Emergency Medicine - Approach To Poisoning

Approach to Poisoning
With Julianna Jung, MD, FACEP
Neuer Nutzer, klhmzwt@five-club.com

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Learning Objectives
By the end of this lecture, the learner will be able

• an approach to the assessment
and stabilization of patients with toxic
ingestions/exposures.
• the physical exam findings

associated with various toxidromes.
• antidotes and treatments for specific

poisonings, along with their indications.

Poisoning Definition and Epidemiology Epidemiology
•
• Recreational drug/alcohol intoxication and overdose
• Occupational/environmental exposures
• Deliberate self-harm
• Accidental ingestions
• Chemical weapon exposures
• True incidence unknown, but very common cause of ED visits
• Essential domain of EM expertise

Man with a Head Injury
Man
20 years
Unresponsive
White powder around his

found down
mouth and nose
street.
How do you approach the assessment and

management of this patient?

Initial Stabilization Examination
Airway Breathing Circulation Disability/Dextrose
• Patients are often • Monitor O2 sat • Cardiac monitor • Perform

obtunded and and ETCO2 and frequent BP neurologic
may be unable to checks, vascular primary survey
protect airway • Supplemental access (GCS, pupils, four-
oxygen and extremity
• Consider respiratory • IV fluid/pressor movement)
intubation for GCS support as support for shock,
< 8, pooling needed manage • Always check
secretions, dysrhythmias glucose
vomiting, hypoxia
Differential Diagnosis Diagnosis
Antihypertensives Nerve agents

Salicylates Gamma-hydroxybutyrate
Amphetamines Opioids Thyroxine
Caustics Ergotamines
Strychnine Lithium Antipsychotics
Cardiac glycosides
SSRIs
Benzodiazepines Calcium channel blockers
Bath salts Rohypnol
Neuroleptics Local anesthetics Nitrites
MAOIs
Tricyclic antidepressants Phencyclidine
Nitrates Barbiturates
Cyanide PDE inhibitors
Hydrocarbons
Anticholinergics Hallucinogenics Methylxanthines
Anticonvulsants
Cannabinoids Arsenic
Insulin Cocaine Organophosphates
Alkalis
Beta-blockers Ethanol Herbal supplements
Methylxanthines
Antihypertensives Heavy metals
Hypoglycemics
Differential Diagnosis Diagnosis
Antihypertensives Nerve agents

Salicylates Gamma-hydroxybutyrate
Amphetamines Opioids Thyroxine
Caustics Ergotamines
Strychnine Lithium Antipsychotics
Cardiac glycosides
SSRIs
Benzodiazepines Calcium channel blockers
Bath salts Rohypnol
Neuroleptics Local anesthetics Nitrites
MAOIs
Tricyclic antidepressants Phencyclidine
Nitrates Barbiturates
Cyanide PDE inhibitors
Hydrocarbons
Anticholinergics Hallucinogenics Methylxanthines
Anticonvulsants
Cannabinoids Arsenic
Insulin Cocaine Organophosphates
Alkalis
Beta-blockers Ethanol Herbal supplements
Methylxanthines
Antihypertensives Heavy metals
Hypoglycemics
Toxidromes Signs/Symptoms
• Clinical signs/symptoms associated with classes of toxins
• Based on autonomic effects of the toxin in question
• Rely on readily observable findings:

• Eyes
• Skin
• Secretions
• Vital signs
• Allow rapid narrowing of the toxicologic differential

Traditional Toxidromes Types
Sympathomimetic Opioid
Anticholinergic Sedative/hypnotic
Cholinergic

Traditional Toxidromes Types
Others have more recently been well described: neuroleptic

malignant syndrome, serotonin syndrome, etc

Sympathomimetic Toxidrome Signs/Symptoms
Clinical Indicator Findings
Heart rate Fast
Blood pressure High
Cardiac rhythm Sinus tach; tachyarrhythmias may occur

Respiratory rate Normal to high
Temperature Normal to high
Eyes Mydriatic
Skin Normal to diaphoretic
Secretions Normal

Anticholinergic Toxidrome Signs/Symptoms
Heart rate Fast
Blood pressure High
Cardiac rhythm Fast Unopposed

sympathetic tone
Respiratory rate Normal to high
Temperature High
Eyes Mydriatic
Skin Dry Loss of

cholinergic
Secretions Dry
innervation

Anticholinergic Mnemonic Signs/Symptoms
Mad as a hatter
Altered mental status
Blind as a bat
Mydriasis
Red as a beet
Flushed skin
Hot as a hare
Dry skin (anhydrosis)
Dry as a bone
Dry mucous membranes
Cholinergic Toxidrome Signs/Symptoms
Heart rate Slow
Blood pressure Normal to low
Cardiac rhythm Sinus brady
Respiratory rate Low
Temperature Normal to low
Eyes Miotic
Skin Profusely diaphoretic
Secretions Copious

Chlolinergic Mnemonics Signs/Symptoms
D Diarrhea
S Salivation
U Urination
L Lacrimation
M Miosis/muscle weakness
U Urination B Bronchorrhea
D Defecation/diarrhea B Bradycardia
G GI dysmotility
E Emesis
L Lacrimation
E Emesis
S Salivation/sweating
Sedative Hypnotic Toxidrome Signs/Symptoms
• Sedation is primary hallmark

• Somnolence
• Loss of airway protective reflexes in severe cases
• Respiratory depression may occur
• Autonomic effects are minimal (or due to co-ingestions)

Opioids Signs/Symptoms
It is similar to sedative- Except, miosis is And respiratory

hypnotics. universally present. depression is common
and often fatal.

Toxidromes Review Signs/Symptoms
Skin/ Mental
Toxin HR/BP Resp Temp Eyes
Secretions Status
Sympathomimetic Diaphoretic Agitated
Anticholinergic Dry Agitated
Copiously
Cholinergic Somnolent
wet
Somnolent-
Sedative-hypnotic -- -- or -- -- Normal
Coma
Somnolent-
Opioids -- -- --
Coma

Case 1 The Landscaper
A 22-year-old man was brought to the ED, because he was found on the
ground in a shed at work. He has white powder on his face and clothing.
He began vomitting during the exam.
What can you do to save his life?
His vital signs are:

• VS: T 35.9, P 55, R 24, BP 108/55, SpO2 85% on room air
• Gurgling respirations with pooled secretions in oropharynx
• Pupils 2mm
• Skin cool and diaphoretic
nastya_gepp, CC0/PD
Case 1 Cholinergic Poisoning
• Bodily fluids everywhere = cholinergics
• Most exposures are from pesticides (organophosphates)
• Management:
• DECONTAMINATE prevent further exposure for patient and for YOU
• Intubate early patients will drown in their own secretions
nastya_gepp, CC0/PD
Case 1 Cholinergic Poisoning
• Management:
• High-flow O2 and positive pressure to maintain adequate oxygenation
• Antidotes:
• Atropine - restores cholinergic tone
• Pralidoxime (2PAM) reactivates acetylcholinestersase
nastya_gepp, CC0/PD
Case 2 Empty Pill Bottle
A 38-year-old woman was found unresponsive in her bedroom by her

family, there were empty pill bottles standing next to her bed but her
family did not bring them.
What is the toxidrome?
Her vital signs are:

• Pupils 1mm
• Skin cyanotic but dry
bollie6734, CC0/PD
Case 2 Opioid Overdose

• Pinpoint pupils + respiratory depression = opioids
• Exposure may be recreational or attempted suicide
• Management:
• Support respiration bag-valve-mask ventilation is usually sufficient,
• Restore oxygenation
bollie6734, CC0/PD
Case 2 Opioid Overdose

• Antidote: Naloxone
• Opioid receptor antagonist, rapidly reverses opioid effects
• Dose required is variable titrate to effect
bollie6734, CC0/PD
Case 3 Combative Patient
A 44-year-old man with depression was found altered at home by his

family. In the trash can they also found over-the-counter-pill bottles. The
patient is alert but agitated and combative.

• Pupils 8mm
• Skin flushed and dry
• Dry mucous membranes
Derallrounder, Neuer
CC0/PDNutzer, klhmzwt@five-club.com
Case 3 Anticholinergic Poisoning

• Mad + blind + red + hot + dry = Anticholinergic
• Management:
• Find out what he took
• Sedation for patient and staff safety
• IV fluids to restore intravascular volume

• Antidote:
• Physostigmine acetylcholinesterase inhibitor
• Not given routinely
• Use for dysrhythmia, seizure or severe psychosis
Common Anticholinergics
• Antihistamines
• Antiemetics
• Antipsychotics
• Antispasmodics
• Motion sickness remedies
• Muscle relaxers
• Tricyclic antidepressants

Family returns home and retrieves pill bottles
What do you want to do now?
• Substances:
• Acetaminophen 325mg + Diphenhydramine 25mg
• 100 pill bottle now empty!
• Total ingestion = 32.5 grams acetaminophen and 2.5 grams

diphenhydramine
High-Toxicity Ingestions
• Consult your local poison center or toxicologist
• Consider GI decontamination
Weigh the potential
• Nasogastric lavage (for ingestions < 1 hour) benefit against the risk
of aspiration!
• Activated charcoal by mouth/NG tube
Intubation may be
• Whole-bowel irrigation needed in high-risk
patients.
• Optimize supportive care
• Administer any available antidote promptly

Acetaminophen (Paracetamol) Overdose
• Readily available, highly lethal, minimally symptomatic (initially)
• Mechanism:
• Hepatic metabolism to N-acetyl-p-benzoquinone-imine (NAPQI) highly toxic
• In normal doses, NAPQI combines with thiols to produce nontoxic metabolites
• In overdoses, thiol stores are depleted and NAPQI accumulates
• Clinical effect is hepatic injury and potentially fulminant liver failure
• Antidote: N-acetyl-cysteine (NAC)

• Detoxifies and decreases production of NAPQI
• Very effective when given early within 8 hours of ingestion

When to Give NAC
No guidelines < 4 hr, as GI

absorption is not yet complete at
that point this is still the window
for decontamination!
toxicity threshold better to

overtreat than undertreat!
Ron Walls Robert

NeuerHockberger Marianne Gausche-Hill, Rosen's Emergency Medicine: Concepts and Clinical Practice, 9th Edition, 2017,
Nutzer, klhmzwt@five-club.com
p. 1854, Fig. 143.3, Elsevier
Essential Principles of Managing Poisonings
Use your knowledge of toxidromes to narrow the

differential.
Externally decontaminate your patient to protect yourself

and them.
Provide aggressive supportive care ABCs.
Recognize potential high-toxicity ingestions and get help.
Consider GI decontamination but avoid aspiration.
Give antidotes where available and indicated.

Learning Outcomes
 You are now able to describe an approach to the

assessment and stabilization of patients with
toxic ingestions/exposures.
 You are able to describe the physical exam

findings associated with various toxidromes.
 You are able to list antidotes and treatments for

specific poisonings, along with their indications.

This document is a property of: Neuer Nutzer
Note: This document is copyright protected. It may not be copied, reproduced, used, or
distributed in any way without the written authorization of Lecturio GmbH.


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Approach to Poisoning

With Julianna Jung, MD, FACEP

Neuer Nutzer, klhmzwt@five-club.com

By the end of this lecture, the learner will be able

• the physical exam findings

• antidotes and treatments for specific

Neuer Nutzer, klhmzwt@five-club.com

• Chemical weapon exposures

• True incidence unknown, but very common cause of ED visits

• Essential domain of EM expertise

Neuer Nutzer, klhmzwt@five-club.com

White powder around his

How do you approach the assessment and

Neuer Nutzer, klhmzwt@five-club.com

Airway Breathing Circulation Disability/Dextrose

• Patients are often • Monitor O2 sat • Cardiac monitor • Perform

Antihypertensives Nerve agents

Antihypertensives Nerve agents

• Clinical signs/symptoms associated with classes of toxins

• Based on autonomic effects of the toxin in question

• Rely on readily observable findings:

• Allow rapid narrowing of the toxicologic differential

Neuer Nutzer, klhmzwt@five-club.com

Neuer Nutzer, klhmzwt@five-club.com

Others have more recently been well described: neuroleptic

Neuer Nutzer, klhmzwt@five-club.com

Clinical Indicator Findings

Heart rate Fast

Blood pressure High

Cardiac rhythm Sinus tach; tachyarrhythmias may occur

Temperature Normal to high

Skin Normal to diaphoretic

Neuer Nutzer, klhmzwt@five-club.com

Clinical Indicator Findings

Heart rate Fast

Blood pressure High

Cardiac rhythm Fast Unopposed

Skin Dry Loss of

Neuer Nutzer, klhmzwt@five-club.com

Clinical Indicator Findings

Heart rate Slow

Blood pressure Normal to low

Cardiac rhythm Sinus brady

Respiratory rate Low

Temperature Normal to low

Skin Profusely diaphoretic

Neuer Nutzer, klhmzwt@five-club.com

• Sedation is primary hallmark

• Loss of airway protective reflexes in severe cases

• Respiratory depression may occur

• Autonomic effects are minimal (or due to co-ingestions)

Neuer Nutzer, klhmzwt@five-club.com

It is similar to sedative- Except, miosis is And respiratory

Neuer Nutzer, klhmzwt@five-club.com

Sympathomimetic Diaphoretic Agitated

Anticholinergic Dry Agitated

Neuer Nutzer, klhmzwt@five-club.com

What can you do to save his life?

His vital signs are:

• Gurgling respirations with pooled secretions in oropharynx

• Skin cool and diaphoretic

His vital signs are:

• Bodily fluids everywhere = cholinergics