1- Approach To The Poisoned Patient.pptx

Toxicity Management, Clinical Toxicology

1. APPROACH To…… The Poisoned Patient

2. A pproach to the Poisoned Patient A GEND A 1 2 3 4 5 Overview. Resuscitation Risk Assessment Observation Investigations 6 7 8 9 10 Decontamination Enhanced Elimination Antidotes Disposition Transportation

3. 1- Overview: Incidence of Acute Toxicity: Common Emergency Medicine Presentation . 100-400 Acute Toxicity Case / 100 000 population VISIT ER Annually.

4. Pattern of Acute Toxicity: “ HIGH Dynamic Medical Illness ” Marked Variability Marked Heterogenicity Nontoxic Life-Threatening Homicidal Accidental Suicidal

5. Clinician Needs …. Fixed Algorithm: … … To Diagnose & Treat All Forms of Toxicity In a C ustomized P attern .

6. Clinical Toxicology Knowledge Level: Range From … VERY Weak % ... To … VERY Strong % .

7. Make The Medical Care of Intoxicated Patients , at One Fixed Scientific Medical Level of … … Patient Care. Aim of this COURSE:

8. Underlying Causes of Toxicity: S ocial Problems . S ychiatric Problem . S ubstance Abuse Problems . P

9. WORST Case Scenario: D IFFICULT Risk Assessment … Even Very Well Condition CONSIDER … … P otentially L ife- T hreatening T oxicity.

10. A pproach to the Poisoned Patient 1 2 3 4 5 Resuscitation Risk Assessment Observation Investigations 6 7 8 9 10 Decontamination Enhanced Elimination Antidotes Disposition Transportation Overview. A GEND A

11. RESUSCITATION IN Acute Toxicity Case: A ir Way B reathing C irculation D etect & C orrect E mergency Antidotes.

12. NOTE 1 : P OISONING is a Leading Cause of Death & Cardiac Arrest DD IN < 40 years.: NOTE 2 : R esuscitation Procedure …TAKEN ALL PRIORITY EVEN Decontamination Procedures. NOTE 3 : V. GOOD Prognosis For Poisoning Related CA Resuscitation Prolonged CPR : Hours up to

13. LIFE-THREAT TOXIN (s) Trick (s) AIRWAY OBSTRUCTION Caustics (Acids/Alkalis) Endotracheal Intubation / Tracheostomy BREATHING     ACIDOSIS Methanol / Salicylates Artificial Hyperventilation / Na HCO3 Administration HYPOVENTILATION Opioids Naloxone RESPIRATORY FAILURE OP, ON & NG. Atropine HYPOXIA Paraquat Oxygen Low Flow “Saturation ~90%” CIRCULATION VENTRICULAR FIBRILLATION HydroFluric Acid Ca Mainly / DF “Useless Alone” VENTRICULAR TACHYCARDIA TC/Propranolol/Cocaine/LAA Intubation/Hyperventilation H2CO 3 Administration. VENTRICULAR TACHYCARDIA &/OR V ECTOPY HydroCarbons B-Blockers CARDIAC ARREST OR CV COLLAPSE Local Anesthetic Agent IV Lipid Emulsion REFRACTORY HYPOTENSION BB, CC Blockers, LAA Insulin High Dose Therapy TACHYCARDIA & HYPERTENSION Amphetamines/Cocaine BENZODIAZEPINE/B Blocker…X BRADYCARDIA Digoxin FAB Fragment Resuscitation TRICKs: AS B ASIC R ESUSCITATION A PPROACHES ….. NOT APPLY

14. Detect & Correct SEIZURES C haracter of Toxic Seizure … Generalised Focal Seizure is … Not Toxic : C ontraindicated LINE : Phenytoin: 1 st LINE : IV Benzodiazepines: 2 nd LINE : IV Barbiturates: S pecific LINE : IV Pyridoxin : TTT of TOXIC Seizures

15. Detect & Correct HYPOGLYCAEMIA D iagnosis T reatment A etiology

16. Detect and Correct Hypo/Hyper Thermia 36.7-37.2 ° C >37.2 ° C ... / ... > 39 ° C <36.7 ° C ... / ... < 29 ° C Diagnosis & TTT: Persistent Hyperthermia→ MOF Persistent Hypothermia→ CA Sequalae

17. E mergency Antidote Administration: LIFE-THREAT TOXIN (s) Trick (s) AIRWAY OBSTRUCTION Caustics (Acids/Alkalis) Endotracheal Intubation / Tracheostomy BREATHING     ACIDOSIS Methanol / Salicylates Artificial Hyperventilation / Na HCO3 Administration HYPOVENTILATION Opioids Naloxone RESPIRATORY FAILURE OP, ON & NG. Atropine HYPOXIA Paraquat Oxygen Low Flow “Saturation ~90%” CIRCULATION VENTRICULAR FIBRILLATION HydroFluric Acid Ca Mainly / DF “Useless Alone” VENTRICULAR TACHYCARDIA TC/Propranolol/Cocaine/LAA Intubation/Hyperventilation H 2 CO 3 Administration. VENTRICULAR TACHYCARDIA &/OR V ECTOPY HydroCarbons B-Blockers CARDIAC ARREST OR CV COLLAPSE Local Anesthetic Agent IV Lipid Emulsion REFRACTORY HYPOTENSION BB, CC Blockers, LAA Insulin High Dose Therapy TACHYCARDIA & HYPERTENSION Amphetamines/Cocaine BENZODIAZEPINE/B Blocker…X BRADYCARDIA Digoxin FAB Fragment

18. A pproach to the Poisoned Patient 1 2 3 4 5 Risk Assessment Observation Investigations 6 7 8 9 10 Decontamination Enhanced Elimination Antidotes Disposition Transportation Resuscitation A GEND A

19. 3- Risk Assessment Definition : Mental Process . Resuscitation Phase . Possible Clinical Course & Complications . Specific Situation .

20. 1 Components 2 Tasks 3 Applicability 3- Risk Assessment Criteria :

21. 4 Acceptability 5 Variability 6 Value 3- Risk Assessment Criteria :

22. 3- Risk Assessment & PIC : 1 Best Practice of Risk Assessment Process Done BY …Toxicologist : Due To : 2 Straight Forward & Time Consumed Decision : 3 VALUE of Consultation From PIC .

23. A pproach to the Poisoned Patient 1 2 3 4 5 Observation Investigations 6 7 8 9 10 Decontamination Enhanced Elimination Antidotes Disposition Transportation Risk Assessment A GEND A

24. 4- Observation: 1 AIM: 2 SITE: 3 PARAMETERS: 4 DURATION: 5 ENDORSEMENT : 6 ACTIONs : 7 Termination : ED EOU ICU

25. A pproach to the Poisoned Patient 1 2 3 4 5 Investigations 6 7 8 9 10 Decontamination Enhanced Elimination Antidotes Disposition Transportation Observation A GEND A

26. 4- Investigations : G eneral Tests T oxicological Tests RB Glucose ECG S Paracetamol B asic A dvanced Liver & Kidney Functions CBC & Electrolytes Clotting Profile B lood Poison Level U rine Poison Presence

27. 1-5 Days Average Turnaround Time . 1 Hour Valuable Medical Emergency INTERVENTION 15% Number Poisons with Results → Change Management Line. 300 Max. Number of Drugs/Poison Detected : IN BEST TOXICOLOGY LAB . 10,000 Possible Drugs or Toxins …. “PRODUCE TOXICITY” 6,000,000 Possible Chemicals …. “PRODUCE TOXICITY”. Role of Toxicology Laboratory

28. A pproach to the Poisoned Patient 1 2 3 4 5 6 7 8 9 10 Decontamination Enhanced Elimination Antidotes Disposition Transportation Investigations A GEND A

29. e C ontamination D

30. Surface Gastro-Intestinal Types

31. Skin Decontamination : Personal Protection Victim Washing Chemical Neutralization Extravasation Toxicity

32. Eye Decontamination : 4 th : Check pH of the victim’s tear 5 th : Examine of the Eye & Refeer . 1 st : Remove any Contact Lenses . 2 nd : Drops Local anesthetic agent . 3 rd : Flush exposed eyes with copious amount of FLUIDS . 5 STEPS

33. Eye Decontamination : Cornea Morgan Lenses Nasal Cannula Direct Flushing

34. Lung Decontamination : 1 st: Personal Protection : 3 rd Give Oxygen . 5 th VICTIM Intubate . 4 th CLOSE Observation . 2 nd Victim Remove .

35. Surface Gastro-Intestinal Types

36. Methods of Gastro-Intestinal Decontamination: Induced Emesis Gastric Lavage Activated Charcoal Whole Bowel Irrigation

37. Benefits/Risks Potential Benefits Potential Risks ↓ Morbidity & Mortality ↓ Supportive Care ↓ Other TTT Lines ↓ Hospital length ↑ Pulmonary Aspiration. ↑ GIT Complication. ↑ T reating Staff Distraction. ↑ ER Resources Consumption

38. Emesis

39. Emesis 1 2 3 4 5 6 1 2 3 4 5 6 Definition . Incidence . History . Source . Mechanism Efficiency 30% 40-50% 60%

40. Emesis 1 2 3 4 5 6 7 8 9 10 11 12 INTERFERE . Indication s . Availability . Dose. . C omplications Others

41. Methods of Gastro-Intestinal Decontamination: Induced Emesis Gastric Lavage Activated Charcoal Whole Bowel Irrigation

42. Gastric Lavage DEFINITION . INCIDENCE . EXPERIENCE . INDICATION . TECHNIQUE . CONTRAs. PROCEDURE COMPLICS. LAVAGE &

43. Gastric Lavage 1 Measure Tube’s Length . 2 Introduce Lubricated Ryle Tip . 3 Pass Down Gentilly . 4 Stop if any Resistance Occurs . 5 Confirm the Tube Position .

44. Gastric Lavage 6 ASPIRATE as much as possible . 7 Administrate a tap water or saline . 8 Drain or Aspirate stomach content . 9 Repeat the Procedure . 10 Give Activated charcoal .

45. Activated CHARCOAL

46. Activated CHARCOAL Manufacture 1 Surface Area 2 POWER 3 Onset & Duration 4 BONDS 5 PARAMETER 6 1 Minute

47. Activated CHARCOAL Efficiency 7 Strength 8 Ingestion Time 9 Benefits 10 COMPLICATIONs 11 Prerequisite 12 10:1

48. Activated CHARCOAL Criteria 13 Contraindications . 14 POWERLESS 15 SIDE EFFECTS 16 SINGLE DOSE 17 MULTIPLE DOSES 18

49. Whole Bowel irrigation 1 DEFINITION 2 INDICATIONs 3 CONTRS-INDICATIONs

50. Whole Bowel irrigation A SINGLE NURSE. SUFFICIENT SUPPLY NG TUBE ACTIVATED CHARCOAL PEG COMMODE METOCLOPRAMIDE END POINT EFFICIENCY STOP

51. A pproach to the Poisoned Patient 1 2 3 4 5 6 7 8 9 10 Enhanced Elimination Antidotes Disposition Transportation Decontamination A GEND A

52. Elimination Enhancement: TYPES Decision End Points Therapy

53. Multiple Doses Activated Charcoal 1 DOSE 2 CONCEPT 3 MECHANISMs 4 VALUE & INDICATIONs

54. Urinary Alkalinisation MECHANISM DRUG CRITERIA Acidic - Small Vd - Filtered By Glomeruli INDICATIONs Salicylates - Barbiturates CONTRAINDICATIONS Volume Overload COMPLICATIONS ↑ pH, ↑ Water, ↓ K & ↓ Ca PRECAUTIONS 1 st Correct Hypokalaemia TECHNIQUE Na HCO3 ..&.. K MONITORING Blood/4 hrs … Urine/ hr Therapeutic End Point Clinical & Laboratory FREE TRICK Forced Diuresis : 1 L/ hr … Obsolete 1 2 3 4 5 6 7 8 9 10 Alkalinization of URINE → ↓ Renal Reabsorption → ↑ U rinary Excretion.

55. TYPES: Haemodialysis Haemofiltration, Haemoperfusion , Plasmapheresis, Exchange transfusion. 1 COMPLICATIONS: Invasive. Require specialised staff, Equipment & Monitoring. Significant complications. 2 INDICATIONS Severe TOXICITY 3 Extra-Corporeal Techniques of Elimination

56. Haemodialysis: Indications: TYPES: InterMittent > CONTINOUS M ethanol S alicylates T heophylline A ntiepileptics L ithium K salt M etformin E thylene glycol CRITERIA: Small Molecule Small Vd Rapid Redistribution from TISSUES Slow Elimination From the BODY .

57. A pproach to the Poisoned Patient 1 2 3 4 5 6 7 8 9 10 Antidotes Disposition Transportation Enhanced Elimination A GEND A

58. AntiDotes: Correct The Effects Of Poisoning. Few …. Reported. Many …Rarely Prescribed & Expensive. All Have … √, X, Ds, Rt, M & TE Points. Giving Decision : Risk-Benefit Analysis. National Stocking: Cheaper & Safer. 1 2 3 4 5 6 Anti-Dote

59. A pproach to the Poisoned Patient 1 2 3 4 5 6 7 8 9 10 Disposition Transportation Antidotes A GEND A

60. DisPosition : A Medical Observation … For All Potential Toxicity Patients . Best Observation... Emergency Observation Units (EOUs). CHARACTERS: Not Present In Most of Hospital Adjacent To Emergency Departments, Emergency Doctors Short-term Care. BENEFITS: a Suitable Management Condition ↓ Total Bed Days ↑ Patient Satisfaction ↓ Inappropriate Discharges And Litigation.

61. Toxicology Patients in EOU 1 2 3 4 5 Scattered Admissions all over the hospital Dealing with Less experienced nursing staff Poor availability of Experienced Toxicology Staff . Frequent security incidents/absconding patients Longer admissions. Is Very Effective …. Because IT AVOID :

62. A pproach to the Poisoned Patient 1 2 3 4 5 6 7 8 9 10 Transportation Disposition A GEND A

63. Poisoned Patient Transfer If the medical service is Not Adequate … Immediate transport to Site with Adequate Medical Care: 1 2 3 4 5 Risk Assessment . Indication For Transfer . Worst Phase of Toxicity . Adequate Care . Capable Medical Center . PRINCIPLES

64. Communication : With Medical Provider Psychosocial Assessment: For all intentional exposures Planning: Dramatic Complication Transport: Worst Period of Setting Resuscitation: 1 st Priority 1 2 3 4 5 Poisoned Patient Transfer

65. Poisoned Patient Transfer Main Principle: Bring E xpertise & R esources to the patient NOT transfer patient to Expertise & Resources. ……… IF POSSIBLE

66. A pproach to the Poisoned Patient 1 2 3 4 5 6 7 8 9 10 Transportation A GEND A