Toxidrome approach in emergency room
•
15 j'aime•4,102 vues
The presentation covers an easy method to manage acute poisoning in Ed. It elaborates the tox presentations through four toxidromes and an algorithmic approach to solve the puzzle
Recommandé
Contenu connexe
Tendances
Tendances (20)
Similaire à Toxidrome approach in emergency room
Similaire à Toxidrome approach in emergency room (20)
Plus de Dr.Venugopalan Poovathum Parambil
Plus de Dr.Venugopalan Poovathum Parambil (20)
Dernier
Dernier (20)
Toxidrome approach in emergency room
- 1. Toxidrome approach in Emergency room D V P P, D & L , A DM H : I L
- 2. ❏ Large number of Toxins ❏ Complex presentations of Overdoses ❏ Mimics of OD ❏ Diagnosis is nightmare in ED
- 3. Toxidrome ● Toxidrome (a portmanteau of toxic and syndrome) ● A syndrome caused by a dangerous level of toxins in the body ● The term was coined in 1970 by Mofenson and Greensher ● It is often the consequence of a drug overdose
- 4. Toxidrome ❏ A toxidrome may indicate a medical emergency ❏ Requiring treatment at a poison control center ❏ Aside from poisoning, a systemic infection may also lead to a toxidrome
- 5. Toxins Overdoses in emergency departments Patient presentations SignsSymptoms Toxidromes 1 32 4 ToxinsToxins
- 6. Major Toxidrome 1. Anticholinergics 2. Sympathomimetics / Withdrawal 3. Opiate / Sedative 4. Cholinergic / Anticholinesterase a.
- 7. 1 . Anticholinergics Interfere with binding of Ach with Muscarinic receptors
- 9. Anticholinergic Toxidrome ❏ Hyperthermia ❏ Dilated pupils (mydriasis) ❏ Dry skin ❏ Vasodilation causing flushed skin ❏ Agitation / Hallucinations ❏ Tachycardia and possibly dysrhythmias
- 10. Anticholinergics agents ❏ Tricyclic antidepressants ❏ Atropine ❏ Antihistamines ❏ Antipsychotics ❏ Antispasmodics ❏ Carbamazepine ❏ Jimson seed
- 11. Memory tips
- 12. Treatment for Overdose : Pre- Hospital ❏ Focus on Safe & Rapid transport ❏ Oxygen administration ❏ Cardiac monitoring ❏ Staying alert for complications such as vomiting, seizures or violent behaviour
- 13. Treatment for Overdose : In-Hospital ❏ Supportive measures in most cases ❏ Rarely used option is the administration of antidote drug ❏ Physostigmine, a short-acting cholinesterase inhibitor
- 14. 2.Sympathomimetics ❏ Mimics the sympathetic nervous system effects ❏ Alcohol and Drug withdrawals are also present with similar toxidrome features ❏ They are grouped together
- 15. Sympathomimetic Toxidrome ❏ Tachycardia, ❏ Dysrhythmias ❏ Hypertension ❏ Diaphoresis ❏ Goosebumps ❏ Delusions ❏ Paranoia, ❏ Seizures ❏ Increased temperature ❏ Dilated pupils
- 16. Sympathomimetic agents ❏ Ecstasy ❏ Amphetamine ❏ Theophylline ❏ Caffeine ❏ Cocaine EAT C&C
- 17. Treatment for Overdose : Pre- Hospital ❏ Focus on Safe & Rapid transport ❏ Oxygen administration ❏ Cardiac monitoring ❏ Staying alert for complications such as vomiting, seizures or violent behaviour
- 18. Treatment for Overdose : In - Hospital ❏ Supportive care ❏ Administration of Benzodiazepine to Calm agitated patients
- 20. 3. Opioids ❏ Mu Receptor agonists ❏ Morphin ❏ Pethidine ❏ Fentanyl ❏ Codeine ❏ Methadone ❏ Hydromorphone ❏ Propoxyphene Partial Agonists ❏ Buprenorphine ❏ Pentazocine
- 21. Opioids ❏ Analgesia ❏ Nausea ❏ Vomiting ❏ Sedation ❏ Euphoria ❏ Dizziness CNS ❏ Decreased motility ❏ Decreased pyloric tone ❏ Inhibition of intestinal contraction ❏ Increased absorption of fluid and electrolyte ❏ Increased Anal sphincter tone ENS
- 22. Opioid OD : Toxidrome CPR -3H C-Coma P-Pinpoint Pupil R- Respiratory Depression H-Hypotension H-Hypothermia H-Hyporeflexia
- 23. Opioid OD Always consider an opiate overdose when assessing elderly patients with altered LOC who have been prescribed an opiate for pain control - Increasing pain or confusion can cause accidental overdoses
- 24. Treatment in Opioid OD : Pre- Hospital ❏ Pre-hospital - focus on supporting the ABC’s ❏ Suctioning ❏ Placement of an airway adjunct ❏ Supported ventilations with a BVM
- 25. Treatment in Opioid OD : Pre- Hospital ❏ Even if the patient can be roused, monitor the respiratory effort carefully ❏ Sometimes patients need to be told to ‘take a few deep breaths’ to maintain adequate ventilations
- 26. Sedation exhibited by opiate overdose patients are often due to a combined effect of the drug itself, as well as high carbon dioxide levels
- 27. Treatment in Opioid OD : Pre- Hospital
- 28. Opioid OD - Treatment : In-Hospital ❏ Support ABC ❏ Administration of Naloxone ❏ Always use with caution “It can very quickly go from having an easily managed and sedate patient, to a combative individual in full withdrawal” A Airway & Antidote
- 29. Antidote Naloxone ❏ Start with 0.04mg ❏ Titrate up q 2-3 min as need for ventilation to 0.5 mg, 2mg, 5 mg up to max 10-15 mg
- 31. 4. Cholinergics Elevated levels of acetylcholine 1. Direct ‘cholinergic’ effects 2. Inhibiting the enzyme responsible for the breakdown of acetylcholine (cholinesterase)
- 32. Cholinergics
- 33. Chloninergic Toxidromes ❏ Diaphoresis, Diarrhea, Decreased BP ❏ Urination ❏ Miosis ❏ Bronchorrhea, Bronchospasm,Bradycardia ❏ Emesis, Excitation of skeletal muscles ❏ Lacrimation (tearing) ❏ Salivation, Seizures DUMBBELLS
- 34. Chloninergic Toxidromes ❏ Salivation ❏ Lacrimation ❏ Urination ❏ Defecation ❏ GI Stress ❏ Emesis SLUDGE
- 35. Cholinergics Cholinergic ❏ Nicotine ❏ Mushrooms Anticholinesterase ❏ Organophosphate insecticides ❏ Nerve gas (sarin)
- 36. Cholinergics
- 37. Treatment of Overdose Pre-hospital care ❏ Focuses on the ABC’s ❏ Vigorous monitoring ❏ Be prepared for seizures
- 38. Treatment of overdose In-hospital ❏ Advanced life support ❏ Atropine, an anticholinergic ❏ Antidote - Pralidoxime Triple A
- 39. Diagnosis of poisoning ❖ Ask patient or relatives/friends what drugs or poison have been taken (not always accurate) ❖ Self-poisoning ❏ Under the influence of alcohol ❏ May not know which tablets he/she took ❏ Check any bottles or packets for the names and quantities of drugs/poisons that were available
- 40. Diagnosis of poisoning ❏ Unconscious or severely poisoned, look in hospital notes for details of previous overdosed ❏ Record the time of ingestion of the drug or poison ❏ Examine the patient all over for signs of poisoning, injection marks or self-injury ❏ Mimicking poisoning (eg head injury, meningitis) ❏ Traditional Chinese medicines or herbs or Ayurvedic medicines can cause significant toxicity
- 41. Toxidrome : Features suggesting a particular poisoning 1. Coma 2. Dilated pupils 3. Divergent squint 4. Tachycardia 5. Increase muscle tone 6. Increase reflexes 7. Extensor plantars TCA Orphenadrine
- 42. Toxidrome : Features suggesting a particular poisoning 1. Coma 2. Hypotension 3. Respiratory depression 4. Decrease muscle tone Barbiturate Clomethiazole Benzodiazepines Alcohol Severe TCA OD
- 43. Toxidrome : Features suggesting a particular poisoning ❏ Coma ❏ Slow respiration ❏ Pinpoint pupils Opioid
- 44. Toxidrome : Features suggesting a particular poisoning ❏ Tinnitus ❏ Deafness ❏ Hyperventilation ❏ Sweating ❏ Nausea ❏ Tachycardia Salicylate OD
- 45. Toxidrome : Features suggesting a particular poisoning 1. Agitation 2. Tremor 3. Dilated pupils 4. Tachycardia ❏ Amphetamines ❏ Ecstasy ❏ Cocaine ❏ Sympathomimetics ❏ Tricyclic antidepressants ❏ Selective serotonin reuptake inhibitors
- 46. Assessment & Monitoring ❏ Assess and record conscious level ❏ Observe frequently ❏ Check blood glucose in patients with confusion, coma or fiits ❏ Monitor breathing and record respiratory rate ❏ Use a pulse oximeter ➢ SpO 2 may be misleadingly high in carbon monoxide (CO)poisoning
- 47. Assessment & Monitoring 1. Check ABG if patient is deeply unconscious or breathing abnormally 2. Record and monitor the ECG ➢ Unconscious ➢ Tachy- or bradycardia ➢ Taken drugs or poisons with risk of arrhythmias. 3. Record BP and temperature 290 × 443
- 48. Investigations Most useful tests ❏ Paracetamol ❏ Salicylate levels ❏ Blood glucose ❏ ABG ❏ Urea ❏ Electrolytes Record the time of the sample on the Bottle, and in the Notes
- 49. Investigations ❏ Measure paracetamol if there is any possibility of paracetamol poisoning (this includes all unconscious patients) ❏ Record the time of the sample on the bottle, and in the notes ❏ Many labs can measure salicylate, iron and lithium and also check for paraquat if necessary
- 50. ➢ ➢ Comprehensive drug screening is rarely needed and is only available in specialist centres
- 52. Toxidrome-oriented physical exam: ❏ Vital signs: temperature, heart rate, blood pressure, respiratory rate ❏ Neurologic: level of consciousness, pupils, motor response ❏ Skin moisture: check in patient’s axillae ❏ Lung sounds ❏ Bowel sounds Work-up consider ❏ Bedside glucose Lytes (anion gap) ❏ Serum osm ❏ CK ❏ Acetaminophen ❏ Salicylate ❏ Urine pregnancy ❏ ECG ❏ Tox screen Tachycardia +/- Hypertension Bradycardia +/- Hypotension ❏ Agitated ❏ Behavior ❏ Delirium ❏ Mydriasis ❏ Increased temp Nicot inic ❏ Muscle cramps Tachycardia ❏ Weakness ❏ Twitching ❏ Fasciculations
- 53. ❏ Agitated ❏ Behavior ❏ Delirium ❏ Mydriasis ❏ Increased temp ➢ Dry skin ➢ Decreased bowel sound ➢ Sweaty ➢ Hyperactive bowel Anticholinergic ❏ Anti-H1 ❏ TCA ❏ Anti- psychotics Sympathomimetic ❏ Cocaine ❏ Amphetamines ❏ PCP ❏ Ephedrine
- 54. Bradycardia +/- Hypotension Altered mental status, +/- resp depression Cholinergic ❏ Diarrhea ❏ Urination ❏ Miosis ❏ Bronchorrhea ❏ Bradycardia ❏ Emesis ❏ Lacrimation ❏ Salivation ❏ Sweating Pesticides: ❏ Organophos ❏ Carbamates Beta blocker Calcium channel blocker Hypoglycemia Hyperglycemia
- 55. Altered mental status, +/- resp depression Normal Pupil ❏ Opioid ❏ Clonidine Sedative- Hypnotic -ETOH -Benzos If anion gap, Toxic alcohol Pinpoint Pupil ❏ Vision changes ❏ N/V ❏ Abnormal ECG Digoxin Foxglove Oleander
- 56. Exposure Evaluation A-B-C-D &“D” ❏ Decontamination ❏ Data ❏ Documentation ❏ Dialysis Foleys Gastric Lavage Antidote ❏ Airway ❏ Breathing ❏ Circulation ❏ Disabilty