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Toxicology Intro
1. A FRAMEWORK FOR
EVIDENCE-BASED PRACTICE
Nathan J. Cleveland, MD, University Medical Center, Emergency Medicine Physicians, December 2011
2. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
DISCLAIMER
TRIVIA
GOALS
TOX MASTER
JACK OF ALL
TRADES
TITLE
E.B.M.
WHAT NOT
TO DO
3. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TRIVIA
DISCLAIMER
TRIVIA
GOALS
TOX MASTER
JACK OF ALL
TRADES
TITLE
WHAT NOT
TO DO
E.B.M.
1. INTUBATION 2. RESUSCITATION
3. COORDINATION 4. TOXICOLOGY
4. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
DISCLAIMER
TRIVIA
GOALS
TOX MASTER
JACK OF ALL
TRADES
TITLE
4. TOXICOLOGY
TRIVIA
WHAT NOT
TO DO
E.B.M.
5. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
EPIDEMIOLOGY
DISCLAIMER
TRIVIA
GOALS
TOX MASTER
JACK OF ALL
TRADES
GOALS
• „Whirlwind‟ overview
• Principles for evidence-based
diagnosis/management
• Few specifics
TRIVIA
WHAT NOT
TO DO
E.B.M.
6. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
GOALS
TOX MASTER
JACK OF ALL
TRADES
GOALS
• New PPT style – feedback
please!
EPIDEMIOLOGY
DISCLAIMER
TRIVIA
TRIVIA
WHAT NOT
TO DO
E.B.M.
7. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
PRICIPLE #1
TRIVIA
GOALS
TRIVIA
• 6 Questions
• Famous Poisonings
• Beer
TOX MASTER
EPIDEMIOLOGY
DISCLAIMER
TRIVIA
WHAT NOT
TO DO
E.B.M.
8. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TRIVIA
PRINCIPLE #1
DISCLAIMER
TRIVIA
DISCLAIMERS
• I‟m not a toxicologist
• This is an overview
• No eminence-based
medicine!GOALS
EPIDEMIOLOGY
TRIVIA
WHAT NOT
TO DO
E.B.M.
9. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
EVALUATION
TRIVIA
PRINCIPLE #1
E.B.M.
DISCLAIMER
TRIVIA
EPIDEMIOLOGY
TRIVIA
WHAT NOT
TO DO
10. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
HISTORY
EVALUATION
TRIVIA
PRINCIPLE #1
EPIDEMIOLOGY
TRIVIA
E.B.M.
WHAT NOT
TO DO
DISCLAIMER
11. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
HISTORY
EVALUATION
TRIVIA
PRINCIPLE #1
EPIDEMIOLOGY
TRIVIA
E.B.M.
WHAT NOT
TO DO
DISCLAIMER
P.A.C.E.D.
F.A.S.T.
C.O.O.L.S.
N.A.S.A.
C.R.A.S.H.E.D.
C.T.S.C.A.N.
S.L.O.W.
P.A.N.T.
O.T.I.S.C.A.M.P.B.E.L.L.
A.E.I.O.U.T.I.P.S.
C.O.P.S.
A.A.A.S.
S.O.A.P.
C.O.I.N.S.
A.B.C.D.E.
C.H.A.R.C.O.A.L.
I.S.T.U.M.B.L.E.
12. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
PHYSICAL
HISTORY
EVALUATION
TRIVIA
PRINCIPLE #1
EPIDEMIOLOGY
TRIVIA
WHAT NOT
TO DO
E.B.M.
THE DEATH OF SOCRATES
1787 – JACQUES-LOUIS DAVID
Name this
poison
13. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
PHYSICAL
HISTORY
EVALUATION
TRIVIA
PRINCIPLE #1
EPIDEMIOLOGY
TRIVIA
WHAT NOT
TO DO
DISCLAIMER
HEMLOCK
• Cicutoxin
• GABA-receptor antagonist
• CNS stimulation, seizures, death
14. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
PRINCIPLE #2
PHYSICAL
HISTORY
EVALUATION
TRIVIA
PRINCIPLE #1
EPIDEMIOLOGY
TRIVIA
POISON IN THE U.S.
WHAT NOT
TO DO
15. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
PHYSICAL
HISTORY
EVALUATION
TRIVIA
EPIDEMIOLOGY
TRIVIA
POISON IN THE U.S.
• 2,384,825 encounters in NPDS
• 1,730 Deaths (pharma)
• Deaths rising since 1985
1985 1997 2010
Deaths 328 786 1730
% Suicide 53 53 45
% Peds 6.1 3.2 3.2WHAT NOT
TO DO
PRINCIPLE #1
PRINCIPLE #2
16. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
EPIDEMIOLOGY
TRIVIA
WHAT NOT
TO DO
PHYSICAL
HISTORY
EVALUATION
TRIVIA
PRINCIPLE #1
PRINCIPLE #2
17. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
EPIDEMIOLOGY
TRIVIA
WHAT NOT
TO DO
PHYSICAL
HISTORY
EVALUATION
TRIVIA
PRINCIPLE #1
PRINCIPLE #2
18. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
EPIDEMIOLOGY
TRIVIA
WHAT NOT
TO DO
PHYSICAL
HISTORY
EVALUATION
TRIVIA
PRINCIPLE #1
PRINCIPLE #2
19. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
EPIDEMIOLOGY
TRIVIA
WHAT NOT
TO DO
POISON IN THE U.S.
• Interesting facts:
• 87% are ingestional
• 20% are intentional
• Intentional is more deadly
• 50% are peds
• 50% (at least) are mixed
PHYSICAL
HISTORY
EVALUATION
TRIVIA
PRINCIPLE #1
PRINCIPLE #2
20. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TRIVIA
PRINCIPLE #1
EPIDEMIOLOGY
PRINCIPLE:
• Poisoning is common
• Poisoning is (rarely) deadly
TRIVIA
PHYSICAL
HISTORY
EVALUATION
TRIVIA
PRINCIPLE #2
21. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
WORK-UP
TRIVIA
PRINCIPLE #1
EPIDEMIOLOGY
Georgi Markov
PHYSICAL
HISTORY
EVALUATION
PRINCIPLE #2
TRIVIA
22. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TRIVIA
RICIN
• Inhibits protein synthesis
• LD50 = 22mcg/kg!!
• Organ failure, death over days
EPIDEMIOLOGY
PRINCIPLE #1
WORK-UP
PHYSICAL
HISTORY
EVALUATION
PRINCIPLE #2
TRIVIA
23. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
WORK-UP: EKG
EVALUATION
TRIVIA
EVALUATING
THE POISONED
PATIENT
PRINCIPLE #1
WORK-UP
PHYSICAL
HISTORY
PRINCIPLE #2
TRIVIA
24. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
WORK-UP: EKG
EVALUATION
TRIVIA
PRINCIPLE #1
WORK-UP
PHYSICAL
HISTORY
PRINCIPLE #2
TRIVIA
25. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
COMMON DEADLY
SILENT
WORK-UP: EKG
EVALUATION
TRIVIA
PRINCIPLE #1
WORK-UP
PHYSICAL
HISTORY
PRINCIPLE #2
TRIVIA
26. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
WORK-UP
HISTORY
EVALUATION
HISTORY
Is everything…
• Available meds/drugs
• Missing meds/drugs
• Time course
• Intention
TRIVIA
WORK-UP: EKG
WORK-UP
PHYSICAL
PRINCIPLE #2
TRIVIA
27. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
HISTORY
…and nothing.
• Unobtainable
• Unreliable
• Misleading
WORK-UP
HISTORY
EVALUATION
TRIVIA
WORK-UP: EKG
WORK-UP
PHYSICAL
PRINCIPLE #2
TRIVIA
28. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
PHYSICAL
HISTORY
EVALUATION
PHYSICAL EXAM
Rule #2: Vitals are vital!!WORK-UP
WORK-UP: EKG
WORK-UP
PRINCIPLE #2
TRIVIA
WORK-UP: UDS
29. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
PHYSICAL EXAM
• Pupils – large/pinpoint/sluggish
• Skin – dry/diaphoretic/piloerection
• Reflexes – decreased/brisk/clonus
• Tone – flaccid/fasciculations
• Speech – slurred/pressuredPHYSICAL
HISTORY
EVALUATION
WORK-UP
WORK-UP: EKG
WORK-UP
PRINCIPLE #2
TRIVIA
WORK-UP: UDS
31. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
AGITATED /
DELERIOUS /
SEIZURE
SEDATED /
COMATOSE /
RESPIRATORY
SILENT
PHYSICAL
HISTORY
EVALUATION
WORK-UP
WORK-UP: EKG
WORK-UP
PRINCIPLE #2
TRIVIA
WORK-UP: UDS
32. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
PRINCIPLE #2
PHYSICAL
HISTORY
PRINCIPLE:
A. We rarely know (for
certain)what has been
ingested
B. It will rarely matter
WORK-UP
WORK-UP: EKG
WORK-UP
TRIVIA
WORK-UP: UDS
WORK-UP: BAL
33. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
WORK-UP: OSM
TRIVIA
PRINCIPLE #2
PHYSICAL
Janis Joplin
WORK-UP
WORK-UP: EKG
WORK-UP
WORK-UP: UDS
WORK-UP: BAL
34. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
HEROIN
• Derived from poppy
• Diacetylmorphine
• Morphine prodrug
WORK-UP: OSM
TRIVIA
PRINCIPLE #2
PHYSICAL
WORK-UP
WORK-UP: EKG
WORK-UP
WORK-UP: UDS
WORK-UP: BAL
35. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
WORK-UP: ASA
WORK-UP
TRIVIA
PRINCIPLE #2
Essential components:
• Glucose
• BMP
• APAP
• EKG
TOX TESTING
WORK-UP: OSM
WORK-UP
WORK-UP: EKG
WORK-UP: UDS
WORK-UP: BAL
36. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
PRINCIPLE #3
TOX EKG
WORK-UP: ASA
WORK-UP
TRIVIA
WORK-UP: OSM
WORK-UP
WORK-UP: EKG
WORK-UP: UDS
WORK-UP: BAL
37. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
DRUG LEVELS • Urine drug screen?
• Serum ethanol?
• Osmolality?
• Salicylate?
TOX TESTING
PRINCIPLE #3
WORK-UP: ASA
WORK-UP
WORK-UP: OSM
WORK-UP
WORK-UP: EKG
WORK-UP: UDS
WORK-UP: BAL
38. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
PRINCIPLE #4 • Urine drug screen?
TOX TESTING
DRUG LEVELS
PRINCIPLE #3
WORK-UP: ASA
WORK-UP: OSM
WORK-UP
WORK-UP: EKG
WORK-UP: UDS
WORK-UP: BAL
39. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
• Urine drug screen?
TOX TESTING
PRINCIPLE #4
DRUG LEVELS
PRINCIPLE #3
WORK-UP: ASA
WORK-UP: OSM
WORK-UP
WORK-UP: EKG
WORK-UP: UDS
WORK-UP: BAL
40. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
• Can only tell you what it is
designed to tell you…
…the SOCIAL HISTORY!!!
UDS
PRINCIPLE #4
DRUG LEVELS
PRINCIPLE #3
WORK-UP: ASA
WORK-UP: OSM
WORK-UP
WORK-UP: EKG
WORK-UP: UDS
WORK-UP: BAL
41. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
• Urine drug screen? No
TOX TESTING
PRINCIPLE #4
DRUG LEVELS
PRINCIPLE #3
WORK-UP: ASA
WORK-UP: OSM
WORK-UP
WORK-UP: EKG
WORK-UP: UDS
WORK-UP: BAL
42. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
• Urine drug screen? No
• Serum ethanol?
TOX TESTING
PRINCIPLE #4
DRUG LEVELS
PRINCIPLE #3
WORK-UP: ASA
WORK-UP: OSM
WORK-UP
WORK-UP: UDS
WORK-UP: BAL
TRIVIA
43. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
SERUM ETOH
PRINCIPLE #4
DRUG LEVELS
PRINCIPLE #3
WORK-UP: ASA
WORK-UP: OSM
WORK-UP
WORK-UP: UDS
WORK-UP: BAL
TRIVIA
44. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
SERUM ETOH
• We should be able to
recognize “straight up” EtOH
• Cannot tell you if current
AMS is due to alcohol.
PRINCIPLE #4
DRUG LEVELS
PRINCIPLE #3
WORK-UP: ASA
WORK-UP: OSM
WORK-UP
WORK-UP: UDS
WORK-UP: BAL
TRIVIA
45. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
• Urine drug screen? No
• Serum ethanol? Maybe
TOX TESTING
PRINCIPLE #4
DRUG LEVELS
PRINCIPLE #3
WORK-UP: ASA
WORK-UP: OSM
WORK-UP
WORK-UP: UDS
WORK-UP: BAL
TRIVIA
46. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
• Urine drug screen? No
• Serum ethanol? Maybe
• Osmolality?
TOX TESTING
PRINCIPLE #4
DRUG LEVELS
PRINCIPLE #3
WORK-UP: ASA
WORK-UP: OSM
WORK-UP: UDS
WORK-UP: BAL
TRIVIA
MANAGEMENT
47. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
• Osmotically active small ions
2[Na+]+gluc/18+BUN/2.8+EtOH/4.6
Normal < 10 mOsm/kg
OSMOLALITY
PRINCIPLE #4
DRUG LEVELS
PRINCIPLE #3
WORK-UP: ASA
WORK-UP: OSM
WORK-UP: UDS
WORK-UP: BAL
TRIVIA
MANAGEMENT
48. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
OSMOLALITY
• Severe unexplained acidosis
• MetOH and EG unavailable
PRINCIPLE #4
DRUG LEVELS
PRINCIPLE #3
WORK-UP: ASA
WORK-UP: OSM
WORK-UP: UDS
WORK-UP: BAL
TRIVIA
MANAGEMENT
49. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
• Urine drug screen? No
• Serum ethanol? Maybe
• Osmolality? No
TOX TESTING
PRINCIPLE #4
DRUG LEVELS
PRINCIPLE #3
WORK-UP: ASA
WORK-UP: OSM
WORK-UP: UDS
WORK-UP: BAL
TRIVIA
MANAGEMENT
50. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
• Urine drug screen? No
• Serum ethanol? Maybe
• Osmolality? No
• Salicylate?
TOX TESTING
ABCs
PRINCIPLE #4
DRUG LEVELS
PRINCIPLE #3
WORK-UP: ASA
WORK-UP: OSM
WORK-UP: BAL
TRIVIA
MANAGEMENT
51. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
ABCs
SALICYLATE
• Common
• Deadly
• Silent?PRINCIPLE #4
DRUG LEVELS
PRINCIPLE #3
WORK-UP: ASA
WORK-UP: OSM
WORK-UP: BAL
TRIVIA
MANAGEMENT
52. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
ABCs
SALICYLATE
• Common
• Deadly
• Silent?
• Resp alkalosis easy to miss
• Acidosis could be anything
• No tinnitus in acute ingestion
• Test readily available
PRINCIPLE #4
DRUG LEVELS
PRINCIPLE #3
WORK-UP: ASA
WORK-UP: OSM
WORK-UP: BAL
TRIVIA
MANAGEMENT
53. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
• Urine drug screen? No
• Serum ethanol? Maybe
• Osmolarity? No
• Salicylate?
Yes
TOX TESTING
ABCs
PRINCIPLE #4
DRUG LEVELS
PRINCIPLE #3
WORK-UP: ASA
WORK-UP: OSM
WORK-UP: BAL
TRIVIA
MANAGEMENT
54. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
PRINCIPLE:
A. A test can only tell you
what it can tell you.
B. Resist the false reassurance
of a test result.
ABCs
PRINCIPLE #4
DRUG LEVELS
PRINCIPLE #3
WORK-UP: ASA
WORK-UP: OSM
TRIVIA
MANAGEMENT
PRINCIPLE #5
55. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
• APAP, ASA, Dilantin,
Depakote, Li++, Dig, etc.
• Serum concentration
DRUG LEVELS
ABCs
PRINCIPLE #4
DRUG LEVELS
PRINCIPLE #3
WORK-UP: ASA
TRIVIA
MANAGEMENT
PRINCIPLE #5
ABSORPTION
56. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
PRINCIPLE:
• Drug level has different
implications depending on
chronic vs acute ingestion.ABCs
PRINCIPLE #4
DRUG LEVELS
PRINCIPLE #3
TRIVIA
MANAGEMENT
PRINCIPLE #5
ABSORPTION
CHARCOAL
57. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
Jonestown, Guyana 1978
ABCs
PRINCIPLE #4
DRUG LEVELS
TRIVIA
MANAGEMENT
PRINCIPLE #5
ABSORPTION
CHARCOAL
PRINCIPLE #6
58. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
• Valium
• Chloralhydrate
• Phenergan
• Cyanide
ABCs
PRINCIPLE #4
DRUG LEVELS
TRIVIA
MANAGEMENT
PRINCIPLE #5
ABSORPTION
CHARCOAL
PRINCIPLE #6
59. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
MANAGING
THE POISONED
PATIENTABCs
PRINCIPLE #4
TRIVIA
MANAGEMENT
PRINCIPLE #5
ABSORPTION
CHARCOAL
PRINCIPLE #6
ELIMINATION
60. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
MANAGMENT
1.Supportive Care
ABCs
PRINCIPLE #4
TRIVIA
MANAGEMENT
PRINCIPLE #5
ABSORPTION
CHARCOAL
PRINCIPLE #6
ELIMINATION
61. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
SUPPORTIVE CARE
ABCs
TRIVIA
MANAGEMENT
PRINCIPLE #5
ABSORPTION
CHARCOAL
PRINCIPLE #6
ELIMINATION
DIALYSIS
62. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TRIVIA
PRINCIPLE:
• “…most poisoned patients require
only supportive therapy for
recovery.”
ABCs
MANAGEMENT
PRINCIPLE #5
ABSORPTION
CHARCOAL
PRINCIPLE #6
ELIMINATION
DIALYSIS
63. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
MANAGMENT
1.Supportive Care
2.Decrease Absorption
ANTIDOTES
TRIVIA
ABCs
PRINCIPLE #5
ABSORPTION
CHARCOAL
PRINCIPLE #6
ELIMINATION
DIALYSIS
64. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
ANTIDOTES
ABSORPTION
TRIVIA
ABCs
PRINCIPLE #5
ABSORPTION
CHARCOAL
PRINCIPLE #6
ELIMINATION
DIALYSIS
66. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
CHARCOAL
• Goal – Adsorbtion
• Dose = 10 : 1
• Time – within 2 hours
ANTIDOTES
TRIVIA
PRINCIPLE #5
ABSORPTION
CHARCOAL
PRINCIPLE #6
ELIMINATION
DIALYSIS
PRINCIPLE #7
67. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
CHARCOAL
• Risk – aspiration
• Be extremely careful in
ingestions of sedating drugs
ANTIDOTES
TRIVIA
PRINCIPLE #5
ABSORPTION
CHARCOAL
PRINCIPLE #6
ELIMINATION
DIALYSIS
PRICIPLE #7
68. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TRIVIA
PRINCIPLE:
• Charcoal (and lavage) should be
reserved for recent ingestions of a
lethal dose of a lethal substance
for which there is no effective
treatment.
ANTIDOTES
TRIVIA
ABSORPTION
CHARCOAL
PRINCIPLE #6
ELIMINATION
DIALYSIS
PRINCIPLE #7
69. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
SUMMARY
MANAGMENT
1.Supportive Care
2.Decrease Absorption
3.Increase elimination
ANTIDOTES
TRIVIA
CHARCOAL
PRINCIPLE #6
ELIMINATION
DIALYSIS
PRINCIPLE #7
TRIVIA
70. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
ELIMINATION
1. RENAL
2. BINDERS
3. DIALYSIS
SUMMARY
ANTIDOTES
TRIVIA
CHARCOAL
PRINCIPLE #6
ELIMINATION
DIALYSIS
PRINCIPLE #7
TRIVIA
71. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
DIALYSIS
• Best for small, water-soluble
• Inherent risks
• Serial dialysis for large VD
SUMMARY
ANTIDOTES
TRIVIA
PRINCIPLE #6
ELIMINATION
DIALYSIS
PRINCIPLE #7
TRIVIA
72. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
Viktor Yushenko
SUMMARY
ANTIDOTES
TRIVIA
ELIMINATION
DIALYSIS
PRINCIPLE #7
TRIVIA
73. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
DIOXIN
• Hepatotoxicity, heme metabolism
• Chloracne
• A compound in Agent Orange
SUMMARY
ANTIDOTES
TRIVIA
ELIMINATION
DIALYSIS
PRINCIPLE #7
TRIVIA
74. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
MANAGMENT
1.Supportive Care
2.Decrease Absorption
3.Increase elimination
4.Antidotes
SUMMARY
ANTIDOTES
TRIVIA
DIALYSIS
PRINCIPLE #7
TRIVIA
75. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
ANTIDOTES
1.Inhibitors
2.Antibodies
3.Reversal agents
ANTIDOTES
TRIVIA
DIALYSIS
PRINCIPLE #7
TRIVIA
SUMMARY
76. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
FLUMAZENIL
• BZD receptor antagonist
• Days of the ‘coma cocktail’ are over
ANTIDOTES
TRIVIA
DIALYSIS
PRINCIPLE #7
TRIVIA
SUMMARY
77. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
NARCAN
• Opioid receptor antagonist
• Narcotic withdrawal not deadly
ANTIDOTES
TRIVIA
DIALYSIS
PRINCIPLE #7
TRIVIA
SUMMARY
78. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TYLENOL OD
• Common, deadly, silent
ANTIDOTES
TRIVIA
DIALYSIS
PRINCIPLE #7
TRIVIA
SUMMARY
79. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
TYLENOL OD
ANTIDOTES
TRIVIA
DIALYSIS
PRINCIPLE #7
TRIVIA
SUMMARY
80. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
NAC
• Chronic (aka repeated
supratherapeutic):
• Elevated LFTs OR
• [APAP] > 20 mcg/mL
• Acute:ANTIDOTES
TRIVIA
DIALYSIS
PRINCIPLE #7
TRIVIA
SUMMARY
81. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
NAC
ANTIDOTES
TRIVIA
DIALYSIS
PRINCIPLE #7
TRIVIA
SUMMARY
82. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
NAC
ANTIDOTES
TRIVIA
DIALYSIS
PRINCIPLE #7
TRIVIA
SUMMARY
$$ $$$$
83. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
PRINCIPLE:
A. The existence of an antidote
does not necessarily mean you
should use it. They are for
saving lives!
B. Know NAC, atropine, pyridoxine,
bicarb, DigiBind and CyanoKit
ANTIDOTES
TRIVIA
PRINCIPLE #7
TRIVIA
SUMMARY
84. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
Tokyo Subway
1995ANTIDOTES
PRINCIPLE #7
TRIVIA
SUMMARY
85. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
SARIN
• Odorless, colorless, tasteless
• Organophosphate
• Cholinesterase inhibitor
ANTIDOTES
PRINCIPLE #7
TRIVIA
SUMMARY
86. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
SUMMARY
1. We should be the best at Tox
2. Poisoning is common/deadly
3. Tox = managing the unknown
4. A test can only tell you what it
tells you
5. Toxic level depends on ACUTE
versus CHRONIC
TRIVIA
SUMMARY
PRINCIPLE #7
87. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
SUMMARY
6. Management = Support (usually)
7. Charcoal is rarely useful
8. Know your emergent antidotes,
look everything else up
TRIVIA
SUMMARY
PRINCIPLE #7
88. A FRAMEWORK FOR EVIDENCE-BASED PRACTICE
THANKS!
QUESTIONS?
TRIVIA
SUMMARY
PRINCIPLE #7
Notas do Editor
People often say EPs are the “Jacks of all trades, master’s of nothing.” The veiled insult is that, much like this swiss army knife, we’re capable of doing lots of things, but not really very good at any of them. I couldn’t disagree more. There are many areas in which we should be the best in the hospital. Here’s 4…
1. Intubation – and it’s not really just intubation, but the emergent airway. 2. Resuscitation – not CPR, but the initial stabilization of the acutely ill or injured patient. 3. Coordination – because of our jack-of-all-trades training, we are uniquely qualified to coordinate care between multiple specialists who often have trouble seeing the big picture. 4. Toxicology – which will be the topic of today’s lecture.
Toxicology is OUR field. One of the oldest EM fellowships, and very few people other than emergency physicians get much toxicology training.
This is going to be an overview lecture which is not even close to comprehensive. I want to try to get you to think about HOW to approach the poisoned patient. There will be many gaps and we will only talk about specifics in a few areas. I’ll highlight a few guiding principles to take home.
I’m using a new ppt format. Kind of like the SportsCenter-style line-up of what’s to come on the left. Please let me know what you think of it.
Finally, like always, there’s beer and trivia.
Toxicologists are really smart, I’m not. It is a HUGE field (environmental, industrial, botanical, envenomations) and we will really only be talking about tox in the setting of the adultingestional poisoning patient. As always, we want to practice evidence-based medicine not eminence-based medicine. Don’t believe anything I say unless you’ve double checked it against the literature.
A quick refresher of the quality of evidence. Expert opinion is on the bottom – and I’m not even an expert! We should always strive to practice in light of the best available evidence – and in toxicology it is usually case series and animal studies. With the exception of a few very common and well described poisonings like tylenol, there’s few large randomized controlled trials in humans and even fewer systematic reviews. IRBs tend to frown on poisoning subjects.
When I started working on this talk I Googled “Intro to Toxicology.” This is what I found. From an unnamed medical school in the US, we get…
This is an insane way to approach medicine. This is his list just for poisonings. What if you had the same list for abdominal pain, chest pain, fever, cervical spine injuries, etc., etc. This is a very inefficient way of thinking. Hopefully I can give you a better approach to toxicology.
OK, first trivia question. Greek philosopher Socrates reportedly killed himself by ingesting a tea made from this substance in the 4th century BC.
The first step in the evidence based management of any disease is understanding the epidemiology. This report is put out every year by the NPDS and is actually pretty interesting reading.
Here is a look at the 4 most deadly classes of pharmaceuticals. The number of deaths from each is rising every year.
Again, this chart does not include street drugs but look at some of the most common culprits.
And when we look at the reason for overdose or poisoning, we see that intentional ingeestions are much more dangerous.
A few interesting facts from the NPDS data…
Our first principle comes straight out of the NPDS data.
In 1978 Bulgarian dissident was killed in classic cloak-and-dagger fashion when a tiny pellet of this substance was injected into his thigh – most likely by KGB agents.
Again lots of people try to think about poisoning like this. Lots of flowcharts about toxidromes, vitals signs, different treatments. It’s a very difficult way to function in the ED. This flowchart is actually supposed to show what to do in a zombie invasion
What we really need to do is focus our attention on common and deadly and silent poisons.
We’re not going to spend a lot of times on physical exam findings. But Golden Rule #2 definitely comes into play – vitals are vital!
In addition to your usual P.E., there are some other things you want to note. But again, we’re not gonna spend much time talking about the history and P.E. in poisonings… because it usually just won’t matter.
The classic teaching is to determine whether the patient is displaying a certain toxidrome. Here’s a really incomplete list – just off the top of my head. Suffice it to say that there are a lot of toxidromes.
I’d rather have you simplify it into only three common toxidromes.
Why simplify the toxidromes so much? Because of principle number 2. Which has two parts. A. And B.
In 1970, Janis Joplin was found dead after an overdose on this substance.
Alright, let’s move on to the toxicology work-up. You will hear lots of debate about what this should include. It will obviously depend to some degree on your history and physical exam. Here are the components that I feel are necessary.
Just a quick word on the EKG. The EKG is all about finding TCA overdose although it may help solve the puzzle in CCB, BB or antidysrrhythmic OD as well. This is the classic TCA EKG. A couple points. TCAs are sodium channel blockers. Important findings are stepwise – tachycardia, right axis deviation, QRS prolongation. The RAD is most easily identified in r wave of aVR. QRS > 100 portends 30% chance of seizure. QRS > 160 portends 50% chance of dysrrhythmia. I repeat EKGs if my poisoned pt is tachycardic. Depending on the story/comorbidities, I consider bicarb in pts with QRS > 100.
What about these other common orders? Let’s look at them one by one.
I love this article from ClinTox in 2009. It points out that what we really want to know when we order a tox screen is, “Could my patient’s current condition be caused by a street drug?” The problem is that this test was designed as a workplace screening tool. It was not designed to answer that question and it can’t.
Incidentally, they cost about $300.
The reasoning goes something like this: “My patient has an altered level of consciousness, I think it is from EtOH, let me get an EtOH level and make sure that is why they are altered.”
So what do we know about BALs? They’re easy to get. They cost your pt about $100. EPs are actually pretty good at determining IF someone is alcohol intoxicated. They’re not as good about predicting levels. But the level itself does not actually predict the degree of intoxication. We’ve all seen the rookie drinker that is blasted with a BAL of 90 and the pro who is walking around MSC asking for a sandwich with a BAL of 430. There is a great article out there that shows that BAL does not affect GCS in head-injured patients – so in that situation could an elevated BAL actually cause you to miss more serious head injuries? I don’t know.
At least the BAL (as opposed to a UDS) is reflecting the patient’s current physiology. But EtOHintox is really common. We should be pretty good at recognizing alcohol intoxication. If you are going to attribute a pts AMS to EtOH, I understand the people who want to at least prove there is EtOH on board. I would feel better about ordering this test if it were a qualitative EtOH.
Here’s the problem. The OG is very indirect in measurement. It is just telling you that “something is present.” And it can be elevated in DKA, shock, AKA, renal failure, pseudohyponatremia, proteinemia, lipemia, ethanol, methanol, ethylene glycol, propylene glycol and isopropyl ingestions.
What about salicylate as a standard part of your tox work-up?
What about salicylate as a standard part of your tox work-up?
Which brings us to principle #3. As with all testing in the ED, the test can only tell you what it can tell you.
A quick note on drug levels. We’re able to measure many drug levels. We are only measuring serum concentration, not total body concentration. The serum concentration depends entirely on time course of ingestion and volume of distribution. It’s a long discussion which we won’t get into today but suffice it to say…
Peoples Temple Agricultural Project had established a compound in Guyana. In 1978 their leader, Jim Jones convinced his people to commit mass suicide. 909 people died including 200 children. Name any 2 of the 4 compounds in the KoolAid.
There’s really only 4 options for managing poisons.
Supportive care is really the most important management strategy. It requires no special toxicology training or knowledge. It’s all about the ABCs. Protect the airway, maintain adequate oxygenation and perfusion and most patients will do fine. In fact this assertion is well-supported by the literature and is the basis for principle #5…
There’s really only 4 options for managing poisons.
There’s only four options to decrease absorption.
First of all, the dose is not weight based or standard. It depends on the amount of drug ingested. It’s a 10:1 ratio. If 25 grams tylenol ingested, pt needs 5 bottles of activated charcoal
First of all, the dose is not weight based or standard. It depends on the amount of drug ingested.
Aspiration of charcoal cares a very high morbidity and mortality. Wouldn’t it be awful if your pt’s CXR looked like this after you gave him charcoal for a non-life-threatening overdose.
Not effective for iron, caustics, hydrocarbons, alcohols, lithium
Binders – work by binding drug in the GI tract. Work like kayexelate for K+. Eg: succimer.
Former Ukrainian president was poisoned with this compound during the 2004 campaign.
Inhibitors – both competitive and non-competitive. Bind at the site of action of the drug preventing its action. Eg: narcan, flumazenil, ethanol. Antibodies – bind to the drug preventing its action. Eg: digibind, Cro-Fab. Reversal agents – counteract the effect of the drug, sometimes by a different pathway. Eg: NAC, pyridoxine in INH overdose, glucagon in BB or CCB overdose.
I, personally, would just remove flumazenil from your arsenal. How to BZDs kill you? Do we have a treatment for that? In addition, flumazenil has a very short half-life in comparison to most BZD. So all you are doing is delaying the effects unless you put someone on a drip. And flumazenil w/d is deadly – from sz and dysrrhythmia. So I just don’t use it.
Let’s talk for a minute about Tylenol. It’s is probably the most well-studied poison from both an evaluation and management perspective. I would highly recommend knowing this article from NEJM.
Let me point out a few things about the nomogram. 1. There is nothing prior to 4 hours. It’s ok to get a level before 4 hours – especially if you just want to know if any tylenol was ingested – but don’t make treatment decisions before a 4 hour level. You’ll be making it up and there will be no literature to support you. 2. There is a 25% margin of error built in. 3. If used before (probably 8 hrs) definitely 6 hours, NAC is 100% effective.
A quick word on costs. A course of oral NAC costs a few hundred dollars at our hospital. Last time I checked with Michelle, a single dose of IV NAC costs over $1000. And they’re equally effective. In fact there is some thought that oral might be preferred since it is delivered to the liver in higher concentration via the portal circulation. There is rarely a reason to use IV NAC.
Members of the AumShinrikyo cult released this substance killing 13 and injuring thousands.