o|son|ngs and Cverdose

Ian|ce L. 2|mmerman, M.D.

We||| Corne|| Med|ca| Co||ege
1he Method|st nosp|ta|
nouston, 1exas
D|sc|osure
I have no con|ct of |nterest |n re|anon
to th|s presentanon.
Severa| o-|abe| uses of drugs w||| be
mennoned.
Cb[ecnves
Descr|be phys|ca| and |aboratory hnd|ngs |n
panents w|th |ntox|canon
Cut||ne resusc|tanon and stab|||zanon
measures
D|scuss |ntervennons to decrease tox|n
absorpnon and |ncrease e||m|nanon
L|st |ntervennons and anndotes for se|ected
tox|ns
Management of Drug Cverdose
kesusc|tanon and stab|||zanon
D|agnos|s
1ox|n e||m|nanon
Anndote and]or spec|hc |ntervennons
Suppornve care
D|agnos|s
n|story
Substance and quannty
1|me of |ngesnon
Susta|ned-re|ease or regu|ar
Acute or chron|c
hys|ca| exam|nanon
V|ta| s|gns
Neuro|og|c hnd|ngs

V|ta| S|gns C|ues
-8 0 8
neart kate
8|ood ressure
1emp
ke|anve Change
Amphetam|nes]coca|ne
Anncho||nerg|cs
Sympathom|mencs
Narconcs
Annhypertens|ves
Sedanve]hypnoncs
Increas|ng Decreas|ng
Gastro|ntesnna| Decontam|nanon
Ipecac - |nduced emes|s
Catharncs
Gastr|c |avage
Who|e bowe| |rr|ganon
Acnvated charcoa|
Acnvated Charcoa|
Dose: 1 g]kg
Most eecnve w|th|n 1-2 h of |ngesnon
May need nasogastr|c tube
Not eecnve for:
Iron Cyan|de
L|th|um nydrocarbons
A|coho|s Ac|d]A|ka||s
L||m|nanon of 1ox|ns
Mu|np|e doses of charcoa|
8arb|turates, theophy|||ne, carbamazep|ne,
dapsone, qu|n|ne
Iorced d|ures|s
A|ka||ne d|ures|s (ur|ne pn>7)
Sa||cy|ates, barb|turates, pr|m|done
nemod|a|ys|s]hemoperfus|on
Connnuous d|a|ys|s techn|ques
1. Wh|ch one of the fo||ow|ng agents |s most
||ke|y to resu|t |n death |n a po|soned panent?

A. Methamphetam|ne
8. I|uoxenne
C. Lthano|
D. Acetam|nophen
L. Metopro|o|
Deaths from o|son|ng (2011)
Sedanve]hypnoncs]annpsychoncs 401
Acetam|nophen a|one (162) +
comb|nanons (183) 34S
Card|ovascu|ar drugs 30S
Cp|o|ds 249
Anndepressants 229
Snmu|ants]street drugs 169
A|coho|s 147
Annconvu|sants 88
!!"#$%&'()% +,- (' ./0 ,/)% 1$2)3$/ 45647859:66
Acetam|nophen
A|ways cons|der as a poss|b|e co|ngestant
Un|ntennona| overdose occurs |n S0-61 of
||ver fa||ure cases
2S-33 of un|ntennona| overdoses take >1
acetam|nophen product
Max|mum da||y dose of 3 g ohen exceeded
k|sk factors: chron|c a|coho||sm, ma|nutr|non,
drugs |nduc|ng C4S0
Acetam|nophen roducts
1y|eno| arthr|ns 6S0 mg
1y|eno| extra-strength S00 mg
M|do| S00 mg
Sudafed S|nus 32S mg
V|cod|n LS 7S0 mg
V|cod|n]Lortab S00 mg
Darvocet-N100 6S0 mg
Norco]U|tracet 32S mg
Acetam|nophen (AA)
Charcoa| |s eecnve |f g|ven ear|y
Assess AA |eve| !4 h aher |ngesnon
Use kumack-Mauhew nomogram to
determ|ne tox|c|ty on|y |n &)%;/( .3<'(
|ngesnons
Assess transam|nases for mu|np|e or
chron|c |ngesnons
kumack-Mauhew Nomogram
Acetam|nophen
Anndote: ora| or IV N-acety|cyste|ne
Most eecnve w|th|n 8 h
Used up to 24 h aher |ngesnon
Chron|c, mu|np|e or |ate |ngesnons
Abnorma| transam|nases (>S0 IU]L)
AA |eve| >10 g]mL (10 mo|]L)
nepanc fa||ure present
2. Wh|ch of the fo||ow|ng agents resu|ts
|n an osmo|ar gap and norma| an|on
gap?


A.Methano|
8. L|th|um
C.Lthy|ene g|yco|
D.Lthy|ene g|yco| and ethano|
L. Iron
Metabo||c Ac|dos|s |n 1ox|co|ogy
Lthy|ene g|yco|
Methano|
Sa||cy|ates
Acetam|nophen
Iron
Carbon monox|de
Cyan|de
Va|pro|c ac|d
ropofo|
ropy|ene g|yco|
Lthy|ene G|yco| and Methano|
C||n|ca| hnd|ngs - CNS, GI,
card|opu|monary symptoms
Metabo||c hnd|ngs
An|on gap metabo||c ac|dos|s
Csmo|ar gap
C|ues
Cxa|ate crysta|s
V|sua| d|sturbances
www.||brary.med.utah.edu
Metabo||sm of A|coho|s
Lthy|ene g|yco|
G|ycoa|dehyde
Iorma|dehyde
Iorm|c ac|d
G|yco||c ac|d
G|yoxy||c ac|d
Methano|
+/3$=$/ >(=?>#$;(%.&(
Cxa||c ac|d
Lthano|
Lthy|ene G|yco| and Methano|
Inh|b|non of a|coho| metabo||sm
Lthano| (ora| or IV)
Iomep|zo|e
nemod|a|ys|s to remove a|coho| and
metabo||tes
Leve| >2S mg]dL
Metabo||c ac|dos|s
kena| fa||ure
V|sua| symptoms

Lthy|ene G|yco| and Methano|
Cther therapy
Io||n|c ac|d (methano| tox|c|ty)
1h|am|ne
Io|ate
G|ucose
8|carbonate
ropy|ene G|yco| 1ox|c|ty
Most common|y occurs w|th |orazepam
use for >3 dys
Increased an|on gap and osmo|ar gap
CNS depress|on or ag|tanon
kena| dysfuncnon
Se|zures
Arrhythm|as
nemo|ys|s
ropy|ene G|yco| 1ox|c|ty
Stop |orazepam or other drug
Sedate w|th another agent
M|dazo|am
ropofo|
Ientany|
nemod|a|ys|s usua||y not requ|red
8enzod|azep|nes
A|prazo|am common, ? more tox|c
Anndote = umazen||
Not a subsntute for |ntubanon
kesedanon concerns
Contra|nd|canons
Cyc||c anndepressants
Chron|c benzod|azep|ne use
8radycard|a |n 1ox|co|ogy
8arb|turates
"-8|ockers
Ca|c|um channe|
b|ockers
C|on|d|ne
Cho||nerg|c drugs
(pyr|dosngm|ne)
D|gox|n
"-hydroxybutyrate
Crganophosphates]
carbamates
Sedanve]hypnoncs
"-8|ockers]Ca|c|um Channe|
8|ockers
G|ucagon
Ca|c|um (ch|or|de or g|uconate)
Ventr|cu|ar pac|ng
Atrop|ne, dopam|ne, ep|nephr|ne
Insu||n eug|ycem|a (|nsu||n 0.1-10 U]kg]h +
g|ucose 10-7S g]h)
M||r|none
L|p|d emu|s|on
L|p|d Lmu|s|on as Anndote
otenna| for use w|th ||poph|||c
card|otox|c med|canons
Used w|th |oca| anesthenc-|nduced
arrest
Most|y an|ma| stud|es]case reports
Cyc||c anndepressants, verapam||,
proprano|o|, ateno|o|, ha|oper|do|,
organophosphates
Coca|ne CV 1ox|c|ty
Dysrhythm|as
S|nus tachycard|a
Ventr|cu|ar hbr|||anon]
tachycard|a
nypertens|on
Aornc d|ssecnon
Acute coronary syndromes
Day 1
Day 3
Acute Coronary Syndromes
Asp|r|n
N|trog|ycer|n
8enzod|azep|nes
hento|am|ne
"-8|ockers (|n absence of acute
sympathom|menc hnd|ngs)
keperfus|on
Cther Coca|ne 1ox|c|nes
u|monary edema, bronchospasm,
a|veo|ar hemorrhage
Levam|so|e contam|nanon
Intesnna| |schem|a]|nfarcnon
kena| fa||ure
khabdomyo|ys|s
nypertherm|a
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Coca|ne
No spec|hc anndote
Ag|tanon
8enzod|azep|nes
sychos|s
na|oper|do|
1reat spec|hc comp||canons
Amphetam|nes and
Methamphetam|nes
koutes - |nha|anon,
snornng, IV, ora|
Comp||canons
Myocard|a| |schem|a
Arrhythm|as
Card|omyopathy
Intracran|a| b|eed
khabdomyo|ys|s
Amphetam|nes and
Methamphetam|nes
Gastr|c empty|ng not he|pfu|
Charcoa| has ||m|ted ro|e
8enzod|azep|nes for ag|tanon
Suppornve care
Annc|pate comp||canons
8ath Sa|ts
Mephedrone, MDV (methy|ened|oxy-
pyrova|erone), pyrova|erone
Snmu|ant and ha||uc|nogen
Snorted, |n[ected, |nha|ed
Sympathom|menc eects, parano|a,
aggress|ve behav|or
Se|zures, rhabdomyo|ys|s, rena|
fa||ure, stroke, hypertherm|a
Sedanon w|th |orazepam, suppornve care
www.freeads48.com
Synthenc Mar|[uanas]Cannab|no|ds
8|nd to C8 receptors |n bra|n]sp|na| cord
So|d as k2 and Sp|ce |n 2000s |n Germany
Sp|ce re|eased by "1he syche De||" |n
London
Not detected |n ur|ne drug screens
www.|ega|buds.com
C||n|ca| Lects
CNS: se|zures, ag|tanon, parano|a
CV: tachycard|a, hypertens|on, |schem|a
Autonom|c: fever, mydr|as|s
Metabo||c: hypoka|em|a, hyperg|ycem|a
GI: nausea, vom|nng
kena|: acute k|dney |n[ury
Muscu|oske|eta|: rhabdomyo|ys|s
3. A 30 year o|d w|th h|story of depress|on presents
w|th AMS and the LkG be|ow.






Wh|ch one of the fo||ow|ng |ntervennons |s
|nd|cated for the arrhythm|a?
A. Am|odarone
8. Card|overs|on
C. Magnes|um su|fate
D. Sod|um b|carbonate
L. Metopro|o|
(Cyc||c) Anndepressants
A|rway, card|ac mon|tor|ng
Charcoa|, cons|der |avage
8|ood a|ka||n|zanon (pn 7.4S-7.SS)]sod|um
|oad|ng
nyperton|c sa||ne |n refractory cases
Annarrhythm|c drugs
Vasopressors - #-agon|st
8enzod|azep|nes for se|zures
Cr|ter|a for 8|carbonate Use
Card|ac conducnon de|ay
kS >0.10 or 0.14 or 0.16 sec
W|de comp|ex tachyarrhythm|a
Card|ac arrest
k|ght bund|e branch b|ock
k
avr
!3 mm
kefractory hypotens|on
Cra| nypog|ycem|c Agents
S0 g|ucose IV or ora|, then S or 10
g|ucose
G|ucagon 1 mg SC or IM
Cctreonde S0-100 g q 8h SC]IV
Inh|b|ts |nsu||n re|ease
Shortens hypog|ycem|c per|od
L|th|um
1ox|c|ty (L| > 2.S - 4 mmo|]L)
Centra| nervous system
Arrhythm|as (|ess common)
May cons|der who|e bowe| |rr|ganon
Cpnm|ze |ntravascu|ar vo|ume
Immed|ate and 2 h L|
+
|eve|s
nemod|a|ys|s, connnuous rep|acement
therap|es
rescr|pnon Narconcs
Cra|, snornng,IV use
Deaths |ncreased 66 from
2001-200S (206 for methadone)
Cxycodone, hydrocodone
common|y d|verted
Ientany| formu|anons
ro|onged eects w|th
susta|ned-re|ease forms
Narconc Cverdose
Anndote = Na|oxone
IV, IM, SC, SL, endotrachea|
0.4 - 10 mg (h|gher doses for
synthenc agents)
t
1]2
= 4S-70 m|n
Connnuous |nfus|on
Suppornve care
1ramado|
Lethargy, coma
kesp|ratory depress|on
Ag|tanon
Se|zures
1achycard|a, n1N
May cause fa|se (+) ur|ne tox|co|ogy
for C
Cho||nerg|c Syndrome
Crganophosphates, carbamates
Nerve gases (sar|n)
SLUDGL man|festanons
8radycard|a, weakness
1reatment
Atrop|ne (for secrenons)
ra||dox|me (for weakness)
4. An ICU panent overdosed on a monoam|ne
ox|dase |nh|b|tor and uoxenne. 1he panent |s
de||r|ous, has had severa| se|zures, and has
tremors of the extrem|nes.
Wh|ch one of the fo||ow|ng shou|d be
adm|n|stered?
A. Dantro|ene
8. Lorazepam
C. roprano|o|
D. 8romocr|pnne
L. na|oper|do|

Se|ecnve Seroton|n keuptake
Inh|b|tors
CNS depress|on, se|zures
Arrhythm|as
Seroton|n syndrome
A|tered menta| status
Autonom|c dysfuncnon
Neuromuscu|ar abnorma||nes
Seroton|n Syndrome
kemove prec|p|tanng agents
Suppornve care
Coo||ng
Sedanon (benzod|azep|nes)
Neuromuscu|ar b|ockade
Seroton|n antagon|sts
keso|ves |n 24-72 h
nerba|]Lnergy roducts
Lphedra a|ka|o|ds (banned |n US |n 2006)
Sympathom|menc syndromes
Lphedra-free supp|ements
Conta|n synephr|ne (b|uer orange)
keports of MI, stroke, syncope
Cae|ne]energy dr|nks
Arrhythm|as, card|ac arrest

www.herbmed.org www.mskcc.org]aboutherbs
D|methy|amy|am|ne (DMAA)
Supp|ement that |ncreases energy,
concentranon and metabo||sm
Structure s|m||ar to amphetam|nes
Assoc|ated w|th deaths |n so|d|ers
dur|ng exerc|se
keports of ||ver and rena| fa||ure,
se|zures, tachycard|a, n1N, |ntracran|a|
hemorrhage, card|omyopathy
nosp|ta|-Acqu|red Intox|canons
GabapennnAMS, coma
Narconcs
nand san|nzersethano|,
|sopropy| a|coho|
Methemog|ob|nem|a$ top|ca|
anesthencs
ropy|ene g|yco| (|orazepam)
ropofo| |nfus|on syndrome

ropofo| Infus|on Syndrome
n|gh r|sk: Seps|s, |mpa|red C
2
de||very, head
|n[ury, ICU panents w|th pro|onged |nfus|on
of h|gh doses
Can occur |n surg|ca| panents rece|v|ng |ow
doses
" C||n|ca| hnd|ngs: Myocard|a| fa||ure,
arrhythm|as, |acnc ac|dos|s, hyperka|em|a,
rhabdomyo|ys|s, rena| fa||ure, bradycard|a,
hyper||pem|a
Summary
Use v|ta| s|gns and neuro|og|ca| hnd|ngs to
suggest c|asses of tox|ns
Lmcacy of GI decontam|nanon and tox|n
e||m|nanon techn|ques |s ||m|ted
Adm|n|ster |nd|cated anndotes for spec|hc
tox|ns
Lar|y adm|n|stranon of N-acety|cyste|ne
prevents tox|c|ty |n acetam|nophen overdose
Use benzod|azep|nes to contro| ag|tanon due
to sympathom|menc tox|ns
1hank you for your
auennon