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POISONING 2004

POISONING 2004. Kent R. Olson, MD, FACEP Medical Director, SF Division California Poison Control System. Case 1: Metabolic Acidosis. 20 year old woman found in her parked car, comatose (GCS 8) 3 empty bottles of Tylenol BP 100/50 HR 140-160 RR 38 Na 150 K 3.5 Cl 124 HCO3 6

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POISONING 2004

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  1. POISONING 2004 Kent R. Olson, MD, FACEP Medical Director, SF Division California Poison Control System

  2. Case 1: Metabolic Acidosis • 20 year old woman found in her parked car, comatose (GCS 8) • 3 empty bottles of Tylenol • BP 100/50 HR 140-160 RR 38 • Na 150 K 3.5 Cl 124 HCO3 6 • pH 6.98 pCO2 12 pO2 198

  3. “MUDPILES” • Methanol • Uremia • DKA • Phenformin, Paraldehyde • INH • Lactate • Ethylene glycol, Ethanol • Salicylate

  4. Lactic Acidosis • Many possible causes: • Hypoxia-ischemia • Cyanide poisoning • Carbon monoxide poisoning • Metformin • INH . . . and many others • Order a serum lactate level

  5. “SALAD” • Gives you a quick “what to order”: • Salicylate (order a stat [ASA]) • Alcohols (toxic alcohols – order Osm) • Lactate (order a state [Lactate]) • Anuria (BUN, Cr) • DKA (check glucose)

  6. If the [Lactate] = normal • Then, you have fewer things to consider, e.g.: • Toxic alcohols • Methanol = formic acidosis • Ethylene glycol = glycolic acidosis • Ketoacidosis • Mostly beta-hydroxybutyrate

  7. Case, continued . . . • Salicylate negative • BUN/Cr = 5/1.1 • Glucose 400 mg/dL • Lactate 18 mmol/L • COHgb not detected • Osmolality not sent

  8. “MUDPILES” • Methanol • Uremia • DKA • Phenformin, Paraldehyde • INH • Lactate • Ethylene glycol, Ethanol • Salicylate

  9. What was it? • Serum acetaminophen = 917 mg/L !! • She was treated with NAC, IV NaHCO3 (repeat pH 7.29), insulin • Next day AST, ALT began to rise • Peak measured ALT 5318 • Bili to 2.8, INR 3.1

  10. Acetaminophen overdose • Acidosis, coma uncommon without fulminant liver failure as prior cause • Occasional cases of early coma, severe acidosis with very high drug levels - despite absent liver failure

  11. Mnemonics . . just remember: “Today’s clinical pearl may end up as tomorrow’s fecalith.” . . .John Wallace, MD c.1979

  12. Serum acetaminophen (APAP) levels after ingestion of “Tylenol Extended Relief” Serum APAP level APAP (mg/L) Probably Toxic Possibly Toxic hrs Note: co-ingestion of Nyquil plus up to 44 g Tylenol ER Ref: Bizovi K et al: J Toxicol Clin Toxicol 1995; 33:510

  13. New drug: Acetadote™ • IV formulation of N-acetylcysteine • FDA approved January 2004 • Not yet on the market • Dose? The UK-European protocol: • 150 mg/kg in 200 mL D5W over 15 min + • 50 mg/kg in 500 mL D5W over 4 hours + • 100 mg/kg in 1 L, over 16 hrs

  14. Duration of NAC treatment? • Current US oral NAC protocol = 72 hr • Acetadote IV = 20 hr • Onset of rising AST, ALT ~ 24-30 hr • We recommend Rx (or at least observation) until ~36 hrs after the ingestion to r/o liver damage

  15. Case 2: Little Blue Lady • 80 year old woman just returned from transeophageal echocardiogram • Perioral cyanosis and blue nail beds • Otherwise asymptomatic • Pulse oximetry 87% - did not improve with high-flow oxygen

  16. Arterial blood gases: • pH = 7.43 • pCO2 = 36 • pO2 = 266

  17. Methemoglobinemia • Fe2+ in heme is oxidized to Fe3+ • Unable to carry oxygen • Many causes: (oxidants) • Benzocaine spray (in Hurricaine™) • Dapsone • Phenazopyridine • Nitrites (eg, amyl nitrite)

  18. Another crappy hemoglobin • 67 year old man found unresponsive and covered with vomitus • Barbeque was heating the trailer • COHgb 33% • Intubated, hypotensive on Levophed • Candidate for HBO?

  19. Carbon monoxide poisoning

  20. CO poisoning, continued . . . • Can cause coma, seizures, death • Survivors may have varying degrees of neurological sequelae • Persistent coma, vegetative state, etc • Subtle mood and memory disorders • Incidence up to 30-40%

  21. Controversy over treatment • Hyperbaric oxygen (2.5 ATM) versus • Normobaric oxygen ?

  22. Literature is inconclusive • Most reports are uncontrolled case series • Only two RCTs • Australian study: no difference • Weaver study: small benefit with HBO

  23. Weaver recommends HBO if: • COHgb > 25% • History of loss of consciousness • Metabolic acidosis • Age > 50 years • Cerebellar findings on neuro exam

  24. Another CO case: • 55 year old man found unconscious on his yacht • He had gone downstairs 10 min earlier to check on a burning odor • Pulled out to fresh air, awake in 10 minutes • In ER 2.5 hrs later, COHgb 14.4%alert and normal neuro exam

  25. Child with a Seizure • 14 month old boy had a seizure at home. No prior Hx of seizures. • Had been playing with Effexor bottle • Second seizure on arrival in ER • BP 138/87 HR 150 RR 28 T nl • Pupils dilated

  26. Common causes of seizures • Tricyclic antidepressants • Newer antidepressants (SSRIs) • especially bupropion (Wellbutrin™) • Amphetamines/cocaine • INH • Diphenhydramine • Tramadol (Ultram™)

  27. Toxicology screen showed: • Positive for methamphetamine • Not tested for venlafaxine (Effexor™) • Potential false (+) for amphetamines: • Ephedrine, MDMA, pseudoephedrine, etc • Bupropion, Labetalol, Ranitidine, Sertraline, Selegiline, Trazodone,others . . .

  28. Final case: • 22 year old man ingested 60 lithium tablets (300 mg) • Asymptomatic 1 hour later in ER • How to decontaminate the stomach?

  29. Gut decontamination • Goal: limit systemic absorption • Possible methods: • Induced emesis • Gastric lavage • Activated charcoal • Cathartics/whole bowel irrigation

  30. Induced emesis • Don’t use: • Salt water • Finger gag • Ipecac? • Soapy water?

  31. Ipecac syrup • Easy to perform, but • NOT very effective • Risks: • Pulmonary aspiration • Wretching, GI injury • Delay in administering charcoal • Bottom line: OUTDATED

  32. “Pumping the stomach” • NOT very effective • Risks: • Aspiration • GI trauma • Delay to administering AC • Bottom line: RARELY used

  33. Activated charcoal • Finely divided powder • Huge surface area • Drugs and poisons areadsorbed to surface • Does NOT bind: • Iron • Lithium

  34. Activated charcoal . . . • More effective than ipecac, lavage • First choice for most drugs & poisons

  35. Whole Bowel Irrigation • Mechanical flush • GoLytely or COLYTE • Balanced salt solution • Nonabsorbable PEG • No net fluid loss or gain • Good for: • Lithium, iron, foreign bodies

  36. 1-800-222-1222 • New national toll-free hotline # • Dial from anywhere in the USA • Connects to regional poison center • 24-hr consultation • PharmDs with physician back-up

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