Management of Acute Overdose
By: Peter Rempel
March 27 th , 2013

Presentation Outline
 Introduction and Statistics
 General management strategy
 Identification of Toxidromes
 Management of overdose for specific medications
 Role of pharmacist

Introduction - Overdose
 Definition: The use of a substance in quantities greater than recommended.
 Accidental vs. Intentional misuse

Epidemiology - Overdose
 Approximately 2.3 million cases reported (US)
 50% caused by pharmaceutics
 41,592 deaths occurred in the US (2009)
 76% were unintentional
 91% caused by medications
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Prevalence higher in males during the early years (0-12y)
Rates in females surpass males in older populations

Epidemiology (Continued)
Most common pharmaceutics:
 Analgesics (Opioids)
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Sedative/hypnotic/antipsychotics
Antidepressants
Antihistamines
Cardiovascular drugs
Vitamins, cough and cold products
 Rates of unintentional overdose has been steadily increasing

4)
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3)
General Management Strategy
ABC management (vital signs)
Call Poison Control
Obtain best possible medical history
Order Labs
Prevent absorption of toxin
Enhance elimination (antidote)

General management strategy
1)
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ABC management
Airway patency
- head-tilt and chin-lift, removal of obstructions
Breathing
assisted ventilation
Circulation
colour change, sweating, decreased LOC
- EKG, saline infusion, vasopressers

General Management Strategy
2)
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Call Poison Control
Available 24/7 to provide poison treatment information
Help guide treatment strategy
Prevent unnecessary use of health care resources http://www.capcc.ca/provcentres/on/on.html

General Management Strategy
3)
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Obtain accurate history
Determine the causative agent
Dose
Time since exposure
Route
Demographics (age, weight)
Symptoms*
Physical Examination

What is a Toxidrome?
 Characteristic symptoms that are associated with a specific group of medications.
 These group of symptoms are known as a
“Toxidrome”

Identification of Toxidromes
Cholinergic Toxidrome
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“SLUDGE”
Salivation, Lacrimation, Urination, Defecation, GI upset, Emesis
Miosis, diaphoresis, bradycardia
 Causative Agents: Physostigmine, Organophosphates,
Carbamate

Identification of Toxidromes
Anticholinergic Toxidrome
 Hot as a Hare - fever
 Red as a Beet - flushing
 Mad as a Hatter – confusion, delirium
 Dry as a bone – dry skin/mucus membranes
 Mydriasis, tachycardia, urinary retention
 Causative Agents: Antihistamines, TCA`s, Antiparkinson medications

Identification of Toxidromes
Sympathomimetic Toxidrome
 Anxiety, Delusions, Sweating, Piloerrection, Seizures,
Hyperreflexia, Mydriasis
 Causative Agents: cocaine, salbutamol,, amphetamines, ephedrine, pseudoephedrine, methamphetamine

Sedative/Hypnotic/Opiate Toxidrome
 Slurred speech, confusion , stupor, coma, apnoea, respiratory depression
 Hypotension, bradycardia, miosis
 Causative agents: opioids, anticonvulsants, antipyschotics, barbiturates, benzodiazepines, ethanol

4)
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Order lab tests
Confirm offending agent(s)
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Predict prognosis
Direct therapy/monitoring
Includes: Toxicology screen, anion gap, osmol gap,
CBC, BUN, SCr, blood glucose, electrolytes, EKG monitoring

General Management Strategy
5)
Prevent absorption
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*Activated Charcoal- first line therapy in most emergency departments
Whole Bowel Irrigations- clears the GI tract using high volumes of PEG
Orogastric Lavage- No benefit over the use of activated charcoal
Syrup of Ipecac- NO LONGER RECOMMENDED http://www.freepatentsonline.com
/7077825.html

General Management Strategy
Activated Charcoal
 Ability to adsorb substances due to its high surface area
 Offending agent(s) become trapped by the charcoal and are excreted in the feces
Dosing: 1g/kg po OR by NG tube (usually given multiple times)
AE: aspiration pneumonia, GI obstruction
Contraindications: presence of ileus

General Management Strategy
Activated Charcoal
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Does not adsorb the following compounds:
Iron
Lithium
Lead
Cyanide
Alcohol

General Management Strategy
6)
Enhance Elimination
 Hemodialysis/Hemoperfusion
 Administer Antidote

General Management Strategy
Administer Antidote:
Offending Agent
Tylenol
Anticholinergics
Benzodiazepines
CCB
Beta Blockers
Opioids
Antidote
N-acetylcysteine
Physostigmine
Flumazenil
Glucagon, Calcium
Glucagon
Naloxone
*See my website for a more exhaustive list www.ODmanagement.weebly.com

Opioid Overdose Managment

Opioid Overdose Management
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Opioid Overdose Management
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 Reverses effects from opioid overdose
 Pure opioid receptor antagonist
 Duration of action 30-120 minutes
 0.4-2mg (IV,IM,SC); repeat q2-3 minutes until reversal of symptoms
 Use continuous IV infusion for exposure to long-acting opioids or SR formulations

Acetaminophen Overdose

Hamm J. Acute acetaminophen overdose in adolescents and adults.Critical Care Nurse; Jun 2000; 20(3) 69-74

Hamm J. Acute acetaminophen overdose in adolescents and adults.Critical Care Nurse; Jun 2000; 20(3) 69-74

N-acetylcysteine
 Indicated for the reversal of Acetaminophen toxicity
 Hepatoprotective agent
 Restores hepatic glutathione and acts as a glutathione substitute
 Prevents the production of the toxic by-product of acetaminophen

 21 hour IV dosing regimen (3 doses)
 LD: 150 mg/kg (Max 15g) over 1 hour
 2 nd dose: 50 mg/kg (max 5g) over 4 hours
 3 rd dose: 100 mg/kg (max 10g) over 16 hours
 Oral dosing regimen also available (72 hours)
 Therapy is guided by the Matthew-Rumack
Nomogram

Matthew-Rumack Nomogram
The Merck Manual for Health Professionals. Acetaminophen Poisoning.
http://www.merckmanuals.com/professional/injuries_poisoning/poisoning/acetaminophen_poisoning.html

Anaesthetic Overdose/Refractory Cases

Lipids 20%- Intralipid®
 Used in anaesthetic overdose and refractory cases
(unlabelled use)
 Mechanism unknown
 Effective for lipophilic medication overdose
 Suggested Dose:
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1.5 mL/kg bolus infused over 1 minute (may repeat up to 2 times)
Followed by 0.25 mL/kg/minute continuous infusion http://www.lipidrescue.org/

Role of the Pharmacist
 Role in both the community and hospital setting
 Educating patients on the dangers of drug misuse
 Identifying potential at risk patients
 Identifying inappropriate medication regimens
 Medication Reconciliation

Highlights
 Majority of overdoses are accidental
 Rates of accidental overdose is steadily increasing
 Identifying Toxidromes plays a vital role in the management of overdose
 Activated charcoal and whole bowel irrigation are effective at lowering absorption
 Pharmacists can play a role in both the prevention and treatment of an overdose

References
1) Clinical Practice Guidelines. Management of Drug Overdose
& Poisoning. Ministry of Health, Singapore. May 2000.
2)
Green SL, Dargan PI, Jones AL. Acute poisoning: understanding 90% of cases in a nutshell. Postgrad Med J.
2005;81:204-216.
3)
4)
5)
Tenenbein M et al. Efficacy of ipecac-induced emesis, orogastric lavage, and activated charcoal for acute drug overdose. Annals of Emergency Medicine; 16(8): 838-841
Lab Tests Online. Emergency and Overdose Drug Tests. http://labtestsonline.org/understanding/analytes/emergenc y/tab/test : Accessed March 22, 2013
Thim T, Niels HV, et al. Initial assessment and treatment with the Airway, Breathing, Circulation, Disability, Exposure
(ABCDE) approach. International Journal of General
Medicine; 2012:5 117-121

References
6) Centers for disease control and prevention. Home and
Recreational Safety. Unintentional Poisoning Data and
Statistics. Retrieved from http://www.cdc.gov/HomeandRecreationalSafety/Poiso ning/data.html
; accessed March 3, 2013
7) Hodgman MJ et al. A review of Acetaminophen Toxicity.
Crit Care Clin. 28 (2012) 499-516
8) G Cave et al. Intravenous Lipid Emulsion as Antidote
Beyond Local Anesthetic Toxicity: A Systematic Review.
Academic Emergency Medicine: 2009; 16:815-824
9) Boyer EW. Management of Opioid Analgesic Overdose..
N Engl J Med: 367;2 146-155

Thank you for listening