Send the link below via email or IMCopy
Present to your audienceStart remote presentation
- Invited audience members will follow you as you navigate and present
- People invited to a presentation do not need a Prezi account
- This link expires 10 minutes after you close the presentation
- A maximum of 30 users can follow your presentation
- Learn more about this feature in our knowledge base article
Do you really want to delete this prezi?
Neither you, nor the coeditors you shared it with will be able to recover it again.
Make your likes visible on Facebook?
Connect your Facebook account to Prezi and let your likes appear on your timeline.
You can change this under Settings & Account at any time.
Transcript of General Toxicology
Thank you for your attention!
Tests to order on every suicide attempt:
Patrick Lank, MD MS
Department of Emergency Medicine
Guess the Poison!
E: Enhanced Elimination
F: Focused Therapy (antidotes)
G: Get Help! (Poison Center)
Decr Bowel Sounds
Decr Bowel Sounds
How much? (# pills, mg dose)
When? Over what time period?
What? (extended vs. immediate)
Exposure to other medications?
Eyes (pupils, nystagmus)
Abdomen (bowel sounds)
Skin (color, diaphoresis)
Neuro (rigidity, reflexes, clonus)
(Things to consider in OD patients)
Labs that deserve discussion:
Urine Drug Screen
Urine Drug Screens
Some at other institutions:
- Substance-specific fluctuations
in specificity, sensitivity, NPV, PPV
- Differences in analyzers used
- Very rarely guides management decisions
False-positives: decongestants, bupropion, promethazine
MDMA, MDA variably detected
May not pick up many benzos (e.g., alprazolam, clonazepam)
False positives: efavirenz, PPIs (pretty rare)
Will not pick up synthetic cannabinoids
Cocaine - pretty freakin' reliable
False-positives: quinolones, ?poppy seeds?
Will miss most synthetic/semi-synthetics: methadone, fentanyl, hydrocodone, oxycodone, hydromorphone, buprenorphine
False--positives: venlafaxine, dextromethorphan
Osmolarity - # particles in 1 L solution
Osmolality - # particles per kg solution
2[Na+] + ([glucose]/18) + ([BUN]/2.8)
Chemistry and serum osmolality MUST be drawn at the same time!!
Depends who you ask
Quite different for each person
Generally accepted range: 10 6 mOsm/L
Things that raise your osm gap:
Osmotically active medications (e.g., ativan, etomidate)
In a sick tox patient with no history of toxic alcohol ingestion...
(Unless there is an incredibly high gap [>50])
ZERO role in the hospital setting
Essentially zero role in pre-hospital
Use has fallen out of favor
But utility still academically debatable
Must be a life-threatening ingestion
Can be performed within 60 minutes of TOI
Risk of the procedure is minimized
Whole Bowel Irrigation
Polyethylene glycol-electrolyte lavage solution (PEG-ELS)
Children: 25 mL/kg/h
Adults: 1.5-2 L/h
Can really only be performed w/ NGT
Continued until clear rectal effluent
Really hard to perform correctly
Decreases effectiveness of AC if given at same time
Few and specific indications
Ingestion of large amount of something that is not adsorbed well by AC and is associated with high morbidity.
Large iron overdoses
Other oral metal ingestions
Body PACKERS (not stuffers)
What is it?
1) Pyrolysis of carbonaceous materials:
Wood, coconut, petroleum, and/or peat
2) High temperature treatment with steam and/or carbon dioxide to form an internal maze of pores
Shortly after ingestion
Much longer after if one of a few substances that readily adsorbs: ASA, APAP, theophylline, TCAs
Must be adsorbable by charcoal
Not adsorbed by AC
Presumed GI perforation
When need endoscopy
Unprotected airway in a patient at risk for aspiration
Decreased bowel sounds
Simply Not Helpful
(And sometimes harmful)
Unknown adult ingestion/amount: give at least 50g
Weight-based widely taught but makes no sense
Ideal = AC:drug ratio of 10:1
BE CAREFUL with sorbitol - good for first dose but NOT to be repeated
Multi-dose activated charcoal
Xenobiotic-specific antibody fragments
Less Common Methods
Small molecular weight
Low protein binding
Small volume of distribution
Classic Best Drugs to Dialyze:
Toxic alcohols (including ethylene glycol, methanol, diethylene glycol, and propylene glycol)
Rare Drugs Amenable to Dialysis:
Dialyzable Drugs, Questionable Clinical Utility:
Isopropanol (essentially never necessary)
Advice on Consulting Renal to Dialyze a Toxin:
Offer to place the Quinton yourself
Not really a consult, simply a procedure that needs to happen
Rarely anything to trend - usually a yes/no decision
Specifically if Fomepizole is given, you cannot trend acid/base status!
Multi-Dose Activated Charcoal
Enhanced elimination, not decontamination
Entero-enteric or entero-hepatic circulation
Only certain drugs:
A - aminophylline (aspirin?)
B - barbiturates
C - carbamazepine
D - dapsone
Q - quinine
For drugs that are weak acids
Weak acids are ionized at alkaline urine pH
It's harder for ionized drugs to cross cell membranes
Ion trapping: "trapping" the ionized drug in the renal tubular lumen, preventing systemic re-absorption
How to Do It!
3 amps of sodium bicarb in 1L D5W
Infusion at 1.5x maintenance