidepressants

Barbiturates Volatiles:

Benzodiazepines Acetone

Cocaine Ethanol

Methadone Isopropanol

Opiates Methanol

Phenothiazines

Requires approval of Laboratory Medicine physician. Confirmation of drugs in the urine by a second method performed only upon request and at additional cost.

Stat requests may result in extra charges for transportation. Drug Screens rarely help in immediate management of an acutely ill patient. The preferred test for evaluation of a drug ingestion, primarily for purposes of documentation, is the Routine Comprehensive Drugs of Abuse Screen (see entry above), which covers the same spectrum of drugs but at minimal cost.

------------------------------------------------------

- Stat Volatiles, Blood MTOX SKSF Gray top  5 mL

including acetone, ethanol, isopropanol and methanol Use iodophor skin disinfection;do not use alcohol or tincture of iodine!

Method: GC

Requires approval of Laboratory Medicine physician. Positive results are quantified. (Refrigerate.)

--------------------------------------------------------------------------------

Activated Charcoal, Limitations of:

Once the principal ingredient of a product called "Universal Antidote," (there's no such thing, and the product as been discarded as less effective than its principal ingredient) Activated Charcoal is a mainstay of treatment. However, substances not well absorbed by it are:

generally small or charged particles

acetaminophen (>140mg/kg)

alcohol, methanol, ethylene glycol

digitalis

formaldehyde

iron

lithium

heavy metals (mercury, lead)

Monoamine Oxidase Inhibitors

poisonous mushrooms

sustained release preparations

(source: Emergency Medicine Quick Reference 1995-1996; Chase, Matthew W.; ©1995 Westerville, Ohio; Tangent Medical, Inc.)

 

Rumack-Matthew Nomogram:
<
http://www.merck.com/pubs/mmanual/figures/263fig1.htm>

A graph used to calculate hepatic toxicity potential and to plan treatment of acute single-dose acetaminophen overdose.

              Barry Rumack - A Tribute - Int J Med Toxicol 2002; 5(2): 5

 

Toxidromes:

--Acetaminophen:

emedicine.com: Toxicity, Acetaminophen
http://www.emedicine.com/emerg/topic819.htm
http://www.emedicine.com/emerg/topic819.htm

"Acetaminophen Overdose" http://www.pedianet.com/news/illness/disease/files/acetamin.htm
http://www.pedianet.com/news/illness/disease/files/acetamin.htm

"Acetaminophen is the active ingredient in Tylenol and other pain relievers. In 1996 there were approximately 73,000 cases in the United States of pure acetaminophen poisoning. According to Donovan, while some of these cases involved children who got into the drug accidentally, the vast majority were suicide attempts. Of those 73,000 cases, 580 resulted in major liver damage.

Donovan's research shows that treating patients eight hours or less after the ingestion of acetaminophen with N-acetylcysteine is nearly 100 percent effective in preventing any liver damage. He says treatment from eight to 16 hours after ingestion is about 60 percent effective. After 16 hours the percent of effectiveness continues to decline."
http://www.pslgroup.com/dg/62716.htm http://www.pslgroup.com/dg/62716.htm

When metabolic pathways in the liver are overwhelmed by a toxic dose or the protective stores of glutathione are depleted (as in malnutrition, alcoholism, and AIDS) an accumulation of a toxic metabolite occurs which leads to destruction of the liver. The drugs rifampin, phenobarbital, isonizid, phenytoin, carbamazepine, and chronic alcohol abuse increase the likelihood of damage. (emedicine.com:topic 819)

Acetaminophen binds rapidly and well to Activated Charcoal preventing absorption by the body. Repeated doses may be necessary. If given within eight hours of ingestion, "Muco-Myst™", N-acetylcysteine (NAC), is highly protective and is the effective antidote. Its use is based on the measurement of a toxic serum level of acetaminophen 4 hours after a single dose ingestion, or upon arrival to the ED (whichever comes first). 10 times the ingested dose is given orally. Activated Charcoal reduces availability of NAC, but the dose of NAC may be increased by one-third. NAC smells and tastes like "rotten eggs"; this can be somewhat overcome by giving it in cola and from a covered container with a straw. If the patient is uncooperative or nauseated, it can be instilled via a nasogastric tube, and antiemetics can be used. (preferably Metoclopramide (Reglan®) or Ondansetron (Zofran® which do not decrease motility or mental status and unlike phenothiazines will not add to toxicity of anticholinergic drugs present).

Baseline liver function tests will be needed when there is toxicity, and a pregnancy test should always be done on women of reproductive years.

--Alcohol:

emedicine.com: Toxicity, Alcohols
http://www.emedicine.com/emerg/topic19.htm
http://www.emedicine.com/emerg/topic19.htm

emedicine.com: Toxicity, Ethylene Glycol
http://www.emedicine.com/emerg/topic177.htm
http://www.emedicine.com/emerg/topic177.htm

Ethylene glycol and methanol poisoning: Diagnosis and treatment
Journal of Emergency Nursing April 1999 • Volume 25 • Number 2 • p116 to p120
Helen E. Zimmerman, MSN, RN, CCRN, CEN, Keith K. Burkhart, MD, J. Ward Donovan, MD

Man’s favorite poison, as in the bartender's phrase "what's your poison? Ubiquitous. Pandemic within emergency patient populations. A chief danger of ethanol intoxication is that the patient will be dismissed as "just drunk". Alcohol may be the cause of, or mask trauma that has occurred (especially head injury), other intoxications, hypoglycemia, phenytoin toxicity, or metabolic derangements.

--Antihistamines:

emedicine.com: Toxicity, Antihistamine
http://www.emedicine.com/emerg/topic38.htm
http://www.emedicine.com/emerg/topic38.htm

Antihistamines, chiefly diphenhydramine [Benadryl®, Sominex®] and doxylamine succinate [Unisom®] are used in over-the-counter sleeping medications, cold remedies, and analgesic"-PM" combinations. The presentation is of lethargy and drowsiness, "spacy" distracted appearance, and anticholinergic symptoms of dry mouth, decreased or absent bowel sounds, dilated pupils, resting tachycardia which is not responsive to fluids, seizures, and cardiac dysrhythmias. Persons taking multiple medicines during a viral illness may not notice that several medications contain the same or similar ingredients.

--Aspirin/Salicylates:

emedicine.com: Toxicity, Salicylates
http://www.emedicine.com/emerg/topic514.htm
http://www.emedicine.com/emerg/topic514.htm

Aspirin and other salicylates (oil of wintergreen) taken in excess can produce a characteristic tinnitus, and a metabolic acidosis which may be partially compensated by Kussmaul respiration attempting to "blow off" the acidosis with full deep breaths at increased rate (hyperpnea without labor or increased work of breathing).

Other effects include tachycardia, hypotension, and cardiac dysrhythmias; depressed CNS, seizures, cerebral edema and encephalopathy; GI irritation and bleeding; renal failure; coagulopathies.

Labs should include renal and electrolyte studies, coagulation, ABG, and EKG.

A likely treatment is to "alkalinize the urine" to enhance excretion and protect from acidosis. Sodium Bicarbonate would be loaded with 50-100 mEq IV push, followed by an infusion of 100-150 mEq/L D5%W. (Remember to remove from the IV bag the same volume of D5W as of NaHCO3 that you add). Other electrolyte adjustments may be necessary.

--Beta-Blockers:

emedicine.com: Toxicity, Beta-blocker
http://www.emedicine.com/emerg/topic59.htm
http://www.emedicine.com/emerg/topic59.htm

Beta-blockers are used for a number of purposes: lower blood pressure, lessen the work and oxygen consumption of the heart after MI, suppress arrhythmias, ease tremor, prevent migraine, even decrease stage-fright and anxiety. Excess dosage will accentuate the actions but may also alter sodium and calcium channels and be a cardiac depressant; cause seizures, or hypoglycemia.

Exact identification is useful due to both non-selective and selective b -blockers, the existence of sustained-release formulations, differing distribution and effects of as to whether the drug is hydrophilic or lipophilic, and Sotalol prolongs QT intervals leading to ventricular arrhythmias including VT, VF, and Torsades de pointes.

Activated Charcoal, and gastric lavage, may be used. Hypotension should be managed with fluids, Trendelenburg's Position, catecholamine pressors (Dopamine, Epinephrine, Isoproterenol). Calcium Chloride, 10%solution, may be used to overcome blocking of the calcium channel (100mgm to 1 gram as slow IV push). Glucagon is thought to be the drug of choice as it enhances myocardial contractility, increases heart rate and atrioventricular conduction through non-adrenergic pathways (­ cyclicAMP); the dose is much larger (3-10mgms, followed by an infusion) than that (1mgm) to treat insulin reaction hypoglycemia. Magnesium may be needed for Torsades de pointes, and pacing should that fail. Some b -blockers may be dialyzable.

--Calcium-Channel Blockers:

emedicine.com: Toxicity, Calcium Channel Blockers
http://www.emedicine.com/emerg/topic75.htm
http://www.emedicine.com/emerg/topic75.htm

Calcium Channel Blockers are used to decrease afterload, decrease heart rate, decrease cardiac conduction, and cardiac contractility is also decreased. Overdoses also lead to hyperglycemia as insulin release is suppressed which leads to lactic acidosis which also depresses contractility.

When children have unexplained hypotension or bradycardia, the family should be questioned as to members or visitors with blood pressure or heart medications.

Careful identification should be made to as specific drug and release formulation.

Glucagon may be needed empirically to overcome bradycardia or hypotension. High dose (5-15 mgms) may be needed. The propylene glycol diluent should not be used. Put in a small bag of Normal Saline and infuse over several minutes.

If Calcium Channel Blocker is confirmed by a witness, or Digitalis toxicity is excluded, Calcium Chloride (1-4 grams) can be given .

Initial fluid resuscitation of blood pressure may be supplanted by Dopamine and Norepinephrine infusions.

Insulin infusion may be necessary to control hyperglycemia.

Activated Charcoal, possibly in multi-dose regimen, gastric lavage, and Go-lytely may be used. Some patients have had cardiopulmonary bypass.

--Carbon Monoxide:

emedicine.com: Toxicity, Carbon Monoxide
http://www.emedicine.com/emerg/topic817.htm
http://www.emedicine.com/emerg/topic817.htm

Carbon Monoxide is preferentially bound to hemoglobin (by a factor of 435) and prevents oxygen transport by the hemoglobin. However, 100% oxygen concentration will cause CO to be released more quickly (that which would need to clear over 4 hours at room air (sea level) will clear in 45 minutes with 100% O2. While hope has long been held that hyperbaric oxygen chambers would produce a better result, this has not proven out as yet in any studies, and too few such chambers are available.

The patient will have had headache, malaise, nausea and vomiting, and lethargy progressing to unconsciousness. The skin color will be normal or pale; --not "cherry-red."

Test immediately by Arterial Blood Gas with Co-Oximetry checked off to obtain the COHgb result. Administer 100% Oxygen via Non-Rebreather mask while awaiting the result. Do not be deceived by the SPO2 reading of pulse oximetry (which will be false)!

If the patient was exposed to fire gasses (or was trapped in an enclosed space with combustion), check for carbonaceous sputum of smoke inhalation or potential pulmonary burns. Give 100% Oxygen via aerosol mask with double flow-meters and nebulizers or have Respiratory Care Services set-up a special high-flow high-FIO2 nebulizer. With pulmonary burns, plan for early intubation.

--Cyanide:

emedicine.com: Toxicity, Cyanide
http://emedicine.com/emerg/topic118.htm  http://emedicine.com/emerg/topic118.htm

Textbook of Military Medicine: Medical Aspects of Chemical and Biological Warfare: Chapter 10 Cyanide Poisoning
http://www.vnh.org/MedAspChemBioWar/chapters/chapter_10.htm http://www.vnh.org/MedAspChemBioWar/chapters/chapter_10.htm
Steven I. Baskin, Pharm.D., PH.D., FCP, FACC, DABT, FATS* and Thomas G. Brewer, M.D., FACPÜ
from the Virtual Naval Hospital website

Cyanide blocks cellular respiratory metabolism by interfering with cytochrome oxidase. Essentially, oxygen cannot be used and cellular work stops.

A lethal or near-lethal dose of cyanide, taken or given deliberately is so rapid and powerful in its effects that the patient may not survive to the hospital. If the patient is here and cyanide is identified, a special Cyanide Antidote Kit (Lilly) is kept in the Med. Room, to try to convert the cyanide to a form more readily excreted by the body. Additional kits from the pharmacy or other hospitals may be needed.

[CYANIDE ANTIDOTE KIT Kit: Sodium Nitrite 300 mg/10 mL (#2), Sodium Thiosulfate 12.5 g/50 mL (#2), Amyl Nitrite 0.3 mL (#12)

The inhalant ampoule of amyl nitrite should be broken and inhaled by the patient for 15 seconds on and 15 seconds off; when oxygen is available, it can be continued for 15-30 seconds of every 2-3 minutes (can be placed by the reservoir tail of the BVM).

When IV access is established, Sodium Nitrite is injected,

Sodium Thiosulfate is given next.

Repeat doses of ˝ the original may be repeated.

Instructions are inside the lid. Everything needed is in the kit.

Cyanide is also a toxic by-product of polyurethane and other furnishings that may be found in fires.

--Cyclic Antidepressants:

emedicine.com: Toxicity, Cyclic Antidepressants
http://www.emedicine.com/emerg/topic616.htm
http://www.emedicine.com/emerg/topic616.htm

Of approximately 500,000 cases per annum in the US, "Approximately 70% of patients attempting suicide with TCAs die prior to reaching a healthcare facility. TCAs are the number one cause of death from drug ingestion. Only 2-3% of TCA overdoses that reach care result in death." (from above)

Features of toxicity are hypotension; cardiac arrhythmias; an anticholinergic effect leading to confusion, hallucinations, seizures, and coma. Sodium Bicarbonate is a principal rescue agent to maintain serum pH and to prevent/control arrhythmias, given as a bolus and drip. Hypotension is treated with Norepinephrine. Dopamine is thought to be less effective. Lorazepam is used to control seizures.

--Iron:

emedicine.com: Toxicity, Iron
http://www.emedicine.com/emerg/topic285.htm
http://www.emedicine.com/emerg/topic285.htm

Often an ingredient in vitamin compounds. Can lead to errosive perforation of the stomach. Radiopaque. Multiple tablets taken at once may "clump" and form a bezoar in the stomach. May mistakenly be thought to be non-lethal. Vomitus or gastric lavage effluent is rust-red in appearance and guiac positive; looks bloody.

Beyond initial evaluation and treatment, viz., diagnosis, IV access, abdominal x-ray to check for amount and distribution of iron tablets, gastric lavage, analgesia and emesis control, specific chelation therapy would most likely be done "upstairs." Activated Charcoal is of no effect.

--Isoniazid [INH]:

emedicine.com: Toxicity, Isoniazid
http://www.emedicine.com/emerg/topic287.htm
http://www.emedicine.com/emerg/topic287.htm

INH is an important anti-tubercular agent for prophylaxis and treatment. TB ("the white plague") is a constant factor in San Francisco. When taken in overdose, seizures result which can be fatal. Overdose can be accidental due to misunderstanding ("when you next come to the clinic in one month, you should have finished taking all of this medicine"; missed doses/forgot to take; tried to catch up by taking all remaining tablets).

When specific treatment is needed, Pyridoxine (Vitamin B6) is given intravenously to counter the effects.

--Organophosphates:

Textbook of Military Medicine: Medical Aspects of Chemical and Biological Warfare: Chapter 5 Nerve Agents
Frederick R. Sidell, M.D.*
http://www.vnh.org/MedAspChemBioWar/chapters/chapter_5.htm http://www.vnh.org/MedAspChemBioWar/chapters/chapter_5.htm
from the Virtual Naval Hospital website

Common in pesticides (malathion, parathion) {consider when patients come from agricultural background, chemical or shipping industries}, nerve gasses used in warfare (Iraq), or terrorism (the Tokyo Subway Sarin Release Scare). Interrupts synaptic nerve transmission (by keeping acetylcholinesterase from re-setting the synapse for further use).

SLUDD= Salivation, lacrimation, urination, defecation, diaphoresis, dizziness, diplopia; other symptoms include nausea, vomiting, weakness, miosis, fasiculations, collapse, coma.

Mask and remove patient from toxic environment. Decontaminate clothing and skin. Give Atropine 2 mgm (2-5 mgm) IM/IV Q5minutes until signs of "atropinization" occur {decreased diaphoresis, dilatation of pupils, decreased  respiratory difficulty). Pralidoxime "PAM" is an additional drug that may be used. Contact pharmacy early for additional supplies of atropine and to obtain "PAM". Contact poison control center for guidance, and to track epidemiology of exposure/outbreak.

--Sedative-Hypnotics & Narcotics:

emedicine.com: Toxicity, Barbiturate
http://www.emedicine.com/emerg/topic52.htm
http://www.emedicine.com/emerg/topic52.htm

emedicine.com: Toxicity, Benzodiazepine
http://www.emedicine.com/emerg/topic58.htm
http://www.emedicine.com/emerg/topic58.htm

emedicine.com: Toxicity, Sedative-Hypnotics
http://www.emedicine.com/emerg/topic525.htm
http://www.emedicine.com/emerg/topic525.htm

emedicine.com: Narcotics
http://www.emedicine.com/emerg/topic330.htm
http://www.emedicine.com/emerg/topic330.htm

Overdoses of this group cause central nervous system and cardiorespiratory depression which generally respond to "supportive measures": airway control, intravenous access, fluids, and occasionally pressors.

Obtunded patients who are poorly rousable to noxious stimuli, especially those with snoring respiration, should be assessed for gag reflex and whether the airway must be controlled or assisted, and be continuously observed with pulse oximetry monitoring. If unstable, the patient should be in a code room environment and evaluated by the attending physician (the airway must be controlled if the patient does not respond to initial measures); if stable, the patient with appropriate monitoring should be in a high-visibility location with frequent observation.

Specific reversal agents available include:

Naloxone [Narcan®] ("The response is the diagnosis.") for all opiates and opioids. A pure antagonist that competitively blocks receptor sites.

Nalmefene [Revex®] is a longer acting narcotic antagonist. The same indications and cautions would apply, however, I have not seen it used in this ED.

Flumazenil [Romazicon®] for benzodiazepines. A pure antagonist that competitively blocks receptor sites.

Over-reliance should not be placed on reversal agents. The span of action is usually shorter than the effects of the drug being reversed. They are a bridge to when the patient has sufficiently metabolized the drug and no longer needs reversal.

Some patients, especially those with intoxications of long-acting opiates, may need a Naloxone drip to support them. Naloxone , may be given IV, IM, SC, via endotracheal tube (has even been nebulized), and even intra-glossal injection. Assuming reasonable perfusion of the area injected, response time is approximately equal for all routes (2-5 minutes). Propoxyphene [Darvon®], a synthetic, may need as much as 10 mgs of Naloxone to reverse. This would be 2 mgs Q5Minutes to a total of 10 mgs.

Giving Naloxone can precipitate a withdrawal reaction including not only arousal and increased respiratory rate and depth, but also chills, piloerection (hair standing on end), cutis anserina ("goose flesh"), ­ GI motility with nausea, vomiting, borborygmi, and diarrhea possibly occurring. If the patient was taking the opiate for therapeutic effect, the patient’s pain will be restored to him. It may be desirable to give Naloxone incrementally and titrating to level of consciousness and respiration without seeking full reversal. If excessive reversal occurs, additional narcotic analgesia can be given back to the patient.

If the patient’s pulmonary status worsens, despite adequate effort, assess the patient by auscultation and chest x-ray for narcotic-induced non-cardiogenic pulmonary edema. Consider also prior aspiration with resultant pneumonitis.

The patient must be observed for relapse after the reversal agent has worn off and a period thereafter before he can safely be discharged.

Flumazenil can precipitate withdrawal in the benzodiazepine habituated patient (this can occur in as little as two weeks of therapeutic usage). Additionally, seizure threshold can be lowered. Flumazenil should be withheld when there is a likelihood of seizures from any cause or when there is a tricyclic antidepressant overdose. Respiratory status may not improve as much as level of consciousness. Amnesia may not be fully recovered.

Flumazenil is prepared as 100mcg/ml. The initial dose for reversing benzodiazepine "conscious sedation" is 200 mcgs. (2 ml) over 15 seconds, wait until the end of the minute (45 seconds more) before repeating the same dose; this may be done until 5 doses have been given in 5 minutes (1.0 mgm total). Repeat doses of up to 1.0 mgm at 200 mcg/min rate may be given at 20 minute intervals if resedation occurs for an hourly total not to exceed 3.0 mgms. It will work better at reversing low doses of short acting single agents than high doses of longer-acting or multiple-agent treatment.

If Flumazenil is given because of suspected benzodiazepine overdose, 200 mcgs is given over 30 seconds, wait 30 seconds, then 300 mcgms (3 ml) over 30 seconds (total now 500 mcgms). Further doses of 500 mcgms may be given over 30 seconds at 1 minute intervals until 3.0 mgms has been given. Further doses are not usually needed, but those who have partially responded at 3.0 mgms may improve somewhat with up to a total of 5.0 mgms. Those who do not respond with 5.0 mgms usually will not benefit with more. ("If a patient has not responded 5 minutes after receiving a cumulative dose of 5 mg Romazicon®,, the major cause of sedation is likely not to be due to benzodiazepines, and additional Romazicon® is likely to have no effect.[PDR])

 

Triage Key Words:

"I took some pills." I'd be better off dead." "What's the use?" "I can't go on."

"Date Rape":

Occasionally, allegations are made of surreptitious intoxication by others for the purpose of rape or robbery. Such events do occur, and require careful investigation and documentation, in case prosecution is possible. False allegations are also made to deflect responsibility for events. The oldest drug used for seduction is alcohol. Others, chiefly sedatives, may be used in combination with alcohol.

Restraints:

 

 

emedicine.com: Restraints
http://www.emedicine.com/emerg/topic776.htm
http://www.emedicine.com/emerg/topic776.htm

Call: 1-800-876-4766

anytime, anyplace in California

Statewide Toll-Free Emergency Numbers:
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Statewide Number to Request Poison Prevention
Education Materials: 1.800.582.3387

California Poison Control System
http://www.calpoison.org/home.html
http://www.calpoison.org/home.html

American Association of Poison Control Centers
http://www.aapcc.org
http://www.aapcc.org/

Agency for Toxic Substances & Disease Registry (US Govt.)
http://www.atsdr.cdc.gov/
http://www.atsdr.cdc.gov/

EXTOXNET InfoBase provides a variety of information about pesticides
http://ace.orst.edu/info/extoxnet
/  http://ace.orst.edu/info/extoxnet/

Medical NBC - Online (Nuclear, Biological, Chemical warfare)
http://www.nbc-med.org/others/Default.html
http://www.nbc-med.org/others/Default.html

FM 8-9 NATO HANDBOOK ON THE MEDICAL ASPECTS OF NBC DEFENSIVE OPERATIONS AMedP-6(B)
http://www.vnh.org/MedAspNBCDef/toc.htm
from the Virtual Naval Hospital website

FM 8-285 Treatment of Chemical Agent Casualties and Conventional Military Chemical Injuries
http://www.nbc-med.org/SiteContent/MedRef/OnlineRef/FieldManuals/FM8_285/new/toc.pdf
http://www.nbc-med.org/SiteContent/MedRef/OnlineRef/FieldManuals/FM8_285/new/toc.pdf


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