Epidemiology of acute intoxycations in Croatia. Acute poisonings by intent. Patient ST, female, 28 y. Most common poisons

Transcription

1 Epidemiology of acute intoxycations in Croatia Vladimir Gašparović Department of Intensive Care Medicine, Zagreb, Croatia Poisonings are on the rise worldwide WHO:...it may be speculated that up to half a million people die each year as a result of various kinds of poisoning, including poisoning by natural toxins. Developed countries More drugs prescribed, more OTC drugs available Substances of abuse more available new sinthetic drugs Developing countries Industrialization, modern agriculture more toxic substances Developing medicine prescribed drugs, OTC drugs... Development of urban areas drug addicts... Acute poisonings by intent Accidental Unintentional drug overdose Domestic chemicals (cleaning and DIY) Mushrooms Agricultural products Industrial (toxic waste, spills, disasters...) Intentional Suicidal Homicidal Chemical warfare & terrorism Acute poisonings by route of exposure Ingestion (~80%) Inhalation Parenteral Dermal... Most common poisons Drugs most common poisonings (>50%) accidental and intentional (suicidal) Psychopharmacologic substances (>50%) Antiarrhythmic drugs Paracetamol (UK,USA) Substances of abuse alcohol, heroin, cocaine,... all other Chemicals household (ethylene glycol), industrial, agricultural (organophosphates,...) Toxic gasses (CO, CO 2, NH 3,...) Mushrooms Patient ST, female, 28 y. Hospital admission, GCS 7, in the past drug abuser Positive sedative in toxilab, opiates negative Respiratory insufficiency, artificial ventilation 8 days 1

2 Bilateral pneumonia in acute intoxication Bilateral pneumonia in acute intoxication Bilateral pneumonia in acute intoxication Patient ST, female, 28 y. Artificial ventilation 8 days, ceftriaxone 2x1g, additional vancomycine Improvement of respiratory function, extubation, discharge from hospital after 18 days, in good condition Patient, female,ic, 35 y. Patient, female, 35 y. History: somnolent by admition, trace of vomiting, Depresion under psychiatric control - TH: Xanax (alprazolam), Ladiomil (maprotilin), Zyprexa (olanzapin) Status: GCS 8 Lung: bronchial rales, respiratory insufficiency BP 140/100, cp 100/min Admission in ICU 2

3 Patient, female, IC, 35 y. Toxicology analyses: (maprotilin, olanzapin, benzodiazepines..) Ethanol in blood: 0 Patient, female, 35 y. Respiratory insufficiency, artificial ventilation, antibiotics, other supportive therapy CMV: R 20/min; Fi02 70%; Vt 0,6-0,7 L; PEEP 5-10 cm H20; Sa %) PEEP 5-10 cm H20; Sa %) 8th day bradicardia, ventricular fibrilation, multiple defibrilations, asystole despite of electrostimulation Letal outcome in intractabile asystole Patient, female, 35 y. PHD: - Necrosis hepatis focalis - Membranae hyaloideae pulmonum - Aspiratio contenti ventriculi - Pneumonia bilateralis e aspiratione - Cyanosis universalis - Hydropericardium (50 ml) - Oedema cerebri et pulmonum INCIDENCY OF POISONING (Schwitzerland, 30 years ago) Adults (%) Children (%) psychotrop.drugs 47,6 20,9 analgetics 7,4 3,8 CO 10,7 2,8 C2H5OH 8,9 3,0 muschrooms 7,4 6,5 caustics 2,9 5,5 3

4 Greater incidence of intoxications in our emergency department admissions of poisoned patients (10.6% of 1055 emergency admissions to Department) 18% admitted to medical ICU, 82% to Medical observation unit admitted poisoned patients (17.6% of 1278 emergency admissions) 21% admissions to medical ICU, 79% to Medical observation unit INCIDENCE OF POISONING IN ICU (CRO ) F M Total % Psychotrop ,0 Antiarrhyt ,6 Mushroom ,6 Pesticides ,0 Caustics ,8 Solvents ,8 INCIDENCE OF POISONING IN ICU (CRO ) PSYCHOPHARMACS > 50 % HEROIN & OTHER DRUG ADDICTIONS ca 16 % CO, PESTICIDES, ALCOHOL <30 % Epidemiology of acute intoxycations in Cro, pts in ICU APACHE II 0 5,1+/-7,2,6,APACHE II 1 10,6+/-6,2 (p 0,001) GCS 0 8,2+/-4,1;GCS 1 13,4+/-4,1(P 0,001) AGE 44+/-17 66F(52%)+61M(48%) PSYCHOPHARMACS (53%),DRUGS(16%),CO (4%),MUSCHROOMS (6,5%),OTHERS(20,5%) INCIDENCY OF SEVERE RESPIRATORY INSUFFICIENCY (ARTEFICIAL VENTILATION) IN ACUTE POISONED PTS SURVIVAL OF POISONED PTS ACCORDING TO AGE DEAD SURVIVED TOTAL PSYCHOPHARMACS CAUSTICS PESTICIDES SOLVENTS OTHER TOTAL 29 AGE SURVIVED DEATH TOTAL < > * TOTAL *p<0.01 4

5 Presentation Sometimes specific syndromes cholinergic anti-cholinergic metabolic acidosis (ethylen-glicole) Opioide syndrome... Commonly non-specific presentation altered consciousness respiratory insufficiency arrhythmias gastrointestinal symptomes (vomiting, diarrhoea...)... Admission to ICU Suspected exposure to a life-threatening substance Severe alterations of consciousness Respiratory complications (need for mechanical ventilation) Arrhythmias or conduction disturbances in ECG Haemodynamic instability (need for monitoring or vasoactive/inotropic support) Convulsions Need for continuous administration of antidotes Patient designated as high risk for any other reason... any complication can be a reason for ICU admission Neurological complications Most common presentation of all intoxications Can be a result of pharmacologic properties of the poison / drug or a consequence of other failing organ (renal, respiratory, circulatory, metabolic...) Quantitative and qualitative disorders of consciousness Convulsions (CO, cyanide, tricyclic antidepressants, lithium,...) Agitation and halucinations (LSD, anticholinergic substances, mushrooms,...) Neurological complications Other causes of altered consciousness trauma, SAH, metabolic and/or respiratory status... head CT scan, lab. workup, ABGs... Monitoring GCS Treatment of aggravating conditions HD, mechanical ventilation, Drug caused coma usually improves in the first hours Respiratory complications Common in all kinds of intoxications Respiratory insufficiency Central depression of respiration Aspiration in unconscious state Bronchial spasm ARDS Inhalation of smokes and fumes Drugs (overdose of aspirin, cocaine, opioids, phenothiazines, tricyclic antidepressants...) Aspiration of gastric content Pneumonia Aspiration Mechanical ventilation Respiratory complications Mechanical ventilation ARDSnet recommendations Treatment of pneumonia coverage for anaerobes 5

6 Cardiovascular complications Hypotension (CNS depression) Myocardial depression (tricyclic antidepressives, beta-blockers, Ca-antagonists,...) Peripheral vasodilation (hypnotics, sedatives) Hypertension (sympaticomimetics, anticholinergics, MAO inhibitors) Disturbances of rhythm and conduction (intoxications by antiarrhythmic drugs, hypoxia, metabolic disturbances, excitability) Renal complications Acute renal failure direct toxicity (NSARD, organophospates,co, diethylene glycol, methanol,...) hypotension rhabdomyolysis hepatorenal syndrome Hepatic complications Liver toxicity Cytotoxic Zonal necroses Drugs and poisons with predictable toxicity carbon tetrachloride, acetaminophen, yellow phosphorus Nonzonal necroses unpredictable idiosyncratic injury phenytoin, methyldopa, isoniazid, diclofenac... all drugs Cholestatic injury resembles extrahepatic obstructive jaundice toxicity is dose-dependant chlorpromazine, nafcillin, trimethoprim-sulfamethoxazole, rifampin, erythromycin estolate, captopril, estradiol, and rarely amiodarone Steatosis Rare in acute toxicity, resembles Reye s syndrome Hepatic complications Supportive treatment Stimulate elimination of the drug and metabolites Exception: use of n-acetylcysteine for acetaminophen (paracetamol ) toxicity GENERAL MANAGEMENT OF THE POISONED OR OVERDOSED PATIENT GENERAL MANAGEMENT AND DIAGSTIC TOOLS Is the patient breathing adequately? Attain control of airway, ventilation, and oxygenation Assess or stabilize the cervical spine. while stabilizing the cervical spine Is the patient conscious? Can a toxic syndrome or definite ingestion composition be identified? Obtain vital signs Is the patient uncooperative? Agitated? Proceed with general management Is there an effective antidote or antagonist? CHECK BLOOD PRESSURE, PULSE RATE, RECTAL TEMPERATURE AND IMMEDIATELY STABILIZE ABRMAL VITAL SIGNS 1. Supplemental oxygen 2. IV line - saline or D5W 3. Blood for serum glucose and CBC, BUN, electrolytes, ABGs, appropriate toxicology tests 4. Dextrose, thiamine, naloxone 5. Quick physical axamination - lungs, heart, abdomen, nervous system 6. ECG and additional bloods if not already obtained 1. Talk to patient, obtain history 2. Obtain bloods, urine 3. IV line, therapy as indicated 4. Quick physical - check gag reflex 5. ECG and additional bloods a 6. Emesis or lavage a 7. Activated charcoal/cathartic 8. Observation or admission as indicated 7. Protect airway - if not already done - and pass orogastric, tube, lavage, activated charcoal, and cathartic as indicated 8. ADMIT TO ICU 1. Talk to patient, obtain history, explain 2. Recheck level of consciousness 3. Obtain bloods 4. IV line, dextrose, thiamine 5. Quick physical examination 1. Proceed with general management 2. Anticipate and observe closely for expected sequelae Proceed with general management and administer specific antagonists or antidotes 6. ECG and additional bloods 7. Observation or assessment until capable of proceeding or presence of critical ingestion found a 8. Emesis of lavage a 9. Activated charcoal/cathartic 10. Observation or admission as indicated Psychiatric and/or social service evaluation prior to discharge 6

7 ANTIDOTES IN POISONINGS BENZODIAZEPINES-FLUMAZENIL(0.2 MG/30 SEC ) TRICYCLIC ANTIDEPRESANTS- BICARBONATES OPIATES-NALOXONE(2 MG I.V.) ORGAPHOSPHATE OR CARBAMATE- ATROPIN( 2 MG I.V ) METHAL, ETHYLENGLYCOL-ETHAL Conclusions Incidence of acute poisoning is increasing Complications of acute poisonings are very common Ethyology-Psychopharmacs > 50 % Infections(respiration, vascular accesses, urinary tract, serious problem) Lesions of other organ systems depends on specific characteristics of poison 7