2/1/2013. Anti dos and don ts: Pearls and pitfalls in the use of antidotes. The first rule of surfing... The ABC s of the poisoned patient

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1 According to the American Academy of Poison Control Centers, what is the most common intervention performed in the management of acutely poisoned patients? 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 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 1

2 Suggested antidotes for stocking For this talk 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 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. Vital signs = BP 159/96, P 105, RR 20, 97% RA Initial FSG = 41 mg/dl 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. 2

3 A problem of persistent hypoglycemia... Patient receives 1 amp D50 with improvement in GCS to 14. He confirms that he has no h/o diabetes and did not overdose 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 Drugs and toxins commonly associated with hypoglycemia Insulin sulfonylureas Pentamidine Aspirin Beta blockers Alcohol Ackee fruit VPA Quinine Vacor When purchasing valium on the street which of these pills do you want? A. B. Which of the following has been shown to be the most effective in the treatment of persistent hypoglycemia related to sulfonylureas? The use of octreotide for sulfonylurea overdose 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 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: mcg SQ every 6 hours Peds dosing: 5 mcg/kg divided every 6 hours. 3

4 Case 2 Rat Poisons 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. Super warfarins Phosphides Strychnine Vacor Arsenic Bromethalin Sodium fluoroacetate Tetramine Case 2 SLUDGE 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. Salivation Lacrimation Urination Defecation GI irritation Emesis Bronchorrhea Bronchoconstriction Bradycardia Tres Pacitos Why should emergency physicians be able to recognize and treat this rare poisoning? Carbamates and organophosphates are still used as insecticides. International travel and immigration increase the possibility of encountering patients who have ingested toxic substances from other countries. Increased concerns of terrorism 4

5 Rx of organophosphate and carbamate toxicity Case 3 Special attention to airway and breathing Intubation Administration of antidote titrated to secretions Atropine (often in large doses) Pralidoxime Rigorous IV hydration Decontamination 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 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 Heart Peripheral vasculature Pancreas Myocardial depression Sinus bradycardia AV node blockade Vasodilation decreased afterload systemic hypotension Hypoinsulinemia Insulin resistance Hyperglycemia Ca+ administration Atropine Vasopressors Cardiac pacing Intravenous fluids Ca+ administration Vasopressors Ca+ administration High dose insulin Hyperglycemia a predictor of poor outcome High dose insulin euglycemia therapy (HIET) 5

6 Case 4 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 nonrebreather, 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. A. Carboxyhemoglobin level B. Sulfhemoglobin level C. LFT s D. Methemoglobin level E. None of the above Case 4 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 nonrebreather, 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% Common drugs and toxins producing Methgb Drugs Toxins Local anesthetics Chloraquin Dapsone Metaclopramide Nitrites Phenazopyridine Primaquin Sulfamethoxazole Aniline dyes Benzene derivatives Nitrates or nitrites (food, water) Paraquat 6

7 Treatment with methylene blue Summary 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 - Summary - Case 2 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 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 3 Summary - Case 4 Calcium channel blocker overdoses present with hypotension, bradycardia and shock. Consider the use of high dose insulin euglycemia therapy early. 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. 7