1. Updates in Clinical Toxicology
Emerging Trends in
Emergency Medicine 2012-13

2. Introduction
• Welcome
• CGD – Toxicology 20-40 mins
• My Background
• Emergency Medicine
• 6 months as Toxicology Registrar in 2010
• Disclosures
• None to declare

4. Learning Objectives
• Aims and Learning Objectives
 Topics
 Emerging Therapies in Toxicology
 Emerging Illicit Drugs
 Updates in Toxinology
 Approach
 Case based approach
 Interactive session
 Discussion of emerging topics in Toxicology
* There is emerging evidence in the areas discussed
but an absence of Randomised Control Trials (RCTs)

5. Risk Assessment Based Approach to
Poisonings

6. Risk Assessment
• (1) Drug* taken, form, route and dose
▫ Defined Daily Dose
▫ Threshold for Toxicity
• (2) Time since the Ingestion
• (3) Progress and Clinical Features
• (4) Patient Specific Factors
▫ Age
▫ Weight
▫ Past Medical History
• Resources – CIAP, Toxinz, Handbooks, Poisons

7. Toxicology in Retrieval
• Common Secondary Transfer
• 3/50 for me
• Data from recent months….

8. - High Dose Insulin
- Intralipid Emulsion (ILE)
- Methylene Blue

9. Case 1
• Cassie
• 17 years old, no medical history
• From Parkes (rural NSW)
• Living with her parents and grandma
• After a fight with her mother at dinner she
stormed out stating ‘I hate you all’ – 1 hour later
she tells her mother she has taken ‘Gran’s pills’
• Mum tearfully calls an Ambulance and she is
brought to the local rural Emergency
Department with single weekend coverage

11. Parkes

13. Case 1 - Cassie
• On arrival in Emergency she states regret at taking
the tablets and wants to go home
• Risk assessment
▫ 2 hours ago she took 2 full blisters (24) of Verapamil
▫ The tablets were Slow release (240mg)
▫ She also took 7 Panadol (5oomg)
• Is this a concerning overdose?
• What do we expect to happen?

14. Progress
• Cassie initially has normal observations (BP 121/70)
• Activated Charcoal (50g) is given
• Routine bloods are taken from the patient
• On advice from poisons information IV fluids are
started and she is monitored.
• A discussion in regards to W.B.I. is undertaken and it
is decided against

15. Progress 2
• The patient is persuaded to stay in hospital
• After 4 hours of observation she feels light headed
and nauseous. She has had 20ml/kg of fluid
• Her blood pressure quickly drops to 70/40
(confirmed by manual readings)
• Her heart rate is now 45/min and despite further
fluids, IV calcium, atropine and glucagon she
develops evidence of cardiac failure…
• Now Retrieval Rescue 23 is tasked to get patient

16. High Dose Insulin Therapy
• High-dose insulin euglycemic therapy (HIET)
• High-dose insulin therapy with IV glucose
▫ Emerging as an effective treatment for severe
beta-blocker & calcium channel-blocker poisoning
• Animal data and case reports demonstrate that
high-dose insulin (1-10 U/kg/hour) is a superior
to standard treatment* in terms of safety and
survival in both beta-blocker and calcium-
channel blocker poisoning**.

17. Kearns et al – Free at http://emcrit.org/wp-content/uploads/ccb.pdf

20. Local Case Reports

22. Case 2
• John
• 79 year old
• Presenting to hospital following a fall on the
front porch of his house
• He was unable to get up afterwards and has an
obvious deformity of his right leg

24. Analgesia
• John receives Morphine and Paracetamol IV but still
has persistent pain
• The local locum places a femoral block using
Marcaine® (Bupivicaine) 20mls with a landmark
technique with aspiration every 5mls infiltrated
• A few moments later the patient becomes
unresponsive and CPR is started
• The patient’s rhythm is Asystole

25. Intralipid Emulsion (ILE)
• Intralipid is emerging as a first line therapy for
treating the cardiotoxic effects of Local
Anaesthetic toxicity and other
refractory emergencies
• First described in the 1990s
• Data emerging for LA and TCA from
▫ Human Case Series
▫ Animal Data

26. Intralipid
• Oil and Water Micro Emulsion
• Derived from Soya Bean
• pH 8.0
• How does it work?
▫ (1) Lipid Sink
 Redistribution**
▫ (2) Effects on channels
 Sodium Channels
 Calcium Channels
▫ (3) Metabolotropic

27. How to give…

28. Intralipid Emulsion (ILE)

29. Intralipid Emulsion (ILE)

31. Methylene Blue – EAPCCT Abstract

32. Summary
• Risk assessment is the mainstay of good
management of toxicological emergencies
• New therapies are emerging and awareness of
these is useful
• These new therapies should be used in the
context of advice from a toxicologist and
reserved in the main for refractory cases

33. - Quetiapine
- The Synthetic Cannabinoids

34. Case 3
• Richard is a 41 year old man
• History of Schizophrenia managed with “Seroquel®”
• Treated in the community

35. Case 3
• Richard presents to his GP in Warren (NSW)
stating he has taken extra tablets ‘to help him
sleep’ but is now worried he has taken too many!
• An ambulance is called after he reveals he has
taken 40 x 200mg tablets (a total of 8g) today
• On route he is tachycardic (120) and drowsy but
opens his eyes to speech and obeys commands
• Where is Warren?
• What is your risk assessment?

36. Warren

37. Risk Assessment
• (1) Drug* taken, form, route and dose
▫ Defined Daily Dose
▫ Threshold for Toxicity
• (2) Time since the Ingestion
• (3) Progress and Clinical Features
• (4) Patient Specific Factors
▫ Age
▫ Weight
▫ Past Medical History

38. On arrival at Warren Hospital

39. Quetiapine (Seroquel®)
Emerging as the number 1 toxicological cause of
ICU admission in Australia

40. Adverse Effects
• Tachycardia (common)
• Reduced Level of Consciousness (variable)
• Delirium (masked)
• Coma (dose dependent)
▫ Common in overdoses > 3 grams
• Respiratory Depression
• Hypotension
• ECG changes include prolonged QT
▫ Arrhythmias are described but are unusual

42. The ECG of Quetiapine overdose

43. ECG QT interval

46. Case 4
• Raymond is a 39 year old
• He doesn’t normally take drugs
• However he accepted the offer of trying a ‘new’
drug at a party
• After a short time Raymond became agitated and
appeared to be disorientated
• An ambulance was called and he arrives at your
ED being held down by police and paramedics

47. K2 Spice – Synthetic Drug
• Potent Cannabinoid
▫ Multiple Formulations
• Reports of Seizures and Psychosis at increased
rates compared to organic Marijuana
• Risk of seizures
• Risk assessment should predict a higher
likelihood of adverse outcomes and a longer
duration of observation in the ED
• Treatment is primarily supportive

48. K2 Spice

50. ‘New’ Drugs

51. ‘New’ Drugs

52. Summary

54. - Snake antivenom use - what has changed in recent years?
- Trends in Red-back spider antivenom use

55. Case 5
Jason - 13 years old
• Playing cricket
• While retrieving the ball stood on a ‘twig’
• He ran back to the field complaining of pain
• A few minutes later he collapsed and is taken to
hospital by ambulance
• On the way to hospital he develops epistaxis and
bleeding from the gums
• What is the most likely diagnosis?

56. Australian Snakes
 *Brown Snake (pictured) – A common snake,
can be aggressive Causes the most fatalities due
to Coagulopathy
 *Death Adder
 *Tiger Snake
 *(Red Bellied) Black Snake
 Mulga & Collett’s Snake
 *Taipan - reclusive hunter and therefore has
minimal contact with humans. Bites are
therefore uncommon. This snake having the
most potent venom (LD50) of all snakes
 *Sea Snake

57. Envenomation Summary
 COAGULOPATHY (VICC, AC) and MAHA
 LOCAL EFFECTS
 MYOTOXICITY
 RENAL FAILURE
 NEUROTOXICITY

58. Snake Bite - Updates
• Recent years have seen changes in recommendations:
▫ Antivenom
 Cross over
 Quantity
 Indications for antivenom
 Effectiveness of antivenom
 Use of the Snake VDK
▫ Snake Coagulopathy
 FFP and antivenom
▫ When to Discharge?

59. Antivenom Dosing

60. Antivenom – early 2000s

61. Antivenom Effectiveness

64. Discharge

65. Summary
• PIB
• PIB removal in a monitored setting
• VDK
• Antivenom use
• FFP

66. Case 5
• A young mother presents in distress after being
bitten by a spider in a shoe
• She has severe leg pain, nausea and has noticed
sweating on both legs as well as ‘goose-bumps’ at
the site of the bite
• Her confident husband identifies the spider as a
Redback and has brought the ‘specimen’ into
hospital (alive) in a glass jar

67. Spider Bite – Redback
• Common presentation
• Clinical Syndrome
▫ Pain +
▫ Sweating
▫ Piloerection

68. Redback
Spider Bite
Clinical Effects
Local and
Regional
NB – There
May be no
‘History’ of
Spider Bite
Systemic
Effects
Local Pain
Radiating Pain
Piloerection
Local Sweating
Nausea
Vomiting
Headaches
Lethargy
Remote Pain
Agitation
Hypertension
Neurological
Spider Bite – Redback

69. Redback Antivenom
• Historically there has been a low threshold for use
• Now Controversial

70. Redback Antivenom

71. IM Antivenom

73. Summary and Future Directions
• Provisional results of the FFP and RAVE II study
are imminently pending
• A single vial of antivenom is sufficient for the
treatment of snake envenomation
• Analgesia is the mainstay of treatment for
redback spider bite.

74. Other Emerging Topics
(Brief Discussion if Time)
• New Anticoagulants
• Decontamination and WBI
• Naloxone
• Sulphonyureas

75. Questions and Discussion