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What is a toxidrome?
- General survey
- mucous membranes
- Lungs, heart, CNS
When is gatric lavage indicated?
when someone downs a bottle of pills in the ED
What should you know before calling poison control?
- Neuro Exam
- Vital signs
- Pupillary reaction
How to decontaminate the eyes
- copious irrigation - 2L NSS
- check pH
Alkali solution is the worst of the eyes
What are the contraindications of ipecac?
- Active or prior vomitting
- may alter MS
- may cause seizures
Explain orogastric lavage
- best means of gastric emtyping
- lateral decubitus position - tube placed in stomach
- lavage with H20 until contents are clear
- Use charcoal
What are the indications for orgastic lavage?
- Recent ingection (within 1 hour)
- Potential life threatening
Contraindications for orgastric lavage
- Pills are too large
- more harmful to lungs then GI
- non life threatening
Complications or Orogastric lavage
- perforation of esophagus or stomach
- tracheal insertion
- decreased O2
- inability to withdrawl tube
Explain activated charcoal
- Most appropriate for decontamination of the gut
- has a large surface area and binds many drugs to keep them in the GI instead of being absorped into blood
- *used approximately 10 times the amount of ingested drug
Indications for AC
- Unknown substance ingested
- known substance that AC binds
- ingection within a couple hours
contraindications of AC use
- Lead, Lithium, Iron, ETOH
- esophageal/gastric perf
- chance of endoscopy
- unsecured airway
When is Multi dose AC used?
- When LARGE ingestion
- toxins that slow GI
- sustained release products
- enterhepatic, or enteroenteric recirculation
- No definitive clinical data supports its use
- used with AC always
- causes cramping, ab pain, volume depletion
- renal failure in children
What is a Whole Bowel irrigation
- Use Polyethylene glycol - no electrolyte inbalance
- used 2L/hour until fluid is clear
- use when ingested drug is life threatening with sustain release
What are TCA and what are clinical features
- -antidepressants that cause the most deaths out of any Rx drug
- Cause sodium channel blockage and arrythmias(death)
- cause confusion, ataxia, slurred speech, ileus, urinary retention, decreased bowel sounds
- SVT, VTach, coma, seizures, hypotension, coma
Treatment of TCA ingestions
- Lavage (serious enough)
- Na Bicarb to get pH to 7.5
Ingestion of Non SSRI and Non TCA
- Cause seizures
- no change in QT
- Can cause Serotonin syndrome
- LESS dangerous then TCA
- Wide theraputic window
Treatment of Non SSRI and Non TCA ingestion
- Activated charcoal
- Lavage is NOT indicated
- no antidote
- Do not inhibit sodium channels so theres no arrythmia
- Cause seizures and serotonin syndrome
- give benzo for seizures
Treatment of SSRI ingestion
- observe for 8 hrs
- admit if lethargy, seizures, tachycardia, signs of serotonin synd.
What is serotonin syndrome?
- Seen with a patient already on MAOI and ingests an SSRI or atypical antidepressent
- can be seen with combo of two SSRI
What are clinical findings of serotonin syndrome?
- Confusion, hypomania, myoclonus, hyperreflexia, diaphoresis, shivering, tremor
- *Incoordination, hyperthermia, hypertension
What three drugs should you be careful prescribing SSRI's?
- ultram or tramadol
Clinical features of mild-moderate barbituate overdose?
Drowsiness, disinhibition, ataxia, slurred speech, confusion
What are clinical features of severe barbituate intoxication?
Stupor, coma, hypotension, respiratory distress
Treatment of barbituate OD in ED?
- Charcoal - maybe MDAC
- forced diuresis
- Long acting barbs
Describe benzo OD
- **Hypotn. and Respiratory distress**
- Less toxis than Barb OD but presents the same way
- Elderly more susecptible
- worry about withdrawal more
Treatment of benzo OD in ED?
- AC only - no indication for MDAC
- Flumazenil - reverse agent but WILL CAUSE SEIZURES
Describe ETOH ingestion according to the numbers
- 80-100 mg/dl considered legally intoxicated
- >500 mg/dl need to go to ICU
- Levels drop 20-30 mg/dl per hour
What are the clinical features of Opiod overdose?
- TRIAD - 1. Miosis, 2. Respiratory Depression, 3. Coma
- also see N/V, hypotension, bradycardia
What is ED management of Opiod ingestions?
- Heroin OD will walk out
- Worry about Methdone - its long acting and has 24 hr 1/2 life
- give AC
Clinical features of cocaine/amphetamine ingestions
- dysrhythmia, ichemia, cocaine chest pain, seizures, CVA, asthma, ARDS
- Tachycardia, tachypnea, HTN, hyperthermia, Rhabdo
what is the treatment of Cocaine and amphetamine ingestion?
- ASA, nitrates, benzo for Chest pain
What can cocaine and amphetamine ingestion cause?
- HTN crisis - tx w/phentolamine
- concaine induced arrythmias - alkalinize the urine
CLinical effects of LCD
Coma, respiratory depression, hyperthermia
Clinical findings of PCP
- CNS stimulation or depression
- Rhabdo and renal failure
Management of Hallucinogen ingestion in ED?q
- Supportive, ABC's
- Respiratory support
- If sx last more than 8 hrs-admit
What are sx of moderate toxicity of Salicylates?
Hyperventilation, swelling, Tinnitus
What are sx of severe toxicity from salicylates?
- Metabolic acidosis and respiratory alkalosis
- seizures, hypoglycemia, N/V
Diagnosis of salicylate intoxication
- Blood levels - chronic theraputic 10-30mg/dl
- >30mg/dl w/sx is suggestive
- >60mg/dl w/acidosis is very persuasive
Treatment of Salicylate ingestions
- Whole bowel irrigation for enteric coated prep
- give NSS and D5 for hypoglycemia
Describe Stage 1 of Acetaminophen overdose
- first 24 hours
- few or no symptoms
- N/V some GI complains
Describe Stage 2 of Acetaminophen overdose
- Days 2-3
- RUQ pain
- Elevated LFTs
- Most will recover w/o treatment
Describe stage 3 of acetaminophen overdose
- Days 3-4
- Fulminat hepatic failure
- metabolic acidosis
- renal failure
Describe stage 4 of Acetaminophen overdose
- Those who recover - occurs in a one week period
- complete resolution
- or you die
Treatment of Acetaminophen ingestions in ED?
- IV form
- get serum levels
What is the general lab workup in overdoses?
- Chem 7
- Urine toxiocology screen
- ETOH level
- PT/PTT and LFT
- ASA and APAP levels
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