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Overdose and poisoning
Overdose & Poisoning
Table of Contents
  • EPIDEMIOLOGY
  • MANAGEMENT

    • EPIDEMIOLOGY

    PAEDIATRIC

    • majority of O/D's (approx 80%)
    • usually accidental, peak age 2 years
    • approx 10% paeds admits

    ADULT

    • minority of all O/Ds ( 20%)
    • majority admitted (90%)
    • rarely accidental

    O/D's & POISONING

    • 1% all hospital admissions
    • 10% all ICU pts.
    • Mortality falling 4-5% p.a.due to prevention strategies, Poisons info centres & lines
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    MANAGEMENT

    MANAGEMENT SUMMARY
    EVALUATION
    DECONTAMINATION
    SUPPORTIVE CARE
    DIAGNOSTIC STUDIES
    ENHANCEMENT OF ELIMINATION
    ANTIDOTES
    TOXIC SYNDROMES
    DISPOSITION

    EVALUATION

    AIRWAY

    • Adequacy
    • Protective reflexes
    • Supplemental oxygen

    BREATHING

    • If inadequate intubate and ventilate prior to further Rx
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    CIRCULATION

    • Hypotension
    • Hypertension
    • IV Access
    • Monitor for arrhythmia

    DEGREE OF CONSCIOUSNESS

    • GCS is a useful guide though not specific for O/D.
    • If GCS < 9 needs intubation

    HISTORY OF EXPOSURE/ INGESTION

    • What, When, How many, Coingestants
    • Why?
    • Route of exposure

    PHYSICAL EXAMINATION

    • A thorough head to toe assesment
    • Identification of toxic syndromes
    • Any obvious complications e.g.aspiration
    • Coexistent diseases
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    DECONTAMINATION

    GASTRIC LAVAGE

    • useful < 2hrs after ingestion or longer with agents that are stongly anticholinergic
    • may be done in an awake pt. in left lateral with head down or in unconscious pt after intubation
    • best done with wide bore Orogastric tube 36 Adult, >14 Child
    • warm tap water 200ml/time until clear

    INDUCTION OF EMESIS

    • Ipecac syrup contains multiple alkaloids notably emetine
    • dose
      • 10ml 6-18/12
      • 15ml > 18/12
      • 30ml adult
    • onset emesis 10-25mins
    • offset emesis 30-120+mins
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    CONTRAINDICATIONS TO EMESIS

    • Coma, Convulsions, GCS<9
    • Caustic, Corrosive or Hydrocarbon ingestion
    • Rapid acting CNS stimulant e.g.strychnine, camphor, naphtha
    • Rapid acting CNS depressant e.g.TCA's, Eucalyptus oil
    • Anyone with impaired airway reflexes
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    ACTIVATED CHARCOAL

    • may be given via orogastric tube
    • adsorbs molecules to particle surface
    • 1000(m)2/gram surface area
    • proven effectiveness with many drugs
    • usually mixed with a cathartic e.g. mannitol or sorbitol
    • some use in repeated doses 4hrly
    DRUG ADSORPTION BY CHARCOAL

    POOR

    MODERATE

    WELL

    Cyanide aspirin Everything else
    Iron/Boron Paracetamol
    Li/Metals NSAIDS
    Corrosives Tolbutamide
    Organo-phosphates Cardiac drugs

    OTHER DECONTAMINATION

    REMEMBER : SKIN

    REMEMBER : EYES

    REMEMBER : CLOTHING

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    SUPPORTIVE CARE

    RESPIRATORY

    • VENTILATION * Supplemental O2
    • AIRWAY PROTECTION *Prevent aspiration
    • ANTIBIOTICS * For aspiration
    • PEEP * Non cardiogenic Pulm Oedema especially with narcotics & salicylates

    CARDIOVASCULAR

    • MONITOR: BP, HR, U/O, ECG & EUC'S
    • HYPOTENSION * Usually correctable with IV fluids, Inotropes
    • HYPERTENSION * Manage with vasodilators e.g. nifedipine, diazoxide, SNIP
    • BRADYCARDIA * Treat if CVS compromise with Atropine, Isopren, Pacing
    • TACHYCARDIA * Treat if cvs risk with cardioversion, beta blocker or lignocaine
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    CNS

    • DECREASED LOC * not a problem per se
    • SEIZURES * must be properly controllede.g. diazepam, midazolam or clonazepam phenytoin &/or phenobarb if resistant
    • BEHAVIOURAL DIFFICULTIES * usually as combativeness, aggression best Rx is physical and chemical restraint but be prepared to manage airway

    DIAGNOSTIC STUDIES

    BLOOD TESTS

    • paracetamol 4hrs post ing
    • FBC, EUC'S
    • ABG's
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    ECG

    * especially with TCA'S and cardioactive drugs

    X RAYS

    *may help with metal ingestion phenothiazines and chloral hydrate

    SPECIFIC DRUG LEVELS

    * only if Rx will be altered .

    ENHANCING ELIMINATION

    ACTIVATED CHARCOAL

    FORCED ALKALINE DIURESIS

    HAEMODIALYSIS/PERFUSION

    • Best suited to low MW
    • water soluble
    • low protein bind
    • high toxicity
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    ANTIDOTES

    SPECIFIC ANTIDOTES ARE FEW

    DRUG

    ANTIDOTE

    Opiates Naloxone
    Benzo's Flumazenil
    Paracetamol NAC/ Cimetidine
    Digoxin FAB Digibind
    OrganoPates Atropine/ PAM
    Cyanide Kelocyanor

    ASSOCIATED CONDITIONS

    CHRONIC ILLNESS

    TRAUMA

    ENVIRONMENTAL INFLUENCES

    All the above need to be considered in the setting of poisoning and/or overdose     Top of Page

    TOXIC SYNDROMES

    Syndrome Symptoms & Signs Causes Rx
    NARCOTIC CNS depression Miosis Respiratory & CVS depression Reversal of symptoms by Naloxone NARCOTICS of all types including codeine, diphenoxylate, dextropropoxyphene SUPPORT, CHARCOAL, NALOXONE
    ANTICHOLINERGIC CENTRAL *confusion, excitement, delirium, hallucination, ataxia, seizure, Resp/CVS collapse VAGOLYTIC * dry skin, mouth, mydriasis, tachycardia, hyperthermia, ileus, retention Atropine, Belladonna, PTZ's, TCA's Antihistamines. Rx: Support, Charcoal, NaHCO3, (?Physostig)
    CHOLINERGIC MUSCARINIC * 'SLUDGE ' syndrome plus bradycardia, hypotension, miosis NICOTINIC * muscle fasciculations, paralysis GANGLIONIC * tachycardia, hypertension CENTRAL * anxiety, restless, seizures Resp/CVS depression Organophosphates Amanita muscaria mushrooms Betel nut Bethanecol Supportive Charcoal Atropine ++++ Pralidoxime for O/P's
    SYMPATHOMIMETIC CNS EXCITATION * seizures CVS *either hypertension if alpha dominant or hypotension if beta. * tachycardia MYDRIASIS HYPERTHERMIA Theophylline, Amphetamine, Ephredrine, Cocaine, Caffeine, PCP.
    SYMPATHOLYTIC * SYMPTOMS AS FOR NARCOTIC BUT....NO RESPONSE TO NALOXONE! Clonidine, Aldomet, Alcohols Sedative Hypnotics Rx: Supportive, Charcoal & trial of Naloxone
    MOVEMENT DISORDERS DYSTONIAS, O/GYRIC CRISES, Antihistamines, Maxolon, Phenothiazines, Stemetil, Carbamazepine Narcotics, Amphetamine Phenytoin, Cocaine TCA's, Lithium, Strychnine Rx: Restraint, Charcoal, Benztropine IV or IM
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    DISPOSITION

    • MEDICAL FITNESS * at least alert , orientated, normal vitals, no neuroabnormality, no ongoing complications
    • PSYCHIATRIC FITNESS * able to be safely discharged with appropriate F/U
    • FORMAL SUICIDE RISK ASSESMENT
    Dr Chris Gavaghan FRACEM is the director of Accident & Emergency, Lismore Base Hospital, Lismore, NSW, Australia.

    Email:chrisg@doh.health.nsw.gov.au

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