Tint7 Ch 170 General Management Of Poisoned Patients

Front 1

Inadvertent exposures to substances that meet specific criteria are considered "nontoxic" and require only that the exposed patient undergo a brief observation period prior to discharge

• Table 170-1 Criteria for Nontoxic Ingestions:

Back 1

• Table 170-1 Criteria for Nontoxic Ingestions: (Note: All of the listed criteria must be fulfilled in order for an ingestion to be classified as nontoxic)

o Only one substance must be involved in the exposure.
o The substance must be absolutely identified.
o The substance's product label must not contain any consumer product safety commission signal words indicating a potential hazard of toxicity.

o The exposure must have been unintentional.
o The route of exposure must be known.
o An approximate amount of the substance involved in the exposure must be known.

o The exposed individual must be free of symptoms for the extent of the observation period.
o Follow-up consultation must be easily available or a responsible parent or guardian must be present.

Front 2

First actions (priorities) in treating poisoned patients is:

Back 2

• The first priority in treating poisoned patients is assessment and stabilization of cardiopulmonary function (e.g., the ABCs, or airway, breathing, and circulation).
o Once the airway and respiratory status,
o blood pressure, and pulse are stabilized,
o abnormalities of core (rectal) temperature,
o oxygen saturation, and
o hypoglycemia are addressed.

• Although the proper use of antidotes (Table 170-2) is essential in the treatment of poisoned patients, only in very rare instances (such as in Cyanide poisoning) does the administration of an antidote take precedence over completing the primary evaluation and implementing standard methods to stabilize the ABCs.

Front 3

Acetylcysteine
Initial Dosages and Indications

Back 3

• Acetylcysteine
o 140 milligrams/kg PO load, followed by 70 milligrams/kg PO every 4 h for 17 total doses or
150 milligrams/kg IV load over 60 min, followed by 50 milligrams/kg IV over 4 h and then 100 milligrams/kg IV over 16 h
o Indication: Acetaminophen

Front 4

Activated Charcoal
Initial Dosages and Indications

Back 4

• Activated Charcoal
o child: 1 gram/kg PO
o adult: 50–100 grams
o Indication: Most ingested poisons

Front 5

Antivenom Fab
Initial Dosages and Indications

Back 5

• Antivenom Fab
o 4–6 vials IV initially over 1 h, may be repeated to gain control of progressive symptoms
o Indication: Envenomation by Crotalidae

Front 6

Calcium chloride

Back 6

• Calcium chloride 10% (27.2 milligrams/mL elemental calcium)
o child: 0.2–0.25 mL/kg IV
o adult: 10 mL IV
o Indication: Calcium channel antagonists

Front 7

Calcium gluconate

Back 7

• Calcium gluconate 10% (9 milligrams/mL elemental calcium)
o child: 0.6–0.8 mL/kg IV
o adult: 10–30 mL IV
o Indication: Hypermagnesemia, Hypocalcemia

Front 8

Cyanide antidote kit
Amyl nitrite

Back 8

o Amyl nitrite
 child: Not typically used
 adult: 1 ampule in oxygen chamber of ventilation bag 30 s on/30 s off

Front 9

Cyanide antidote kit
Sodium nitrite

Back 9

o Sodium nitrite (3% solution)
 child: 0.33 mL/kg IV
 adult: 10 mL IV

Front 10

Cyanide antidote kit
Sodium thiosulfate

Back 10

Sodium thiosulfate (25% solution)
 child: 1.65 mL/kg IV
 adult: 50 mL IV

Front 11

Calcium chloride

Back 11

• Calcium chloride 10% (27.2 milligrams/mL elemental calcium)
o child: 0.2–0.25 mL/kg IV
o adult: 10 mL IV
o Indication: Calcium channel antagonists

Front 12

Calcium gluconate

Back 12

• Calcium gluconate 10% (9 milligrams/mL elemental calcium)
o child: 0.6–0.8 mL/kg IV
o adult: 10–30 mL IV
o Indication: Hypermagnesemia, Hypocalcemia

Front 13

Cyanide antidote kit
Amyl nitrite

Back 13

o Amyl nitrite
 child: Not typically used
 adult: 1 ampule in oxygen chamber of ventilation bag 30 s on/30 s off

Front 14

Cyanide antidote kit
Sodium nitrite

Back 14

o Sodium nitrite (3% solution)
 child: 0.33 mL/kg IV
 adult: 10 mL IV

Front 15

Cyanide antidote kit
Sodium thiosulfate

Back 15

Sodium thiosulfate (25% solution)
 child: 1.65 mL/kg IV
 adult: 50 mL IV

Front 16

Cyanide antidote kit
Initial Dosages and Indications

Back 16

• Cyanide antidote kit
o Amyl nitrite
 child: Not typically used
 adult: 1 ampule in oxygen chamber of ventilation bag 30 s on/30 s off
o Sodium nitrite (3% solution)
 child: 0.33 mL/kg IV
 adult: 10 mL IV
o Sodium thiosulfate (25% solution)
 child: 1.65 mL/kg IV
 adult: 50 mL IV
 Indication:
• Cyanide
• Hydrogen sulfide (use only Sodium nitrite)

Front 17

Deferoxamine
Initial Dosages and Indications

Back 17

• Deferoxamine
o child: 90 milligrams/kg IM (1 gram maximum)
o adult: 2 grams IM
or
o child: 15 milligrams/kg/h IV (maximum dose, 1 gram/d)
o adult: 15 milligrams/kg/h IV (maximum dose, 6–8 grams/d)

Front 18

Dextrose (Glucose)
Initial Dosages and Indications

Back 18

• Dextrose (Glucose)
o child: 0.5 gram/kg IV
o adult: 1 gram/kg IV
o Indication: Insulin, Oral hypoglycemics

Front 19

• Digoxin Fab
o Acute:
o Chronic:
Initial Dosages and Indications

Back 19

• Digoxin Fab
o Acute
 child: 1–2 vials IV
 adult: 5–10 vials
 Indication: Digoxin and other cardioactive steroids
o Chronic
 child: 1–2 vials IV
 adult: 3–6 vials IV
 Indication: Cardioactive steroids

Front 20

Ethanol for IV administration
Initial Dosages and Indications

Back 20

• Ethanol (10% for IV administration)
o child: 10 mL/kg IV over 30 min, then 1.2 mL/kg/h*
o adult: 10 mL/kg IV over 30 min, then 1.2 mL/kg/h*
o Indication: Ethylene glycol, Methanol
 *This is an approximation. Dose should be titrated to level

Front 21

Fomepizole

Initial Dosages and Indications

Back 21

• Fomepizole
o child: 15 milligrams/kg IV, then 10 milligrams/kg every 12 h
o adult: 15 milligrams/kg IV, then 10 millgrams/kg every 12h
o Indication: Methanol, Ethylene glycol, Disulfiram-ethanol interaction

Front 22

Folic acid/Leucovorin

Initial Dosages and Indications

Back 22

• Folic acid/Leucovorin
o child: 1–2 milligrams/kg IV every 4–6 h
o adult: 1–2 milligrams/kg IV every 4–6 h
o Indication: Methotrexate (only leucovorin)

Front 23

Flumazenil

Initial Dosages and Indications

Back 23

• Flumazenil
o child: 0.01 milligram/kg IV
o adult: 0.2 milligram IV
o Indication: Benzodiazepines

Front 24

Glucagon

Initial Dosages and Indications

Back 24

• Glucagon
o child: 50–150 micrograms/kg IV
o adult: 3–10 milligrams IV
o Indication: Calcium channel antagonists, Beta-Blockers

Front 25

Methylene blue

Initial Dosages and Indications

Back 25

• Methylene blue
o child: 1–2 milligrams/kg IV
o neonates: 0.3–1.0 milligram/kg
o adult: 1–2 milligrams/kg IV
o Indication: Oxidizing chemicals (e.g., Nitrites, Benzocaine, Sulfonamides)

Front 26

Methylene blue

Initial Dosages and Indications

Back 26

• Methylene blue
o child: 1–2 milligrams/kg IV
o neonates: 0.3–1.0 milligram/kg
o adult: 1–2 milligrams/kg IV
o Indication: Oxidizing chemicals (e.g., Nitrites, Benzocaine, Sulfonamides)

Front 27

Octreotide

Initial Dosages and Indications

Back 27

• Octreotide
o child: 1 microgram/kg SC every 6 h
o adult: 50–100 micrograms SC every 6 h
o Indication: Refractory hypoglycemia after oral hypoglycemic agent ingestion

Front 28

Naloxone

Initial Dosages and Indications

Back 28

• Naloxone As much as is needed As much as needed Opioid
Typical starting dose is 0.01 milligram IV Typical starting dose is 0.4–2.0 milligrams IV Clonidine

Front 29

Physostigmine

Initial Dosages and Indications

Back 29

• Physostigmine
o child: 0.02 milligram/kg IV
o adult: 0.5–2.0 milligrams slow IV over 2–5 min
o Indication: Anticholinergic agents (not cyclic antidepressants)\

Front 30

Pralidoxime (2-PAM)

Initial Dosages and Indications

Back 30

• Pralidoxime (2-PAM)
o child: 20–40 milligrams/kg IV over 5–10 min, followed by 20 milligrams/kg/h infusion
o adult: 1–2 grams IV over 5–10 min, followed by 500 milligrams/h infusion
o Indication: Cholinergic agents

Front 31

Protamine

Initial Dosages and Indications

Back 31

• Protamine
o 1 milligram neutralizes 100 units of Unfractionated Heparin, administered over 15 min
o child: 0.6 milligram/kg IV (empiric dose)
o adult: 25–50 milligrams IV (empiric dose)
o Indication: Heparin

Front 32

Pyridoxine

Initial Dosages and Indications

Back 32

• Pyridoxine
o Gram for gram of ingestion if amount of Isoniazid is known
o child: 70 milligrams/kg (maximum 5 grams) IV
o adult: 5 grams IV
o Indication: Isoniazid, Gyromitra esculenta, Hydrazine

Front 33

Sodium bicarbonate

Initial Dosages and Indications

Back 33

• Sodium bicarbonate
o child: 1–2 mEq/kg IV bolus followed by 2 mEq/kg/h IV infusion
o adult: 1–2 mEq/kg IV bolus followed by 2 mEq/kg/h IV infusion
o Indication: Sodium channel blockers, For urinary alkalinization

Front 34

Thiamine

Initial Dosages and Indications

Back 34

• Thiamine
o child: 5–10 milligrams IV
o adult: 100 milligrams IV
o Indication: Wernicke syndrome, Wet beri-beri

Front 35

Vitamin K1

Initial Dosages and Indications

Back 35

• Vitamin K1
o child: 1–5 milligrams/d PO
o adult: 20 milligrams/d PO
o Indication: Anticoagulant rodenticides

Front 36

altered mental status causing conditions readily treated by specific antidotes:

Back 36

• Patients may have an altered mental status because of conditions readily treated by specific antidotes:
o hypoxia,
o opioid intoxication,
o hypoglycemia, and
o Wernicke encephalopathy

Front 37

When altered mental status; after the medical history, vital signs, and immediately available laboratory data are taken into account should be considered empiric administration of these antidotes:

Back 37

• After the medical history, vital signs, and immediately available laboratory data are taken into account should be considered empiric administration of antidotes (the "coma cocktail"), including
o supplemental oxygen,
o naloxone,
o glucose, and
o thiamine,.

Front 38

In giving coma cocktail, IV Glucose should be administered when:

Back 38

• IV Glucose should be administered when serum glucose level cannot be rapidly ascertained or hypoglycemia is confirmed.
• Empiric Thiamine is often administered to unresponsive hypoglycemic adults along with IV Glucose.

Front 39

Naloxone should be given when:

Back 39

• Naloxone is a competitive opioid antagonist without any intrinsic toxicity that can be administered IV or IM and is appropriate to use in a hypoventilating opioid-intoxicated patient who is not intubated.
• Naloxone may be given to children as a therapeutic challenge when unintentional or intentional opioid exposure cannot be excluded.
• Although opioid intoxication often presents with the classic triad of central nervous system depression, miosis, and respiratory depression,
• only a respiratory rate of <12 breaths/min is useful as a predictor of response to naloxone.

Front 40

• Using miosis as the sole indication for naloxone administration is unreliable, because
o many other toxins can produce small pupils along with mental status depression, and
o which opioids classically leave pupil size unaltered?

Back 40

• Using miosis as the sole indication for naloxone administration is unreliable, because
o many other toxins can produce small pupils along with mental status depression, and
o some opioids classically leave pupil size unaltered (e.g., Meperidine, Propoxyphene).

Front 41

For how long after IV Naloxone should patient be observed?

Back 41

• Naloxone often completely reverses the effects of the opioid and restores effective ventilations and mental status for 20 to 60 minutes,
o so patients should be observed for 2 to 3 hours after IV administration.

Front 42

Something to think about before giving Naloxone:

Back 42

• A protocol for ensuring that patients cannot leave the ED (e.g., extremity restraints) during this transiently awakened period should be considered before administering Naloxone, because sedation, hypoventilation, and respiratory arrest can occur after the opioid-reversal effects of Naloxone dissipate.

Front 43

Treatment if following Naloxone administration, the patient becomes resedated:

Back 43

o Patients who become re-sedated may require additional naloxone doses administered either in intermittent boluses or via a continuous infusion.
o The latter is achieved by the administration of two thirds of the dose of the naloxone that fully aroused the patient in the initial bolus, infused over an hour, with dose adjustments made as directed by the patient's ventilatory status.

Front 44

Get a history from overdose patient with these "drug" questions:

Back 44

• Ask about
o the agent or drug,
o estimated amount or dose, and
o route of exposure, as well as
o whether other individuals were exposed.

• If possible, the patient's intent should be determined.
• Corroborating information should be obtained from the patient's physician, prior medical records, witnesses, or emergency medical technicians.

Front 45

History from overdose patient, in addition to the "drug" questions should include these questions:

Back 45

• Ask about
o the environment in which the patient was found,
o the presence of empty pill bottles or containers nearby,
o any smells or
o unusual materials in the home,
o the occupation or hobbies of the patient, and
o the presence of a suicide note.

Front 46

Opioid toxidrome:

Back 46

• Opioid toxidrome:
o Heroin, Morphine, Oxycodone
o most commonly:
 Central nervous system depression,
 miosis,
 respiratory depression
o additionally:
 Hypothermia,
 bradycardia
 Death may result from respiratory arrest, acute lung injury

Front 47

Opioid toxidrome
possible interventions:

Back 47

Opioid toxidrome possible interventions:
 Ventilation or
 Naloxone

Front 48

Sympathomimetic toxidrome:

Back 48

• Sympathomimetic toxidrome:
o Cocaine, Amphetamine
o most commonly:
 Psychomotor agitation,
 mydriasis,
 diaphoresis,
 tachycardia,
 hypertension,
 hyperthermia
o additionally:
 Seizures,
 rhabdomyolysis,
 myocardial infarction
 Death may result from seizures, cardiac arrest, hyperthermia

Front 49

Sympathomimetic toxidrome
possible interventions:

Back 49

Sympathomimetic toxidrome possible interventions:
 Cooling,
 sedation with benzodiazepines,
 hydration

Front 50

Cholinergic toxidrome:

Back 50

• Cholinergic toxidrome:
o Organophosphate insecticides, Carbamate insecticides
o most commonly:
 Muscarinic effects (salivation, lacrimation, diaphoresis, nausea, vomiting, urination, defecation, bronchorrhea)
 Nicotinic effects (muscle fasciculations and weakness)
o additionally: Bradycardia, miosis/mydriasis, seizures, respiratory failure, paralysis
o Death may result from respiratory arrest from paralysis, bronchorrhea, or seizures

Front 51

Cholinergic toxidrome possible interventions:

Back 51

Cholinergic toxidrome possible interventions:
 Airway protection and ventilation,
 Atropine,
 Pralidoxime

Front 52

Anticholinergic toxidrome:

Back 52

Anticholinergic toxidrome:
o Scopolamine, Atropine
o most commonly:
 altered mental status,
 mydriasis,
 dry flushed skin,
 dry mucous membranes,
 urinary retention,
 decreased bowel sounds,
 hyperthermia
o additionally:
 seizures,
 dysrhythmias,
 rhabdomyolysis
 Death may result from hyperthermia and dysrhythmias

Front 53

Anticholinergic toxidrome possible interventions:

Back 53

o possible interventions:
 Physostigmine (if appropriate),
 sedation with benzodiazepines,
 cooling,
 supportive management

Front 54

Salicylate toxidrome:

Back 54

• Salicylate toxidrome
o Aspirin, Oil of wintergreen
o most commonly:
 altered mental status,
 respiratory alkalosis, metabolic acidosis,
 tinnitus,
 hyperpnea,
 tachycardia,
 diaphoresis,
 nausea, vomiting
o additionally:
 Low-grade fever,
 ketonuria
 Death may result from acute lung injury or cerebral edema

Front 55

Salicylate toxidrome possible interventions:

Back 55

Salicylate toxidrome possible interventions:
 Multidose Activated Charcoal,
 Alkalinization of urine with Potassium repletion,
 Hemodialysis

Front 56

Sedative-hypnotic toxidrome:

Back 56

• Sedative-hypnotic toxidrome
o Barbiturates, Benzodiazepines
o most commonly:
 Depressed level of consciousness,
 slurred speech,
 ataxia
o additionally:
 Stupor to coma,
 depressed respirations,
 apnea,
 bradycardia

Front 57

Sedative-hypnotic toxidrome possible interventions:

Back 57

Sedative-hypnotic toxidrome possible interventions:
 Ventilatory support

Front 58

Hypoglycemic toxidrome:

Back 58

Hypoglycemic toxidrome
o Sulfonylureas, Insulin
o most commonly:
 Altered mental status,
 diaphoresis,
 tachycardia,
 hypertension
o additionally:
 Paralysis,
 slurring of speech,
 bizarre behavior,
 seizures
 Death may result from seizures, altered behavior

Front 59

Hypoglycemic toxidrome possible interventions:

Back 59

Hypoglycemic toxidrome possible interventions:
 Glucose-containing solution IV and oral feedings if possible,
 frequent glucose measurement,
 Octreotide

Front 60

Hallucinogenic toxidrome:

Back 60

Hallucinogenic toxidrome:
o Phencyclidine, Lysergic acid diethylamide, Psilocybin, Mescaline
o most commonly:
 Hallucinations,
 dysphoria,
 anxiety
o additionally:
 Hyperthermia,
 mydriasis,
 nausea,
 sympathomimetic symptoms

Front 61

Hallucinogenic toxidrome possible interventions:

Back 61

Hallucinogenic toxidrome possible interventions:
 Generally supportive

Front 62

Serotonin toxidrome:

Back 62

Serotonin toxidrome:
o SSRIs, Meperidine, A variety of drug interactions with Dextromethorphan, Monoamine oxidase inhibitors, Tricyclic antidepressants, other SSRIs, and Amphetamines
o most commonly:
 Altered mental status,
 increased muscle tone,
 hyperreflexia,
 hyperthermia
o additionally:
 Intermittent whole-body tremor
 Death may result from hyperthermia

Front 63

Serotonin toxidrome possible interventions:

Back 63

Serotonin toxidrome possible interventions:
 Cooling,
 sedation with benzodiazepines,
 supportive management,
 theoretical benefit of cyproheptadine

Front 64

Extrapyramidal toxidrome:

Back 64

Extrapyramidal toxidrome
o Haloperidol, Phenothiazines, Risperidone, Olanzapine
o most commonly:
 Dystonia,
 torticollis,
 tremor,
 muscle rigidity
o additionally:
 Choreoathetosis,
 hyperreflexia,
 seizures

Front 65

Extrapyramidal toxidrome possible interventions:

Back 65

Extrapyramidal toxidrome possible interventions:
 Diphenhydramine
 Benztropine
 Benzodiazepines

Front 66

Toxicologic Screen
• In the emergency setting, toxicologic screening tests of blood and/or urine do not contribute significantly to the evaluation, management, or outcome for most patients.
• On the other hand, what are the toxins for which the serum level does influence emergency treatment and disposition:

Back 66

Substances for Which Serum Level May Affect Therapy:
o Acetaminophen
o Salicylate

o Phenytoin
o Valproate
o Carbamazepine

o Lithium
o Theophylline

o Methanol
o Ethylene glycol

o Digoxin

o Iron

o Carbon monoxide
o Methemoglobin

o Paraquat

Front 67

Most toxicology urine screens use enzyme-multiplied immunoassays that detect which common typical drugs?

Back 67

• Most toxicology urine screens use enzyme-multiplied immunoassays that detect common typical drugs within a class, such as
o cannabinoids,
o opioids,
o cocaine,
o amphetamines,
o barbiturates,
o benzodiazepines, and
o phencyclidine (PCP, angel dust),
o tricyclic antidepressants,

Front 68

• Interpretation of urine toxicology screening test results requires an understanding of their limitations.
o Positive results may occur with many substances because they persist in body fluids for days to weeks, depending on the chronicity of use.
 Thus, positive results may not be related to the acute symptoms.
o Furthermore, positive results may occur from substances that cross-react with the assay (e.g.,
 for amphetamines:

Back 68

• Interpretation of urine toxicology screening test results requires an understanding of their limitations.
o Positive results may occur with many substances because they persist in body fluids for days to weeks, depending on the chronicity of use.
 Thus, positive results may not be related to the acute symptoms.
o Furthermore, positive results may occur from substances that cross-react with the assay (e.g.,
 for amphetamines: pseudoephedrine, oxymetazoline, methylphenidate, and selegiline;

Front 69

• Interpretation of urine toxicology screening test results requires an understanding of their limitations.
o Positive results may occur with many substances because they persist in body fluids for days to weeks, depending on the chronicity of use.
 Thus, positive results may not be related to the acute symptoms.
o Furthermore, positive results may occur from substances that cross-react with the assay e.g.,
for tricyclic antidepressants:

Back 69

• Interpretation of urine toxicology screening test results requires an understanding of their limitations.
o Positive results may occur with many substances because they persist in body fluids for days to weeks, depending on the chronicity of use.
 Thus, positive results may not be related to the acute symptoms.
o Furthermore, positive results may occur from substances that cross-react with the assay e.g.,
for tricyclic antidepressants: chlorpromazine, cyclobenzaprine, thioridazine, diphenhydramine, and cyproheptadine

Front 70

• Interpretation of urine toxicology screening test results requires an understanding of their limitations.

o Negative results may be due to
 sampling error (e.g., very dilute urine after hydration)
 or assay specificity (e.g.,
• opioid screens do not detect:

Back 70

o Negative results may be due to
 sampling error (e.g., very dilute urine after hydration)
 or assay specificity (e.g.,
• opioid screens do not detect Methadone and Meperidine

Front 71

• Interpretation of urine toxicology screening test results requires an understanding of their limitations.
• amphetamine screens do not detect:

Back 71

amphetamine screens do not detect Methylenedioxymethamphetamine;

Front 72

• Interpretation of urine toxicology screening test results requires an understanding of their limitations.
• benzodiazepine screens do not detect:

Back 72

benzodiazepine screens do not detect Flunitrazepam

Front 73

• Toxicologic screens may have a place in the evaluation of children.
o The unexpected return of a positive result for a controlled or illegal substance should prompt:.

Back 73

• Toxicologic screens may have a place in the evaluation of children.
o The unexpected return of a positive result for a controlled or illegal substance should prompt further evaluation of the child's home environment and
o may require assessment by the appropriate child protective services agency.