20/09/2018. Disclosures. Frédéric Lapostolle Urgences - SAMU 93, UF Recherche Hôpital Avicenne & Université Paris 13, Bobigny

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1 Disclosures Speaker Astra-Zeneca, Bayer, BMS, Boehringer-Ingelheim, Daiichy-Sankyo, Lilly, Medtronic, Merck-Serono, Mundipharma, Novartis, Pfizer, Teleflex, The Medicine Company Investigator Frédéric Lapostolle Urgences - SAMU 93, UF Recherche Hôpital Avicenne & Université Paris 13, Bobigny Astra-Zeneca, Merck-Serono, Mundipharma, Novartis, Teleflex Frédéric Lapostolle Urgences - SAMU 93, UF Recherche Hôpital Avicenne & Université Paris 13, Bobigny 1 Frédéric Lapostolle Urgences - SAMU 93, UF Recherche Hôpital Avicenne & Université Paris 13, Bobigny 1

2 1 Human Toxicity Excerpts: /SIGNS AND SYMPTOMS/ Ingestion of five or more grams of nutmeg causes acute nutmeg poisoning, which includes giddiness, hallucinations, and feelings of depersonalization. Symptoms usually appear three to six hours after ingestion of 1 3 whole nutmegs or 5 15 gm of the grated spice. Recovery usually occurs within 24 hours. Nevertheless, duration of action may extend beyond several days and even include death. /Nutmeg/ [Green RC, Jr; JAMA 171 (10): (1959); Painter JC et al; Clin Toxicol 4 (1): 1 4 (1971)] **PEER REVIEWED** Human Toxicity Excerpts: /SIGNS AND SYMPTOMS/ Ingestion of five or more grams of nutmeg causes acute nutmeg poisoning, which includes giddiness, hallucinations, and feelings of depersonalization. Symptoms usually appear three to six hours after ingestion of 1 3 whole nutmegs or 5 15 gm of the grated spice. Recovery usually occurs within 24 hours. Nevertheless, duration of action may extend beyond several days and even include death. /Nutmeg/ [Green RC, Jr; JAMA 171 (10): (1959); Painter JC et al; Clin Toxicol 4 (1): 1 4 (1971)] **PEER REVIEWED** 2

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4 2 2 Boyer, NEJM, 2005 Boyer, NEJM, 2005 Serotonin syndrome 4

5 2 Coma Bradypnea Myosis 5

6 Diagnostic strategy Diagnostic strategy Diagnostic strategy Diagnostic strategy 6

7 Diagnostic strategy Diagnostic strategy Diagnostic strategy EKG heart rate blood pressure It s not a poisoning There is another toxic (to identify) There is a complication (to identify) Myosis EKG heart rate blood pressure Interaction with diagnostic, severity and outcome Aspiration Rhabdomyolysis Myosis Rhabdomyolysis Aspiration 7

8 blood EKG heart pressure 2 rate Congruence = Security Myosis

9 3 Result likely to influence treatment Proudfoot, Critical Care Toxicology, Result likely to influence treatment Proudfoot, Critical Care Toxicology, Acetaminophen Isopropanol 3 Acetaminophen Isopropanol Carboxyhemoglobin Methanol Carboxyhemoglobin Methanol Digoxin Methemoglobin Digoxin Methemoglobin Ethylene glycol Phenobarbital Ethylene glycol Phenobarbital Iron Salicylates Iron Salicylates Lithium Theophylline Lithium Theophylline Proudfoot, Critical Care Toxicology, 2005 Proudfoot, Critical Care Toxicology, 2005 Brent, NEJM, 2009 Brent, NEJM, 2009 Finkle, Acid-base and Electrolyte disorders,

10 Equimolar curative neutralization Asystole Ventricular dysrhythmia Heart rate < 40/min after intravenous atropine Serum potassium > 5.0 mmol/l Semi-equimolar prophylactic neutralization Age>55 Cardiac disease Heart rate <60/min after atropine Second or third degree block Serum potassium > 4.5mmol/L Lapostolle, Crit Care Toxicology, Supportive treatment Decontamination / drug removal Antidote treatment 10

11 Clinical Toxicol, 2005 Clinical Toxicol, 2005 Clinical Toxicol, 2005 Clinical Toxicol,

12 Antidotes Clinical Toxicol, 2004 Antidotes with alternative treatment Antidotes with alternative treatment Antidotes with alternative treatment Antidote without alternative treatment 12

13 Simmons, Drug Alcohol Depend,

14 Dart, Ann Emerg Med, 2017 Dart, Ann Emerg Med, 2017 California Health and Human Services Agency Department of Public Health. Hospital Administrative Penalties 14

15 Make exceptional treatment available 4 4 Make exceptional treatment available 1&2 The doubt kills 1&2 The doubt kills 3 Toxicologic screening is not useful

16 1&2 3 The doubt kills Toxicologic screening is not useful 3 Make exceptional treatment available 16