EM Clerkship:
Approach to Overdose/
Poisoned ED Patients
Objectives
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Describe US Poison Systems/Services
Poison Epidemiological Highlights
Describe common Toxidromes
Describe Indications for Tox Screens and
other diagnostic tests
• Describe GI Decon Options, Indications
• List Common Antidotes
800 222-1222
Regional Poison Centers
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Major Med Centers/ High Call Volume
Many Toxicological Info Resources
Available 24 hr/d, 7 d/wk
Certified Specialists in Poison Info
Med Tox Board Certified Backup
Follow Up Calls - Determine Outcome
AAPCC National Poison Data Base (NPDS)
1995 US Poisonings
Exposures 2,400,000
ED Visits 1,000,000 42%
Hospitizations 215,000 9%
Deaths 18,549 <1%
80% DOA
Fatal Accidents SEA/KC 2008
S/KC 2008 Medical Examiner Report
“Recent changes in drug poisoning mortality in
US by urban–rural status & drug type”
• Paulozzi LJ: Pharmacoepi Drug Safety 08
• 99 - 04 Nonsuicide drug poisoning deaths
62%
•  Primarily due to prescription opioids.
• By 04, prescription opioids caused more
deaths than either heroin or cocaine
1.5
Basic Approach to the poisoned
patient
Stabilization
History and Physical Exam
Diagnostic tools
Measures to reduce absorption
Measures to enhance elimination
Specific antidotes
Supportive care
Stabilization
• Airway, Breathing, Circulation
• DON’T regimen
– Dextrose (or rapid finger stick glucose check)
– Oxygen
– Naloxone
– Thiamine
• EKG
History and physical
• History and Physical
– Info from family/friends/EMS/Police
– Look for signs of toxidromes
• Consider GI decontamination and
enhanced elimination
• Call the poison center
– Assistance with management
– Reporting and surveillance
Toxicologic focus physical exam
• Vital signs
• Mental status –
depressed or
agitated?
• Eyes- miosis or
mydriasis
• Skin/Axilla/Mucus
membranes-moist or
dry?
Toxicologic focused exam cont.
• Respirations
-Increased or decreased rate/adventitious
sounds?
• Bowel sounds
-Present? Absent?
• Neuro
-Rigidity, hypo/hyperreflexive?
Toxidromes
• Toxidrome: Cluster of
clinical sign and
symptoms that can
help identify a toxin
and aid in the
management of a
poisoned patient.
• Types of Toxidromes
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Opioid
Sedative/hypnotic
Sympathomimetic
Anticholinergic
Cholinergic
Case 1
• Case: 29 year old male is
found lying on the floor of a
bathroom of a gas station.
• He is somnolent and
responds only to deep
stimulation
• His respiratory rate is 6 with
• shallow breaths
• Pupils are pinpoint
• Track marks are noted
• What toxidrome is this?
Opoid toxidrome
• Opioid toxidrome
– Miosis, usually
– Respiratory
depression
– CNS depression
• Treatment
– Oxygen and airway
management
– Assisted ventilation
– Naloxone?
– Intubation
• The main culprits:
• Heroin
• Prescription narcotics
(methadone/vicodin/
oxycodone/etc.)
Case 2
• A 39 year old female well
known to EMS and ED for
alcohol abuse is found
sleeping in the street by
police stating she took
some “stix”
• She is somewhat sleepy
but answers questions
appropriately with slurred
speech.
Vitals are normal, pupils are
3mm reactive bilateral
She shows horizontal
nystagmus on visual testing
What toxidrome is present?
Sedative/hypnotic toxidrome
• Sedative/hypnotic toxidrome
– CNS depression
– Respiratory depression
(sometimes)
– Nystagmus
– Normal to dilated pupils
• Treatment
– Largely supportive
– Extreme caution with
antidotes
• Main culprits
-ethanol
-benzodiazpines
(lorazepam/diazepam/clo
nazepam etc..)
-barbiturates (phenobarbital)
Case 3
• 24 year old male is found by
police wildly agitated and
threatening and is not
restrained by 4 large officers
after kicking out the
windows of a police cruiser.
• His pupils are markedly
dilated and he is diaphoretic
and tachycardic
• Between insults and threats,
he complains of chest pain
What is your initial
management ?
What is this
toxidrome?
Sympathomimetic toxidrome
• Sympathomimetic
toxidrome
– Agitation to aggressive
behavior
– Seizure
– Dilated pupils
– Increased pulse and
respiratory rate
– Rigid and febrile in
severe cases
• Examples:
– Cocaine (crack/powder)
– MDMA (ecstasy)
– Methamphetamine
– PCP (sherms)
• Treatment
– Support
– Sedation (benzodiazepines!)
Case 4
• 17 year old high
school senior is found
mumbling and
hallucinating after
ingesting jimson weed
seeds.
• Pupils are dilated
• Skin is red and dry
• He has decreased
bowel sounds and a
full bladder
Anticholinergic toxidrome
• Anticholinergic
Toxidrome
– Dilated pupils
– Dry, flushed skin
– Dry, mucous
membranes
– Sedation agitation and
hallucinations
– Urinary retention
• Examples:
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Benadryl
Phenergan
Jimson weed
Scopolamine
• Treatment
– Support
– Sedation (benzos)
Case 5
• 35 year old migrant
farm worker is found in
respiratory distress
and vomiting. He was
spraying the fields with
an unknown chemical
today without a mask.
• His saturation on room
air is 92% and he has
rales and wheezing
bilaterally
• Pupils are pinpoint and
he is somewhat
agitated
• What is this
toxidrome?
Cholinergic Toxidrome
SLUDGE
– Salivation
– Lacrimation
– Urination
– Defecation
– GI cramping
– Emesis
DUMBELS
• Defecation
• Urination
• Meiosis
• Bronchorrhea
• Emesis
• Lacrimation
• Salivation
Cholinergic Toxidrome
Treatments
• Decontamination
• Atropine
• 2-PAM
• Supportive care
Main Culprits
• Organophosphate
pesticides
• Nerve gas
Putting it all together
Opoids
Anticholinergic
Cholinergic Sympathomimetic
Pulse
Decreased
Increased
Decreased
Increased
BP
Decreased
Increased
Variable
Increased
Resp
Decreased
Variable
Variable
Increased
Temp
Decreased
Increased
Decreased
Increased
Bowel
Sounds
Decreased
Decreased
Hyperactive
Normal
Skin
diaphoretic
Dry, hot
diaphoretic
Diaphoretic
Mental
Status
Depressed
Agitated
Depressed
Agitated
Pupils
Miosis
Mydriasis
Miosis
Mydriasis
Toxicology Evaluation
• Serum labs
– Chem 7 (look for anion gap), osmol, ABG if
indicated, HCG
• Quantitative levels
– Tylenol, aspirin, lithium, seizure meds (dilantin,
VPA, tegretol), digoxin
• Urine toxicology
– Send if helps with diagnosis or management
• EKG
 Anion
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Gap Acidosis
Methanol, Metformin
Uremia
Diabetic Ketoacidosis
Paraldehyde, Phenformin
Idiopathic, Iron, Isoniazid
Lactic Acidosis (Cyanide)
Ethylene & Other Glycols
Salicylate, Strychnine
“Double Gap Acidosis”
• Screens for toxic alcohol poisoning
• Anion Gap
– Na - (Cl + HCO3)
– Normally < 10
• Osmolal Gap (OG)
– (2*Na) + (Gluc/18) + (BUN/2.8) + ETOH/4
– Normally < 10
Increased Osmolal Gap
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Ethanol
Ethylene Glycol*
Isopropanol
Methanol*
Acetone
Ketoacidosis*
* Double Gap Acidosis
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Renal Failure*
Mannitol
Sorbitol
Hyperlipidemia
Hyperproteinemia
Main GI Decon Options
• None
–First, do no harm
• Gastric Lavage
• Activated Charcoal
• Whole Bowel Irrigation
Gastric Lavage
• Indications:
– Life threatening OD or pharmacobezoar
• Contraindications:
– Unprotected airway, hydrocarbon or caustic ingestions,
esophageal pathology
• Complications:
– Aspiration  Hypoxia, Pneumonia
– Kinked Orogastric Tube
– Perforation (throat, esophagus, stomach),
laryngospasm, epistaxis, great discomfort
With LOC
Protect Airway Rapid Sequence
Intubation
Activated Charcoal
• Indications:
– Potentially adsorbable toxic OD presenting < 1-2 hr
after ingestion
• Contraindications:
– Unprotected airway, non adsorbable toxin (metals,
caustics)
• Dose: 1 gm/kg up to 50 gm
Whole Bowel Irrigation WBI
• Very little literature available
• Indications:
– Sustained release, enteric coated, heavy metals
• Contraindications:
– Bowel obstruction, perforation, ileus; unprotected
airway, dehydration
Multidose Activated
Charcoal (MDAC)
Enhanced Elimination
Serial dosing of activated charcoal
Enhance elimination by interruption of enteroenteric circulation
Consider in ingestion of:
Phenobarbital
Salicylates
Theophyline
Carbamazepine
Digoxin
Phenytoin
Hemodialysis
Utility depends on toxin
physical
characteristics
-size
-high water solubility
-low protein binding
-small Vd (volume of
distribution)
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Salicylates
Phenobarbital
Methanol
Ethylene glycol
Lithium
Hyperbaric oxygen
• Potential benefit in
carbon monoxide
(CO) poisoning
• Increase dissociation
of CO from
carboxyhemoglobin
• Consider for highly
symptomatic patients
or pregnant patients
with CO poisoning
Common Antidotes
Toxin
Antidote
Opioids
Narcan
Tylenol
NAC
TCA
NaBicarbonate
Digoxin
Digibind
Cyanide
Cyanide kit (hydroxycobalamin)
Carbon Monoxide
O2, Hyperbaric O2
Beta blockers
Glucagon
Calcium channel blockers
Calcium, glucagon, insulin/glucose
Cholinergics
Atropine, 2-PAM
Supportive care
• Continual re-assessment of patient
stability (don’t forget the ABCs!)
• Psychiatric care and precautions for
suicidal patients
In Summary
• Initial stabilization
• Complete history and
physical (as possible)
• Identify toxidromes if
present
• Call poison control for
guidance
• Utilize tests as
indicated
• Determine whether GI
decontamination/enhanc
ed elimination is
indicated
• Antidotes
• Continual reassessment/supportive
care