2/1/2013 According to the American Academy of Poison Control - - PDF document

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Anti’dos and don’ts: Pearls and pitfalls in the use of antidotes

Craig Smollin MD

Associate Medical Director, California Poison Control System - SF Division Assistant Professor of Emergency Medicine, UCSF

• A. Administration of sodium bicarbonate
• B. Administration of the the cyanide antidote kit
• C. Administration of n-acetylcysteine
• D. Administration of calcium gluconate
• E. None of the above

According to the American Academy of Poison Control Centers, what is the most common intervention performed in the management of acutely poisoned patients?

Most common interventions in poisoning

The first rule of surfing... The first rule of poisoning...

Poisoned patient need good supportive care!

The ABC’s of the poisoned patient Airway Breathing Cirulaiton Drugs, dextrose, decontamination Exposure, enhanced elimination

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Suggested antidotes for stocking

• Acetylcysteine
• Antivenin (rattlesnake)
• Antivenin (black widow spider)
• Atropine sulfate
• Botulism antitoxin
• Calcium chloride
• Calcium gluconate
• Calcium disodium EDTA
• Cyanide antidote kit or

hydroxocobalamin

• Defuroxamine
• Digoxin Immune Fab
• Dimercaprol
• Ethanol or fomepizole
• Flumazenil
• Glucagon hydrochloride
• Methylene blue
• Naloxone hydrochloride
• Octreotide acetate
• Physostigmine salicylate
• Postassium iodide
• Pralidoxime chloride
• Pyridoxine hydrochloride
• Prussian blue
• Sodium bicarbonate

For this talk

• Atropine sulfate
• Calcium chloride
• Calcium gluconate
• Methylene blue
• Pralidoxime chloride
• Pyridoxine hydrochloride
• A 57 year-old male with h/o benzodiazepine abuse

presents after found by EMS with altered mental status. Initial GCS in the field was reported as 11. Upon arrival in the ED he is confused and ataxic with slurred speech. He is noted to be mildly hypertensive, tachycardic and he has diaphoresis.

Case 1

• Vital signs = BP 159/96, P 105, RR 20, 97% RA
• Initial FSG = 41 mg/dL

Case 1 Clinical signs and symptoms of hypoglycemia

Autonomic Neuroglycopenic ?

• Tremor
• Tachycardia
• Sweating
• Pallor
• Weakness
• Nausea
• Hunger
• Palpitations
• Dizzy/lightheaded
• Confusion
• Ataxia
• Blurred vision
• Paresthesias
• Focal neuro deficit
• Seizures
• Coma
• Hypothermia
• Bradycardia
• A 57 year-old male with h/o benzodiazepine abuse

presents after found by EMS with altered mental status. Initial GCS in the field was reported as 11. Upon arrival in the ED he is confused and ataxic with slurred speech. He is noted to be mildly hypertensive, tachycardic and he has diaphoresis.

Case 1

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• Patient receives 1 amp D50 with improvement in GCS to

14.

• He confirms that he has no h/o diabetes and did not
• verdose on any medications.
• Utox positive for cocaine, benzo, opiates and methadone
• One hour later the patient has recurrent hypoglycemia with

repeat glucose = 47 mg/dL

Case 1

• Insulin
• sulfonylureas
• Pentamidine
• Aspirin
• Beta blockers
• Alcohol
• Ackee fruit
• VPA
• Quinine
• Vacor

A problem of persistent hypoglycemia...

Drugs and toxins commonly associated with hypoglycemia

When purchasing valium on the street which of these pills do you want? A. B.

• A. Boluses of D50 as need to maintain blood sugar
• B. Place patient on a D10 infusion
• C. Feed the patient a carbohydrate rich meal
• D. Start octreotide
• E. All of the above

Which of the following has been shown to be the most effective in the treatment of persistent hypoglycemia related to sulfonylureas?

• Longer acting analogue of somatostatin
• Acts on pancreatic islet cells to reduce insulin secretion
• Effective in reducing glucose requirements in patient

sulfonylurea overdose

• Adult dosing: 50-100 mcg SQ every 6 hours
• Peds dosing: 5 mcg/kg divided every 6 hours.

The use of octreotide for sulfonylurea overdose

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• A 29 year-old male presented to the ED after a suicide

attempt by ingesting a large amount of rat poison. In the ED the patient was diaphoretic and in respiratory distress.

• Vital signs = BP 113/99, P 100, RR 28, O2 sat 88% on RA.
• PE significant for profound diaphoresis, diffuse rhonchi

throughout both lung fields, tachycardia, urinary incontinence, and muscle fasciculations.

Case 2 Rat Poisons

• Super warfarins
• Phosphides
• Strychnine
• Vacor
• Arsenic
• Bromethalin
• Sodium fluoroacetate
• Tetramine
• A 29 year-old male presented to the ED after a suicide

attempt by ingesting a large amount of rat poison. In the ED the patient was diaphoretic and in respiratory distress.

• Vital signs = BP 113/99, P 100, RR 28, O2 sat 88% on RA.
• PE significant for profound diaphoresis, diffuse rhonchi

throughout both lung fields, tachycardia, urinary incontinence, and muscle fasciculations.

Case 2

• Salivation
• Lacrimation
• Urination
• Defecation
• GI irritation
• Emesis

SLUDGE

• Bronchorrhea
• Bronchoconstriction
• Bradycardia

“Tres Pacitos”

• Carbamates and organophosphates are still used as

insecticides.

• International travel and immigration increase the possibility
• f encountering patients who have ingested toxic

substances from other countries.

• Increased concerns of terrorism

Why should emergency physicians be able to recognize and treat this rare poisoning?

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• Special attention to airway and breathing
• Intubation
• Administration of antidote titrated to secretions
• Atropine (often in large doses)
• Pralidoxime
• Rigorous IV hydration
• Decontamination

Rx of organophosphate and carbamate toxicity

• A 45 year-old female with a history of depression presents

1 hour after a large ingestion of her antihypertensive

• medications. On arrival she is somnolent but arousable and

has a GCS of 14.

• Vital signs: BP 83/50, HR 65, RR 18, O2 sat 98% RA
• Finger stick glucose = 235

Case 3

• A 45 year-old female with a history of depression presents

1 hour after a large ingestion of her antihypertensive

• medications. On arrival she is somnolent but arousable and

has a GCS of 14.

• Vital signs: BP 83/50, HR 65, RR 18, O2 sat 98% RA
• Finger stick glucose = 235

Case 3 Where are the calcium channels?

Location Effect of blockade Intervention Heart

• Myocardial depression
• Sinus bradycardia
• AV node blockade
• Ca+ administration
• Atropine
• Vasopressors
• Cardiac pacing

Peripheral vasculature

• Vasodilation
• decreased afterload
• systemic hypotension
• Intravenous fluids
• Ca+ administration
• Vasopressors

Pancreas

• Hypoinsulinemia
• Insulin resistance
• Hyperglycemia
• Ca+ administration
• High dose insulin

Hyperglycemia a predictor of poor outcome High dose insulin euglycemia therapy (HIET)

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• A 34 year old HIV+ woman presents with a complaint of

feeling light headed, nauseated, and short of breath. Vital signs were BP 124/88, P 116, RR 18, O2 sat 82% on non- rebreather, afebrile. She was in no respiratory distress, but appeared to have blue discoloration of the lips, gums, face and peripherally in the digits and nail beds. The rest of the exam was unremarkable.

• Arterial blood gas = pH 7.44, pCO2 31, pO2 307, Sat 98%,

Lactate 1.0.

Case 4

• A. Carboxyhemoglobin level
• B. Sulfhemoglobin level
• C. LFT’s
• D. Methemoglobin level
• E. None of the above

Which of the following studies would be the most helpful in determining the diagnosis?

• A 34 year old HIV+ woman presents with a complaint of

feeling light headed, nauseated, and short of breath. Vital signs were BP 124/88, P 116, RR 18, O2 sat 82% on non- rebreather, afebrile. She was in no respiratory distress, but appeared to have blue discoloration of the lips, gums, face and peripherally in the digits and nail beds. The rest of the exam was unremarkable.

• Arterial blood gas = pH 7.44, pCO2 31, pO2 307, Sat 98%,

Lactate 1.0.

• Methemoglobin level = 41%

Case 4

Drugs Toxins

• Local anesthetics
• Chloraquin
• Dapsone
• Metaclopramide
• Nitrites
• Phenazopyridine
• Primaquin
• Sulfamethoxazole
• Aniline dyes
• Benzene derivatives
• Nitrates or nitrites (food, water)
• Paraquat

Common drugs and toxins producing Methgb

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Treatment with methylene blue

• Poisoned patients need good supportive care.
• Consider sulfonylurea exposures in patients with persistent

hypoglycemia.

• Octreotide is effective in the management of persistent

hypoglycemia due to sulfonylurea exposures.

• Rat poison can be more than just super warfarin exposure.
• Cholinergic toxidrome presents as “sludge” syndrome
• Atropine should be titrated to secretions

Summary

• Consider sulfonylurea exposures in patients with persistent

hypoglycemia.

• Octreotide is effective in the management of persistent

hypoglycemia due to sulfonylurea exposures.

• Rat poison can be more than just super warfarin exposure.
• Cholinergic toxidrome presents as “sludge” syndrome
• Atropine should be titrated to secretions

Summary - Case 1

• Rat poison can be more than just super warfarin exposure.
• Cholinergic toxidrome presents as “sludge” syndrome.
• Atropine should be administered aggressively and titrated to

secretions.

• Pralidoxime although controversial in carbamate toxicity

should also be administered. Summary - Case 2

• Calcium channel blocker overdoses present with

hypotension, bradycardia and shock.

• Consider the use of high dose insulin euglycemia therapy

early. Summary - Case 3

• Consider methemoglobinemia in patient’s with “cyanosis”

and normal ABG.

• “Chocolate” colored blood is a clue to the diagnosis.
• Use methylene blue in symptomatic patients or those with

methgb levels > 20%.

• Methylene blue may cause hemolysis and worsening of

symptoms in patient with G6PD deficiency. Summary - Case 4