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==Background== | ==Background== | ||
=== | ===Epidemiology=== | ||
*In 2014, ~2.2million human exposures reported to US poison control centers | |||
*Top 5 substance classes: | |||
**analgesics (11%) | |||
**cosmetics/personal care products (8%) | |||
**household cleaning substances (8%) | |||
**sedatives/hypnotics/antipsychotics (6%) | |||
**antidepressants (4%) | |||
*1,835 human exposures resulted in death | |||
{{Autonomic nervous system receptors}} | |||
== | ==Clinical Features== | ||
{{Template:Toxidrome Chart}} | {{Template:Toxidrome Chart}} | ||
== | ==Differential Diagnosis for Specific Signs== | ||
===Hyperthermia=== | ===Hyperthermia=== | ||
*Altered Metabolism | |||
**[[Aspirin (Salicylate) Toxicity]] | |||
**withdrawal states | |||
**thyroid hormones | |||
**dinitrophenols | |||
*Increased Muscle Activity | |||
**withdrawal, sympathomimetics | |||
**[[MAOI Toxicity]] | |||
**[[PCP]], LSD | |||
**[[Lithium]] | |||
**Amoxapine | |||
**[[Serotonin Syndrome]] | |||
*Impaired Heat Dissipation | |||
**anticholinergics | |||
**antihistamines | |||
**antipsychotics ([[TCAs]]) | |||
*[[Malignant Hyperthermia]] | |||
**anesthestics | |||
*[[Neuroleptic Malignant Syndrome]] | |||
**phenothiazines, [[Lithium]], LevoDopa | |||
===Hypothermia=== | ===Hypothermia=== | ||
*Exposure | |||
**[[Ethanol Toxicity]] | |||
**Sedative hypnotics | |||
**[[Opioids]] | |||
**[[TCAs]] | |||
**Phenothiazines | |||
**[[Insulin]] ([[Hypoglycemia]]) | |||
===Increased Respiratory Rate=== | ===Increased Respiratory Rate=== | ||
*Direct Stimulation | |||
**[[Aspirin (Salicylate) Toxicity]] | |||
**[[Metabolic Acidosis]] | |||
**dintirophenol, pentachlorophenol | |||
**hepatorenal failure | |||
**CNS stimulants (cocaine, amphet, theophylline) | |||
*Tissue [[Hypoxia]] | |||
**[[CO]] | |||
**[[Cyanide]] | |||
**[[Hydrogen Sulfide]] | |||
**[[Methemoglobinemia]] | |||
===Respiratory Depression=== | ===Respiratory Depression=== | ||
*Central Depression | |||
**antipsychotics | |||
**Chlorinated hydrocarbons | |||
**[[Sedative/Hypnotics]] ([[Ethanol Toxicity]], glycols) | |||
**[[Tricyclic (TCA) Toxicity]] | |||
**Lomitil | |||
*Muscle Failure | |||
**[[Organophosphates]] | |||
**[[Marine Toxins]] | |||
## | **[[Nicotine Poisoning|Nicotine]] | ||
## | **strychnine | ||
## | **botulinis | ||
## | **Mojave rattlesnake, Cobra | ||
===Bradycardia=== | |||
PACED | |||
*Propranolol/ beta-blockers, poppies (opiates), propoxyphene, | |||
physostigmine | |||
*Anticholinesterases, antiarrhythmics | |||
*Clonidine, calcium channel blockers | |||
*Ethanol or other alcohols | |||
*Digoxin, digitalis | |||
===Seizures=== | |||
OTIS CAMPBELL | |||
*[[Organophosphates]], oral hypoglycemics | |||
*[[TCA]], [[theophylline]], tramadol | |||
*Isoniazid, Insulin | |||
*[[Sympathomimetics]], [[salicylates]], strychnine | |||
*Camphor, [[carbon monoxide]], [[cyanide]], chlorinated hydrocarbons, [[cocaine]] | |||
*[[Anticholinergics]] (antihistamines), amphetamines, antidepressants (citalopram, TCAs, buproprion) | |||
*[[Methanol]], Methylxanthines (theophylline, caffeine), [[MAOI]] | |||
*[[PCP]], propranolol | |||
*Benzo withdrawal, buproprion, botanicals (hemlock, nicotine), GHB | |||
*EtOH withdrawal, ethylene glycol | |||
*[[Lead]], [[lithium]] | |||
*Lidocaine, lindane (pesticide, scabies) | |||
==Evaluation== | |||
===Toxicological Exam=== | |||
*All vital signs (Temp, RR, HR, BP) | |||
*[[Neurologic exam]] | |||
**Level of consciousness | |||
**Pupillary exam | |||
**Motor response | |||
**DTRs | |||
*Skin Exam - moisture, temp | |||
*Lung Exam | |||
*Bowel Sounds | |||
*[[ECG]] (ie. look for [[QT prolongation]], QRS prolongation, etc) | |||
==Management== | |||
*Depends on agent | |||
*See [[antidotes]] | |||
*"Coma cocktail" when suspecting toxic ingestion (mnemonic = "DONT") | |||
*#[[Dextrose]] (50mg IV) | |||
*#[[Oxygen]] | |||
*#[[Naloxone]] (0.2-0.4mg IV/IM, repeat dose 1-2mg) | |||
*#*Empiric opioid ingestion treatment | |||
*#[[Thiamine]] (50-100mg) | |||
*#*Treat or avoid [[Wernicke encephalopathy]] | |||
*#*Though some suggest giving thiamine prior to dextrose, do NOT let this delay treatment of hypoglycemia! | |||
*#*Case reports of dextrose precipitating Wernicke's involved thiamine-deficient patients receiving prolonged course of IV glucose, NOT with single bolus<ref>Donnino MW, Vega J, Miller J, Walsh M. Myths and misconceptions of Wernicke's encephalopathy: what every emergency physician should know. Ann Emerg Med. 2007;50(6):715-21.</ref><ref>Gussow, L. Myths of Toxicology: Thiamine Before Dextrose. Emergency medicine news. 2007;29(4):3-11.</ref> | |||
==Disposition== | |||
*Depends on agent | |||
==See Also== | ==See Also== | ||
[[Altered | *[[Altered mental status]] | ||
[[ | *[[Traditional chinese medicine toxicology]] | ||
*[[Drug_levels|Drug Levels]] | |||
*[[Antidote]] | |||
*[[Camphor toxicity]] | |||
== | ==References== | ||
<references/> | |||
[[Category: | [[Category:Toxicology]] | ||
[[Category:EMS]] | [[Category:EMS]] |
Revision as of 03:27, 26 March 2019
Background
Epidemiology
- In 2014, ~2.2million human exposures reported to US poison control centers
- Top 5 substance classes:
- analgesics (11%)
- cosmetics/personal care products (8%)
- household cleaning substances (8%)
- sedatives/hypnotics/antipsychotics (6%)
- antidepressants (4%)
- 1,835 human exposures resulted in death
Autonomic Nervous System Receptors and Their Effects
- Parasympathetic - ACh is transm
- Muscarinic
- receptors in heart, eye, lung, GI, skin and sweat glands
- Bradycardia
- Miosis
- Bronchorrhea / Bronchospasm
- Hyperperistalsis (SLUDGE)
- Sweating
- Vasodilation
- Nicotinic
- receptors in both sympathetic and parasympathetic nervous systems
- fasciculations, flaccid paralysis
- ?Mild bradycardia, hypotension
- Muscarinic
- Sympathetic
- Alpha effects (vessels, eye, skin)
- Mydriasis, hypertension, sweating
- Beta effects (heart, lungs)
- Tachycardia, bronchodilation
- Alpha effects (vessels, eye, skin)
Clinical Features
Toxidrome Chart
Finding | Cholinergic | Anticholinergic | Sympathomimetic | Sympatholytic^ | Sedative/Hypnotic |
Example | Organophosphates | TCAs | Cocaine | Clonidine | ETOH |
Temp | Nl | Nl / ↑ | Nl / ↑ | Nl / ↓ | Nl / ↓ |
RR | Variable | Nl / ↓ | Variable | Nl / ↓ | Nl / ↓ |
HR | Variable | ↑ | ↑ (sig) | Nl / ↓ | Nl / ↓ |
BP | ↑ | ↑ | ↑ | Nl / ↓ | Nl / ↓ |
LOC | Nl / Lethargic | Nl, agitated, psychotic, comatose | Nl, agitated, psychotic | Nl, Lethargic, or Comatose | Nl, Lethargic, or Comatose |
Pupils | Variable | Mydriatic | Mydriatic | Nl / Miotic | |
Motor | Fasciculations, Flacid Paralysis | Nl | Nl / Agitated | Nl | |
Skin | Sweating (sig) | Hot, dry | Sweating | Dry | |
Lungs | Bronchospasm / rhinorrhea | Nl | Nl | Nl | |
Bowel Sounds | Hyperactive (SLUDGE) | ↓ / Absent | Nl / ↓ | Nl / ↓ |
- ^Consider Sympatholytic when looking at Sedative OD or someone who doesn't respond to Narcan
- Withdrawal from substances have the opposite effect
Differential Diagnosis for Specific Signs
Hyperthermia
- Altered Metabolism
- Aspirin (Salicylate) Toxicity
- withdrawal states
- thyroid hormones
- dinitrophenols
- Increased Muscle Activity
- withdrawal, sympathomimetics
- MAOI Toxicity
- PCP, LSD
- Lithium
- Amoxapine
- Serotonin Syndrome
- Impaired Heat Dissipation
- anticholinergics
- antihistamines
- antipsychotics (TCAs)
- Malignant Hyperthermia
- anesthestics
- Neuroleptic Malignant Syndrome
- phenothiazines, Lithium, LevoDopa
Hypothermia
- Exposure
- Ethanol Toxicity
- Sedative hypnotics
- Opioids
- TCAs
- Phenothiazines
- Insulin (Hypoglycemia)
Increased Respiratory Rate
- Direct Stimulation
- Aspirin (Salicylate) Toxicity
- Metabolic Acidosis
- dintirophenol, pentachlorophenol
- hepatorenal failure
- CNS stimulants (cocaine, amphet, theophylline)
- Tissue Hypoxia
Respiratory Depression
- Central Depression
- antipsychotics
- Chlorinated hydrocarbons
- Sedative/Hypnotics (Ethanol Toxicity, glycols)
- Tricyclic (TCA) Toxicity
- Lomitil
- Muscle Failure
- Organophosphates
- Marine Toxins
- Nicotine
- strychnine
- botulinis
- Mojave rattlesnake, Cobra
Bradycardia
PACED
- Propranolol/ beta-blockers, poppies (opiates), propoxyphene,
physostigmine
- Anticholinesterases, antiarrhythmics
- Clonidine, calcium channel blockers
- Ethanol or other alcohols
- Digoxin, digitalis
Seizures
OTIS CAMPBELL
- Organophosphates, oral hypoglycemics
- TCA, theophylline, tramadol
- Isoniazid, Insulin
- Sympathomimetics, salicylates, strychnine
- Camphor, carbon monoxide, cyanide, chlorinated hydrocarbons, cocaine
- Anticholinergics (antihistamines), amphetamines, antidepressants (citalopram, TCAs, buproprion)
- Methanol, Methylxanthines (theophylline, caffeine), MAOI
- PCP, propranolol
- Benzo withdrawal, buproprion, botanicals (hemlock, nicotine), GHB
- EtOH withdrawal, ethylene glycol
- Lead, lithium
- Lidocaine, lindane (pesticide, scabies)
Evaluation
Toxicological Exam
- All vital signs (Temp, RR, HR, BP)
- Neurologic exam
- Level of consciousness
- Pupillary exam
- Motor response
- DTRs
- Skin Exam - moisture, temp
- Lung Exam
- Bowel Sounds
- ECG (ie. look for QT prolongation, QRS prolongation, etc)
Management
- Depends on agent
- See antidotes
- "Coma cocktail" when suspecting toxic ingestion (mnemonic = "DONT")
- Dextrose (50mg IV)
- Oxygen
- Naloxone (0.2-0.4mg IV/IM, repeat dose 1-2mg)
- Empiric opioid ingestion treatment
- Thiamine (50-100mg)
- Treat or avoid Wernicke encephalopathy
- Though some suggest giving thiamine prior to dextrose, do NOT let this delay treatment of hypoglycemia!
- Case reports of dextrose precipitating Wernicke's involved thiamine-deficient patients receiving prolonged course of IV glucose, NOT with single bolus[1][2]
Disposition
- Depends on agent