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General Measures

Tylenol

Opiods

Organophosphates

Phenothiazines

Salicylates

Methanol & Ethanol Glycol

Arsenic

Iron

Lead

Carbon monoxide

Cyanide

Digoxin

Recommended Toxicology Books

Any case with suspected poisoning, do these:

Immediate Treatment:

1. A
2. B – Give oxygen
3. C
4. D
   1. 50% Dextrose, 50ml IV
   2. Thiamine, 100mg IV
   3. Naloxone, 2mg IV (Repeat dose to max of 10mg may be given)
   4. Consider flumazenil 0.2-0.5mg IV

Decontamination:

1. Emesis (avoid if alkali, acid, coma, absent gag, hemetemesis, <6mo, petroleum products)
   1. Syrup of Ipecac, 30ml (15ml in child) followed by a glass of water
2. Gastric lavage with lukewarm tap water or saline. Avoid in comatosed unless intubated.
3. Activated Charcoal, 60-100mg with water . 70% Sorbitol with 1^st dose of charcoal act as cathartic.
4. Whole Bowel Irrigation, with GoLYTELY.

Elimination:

1. Diuresis
2. Dialysis (ASA, Methanol, Ethylene Glycol, Lithium, Phenobarbital, Theohpylline)
3. Repeat-Dose Charcoal (30mg Q4H), absorbs drub excreted into bowel (digoxin, Phenobarbital, theophylline)

Antidotes:

Supportive Treatment:

Labs in all:

• CBC
• Chem 10
• UA
• Myoglobinuria
• EKG
• S. Tylenol and Alcohol levels
• Urine Toxicology (Utox)
• S. osmolality
• ABG (anion gap)

Common Physical Findings:

Tylenol, Cocaine, Ephedrine:

• Dilated pupils
• Sweaty
• Dry mucous membranes
• High Temp
• High HR
• High BP
• Agiateted, anxious, psychosis

Barbiturates, Benzodiazepines, Alcohol, Opioids

·        Pinpoint pupils

·        Low HR

·        Low BP

·        Low Temp

·        Comatosed

Organophosphates, Physostigmine, Nicotine

·        Pinpoint pupil

·        Low HR

·        Sweating

·        Salivation

·        Urination

·        Wheezing

·        Muscle weakness

·        Agitated, anxious

Atropine, Scopolamine, Antihistamines, Tricyclics

·        Dilated pupils

·        High Temp (even hyperthermia)

·        High HR

·        High BP

·        Hot, dry, flushed skin

·        Jerking or choreoathetoid

·        Agitated

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Tylenol:

• >140mg/kg (7 g)
• alcoholics, anticonvulsants at higher risk
• CF
  • N/V
  • 24- 48 hrs later, jaundice, hepatic encephalopathy, renal failure
• Diagnosis
  • Blood levels 4 hr after ingestion. 200 or above at 4hrs and 50 or above at 12 hrs indicate hepatotoxicity
• Treatment
  • Emesis and lavage only if <1hr after ingestion
  • Charcoal
  • If toxic dose (per History) start acetylcystine, donot wait for levels
    • 140mg/kg PO, than 70mg/kg Q4H for total of 17 doses
    • most effective in 1^st 8 hrs (can be given upto 36hrs)
    • If level at or above the upper toxic line on normogram, continue till 17 doses otherwise stop.
    • Can be given IV 1-2mg/kg if vomiting
  • Transplantation
    • PT >100
    • Grade 3 or 4 coma
    • pH < 7.3, after 24hrs

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Opioids:

• Pinpoint pupils
• Low HR
• Low BP
• Low Temp
• Drowsy
• Coma
• Respiratory depression
• Meperidine, propoxyphine can cause seizures
• Treatment
  • If shortly before
    • Emesis, lavage, charcoal
  • Naloxone

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Organophosphates (Parathion, malathion):

·       Constricted pupils

·       Tachycardia followed by Bradycardia

·       Abdominal pain (Hyperperistalsis)

·        

·       Salivation

·       Sweating

·       Lacrimation

·       Muscle weakness

·       Wheezing, respiratory arrest

·       Treatment

o      NO EMESIS. Lavage, charcoal

o      Wash shin

o      Atropine (repeated doses till wheezing disappear)

o      Pralidoxime (prevents binding) as soon as possible

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Phenothiazines:

·       Constricted pupils

·       Low BP

·       Tachycardia

·       Convulsions

·       Coma

·       Prolonged QRS, QT interval

·       Extrapyramidal

o      Spasms, parkinsons, rigidity

o      Neuroleptic malignant syndrome

·       Treatment

o      Lavage, charcoal

o      For wide QRS, IV Na Bicarbonate

o      Extrapyramidal – benadryl, benztropine

o      NMS- bromocriptine, dantrolene

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Salicylates:

• 200mg /kg (14g in 70kg)
• half life increase from 3 hrs to 20hrs in overdose
• N/V
• Deep rapid breathing
• Tachycardia
• Tinnitus
• High temp
• Seizures
• Coma
• Pulmonary edema
• Elevated anion gap metabolic acidosis
• Levels>100 indicate severe poisoning
• ABG= respiratory alkalosis with metabolic acidosis
• Treatment
  • Lavage, charcoal
  • Met acidosis: IV NaHCO3
  • Alkalination of urine: NaHCO3 in 5% dextrose
  • Hemodialysis
    • Severe MA
    • Altered MS
    • Levels > 100

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Methanol & Ethylene Glycol:

• Tachypnea
• Confusion
• Convulsions
• Coma
• Methanol – visual
• Ethylene glycol – renal failure & oxalate crystalluria
• Treatment
  • Emesis, lavage, charcoal (if within 60min)
  • Ethanol
  • Hemodialysis
    • MA
    • Methanol or e EG level > 50
    • Osmolar gap > 10
  • Fomepizole (instead of ethanol) – blocks alcohol dehydrogenase

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Arsenic:

• Abdominal pain
• Diarrhea
• Muscle cramps
• Chronic – peripheral neuropathy
• TX
  • Emesis, lavage, charcoal
  • Dimercaproal (BAL), IM
  • Than Penicillamine PO x 1 wk

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Iron:

• 40-60mg/kg
• hemetemesis
• vomiting
• diarrhea
• hypotension
• acidosis
• hepatic failure
• S iron > 350 toxic
• AXR: pills
• Treatment
  • IV fluids
  • Whole bowel irrigation, emesis, lavage (charcoal not effective)
  • Deferoxamine PO (prolonged treatment cause ARDS)

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Lead:

• Abd pain
• Constipation
• Headache
• Convulsions
• Coma
• Chronic: A (anemia) B (Basophilic stippling) C (Constipation) D(
• Levels
  • >10 – behavioral changes
  • >50- toxic
• micocytic anemia
• inc protoporphyrin
• basophilic stippling
• Treatment
  • Emesis, lavage,
  • Severe toxicity (encephalopathy, > 70) – Edetate Calcium Disodium (EDTA) IV + Dimercaprol IM
  • 50-70: EDTA alone
• Removed from site:
  • Construction worker , one level > 50
  • Other workers, one level >  60 OR 3 levels > 50
  • < 50 should only be treated not removed

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Carbon monoxide:

• headache (>10)
• dizziness
• abd pain
• nausea
• confusion
• syncope
• seizures (> 50)
• coma
• fetus and newborn more susceptible
• ABG and O2 sat not useful
• Treatment
  • Assist ventilation
  • 100% Oxygen by mask or endotracheal tube
  • Hyperbaric O2 if coma or seizure

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Cyanide:

• Rapidly absorbed by skin, inhalation
• Effects instantaneous with inhalation. Delayed to hrs after ingestion
• Headache
• Abd pain
• NV
• Confusion
• Seizures
• Coma
• Venous PaO2 > 90% (as tissues unable to use o2)
• Treatment
  • Lavage, charcoal
  • Amyl nitrate (to produce methemoglobinemia)
  • Na nitrite IV
  • Na thiosulfate IV

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Digoxin:

• NV
• Bradycardia
• High K
• AV block
• Ectopy, bi-directional vent tachy, VFib
• Risk
  • Diuretics
  • Low K
  • Low Mg
• Treatment
  • Monitor K, Ryhtm
  • Arrythmia - Lidocaine IV OR Phenytoin IV
  • Brady - Atropine OR Isoproterinol
  • (No Emesis – inc vagus), lavage, charcoal
  • Digoxin Ab

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 Please contact Irfan A. Khan, MD for suggestions and corrections.