Poisoning Overdose

Poisoning/Overdose :Poisoning/Overdose General Management


Poisoning :Poisoning Exposure to substance that is toxic in any amount


Overdose :Overdose Exposure to substance in excess amount resulting in toxic effects


1998 TESS Data :1998 TESS Data 2,241,082 reported human exposures 97.9 % at home Peak volume 4pm-10pm 91% of calls 8am-midnight


Exposures by Age :Exposures by Age < 6 years old 52.7% < 3 years old 39.6%


Fatalities :Fatalities 775 fatalities 0.03% of total exposures ages 20 - 49 years = 56% >6 years = 2.1%


Number of Substances :Number of Substances 92.8% of all cases--one substance 44.7% of fatal cases-->2 substances


Management Location :Management Location Managed on site 75.2% Treated, released at ER 12.3% Admitted to critical care 2.7% Refused referral 2.0%


Therapy :Therapy No therapy 11.9% Observation only 12.7% Decontamination only 59.6% Activated charcoal 6.8% Ipecac 1.2%


Most Common Substances :Most Common Substances Cleaning substances 10.2% Analgesics 9.6% Cosmetics 9.4% Plants 5.5% Foreign bodies 4.6% Cough, cold 4.5% Bites, stings 4.1%


Most Common Substances :Most Common Substances Insecticides, pesticides, rodenticides 3.9% Sedative, hypnotics, antipsychotics 3.2% Antidepressants 3.0% Hydrocarbons 3.0% Alcohols 2.5%


Largest Number of Deaths :Largest Number of Deaths Analgesics 264 Antidepressants 152 Stimulants, street drugs 118 Cardiovascular medication 118 Sedatives, hypnotics 89 Alcohols 56


Indicators :Indicators Sudden onset of CNS signs: Seizures Coma Decreased LOC Bizarre behavior


Indicators :Indicators Sudden onset of: Abdominal pain Nausea Vomiting


Indicators :Indicators Sudden onset of unexplained illness Bizarre, incomplete, evasive history Trauma (>50% of adult trauma EtOH, drug-related) Pediatric patient with arrhythmias


History :History What? How much? How long? Multiple substances? Treatment attempted? How? Whose advice? Psychiatric history? History of suicide?


General Management :General Management Support ABC’s Secure airway, intubate as needed Ensure adequate oxygenation, ventilation Maintain adequate circulation Monitor ECG Obtain vascular access Manage hypotension initially with volume Use vasopressors cautiously


General Management :General Management Keep patient calm Maintain normal body temperature Evaluate nature/toxicity of poison Check container, package insert, poison center information Treat the patient, not the poison


General Management :General Management Rule out Trauma Neurological disease Metabolic disease Base general management on route of poison entry


Poison Entry :Poison Entry Ingestion Slow movement from injection site throughout body Remove from skin surface Remove from exposure; Support oxygenation, ventilation Prevent absorption from GI tract Inhalation Absorption Injection


Ingested Poisons :Ingested Poisons Objective Remove from GI tract before absorption occurs


Ipecac :Ipecac RARELY used anymore If used, has to have been initiated within few minutes after ingestion Vomiting in 20-30 minutes Only removes about 32% of contaminate Many contraindications


Ipecac :Ipecac Dose 15 cc if 12 months to 12 years old 30 cc if >12 years old Follow with 2-3 glasses of water Keep patient ambulatory if possible


Ipecac :Ipecac If no vomiting after 20 minutes, repeat When emesis occurs, keep head down Collect, save vomitus for analysis


Ipecac :Ipecac Contraindications Comatose or no gag reflex Seizing or has seized Caustic (acid or alkali) ingestion Low viscosity hydrocarbon ingestion Late term pregnancy


Ipecac :Ipecac Contraindications Severe hypertension, cardiovascular insufficiency, possible AMI Ingestion of: Strychnine Phenothiazines (Thorazine, Stellazine, Compazine) Tricyclic antidepressants Iodides Silver Nitrate


Lavage :Lavage Commonly used in ED’s Removes about 31% of substance Helps get activated charcoal in patient, especially if patient is unconscious Not helpful for sustained release tablets Will not remove large tablets


Activated Charcoal :Activated Charcoal Adsorbs compounds, prevents movement from GI tract Very effective at adsorbing substances Binds about 62% of toxin Dose 5 - 10X estimated weight of ingested chemical


Activated Charcoal :Activated Charcoal Inactivates Ipecac Do not give until vomiting stops Do not give with Cyanide Methanol Tylenol (+) Containers must be kept airtight


Inhaled Poisons :Inhaled Poisons Objective: Move to fresh air; optimize ventilation and protect personnel from exposure


Absorbed Poisons :Absorbed Poisons Objective: Remove poison from skin Liquid: Wash with copious amounts of water Powder: Brush off as much as possible, then wash with copious amounts of water Protect personnel from exposure


Dilute / Irrigate / Wash :Dilute / Irrigate / Wash Use soap, shampoo for hydrocarbons No need for chemical neutralization - heat produced by reaction could be harmful


Eye Irrigation :Eye Irrigation Wash for 15 minutes Use only water or balanced salt solutions Remove contact lenses Wash from medial to lateral