1. Approaching the Poisoned Patient!!

2. Objectives Provide a general overview of toxicology How to approach the poisoned patient Understanding common toxidromes

3. What is Toxicology What is it not a poison? All things are poison and nothing is without poison. Solely the dose determines that a thing is not a poison. -Paracelsus (1943-1541), the Renaissance Father of Toxicology, in his Third defence

4. Why do people OD? Significant portion intend to die at time of overdose Most want to escape an intolerable situation or state of mind Small minority of patients want to punish someone or make someone feel guilty Mental health difficulties particularly, depression, ETOH or substance misuse, and personality disorders are frequently seen Inability to tolerate life stressor or events, relationship breakdowns, anniversaries of bereavement, ect. Mitchell, A. Dennis, M. Self harm and attempted suicide in adults: 10 practical questions and answers for emergency department staff. Emerg Med J, 2006: 26, 251-255

5. What Drugs do they OD on? ETOH Paracetamol Benzo’s Antipsychotics Antidepressants Antiepileptic Opiods And many many more!!!

6. Risk Assessment RRSIDEAD Approach Resuscitation Risk Assessment Supportive Care & Monitoring Investigations Decontamination Enhanced Elimination Antidotes Disposition

7. Resuscitation Airway Breathing Circulation Control seizures Correct hypoglycaemia Correct hyperthermia Consider resuscitation antidotes

8. Risk Assessment Agent Dose Time since ingestion Clinical features and course Patient factors Geographical location

9. Supportive Care & Monitoring Supportive Care Airway: Intubation Breathing: O2, Ventilation Circulation: IVIH, Inotropes, Defib or pacing Sedation: Titrate Benzo’s Seizure control/prophylaxis: Titrate Benzo’s Metabolic: control pH, normoglycaemia Fluids & Electrolytes: Monitor Renal function: hydrate, haemodialysis General: Bladder care? IDC, Nutrition, DVT & Stress ulcerprophylaxis, PAC, Monitor mental state

10. Can good supportive care can be done at home?

11. Supportive Care & Monitoring Monitoring & investigation: 12 lead ECG Paracetamol Level BSL below 4 correct with D50 Temp above 38.5 requires continuous monitoring

12. Drug Levels

14. The ECG in TOX Valuable inexpensive screening tool QRS widening R/T sodium channel blockade, common with TCA overdose QT prolongation is a potassium channel effect associated with TDP, common in some antidepressant, antiarrythmics, & antipsychotic overdoses.

15. Urine Drug Screen Why don’t we do it? In general it rarely if ever changes management. Expensive Takes 1-2 days to get back When would we consider it?

17. Gastric Lavage

18. Activated Charcoal

19. Whole Bowel IrrigationActivated charcoal has most benefits in a limited number of poisoning, other methods have limited if any evidence to support their use.

20. Enhanced Elimination Multiple-dose activated charcoal Urinary alkalinisation Haemodialysis and haemofiltration Charcoal haemoperfusion

21. Antidotes Limited number of antidotes available for limited number of poisonings. Common Antidotes: NAC Naloxone Sodium Bicarb Digoxin Immune Fab 5. Octreotide

22. Common Complications in the Critically Poisoned Patient Aspiration Pneumonia ARDS ARF DVT/PE Rhabdomyolysis Compartment Syndrome Hepatotoxicity

23. Disposition The patients journey can be: RESUS ICU Assessment Obs ward Psych Or patients with DSP need Pysch R/V

24. Poisoning in Children Most paediatric poisoning are benign, as children generally ingest small quantities. Always base your assessment on worse case scenario: The time of ingestion is assumed to be the latest possible time Assume all missing or unaccounted for agent(s) have been ingested Do not attempt to account for spillage, which is difficult to estimate If more than child involved, it is assumed that each child ingested all the missing or unaccounted for agent(s)

25. 2 tablets that can KILL a 10kg toddler

26. Management of child who ingest unidentified poison Admit for minimum of 12-hour observation Ensure health care facility can cope Defer IV access until evidence of toxicity Check BSL at presentation and on D/C Monitor GCS & vital signs Cardiac monitor if decreased GCS or abnormal vital signs D/C during daylight hours

28. Common poisoning in the Elderly Digoxin Metformin Lithium Disposition= Generally elderly patients end up in Gen Med units for prolonged periods of care

29. Toxidromes

30. Coma Patients presenting with coma have generally overdosed on a drug with CNS depressant effects. Can be caused by secondary effects: Hypoxaemia Hypoglcaemia Hyponatraemia Hypotension Seizures Cerebral oedema

31. Coma Management RRSIDEAD Good supportive care & airway management Treat secondary effects Look at what else can cause coma Neurotrauma Metabolic encepathopathy Menigioencephalopathy Space occupying lesion Patients generally go to ICU, till conscious states improve Look for complication’s (Asp Pneumonia)

32. Why do we use Diazepam so much in TOX? Good safety profile Long half life Controls agitation well Used to treat toxic seizures Generally drug of choice in managing withdrawals Dose adult 5-10mg, child 0.1-0.3mg/kg/dose every 3-5mins

33. Anticholinergic Syndrome Results from the competitive, reversible blockade of central & peripheral cholinergic blockade. Is potentially life threatening Diagnosed clinically by agitated delirium and peripheral muscarinic blockade History of ingestion of known anticholinergic agent

34. Types of Anticholinergic Agents Antipakinson drugs (benztropine, amantadine) Antihistamines (prometazine, doxylamine) Antitussives (dextromethorphan) Antidepressants (TCA) Antipsychotic agents including atypical (Haloperidol, olazapine, Quetiapine) Anticonvulsant agents (carbamazapine) Motion sickness agents (hyoscine-scopolamine) Antimuscarinic agents (Atropine) Topical ophthalmological agents Bronchodilators (Ipratropium) Urinary antispasmodic agents (oxybutynin) Muscle relaxants Plants & herbal remedies (Selected mushrooms)

35. Clinical Features of Anticholinergic Syndrome

36. Remember the saying!!! Hyperthermia (HOT as a hare) Flushed (RED as a beet) Dry Skin (DRY as a bone) Dilated pupils (Blind as a bat) Delirium, hallucinations (Mad as a hatter) Tachycardia Urinary Retention

39. Clinical features of serotonin syndrome

41. Autonomic instability

42. Delirium

43. Coma

44. Hyperthermia

46. Managing Serotonin Syndrome RRSIDEAD Check BSL Check temp >38.5 continuous core monitoring, temp > 39.5 paralysis and intubate Give benzo’s to achieve gentle sedation HT & tachycardia generally respond to benzo’s, if refractory trial of GTN infusion Antidote: Cyproheptadine, given orally or via NG

47. The Tox Bible

48. THE END!!