Poisoning/Overdose
General Management
Poisoning
Exposure to substance that is toxic in any amount
Overdose
Exposure to substance in excess amount resulting in toxic effects
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
< 6 years old < 3 years old
52.7% 39.6%
Fatalities
775 fatalities 0.03% of total exposures ages 20 - 49 years = 56% >6 years = 2.1%
Number of Substances
92.8% of all cases--one substance 44.7% of fatal cases-->2 substances
Management Location
Managed on site Treated, released at ER Admitted to critical care Refused referral
75.2% 12.3% 2.7% 2.0%
Therapy
No therapy Observation only Decontamination only Activated charcoal Ipecac
11.9% 12.7% 59.6% 6.8% 1.2%
Most Common Substances
Cleaning substances Analgesics Cosmetics Plants Foreign bodies Cough, cold Bites, stings
10.2% 9.6% 9.4% 5.5% 4.6% 4.5% 4.1%
Most Common Substances
Insecticides, pesticides, rodenticides Sedative, hypnotics, antipsychotics Antidepressants Hydrocarbons Alcohols
3.9% 3.2% 3.0% 3.0% 2.5%
Largest Number of Deaths
Analgesics Antidepressants Stimulants, street drugs Cardiovascular medication Sedatives, hypnotics Alcohols
264 152 118 118 89 56
Indicators
Sudden onset of CNS signs:
– – – – Seizures Coma Decreased LOC Bizarre behavior
Indicators
Sudden onset of:
– Abdominal pain – Nausea – Vomiting
Indicators
Sudden onset of unexplained illness Bizarre, incomplete, evasive history Trauma (>50% of adult trauma EtOH, drug-related) Pediatric patient with arrhythmias
History
What? How much? How long? Multiple substances? Treatment attempted? How? Whose advice? Psychiatric history? History of suicide?
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
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
Rule out
– Trauma – Neurological disease – Metabolic disease
Base general management on route of poison entry
Poison Entry
Ingestion Inhalation
Prevent absorption from GI tract
Remove from exposure; Support oxygenation, ventilation
Absorption Injection
Remove from skin surface Slow movement from injection site throughout body
Ingested Poisons
Objective Remove from GI tract before absorption occurs
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
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
If no vomiting after 20 minutes, repeat When emesis occurs, keep head down Collect, save vomitus for analysis
Ipecac
Contraindications
– – – – – Comatose or no gag reflex Seizing or has seized Caustic (acid or alkali) ingestion Low viscosity hydrocarbon ingestion Late term pregnancy
Ipecac
Contraindications
– Severe hypertension, cardiovascular insufficiency, possible AMI – Ingestion of:
» Strychnine » Phenothiazines (Thorazine, Stellazine, Compazine) » Tricyclic antidepressants » Iodides » Silver Nitrate
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
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
Inactivates Ipecac Do not give until vomiting stops Do not give with
– Cyanide – Methanol – Tylenol (+)
Containers must be kept airtight
Inhaled Poisons
Objective: Move to fresh air; optimize ventilation and protect personnel from exposure
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
Use soap, shampoo for hydrocarbons No need for chemical neutralization - heat produced by reaction could be harmful
Eye Irrigation
Wash for 15 minutes Use only water or balanced salt solutions Remove contact lenses Wash from medial to lateral