Toxicologic Emergencies Erin Moorcones, RN, MSN - PowerPoint Presentation

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Toxicologic Emergencies

Erin Moorcones, RN, MSN

Sharon Brown, RN

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Toxicologic emergencies include acute poisonings and intake of drugs/alcohol.

92% of these emergencies occurred in the home according to the American Association of Poison control in 2004.

* 51.3% in children <6, and 38% in children <3

* 94% of toxic exposures were acute and 84% unintentional.

* Therapeutic medication errors were 10% of all poisonings.

In 2004. 1.3 millions ER visits were associated w/ drug ingestion.

Always consider organic causes.

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General Strategy

HPI- information regarding ingestion, route of exposure, reason for exposure, efforts to treat

PMH- diseases, trauma, SA history, pysch history, support network, environmental,

RF- family history, gateway substance use, peer influence, pysch disorders.

Physical exam- general appearance, inspection auscultation, palpation.

Diagnostic- Labs, imaging

Treatment/evaluation

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Interventions to prevent of decrease absorption of drugs or chemicals

Irrigation-

-remove all clothing, flush surfaces with saline.

- indicated= organophosphate, gasoline, acids

- alkali solutions require longer irrigation

Ipecac- contraindicated in drugs causing CNS depression

Gastric lavage- best if initiated w/I 60 minutes.

- potential for aspiration, caution w/ ingestion of caustic substances

Cathartic administration- Mg sulfate, mag citrate. Must have bowel sounds

Activated charcoal- used to absorb ingested chemicals

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Pediatric considerations

Growth & development-

* dec renal clearance in children <6m, has effect on half-life and duration on drugs

* infants have fewer binding sites for drugs, leading to > chance of toxic effects

* lower glycogen stores place child at risk for hypoglycemia

PEARLS

* most poisonings occur in children <6yrs old in home

*Munchausen by proxy must be considered

* very young children less likely to develop hepatotoxicity w/ Tylenol overdose

* adolescents higher risk for recreational abuse

* suicide attempts are infrequently intended to result in death

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Geriatric considerations

Aging related

* high risk for therapeutic med errors due to large number of medications prescribed

*decreased renal clearance= toxicity

* slowed metabolism of meds leads to > chance of toxicity

PEARLS

* consider salicylism poison in older adults

*eliminate mental illness, SA, or depression

* older adults forget meds or take extra

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ALCOHOL

Most common drug used in U.S.

Involved in 70% of overdoses in ED

Affects all SES, male/female.

It is metabolized in the liver and affects all body systems (CNS, GI, & CV)

May be used in conjunction with other drugs

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Important Assessment information

PMH-Hx of problems related to drinking, concurrent medication use, and presenting symptoms.

General Assessment- may he hypo/hyperthermic

* monitor gait, LOC, inspect for injuries.

Diagnostic- labs, Xray, CT scans

Planning/treatment-

ABC’s

monitor airway, treat injuries, referrals, minimize fall risk, seizure precautions

Evaluation- airway, LOC< VS

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Alcohol, cont.

ETOH Seizures

Shorter duration than grand mal

Vitamin and Electrolyte deficits

Decreased Mg = decreased seizure threshold, decreased thiamine – must replace thiamine before glucose

TX – ABC’s, IVF. Body will absorb approx 0.02/hr.

Charcoal will not absorb ETOH

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Alcohol, cont.

Alcohol withdrawal syndrome

Occurs in heavy drinkers that abruptly stop

Can begin within 8 hours of last drink

S/S – elevated HR, diaphoresis, fever, tremors, anxiety, hallucinations

TX – ABC’s, IVF, Banana Bag (Thiamine, MVI, Mg, folic acid, K), Ativan, Valium, Librium

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Delirium Tremens (DT’s)

Begins 48-72 hours after last drink

Peaks at 4 days after

Acute, life threatening emergency

Can last 2-3 days

S/S- HTN, increased HR, tremors, hallucinations

Social services needs to be involved

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Opiate Use-

Substances derived from opium poppy, most prescribed for severe pain

Morphine, heroin, hydrocodone, oxycodone, ultram, fentanyl.

They interfere with a patients perception of pain, produce brief euphoria followed by pleasant dream state

Death occurs from the side effects of the drugs

Common for poly drug use

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Opiate assessment

Information- substance ingested, freq of use, PMH (HIV, hepatitis)

Physical exam-

general- what would you see

pupils would be? What other things would you find on inspection? Classic Triad – Pinpoint puplis, decreased RR, coma

auscultation- crackles

Diagnostic- urine tox, CBC, CXR

Treatment- Narcan – slowly!

Evaluation- airway, VS, LOC

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Cocaine use

Cocaine use, very popular.

Cocaine can be snorted, smoked, or injected

Cocaine stimulates CNS and ANS system to increase the release of catecholamines from the adrenergic nerve terminals. It blocks reuptake of dopamine/norepinephrine.

Causes- euphoria, increased motor activity, insomnia

Treatment aimed at supportive measures.

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Cocaine assessment tips

Important to assess route ingested

PMH- meds, diseases,

Assessment- monitor for seizures, hypertension, tachycardia, hyperthermia.

* may have perforated nasal septum

Diagnostic- labs, head CT, EKG

Treatment- O2, IV, Meds ( haldol)

Dilated pupils are hallmark sign

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Amphetamines

Synthetic sympathomimetics that stimulate the CNS and produce feeling of “energy”.

May see “body packers” in ED.

Can be prescribed for weight loss, ADD, mood

Commonly present with heart racing, feeling sad they are being touch by ants

Decrease risk for violence

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Drugs and key points

Lysergic Acid Diethylamide Use- (LSD

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- causes changes in thoughts, mood, perception, and consciousness. Hallucinogenic effect lasts 6-12 hrs and may include visual illusions, alteration in sound and color.

- absorb through the skin. It is colorless/odorless

- no withdrawal, no physical dependence

Phencyclidine Use (PCP)-

dissociative anesthetic that decreases awareness of surroundings. Similar properties to ketamine.

- affects CNS system causing stimulation/depression or cholinergic effects

- common names “angel dust”, Cadillac, CJ, killer weed

- complications- rhabdomyolysis, renal failure, cerebral hem

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Gamma-Hydroxybutyrate (GHB)- used to be anesthetic.

- GHB used as – diet aid, muscle building agent, date rape drug, sexual enhancer

- regulated schedule 1 CS

- side effects- sedation, amnesia, resp depression, LOC

Inhalants-

vapors from volatile substances, cheap high. Produce a floating or numbing sensation and euphoria. They are readily absorbed into blood stream and cross BBB, reaching brain in high concentrations.

- LTE- neurologic, renal, cardiac

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Carbon Monoxide Poisoning

CO is colorless, odorless, tasteless gas that binds to Hgb to form COHb.

The combination decreases ability of blood to carry O2 leading to severe hypoxia.

Sources- exhaust system,. Smoke from wood fires, propane heaters, hibachi grills.

Length of exposure correlates with symptoms

S/S- HA, n/v, CP, cherry red skin, possible ischemia noted on EKG

Treatment- 100% o2, possible hyperbaric

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Salicylate Poisoning

Salicylate use has decreased due to the attention from Reye’s syndrome.

The elderly are at risk for chronic toxicity due to dec renal function and use of aspirin for medical problems. This outs them at risk for development of ulcers, bleeding, metabolic acidosis.

Salicylate poisoning affects GI mucosa, coagulation, neuro system, and acid-base balance.

Peak serum levels are 6 hours after short-term ingestion(depending on pill ingested)

Toxic dose is 150-200mg/kg, and >500mg/kg is lethal

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Salicylate OD treatment

O2- hyperventilation if acidosis present

Large amt of fluids for renal clearance and hydration

Prevent absorption- gastric lavage, bowel irrigation

Meds- activated charcoal, NaBicarb, replace electrolytes (K)

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Acetaminophen Poisoning

Very common drug used in over the counter products, and in combination with narcotics.

Rapidly absorbed from GI tract, metabolized in liver

Toxicity produces delayed coagulopathies, hepatic necrosis, elevated LFT’s.

Children can metabolize better, and therefore affected less.

S/S- malaise, n/v (24-48hrs), later right upper quad pain, dec UO, jaundice, hypoglycemia, DIC

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Acetaminophen-

Diagnosis/treatment

Serum levels 4 hrs after ingestion, labs

Treatment-

* O2, IV, activated charcoal, Mucomyst (oral, GI tube, IV)

Serial levels must be obtained

Pysch evaluation

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Tricyclic Antidepressant Poisoning (TCA)

Extremely lethal due to narrow therapeutic index.

Produce cardiotoxic effects, CNS depression.

Absorbed in the GI tract and rapidly distributed.

Once absorbed bind to plasma proteins, and hard to remove.

Ex- Elavil, trazodone, nortriptyline

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TCA poisonings

S/S- LOC changes, hypotension, possible CA, cardiac dysrhythmia’s ( ST, PVC’s, SVT. VT), fine tremors. Wide QRS

Diagnostic- tox screen, labs, ECG, UA

Treatment- O2, IV, activated charcoal, benzo’s for SE, NaBicarb for QRS widening.

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Iron poisoning

Impt cause morbidity/mortality in children

Most cases unintentional ingestion by toddlers

Toxicity depends on the amount of elemental iron found in preparation

OD can produce GI hemorrhage and CV collapse

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Phases of Fe Toxicity

Phase 1- less than 6hrs post ingestion

- symptoms include vomiting, abdominal pain, bloody diarrhea, and lethargy

Phase 2- 6-12 hrs post ingestion

- “recovery phase”, may appear to improve

Phase 3- 12-48hr post ingestion

- CV collapse, shock, metabolic acidosis, GI bleeding, coagulopathy, hepatic injury, sepsis, coma

Phase 4- >48hrs

- if pt survives, intestinal strictures and obstructions may develop

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Treatment of Fe toxicity

Meds-

Desferal- binds to iron and increases renal excretion

NaBicarb to correct acidosis

Bowel irrigation

ALS

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Petroleum Distillate Poisoning

Include gasoline, kerosene, paint thinner, motor oil.

Spread over lung surfaces, causing chemical pneumonitis

Some have ability to produce systemic effects (dysrhythmias & seizures)

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Organophosphate Poisoning

s/s- diaphoresis, urination, lacrimation, salivation, diarrhea, seizures, tremors, miosis, tremors, weakness.

Found in insecticides, chemical weapons,.

Peds and elderly more at risk b/c of lower levels of cholinesterase

Treatment-

2-PAM, abx, benzo, atropine

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Organophosphate

MUDDLES

Miosis, Urination, Defecation, Diaphoresis, Lacrimation, Excitation, Salivation

SLUDGEM

Salivation, Lacrimation, Urination, Defecation, GI upset, Emesis, Miosis

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Digoxin Toxicity

Common drug in elderly to increase myocardial contractility

May result from OD, hypo-kalemia, advanced heart disease with conduction disturbances.

Very common because toxicity level is very close to therapeutic level.

S/S-disoriented, hypotension, photophobia, pupil mydriasis, abdominal tenderness, halos

Treatment- replace K/Mg, dilantin for dysrhythmia’s. avoid beta blockers, digibind

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Benzodiazepine

Effects are increased with consumption of alcohol

S/S – slurred speech, incoordination, drowsiness, lethargy

Antidote ~ Romazicon

May give charcoal

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Calcium Channel blocker

Toxic therapeutic margin is small. Children can be symptomatic with as little as one pill

Meds include Verapamil, Nifedipine, Cardizem

S/S – marked hypotension, bradycardia, irregular HR, SOB

Antidote ~ Calcium Chloride

Keep pacer at bedside

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Beta Blockers

“Olol’s”

Usually S/S are seen within 1-2 hours of ingestion, but as little as 20 minutes

Bradycardia, hypotension, hypoglycemia. EKG will show prolonged PR and wide QRS

Antidote ~ Glucagon!

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Cyanide Poisoning

Lethal poisoning. Can cause death within 2 minutes of inhalation

Found in industrial fumigants, insectisides, silver polish

Related to long term use of Nipride

Also found in pits of apricots, cherries, and peaches

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Cyanide

S/S – burning sensation in throat/mouth

Breath smells of bitter almonds

TX

Cyanide antidote kit

Includes methemoglobinemia and thiocynate

Control seizures with Ativan/Valium