Toxin

Unknown Ingestion

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Unknown Ingestion, Toxin Ingestion, Medication Overdose, Poisoning, Accidental Ingestion, Intentional Drug Overdose, Overdose, Toxidrome

  • History
  • Approach
  1. Talk to paramedics and family who were at scene
  2. Review pill bottles including OTC agents
  3. Review drug paraphernalia as well as unusual wrappers and containers
  • History (Mnemonic
  • History MATtERS)
  1. Materials or Medications
  2. Amount and concentration
  3. Time taken
  4. Emesis
  5. Reason
  6. Signs and Symptoms
  • Evaluation
  • Mass Casualty Exposure
  1. Consider Exposure possibilities
    1. Biological Weapon
    2. Chemical Weapon
  2. Mnemonic: Asbestos
    1. Agents
      1. Type and toxicity of agent
      2. Potential Lethality of exposure
    2. State
      1. Solid or Liquid
      2. Gas, Vapor, or Aerosol
      3. State combination
    3. Body Site
      1. Where exposure occurred
      2. Routes of entry and absorption
    4. Effects
      1. Local
      2. Systemic
    5. Severity
      1. Mild, moderate or severe effects and exposure
    6. Time course
      1. Past: When did symptom onset occur
      2. Present: Getting better or worse?
      3. Future: Prognosis
    7. Other diagnoses
      1. Differential diagnosis
      2. Additional or combination diagnoses
    8. Synergism
      1. Combined effects of multiple exposures
  • Labs
  1. Complete Blood Count
  2. Comprehensive Metabolic Panel
    1. See Metabolic Acidosis with Anion Gap
    2. Anion Gap calculation is critical
  3. Arterial Blood Gas (ABG) or Venous Blood Gas (VBG)
  4. Serum Osmolality (where available)
    1. Alerts to possible toxic Alcohol ingestion (e.g. Polyethylene glycol)
    2. May indicate starting antidote (e.g. Fomepizole) empirically
  5. Urinalysis
  6. Urine Tox Screen (Urine superior to blood)
  7. Urine Pregnancy Test (if indicated)
  8. Carboxyhemoglobin (Obtain immediately if Carbon Monoxide Poisoning suspected)
  9. Creatinine Phosphokinase (CPK)
    1. Indicated if Rhabdomyolysis suspected
  10. Drug Levels in all Overdose cases
    1. Serum Aspirin Level (obtain 6-12 hours after ingestion)
    2. Serum Acetaminophen Level (obtain 4 hours after ingestion; also consider at 2 hours)
    3. Blood Alcohol level (obtain 0.5 to 1 hour after ingestion)
  11. Drug levels when indicated
    1. Serum Theophylline Level
    2. Serum Digoxin Level (obtain 2-4 hours after ingestion)
    3. Serum Amitriptyline Level
    4. Serum Iron level (obtain 2-4 hours after ingestion)
  12. Consider evaluation for serious infection
    1. See Septic Shock
    2. See Meningitis
    3. See Bacterial Endocarditis (e.g. IV Drug Abuse)
    4. Consider Blood Cultures and Serum Lactic Acid
    5. Consider Lumbar Puncture
  • Labs
  • Red Flags
  1. Metabolic Acidosis with elevated Anion Gap
  2. Elevated Osmolar Gap
  1. Indicated in all cases (esp. if Tricyclic Antidepressant or Antipsychotic Overdose suspected)
  2. Obtain serial EKGs during emergency department evaluation
  3. Monitor continuous telemetry
  4. Findings suggestive serious cardiotoxicity (and risk of Ventricular Tachycardia or Torsades)
    1. Prolonged QT interval
      1. See Prolonged QT Interval due to Medication
      2. Causes include Antipsychotics, Anticholinergics, Sympathomimetics, Antidepressants
    2. Wide QRS (e.g. Tricyclic Antidepressant Overdose)
      1. Causes include Tricyclic Antidepressants, Cocaine, Diphenhydramine, Antiarrhythmics
  • Imaging
  1. CT Head
    1. Consider in all patients with Altered Level of Consciousness
  2. CT Cervical Spine
    1. Consider at time of CT Head if suspicion for Cervical Spine Injury
    2. Maintain spine precautions until cleared by exam in a CNS intact patient
  3. Chest XRay Indications (indicated in most Altered Level of Consciousness patients)
    1. Chemical pneumonitis
    2. Toxin Induced pulmonary edema
    3. Pneumothorax
  4. Abdominal XRay (KUB) Indications
    1. See Radiopaque Toxins
  • Differential Diagnosis
  • Toxidromes
  1. Sympathomimetic Toxicity (e.g. Amphetamine, Cocaine, Ephedrine)
    1. Tachycardia, Hypertension, hyperthermia, diaphoresis, arrhythmia
    2. Mydriasis, Agitation
  2. Cholinergic Toxicity (e.g. Organophosphate, Pesticide)
    1. SLUDGE: Salivation, Lacrimation, urination, Defecation, gastrointestinal, Emesis
  3. Anticholinergic Toxicity (e.g. Diphenhydramine, Atropine, scopolamine, Jimson weed)
    1. Mad as a hatter (altered)
    2. Blind as a bat (Mydriasis)
    3. Red as a beet (flushed)
    4. Hot as a hare (hyperthermia)
    5. Dry as a bone
  4. Opioid Toxicity (e.g. Heroin, Morphine)
    1. Central Nervous System depression (sedation to coma)
    2. Respiratory depression (apnea)
    3. Miosis
  5. Sedative-Hypnotic Toxicity (e.g. Benzodiazepine Toxicity, Barbiturates, anticonvulsants, Alcohol)
    1. Central Nervous System depression (sedation to coma)
    2. Respiratory depression (apnea)
    3. Confusion, Delirium, Hallucinations
  6. Other presentations
    1. Serotonin Syndrome
    2. Drug Withdrawal
    3. Club Drug or Date Rape Drug
    4. Serious Infection ( Septic Shock, Bacterial Meningitis, Bacterial Endocarditis)
  7. References
    1. ACLS (2013) Provider Manual, AHA, p. 282
  1. See Date Rape Drug
  2. Precautions
    1. Substances of abuse are difficult to distinguish by sight
    2. White powder could be Cocaine, Methamphetamine, synthetic Opioids, NBOMe or bath salts
    3. Crystals could be Crystal Meth, U-47700
    4. Many substances of abuse are reformulated into tablets
      1. Fentanyl may be formed in tablets similar to Oxycodone or Hydrocodone
  3. Alcohol
    1. See Alcohol Abuse
    2. Ethanol-based hand sanitizer (especially in health care centers)
      1. Hand sanitizer can cause significant Alcohol Intoxication (60% Alcohol)
      2. Some abusers of hand sanitizer extract the Alcohol with salt
  4. Cannabinoids (Marijuana, K2, Spice)
    1. See Marijuana (includes Synthetic Cannabinoids such as K2)
    2. Most common drug of abuse in U.S. and progressively increasing annually among grades 8-12
  5. Opioids (e.g. Oxycodone, Morphine, Heroin)
    1. See Opioid Abuse
    2. Opioid Overdose (Narcotic Overdose)
  6. Sedative-Hypnotics
    1. Benzodiazepine Abuse
    2. Benzodiazepine Overdose
    3. Gamma Hydroxybutyrate (GHB)
  7. Stimulants (Sympathomimetics)
    1. Cocaine
    2. Methamphetamine
    3. Synthetic Cathinones (Psychoactive Bath Salts)
    4. Methylenedioxymethamphetamine (MDMA, Ecstasy)
  8. Volatile Inhalants (Sniffing, Huffing, Bagging)
    1. More common drug of abuse in ages 10-14 years old
    2. Risk of Sudden Sniffing Death Syndrome
  9. Hallucinogens
    1. Ketamine Abuse (and Methoxetamine)
    2. Phencyclidine (PCP)
    3. Dextromethorphan Abuse
  • Management
  • General
  1. See Altered Level of Consiousness
  2. Involve poison control early
    1. http://www.aapcc.org/
    2. U.S. Phone: 1-800-222-1222
  3. Consider Coma cocktail (consider for unknown drug ingestion with Altered Level of Consciousness)
    1. Dextrose 25% to 50% (for Hypoglycemia demonstrated by Glucometer)
    2. Naloxone 0.4-2 mg IV (for possible Narcotic Overdose)
    3. Other agents to consider
      1. Thiamine (Alcoholic or malnourished patients)
      2. Flumazenil (for possible Benzodiazepine Overdose)
        1. Uncommon emergency use due to the risk of severe Benzodiazepine Withdrawal (e.g. Seizures)
        2. Use only with caution (due to risk of serious withdrawal in Benzodiazepine addiction)
  4. Consider Toxin Antidotes
  5. Consider Gastric Decontamination with charcoal if presentation within 1-2 hours of poison ingestion
    1. See Activated Charcoal for indications and contraindications
      1. Drugs must be bound by charcoal and patient must be alert or with protected airway
    2. Activated Charcoal given within 30 minutes after ingestion: Decreases absorption by 70%
    3. Activated Charcoal given within 30-60 minutes after ingestion: Decreases absorption by 30%
    4. Do not use Gastric Lavage
  6. Consider Decontamination
    1. Protect medical personnel
      1. Liquid toxin
      2. Vapor off-gassing from patient
    2. Protect patient from further injury
  7. Consider Hemodialysis (for drugs cleared by Dialysis)
  8. Supportive Care
    1. ABC Management
    2. IV Access and appropriate hydration
    3. Oxygen Delivery
    4. Control Seizures (see Status Epilepticus)
  9. Advanced Airway (as indicated)
    1. Rapid Sequence Intubation
      1. Rocuronium is preferred paralytic in ingestions
      2. Risk of Hyperkalemia (which would contraindicate Succinylcholine)
        1. Overdosage with ACE Inhibitors or Digoxin
        2. Rhabdomyolysis associated with unconscious from Overdose
  10. Cardiac monitor
    1. Control dysrhythmias
    2. QRS Widening on EKG
      1. Sodium Bicarbonate 1-2 ampules IV push (requires numerous back-to-back doses until QRS narrows)
  • Management
  • Specific Ingestions
  • Disposition
  1. See Clinical Sobriety
  2. Indications for emergency department discharge
    1. Return to baseline mental status and
    2. Minimal to no residual symptoms and
    3. Hemodynamically stable Vital Signs and
    4. No psychological safety concerns (not suicidal, and no intentional Overdose)
  3. Resources
    1. National Suicide prevention lifeline: 1-800-273-TALK
    2. Substance Abuse and Mental Health Referral Hotline (SAMSHA): 1-800-662-HELP
  • Prevention
  • Childhood Poisonings
  1. See Accidental Poisoning Causes for most common childhood Poisonings
  2. See Medication Dosing Errors in Children
  3. Background
    1. Medication Poisonings are responsible for two-thirds of deaths in children under age 5 years old
    2. U.S. and Canadian restrictions in 2008 on OTC medications for infants and children
      1. Has effectively reduced childhood Poisonings
  4. Education
    1. Do not rely on child-resistant medications as sole protection against Poisoning
    2. Store all medications including pill boxes in a safe place after every time they are accessed
      1. Purses containing medications should also be kept safely away from toddlers and children
    3. Dispose of medications properly
      1. See Medication Disposal
    4. Talk to children about danger of household products
      1. Medications, laundry pods and dish detergent pods, household cleansers are absolutely not candy
    5. Dispose of Ipecac syrup if still in household
      1. No longer recommended (risk of harm such as aspiration, not helpful, and may delay definitive care)
    6. Adults should also Exercise caution to prevent their Accidental Ingestions
      1. Read medication bottles carefully to confirm the medication they are taking (and proper dose)
      2. Turn on the light when using toiletries (e.g. confirm toothpaste tube)
    7. Keep critical phone numbers by telephone (consider programming into telephone)
      1. Poison Control Center: 1-800-222-1212