Toxicity

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More Specific Terms

Introduction

Etiology

  • common agents associated with death
  • others

Epidemiology

  • opioids, including heroin, with highest death rate by far
  • ~80% of overdose deaths in 2015 were unintentional

Clinical-manifestations

Laboratory

Diagnostic-procedures

Complications

Management

  • supportive care
  • stabilization of cardiopulmonary status
  • empiric therapy for altered mental status
  • endotracheal intubation for comatose patients
  • oxygen administration
  • thiamine 100 mg IV
  • one ampule of 50% dextrose
  • naloxone 2-10 mg IV
  • removal of contaminated clothing
  • skin & eye decontamination [5]
  • copious eye irrigation
  • repeated cleansing of skin with soap & water
  • calcium for hydroflouric acid burns polyethylene glycol for phenol burns
  • gastric decontamination
  • ipecac
  • most efficacious when given within 30-45 minutes of ingestion
  • contraindications:
  • ingestion of caustic agents, hydrocarbons, drugs known to cause abrupt loss of consciousness or seizures, foreign bodies, non-toxic substances
  • unconscious patients, patients with seizures, patients with potential for inability to protect airway, patients with intentional ingestion
  • gut not working (antimuscarinic toxidrome)
  • gastric lavage
  • performed prior to administration of charcoal
  • 34-40 French orogastric tube (adults)
  • 150-200 mL aliquots of warm water or normal saline
  • 5-10 liters total
  • activated charcoal - with & without sorbitol
  • useful for salicylates, theophylline, benzodiazepines, carbamazepine & phenytoin overdoses
  • gastric decontamination CONTRAINDICATED ingestion of caustic agents
  • whole bowel irrigation
  • polyethylene glycol-electrolyte lavage solution to facilitate removal of ingested substances
  • indications
  • late presentation following ingestion
  • ingestion of sustained release pharmaceuticals
  • ingestion of toxic substances not removed by activated charcoal
  • foreign bodies
  • most commonly used for:
  • iron, lithium, cocaine packets, sustained release Ca+2 channel blockers
  • dosage:
  • 2 liters/hour for 5 hours (adults)
  • 500 mL/hr (children)
  • specific antidotes
  • specific antidote available for very few toxins & is not always needed
  • duration of antidote may be shorter than duration of toxin activity
  • antidote therapy does not replace gastric decontamination
  • opiates
  • antidote: naloxone
  • start with 2 mg
  • nasal naloxone kits & training for their use by non-healthcare professionals saves lives [8]
  • methanol or ethylene glycol
  • antidote: ethanol 10% solution
  • loading dose: 10 mL/kg
  • maintenance dose: 1.5 mL/kg
  • titrate to blood alcohol level of 22 mmol/L (100 mg/dL)
  • anticholinergics
  • antidote: physostigmine
  • 1-2 mg IV over 5 minutes
  • use only for severe delirium
  • may be useful for treating seizures or tachydysrhythmias but evidence lacking
  • organophosphate poisoning or carbamate insecticides
  • antidote: atropine & pralidoxime
  • atropine test dose: 2 mg IV
  • repeat in larger increments until drying of pulmonary secretions occurs
  • isoniazid
  • antidote: pyridoxine
  • give in gram per gram equivalent of what was ingested
  • start with 5 gm IV if amount ingested unknown
  • beta-blockers
  • antidote: glucagon
  • starting dose 5-10 mg IV
  • titrate to response (normalization of BP & HR)
  • maintenance dose of 2-10 mg/hr
  • tricyclic antidepressants (TCA)
  • digitalis glycosides (digoxin)
  • antidote: digoxin-specific antibodies
  • equimolar to ingestion
  • the number of mg of digoxin ingested / 0.6 is the number of vials required
  • if the amount of ingested digoxin is unknown & the patient has life-threatening arrhythmias, give 10-20 vials IV
  • if steady state serum digoxin concentration is known
 
*                        [digoxin (ng/mL) x 5.6 x weight in kg 
*          # of vials =  ------------------------------------- 
*                                       600


  • benzodiazepines
  • antidote: flumazenil (Romazicon)
  • 0.2 mg over 30 seconds
  • repeat q30 seconds up to 3 mg
  • contraindications
  • coingestion of tricyclic antidepressants (TCA)
  • patients taking benzodiazepines for control of seizures
  • calcium channel blockers
  • antidote: calcium chloride
  • 1 gm CaCl2 given IV over 5 minutes with continuous cardiac monitoring
  • may be repeated in life-threatening situations
  • serum calcium should be monitored after 3rd dose
  • data supporting this treatment lacking
  • acetaminophen
  • antidote: N-acetylcysteine
  • loading dose: 140 mg/kg PO
  • 70 mg/kg PO every 4 hours for a total of 17 doses
  • if 4 hour serum acetaminophen level is in the toxic range, all 17 doses of N-acetylcysteine must be given
  • thiamine
  • hemodialysis may be useful for specific agents
  • urine alkalinization
  • aspirin
  • phenobarbital
  • consultation with regional poison control center
  • National poison hotline (800) 222-1222 [1,2]

More General Terms

Additional Terms

References

  1. Prescriber's Letter 9(3):13 2002
  2. Prescriber's Letter 10(12):67 2003
  3. National poison hotline (800) 222-1222
  4. Prescriber's Letter 11(8): 2004 Poisonings in Toddlers Detail-Document#: [1] (subscription needed) [2]
  5. Daubert GP, Emergency Medicine, University of California, Davis
  6. The National Academy of Clinical Biochemistry (NACB) Recommendations for the use of laboratory tests to support poisoned patients who present to the emergency department Guideline withdrawn from National Guideline Clearinghouse March 2009 [3]
  7. CDC Grand Rounds: Prescription Drug Overdoses - a U.S. Epidemic MMWR January 13, 2012 / 61(01);10-13 [4]
  8. Walley AY et al Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis. BMJ 2013;346:f174 <PubMed> PMID: [5] <Internet> [6]
  9. Jones CM et al Pharmaceutical Overdose Deaths, United States, 2010 JAMA. 2013;309(7):657-659 <PubMed> PMID: [7] <Internet> [8]
  10. Medical Knowledge Self Assessment Program (MKSAP) 16, 17. American College of Physicians, Philadelphia 2012, 2015
  11. Centers for Disease Control and Prevention (CDC) Vital Signs: Overdoses of Prescription Opioid Pain Relievers and Other Drugs Among Women - United States, 1999-2010 MMWR. July 5, 2013 / 62(26);537-542 [9]
  12. Orciari Herman. Sofair A Laundry Detergent Pods Remain Serious Risk, Despite Changes to Packaging. Physician's First Watch, May 18, 2015 David G. Fairchild, MD, MPH, Editor-in-Chief Massachusetts Medical Society [10]
    - Davis MG, Casavant MJ, Spiller HA, Chounthirath T, Smith GA. Pediatric Exposures to Laundry and Dishwasher Detergents in the United States: 2013-2014 Pediatrics May 2016 PMID: [11]
  13. Haring RS, Sheffield ID, Frattaroli S Detergent Pod-Related Eye Injuries Among Preschool-Aged Children. JAMA Ophthalmol. Published online February 2, 2017 <PubMed> PMID: [12] <Internet> [13]
  14. Curtin SC, Tejada-Vera B, Warner M. Centers for Disease Control and Prevention (CDC) Drug Overdose Deaths Among Adolescents Aged 15-19 in the United States: 1999-2015. NCHS Data Brief No. 282, August 2017 [14]
  15. OD Prevention Program Locator Overdose Prevention Alliance [15]
  16. Poisoning: NIH Institute and Center Resources [16]
    - Toxnet Databases [17]
  17. California Poison Control System (800) 222-1222

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