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Toxicologie
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7/18/2019 Bradic. toxicologie
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“What is it that is not a poison?
All things are poison and nothing iswithout poison.
It is the dose only that makes a thing
not a poison.”
—Paracelsus (1493-1541), the Renaissance
“Father of Toxicolog,! in his Thir" #efense$
Toxicology-What Every
Emergency Physician
Should Know
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Dr Michael HaDr Michael HaUniversity of Manitoba
Section of Emergency Medicine
Dr John SoalDr John SoalEmergency Medicine
Health Sciences Centre
Dr !o" SweetlandDr !o" SweetlandEmergency Medicine
Health Sciences Centre
Presenters
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#ME $"%ectives
Be familiar with the initialBe familiar with the initial
management and stabilization of toxicmanagement and stabilization of toxic
ingestionsingestions
Be able to recognize overdoses byBe able to recognize overdoses by
their clinical featurestheir clinical features
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#ase
3 !emale Comatose3 !emale Comatose
"u#ils mm $CS % & S#'"u#ils mm $CS % & S#' % (&)% (&)
B" *&+,, H- .' -- (B" *&+,, H- .' -- (
/hat methods of ra#id reversal are/hat methods of ra#id reversal are
available0available0
How can we decontaminate her gut0How can we decontaminate her gut0
/hat a##roach in case of life threatening/hat a##roach in case of life threatening
120120
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Her EK&
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'#oma #octail(
Consider in all unnown causes ofConsider in all unnown causes ofcoma and decreased 41Ccoma and decreased 41C
5 2,'/ 6 unless 7ccuchec available2,'/ 6 unless 7ccuchec available5 8hiamine 6 alcoholics only8hiamine 6 alcoholics only
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'#oma #octail(
9aloxone :9arcan;9aloxone :9arcan;5 '<= 6 <' mg >?@ >M@ SC@ E88'<= 6 <' mg >?@ >M@ SC@ E88
2uration .A hours2uration .A hours
+A sage at +3 bolus + hour +A sage at +3 bolus + hour Higher doses withHigher doses with
5 "entazocine :8alwin;"entazocine :8alwin;
5 CodeineCodeine5 2i#henoxylate :4omotil;2i#henoxylate :4omotil;
5 "ro#oxy#hene :2arvon;"ro#oxy#hene :2arvon;
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#ase )*ost +arcan,
3 !emale Comatose3 !emale Comatose
"u#ils"u#ils =mm=mm $CS % .' S#'$CS % .' S#' % *.) :r+a;% *.) :r+a;
B" *&+,, H- .'B" *&+,, H- .' --.=--.=
/hat methods of ra#id reversal are/hat methods of ra#id reversal are
available0available0
How can we decontaminate her gut0How can we decontaminate her gut0
/hat a##roach in case of life threatening/hat a##roach in case of life threatening
120120
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Toxic &rill
7ctivated Charcoal will adsorb all the 7ctivated Charcoal will adsorb all the
following medsfollowing meds except:except:
a<a< "henobarbital"henobarbital
b<b< 8heo#hylline8heo#hylline
c<c< !errous sulfate!errous sulfated<d< ?era#amil?era#amil
e<e< SalicylatesSalicylates
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Toxic &rill
7ctivated Charcoal will adsorb all the 7ctivated Charcoal will adsorb all the
following medsfollowing meds except:except:
a<a< "henobarbital"henobarbital
b<b< 8heo#hylline8heo#hylline
c<c< !errous sulfate!errous sulfated<d< ?era#amil?era#amil
e<e< SalicylatesSalicylates
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& Decontamination
*ecac*ecac5 +o+o role for >#ecac in managementrole for >#ecac in management
of overdoses in the E2 settingof overdoses in the E2 setting
&astric .avage&astric .avage5 9o evidence of im#roved outcomes9o evidence of im#roved outcomes
5 Contraindicated with corrosives andContraindicated with corrosives andhydrocarbonshydrocarbons
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& Decontamination
Charcoal ,'gm :.g+g;Charcoal ,'gm :.g+g;
5 !irst line decontamination method!irst line decontamination method
5
2oesnt adsorbD2oesnt adsorbDHeavy metalsHeavy metals
HydrocarbonsHydrocarbons
7cids + 7lalis 7cids + 7lalisEthanolEthanol
5 -e#eated doses for 8heo#hylline-e#eated doses for 8heo#hylline
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Toxic &rill
/hole bowel irrigation is recommended/hole bowel irrigation is recommended
in all of the following ingestionsin all of the following ingestions
except:except:
a<a< 4ead #aint chi#s4ead #aint chi#s
b<b< Cocaine #acetsCocaine #acets
c<c<
Button batteriesButton batteriesd<d< HydrocarbonsHydrocarbons
e<e< SustainedArelease lithium tabletsSustainedArelease lithium tablets
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Toxic &rill
/hole bowel irrigation is recommended/hole bowel irrigation is recommended
in all of the following ingestionsin all of the following ingestions
except:except:
a<a< 4ead #aint chi#s4ead #aint chi#s
b<b< Cocaine #acetsCocaine #acets
c<c<
Button batteriesButton batteriesd<d< HydrocarbonsHydrocarbons
e<e< SustainedArelease lithium tabletsSustainedArelease lithium tablets
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& Decontamination
/hole Bowel >rrigation/hole Bowel >rrigation
5 Heavy metalsHeavy metals
5
SustainedArelease medsSustainedArelease meds5 $o4ytely$o4ytely
,'' 6 ''' ml+hr ,'' 6 ''' ml+hr
,cc+g+hr #eds,cc+g+hr #eds+A metoclo#ro#amide+A metoclo#ro#amide
=A& hours duration=A& hours duration
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Enhanced Elimination
Urinary 7lalinizationUrinary 7lalinization
SalicylatesSalicylates
5
.A me+Fg bolus then 3 am#s.A me+Fg bolus then 3 am#s9aBicarb in (,'cc 2,/9aBicarb in (,'cc 2,/
5 .,' 6 ,' cc+hr .,' 6 ,' cc+hr
5
Urine #H G<,Urine #H G<,5 7dd ' 6 =' me FCl + 4 7dd ' 6 =' me FCl + 4
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Enhanced Elimination
Hemodialysis and CharcoalHemodialysis and CharcoalHemo#erfusionHemo#erfusion5 Confer with a "oison ControlConfer with a "oison Control
Centre@ 8oxicologist@ 9e#hrologistCentre@ 8oxicologist@ 9e#hrologist
5 7S7@ 8oxic 7lcohols@ 4ithium 7S7@ 8oxic 7lcohols@ 4ithium
5 MB "CC (A,*.MB "CC (A,*.5 8oxicology 6 HSC "aging (A'.8oxicology 6 HSC "aging (A'.
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Management Ste*s
.<.< 7BCs 7BCs
<< >mmediate consideration of IComa>mmediate consideration of IComa
CoctailJ treatmentsCoctailJ treatments
3<3< $ather information$ather information
=<=< 2econtaminate $> tract2econtaminate $> tract
/0/0 Su**ort PatientSu**ort Patient&<&< Enhanced EliminationEnhanced Elimination
<< 7ntidotes 7ntidotes
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.i1e Threatening $verdose
-es#iratory 2e#ression0 Hy#oxia0-es#iratory 2e#ression0 Hy#oxia0
5 7ssist res#irations 7ssist res#irations
5
>ntubate as necessary>ntubate as necessary5 Sus#ected 1#iates or Unnown0Sus#ected 1#iates or Unnown0
"u#ils and -es#irations"u#ils and -es#irations
9aloxone mg >?9aloxone mg >?
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Toxic &rill
7ll the following drugs can cause miotic 7ll the following drugs can cause miotic
#u#ils#u#ils except:except:
a<a< ClonidineClonidine
b<b< M2M7M2M7
c<c< 1rgano#hos#hates1rgano#hos#hates
d<d< HeroinHeroine<e< CodeineCodeine
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Toxic &rill
7ll the following drugs can cause miotic 7ll the following drugs can cause miotic
#u#ils#u#ils except:except:
a<a< ClonidineClonidine
b<b< M2M7M2M7
c<c< 1rgano#hos#hates1rgano#hos#hates
d<d< HeroinHeroine<e< CodeineCodeine
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The Eyes Have t
MiosisMiosis 1#iates61#iates6
5 BU8 dilated withDBU8 dilated withD
Me#eridine :2emerol;Me#eridine :2emerol; "ro#oxy#hene :2arvon;"ro#oxy#hene :2arvon; Hy#oxia@Hy#oxia@ CoAingestants@ 4omotil:mixed agent;CoAingestants@ 4omotil:mixed agent;
Cholinergics@ "henothiazinesCholinergics@ "henothiazines 7bsence of miosis doesnt rule out o#iate 7bsence of miosis doesnt rule out o#iate
ingestioningestion
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The Eyes Have t
MydriasisMydriasis
5 7nticholinergics 7nticholinergics
5
Sym#athomimeticsSym#athomimetics
+ystagmus+ystagmus
5 Ethanol@ 4ithium@ "henytoin@Ethanol@ 4ithium@ "henytoin@Carbamaze#ine@ SedativeAhy#noticsCarbamaze#ine@ SedativeAhy#notics
5 ?ertical 9ystagmus A "C"?ertical 9ystagmus A "C"
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.i1e Threatening $verdose
Evidence of acute cardiacEvidence of acute cardiac
manifestations0manifestations0
Chest #ain0Chest #ain0
EF$ and 3Alead rhythm stri#EF$ and 3Alead rhythm stri#
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.i1e Threatening $D - EK&
?ery im#ortant to do EF$@ es# in?ery im#ortant to do EF$@ es# in
8C7@ BetaA and CaABlocers8C7@ BetaA and CaABlocers
5 8C7D8C7D
8achycardia@ K-S widening8achycardia@ K-S widening
-ightward shift of terminal '<'= s-ightward shift of terminal '<'= s
of frontal #lane K-Sof frontal #lane K-S5 ie #rominent - in 7?-ie #rominent - in 7?-
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T#2 EK&
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.i1e Threatening $verdose
/ide Com#lex 8achycardia with/ide Com#lex 8achycardia with#ulse0#ulse0
EF$ evidence of 8C7 120EF$ evidence of 8C7 1205 Sodium BicarbonateSodium Bicarbonate
.A me+g.A me+g8itrate to K-S narrowing or8itrate to K-S narrowing or
#H <,#H <,5 >f cocaine@ may also try lidocaine>f cocaine@ may also try lidocaine5 7?1>2 #rocainamide 7?1>2 #rocainamide
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Toxic &rill
Bradycardia is commonly associatedBradycardia is commonly associated
with all the following overdoseswith all the following overdoses
except:except:
a<a< ClonidineClonidine
b<b< 2igoxin2igoxin
c<c< "ro#anolol"ro#anolol
d<d< MethadoneMethadone
e<e< 7m#hetamines 7m#hetamines
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Toxic &rill
Bradycardia is commonly associatedBradycardia is commonly associated
with all the following overdoseswith all the following overdoses
except:except:
a<a< ClonidineClonidine
b<b< 2igoxin2igoxin
c<c< "ro#anolol"ro#anolol
d<d< MethadoneMethadone
e<e< 7m#hetamines 7m#hetamines
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.i1e Threatening $verdose
7cute coronary syndrome associated 7cute coronary syndrome associated
with Cocaine0with Cocaine0
5 9itrates9itrates
5 Benzodiaze#inesBenzodiaze#ines
5 7s#irin 7s#irin
5
"hentolamine if #ersistent severe"hentolamine if #ersistent severehy#ertensionhy#ertension
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.i1e Threatening $verdose
Hy#otension0Hy#otension0
5 !luids!luids
-esistant shoc0-esistant shoc0
E#ine#hrine or nore#ine#hrineE#ine#hrine or nore#ine#hrine
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.i1e Threatening $verdose
Hy#otension associated withDHy#otension associated withD
5 8C708C70
Bicarbonate to #H <,' 6 <,,Bicarbonate to #H <,' 6 <,,
5 CaAchannel Blocer0CaAchannel Blocer0
CaCl .A3 $ms >?CaCl .A3 $ms >?
5 CaAchannel or Beta Blocer0CaAchannel or Beta Blocer0$lucagon ,A.' mg >? bolus then$lucagon ,A.' mg >? bolus then
hourly dri#hourly dri#
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.i1e Threatening $verdose
Status Seizures0Status Seizures0
5 $lucose if hy#oglycemia$lucose if hy#oglycemia
5
4oraze#am '<. mg+g >?4oraze#am '<. mg+g >?
5 "henobarbital 'A3' mg+g >?"henobarbital 'A3' mg+g >?
5 7?1>2 #henytoin 7?1>2 #henytoin
5 >soniazid0>soniazid0"yridoxine , gm 7dult@ . gm "ed"yridoxine , gm 7dult@ . gm "ed
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.i1e Threatening $verdose
"rofound Coma0"rofound Coma0
5 Ensure airway controlEnsure airway control
5
Coma CoctailComa Coctail
5 Consider C8 scan :occult trauma;Consider C8 scan :occult trauma;
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.i1e Threatening $verdose
Severe Metabolic 7cidosis0Severe Metabolic 7cidosis0
5 Bicarb and loo for causeBicarb and loo for cause
8oxic 7lcohols8oxic 7lcohols
SalicylatesSalicylates
>ron>ron
4actic 7cidosis from shoc4actic 7cidosis from shoc2F72F7
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Elevated 7$ Metabolic 7cidosis
)MET2. 2#D &2P,MMethanolethanol@ Metformin@ Metformin
EEthylene $lycolthylene $lycol
TTolueneoluene
22lcoholic F7lcoholic F7
..acticactic
22minogycosides@ other uremic agentsminogycosides@ other uremic agents
##yanide@ C1yanide@ C1
ron@ron@ >soniazid>soniazidDDF7F7
&&eneralized Seizureseneralized Seizures
22S7S7
PParaldehydearaldehyde
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Toxic &rill
7ll of the following toxins are #ro#erly 7ll of the following toxins are #ro#erly
matched with their associated odourmatched with their associated odour
except:except:
a<a< Cyanide + Bitter almondsCyanide + Bitter almonds
b<b< Methylsalicylate + 1il of /intergreenMethylsalicylate + 1il of /intergreen
c<c< 1rgano#hos#hates + $arlic1rgano#hos#hates + $arlic
d<d< Mercury + MothballsMercury + Mothballs
e<e< Sulfur 2ioxide + -otten eggsSulfur 2ioxide + -otten eggs
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Toxic &rill
7ll of the following toxins are #ro#erly 7ll of the following toxins are #ro#erly
matched with their associated odourmatched with their associated odour
except:except:
a<a< Cyanide + Bitter almondsCyanide + Bitter almonds
b<b< Methylsalicylate + 1il of /intergreenMethylsalicylate + 1il of /intergreen
c<c< 1rgano#hos#hates + $arlic1rgano#hos#hates + $arlic
d<d< Mercury + MothballsMercury + Mothballs
e<e< Sulfur 2ioxide + -otten eggsSulfur 2ioxide + -otten eggs
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2ccording to Historians3
“ “ Sir, if you were my husband, I wouldSir, if you were my husband, I would
poison your drink.” poison your drink.”
A 4ady 7stor to /inston Churchill<A 4ady 7stor to /inston Churchill<
A/inston Churchill in re#lyDA/inston Churchill in re#lyD
“ “ Madam, if you were my wife,Madam, if you were my wife,
I would drink it.” I would drink it.”
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Toxidromes
2nticholinergic2nticholinergic
dry@ tachycardicdry@ tachycardic
mydriasismydriasis
Sedative-$*iateSedative-$*iate
bradycardicbradycardic
miosismiosis
Sym*athomimeticSym*athomimetic
wet@ tachycardicwet@ tachycardic
mydriasismydriasis
#holinergic#holinergic
all wet@ bradycardicall wet@ bradycardic
miosismiosis
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2nticholinergic Toxidrome
2ry mouth and sin2ry mouth and sin
2elirium2elirium
5 "eculiar mumbling s#eech"eculiar mumbling s#eech
5 "icing finger movements"icing finger movements
H-@H-@ 8em#8em#
4arge "u#ils4arge "u#ils↓ Bowel soundsBowel sounds
Urinary retentionUrinary retention
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Sym*athomimetic
Toxidrome 2elusional + #aranoid2elusional + #aranoid
Seizures@ or #ostictal confusionSeizures@ or #ostictal confusion
B"@B"@ H-@H-@ "u#ils"u#ils
2ia#horesis2ia#horesis
9ormal 69ormal 6 Bowel soundsBowel sounds
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$*iate 4 Sedative
Toxidrome
↓
EverythingEverything
5 --@ H-@ 41C@ 8em#@ 28-@--@ H-@ 41C@ 8em#@ 28-@Bowel SoundsBowel Sounds
Usually miosis@ but several exce#tionsUsually miosis@ but several exce#tions
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#holinergic Toxidrome
ConfusionConfusion ComaComa SeizuresSeizures
/eaness@ !asiculations/eaness@ !asiculations
2ia#horesis2ia#horesis
BradycardiaBradycardia Miotic #u#ilsMiotic #u#ils
>nsecticides 6>nsecticides 65 1rgano#hos#hates1rgano#hos#hates
5 CarbamatesCarbamates
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#holinergic Toxidrome
II/etJ "atient@/etJ "atient@ S.5D&ES.5D&E
5 SSalivationalivation
5
..acrimationacrimation5 55rinationrination
5 DDefecation@ 2ia#horesisefecation@ 2ia#horesis
5 &&> Cram#s> Cram#s
5 EEmesismesis
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Jimson Weed
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Toxic &rill
Mydriasis@ tachycardia@ urinary retention@Mydriasis@ tachycardia@ urinary retention@
diminished bowel sounds@ and drydiminished bowel sounds@ and dry
mucous membranes would bemucous membranes would be
ex#ected for all the followingex#ected for all the following except:except:a<a< Limson /eedLimson /eed
b<b< 8C78C7
c<c< 2i#henydramine2i#henydramine
d<d< 7m#hetamines 7m#hetamines
e<e<
CogentinCogentin
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Toxic &rill
Mydriasis@ tachycardia@ urinary retention@Mydriasis@ tachycardia@ urinary retention@
diminished bowel sounds@ and drydiminished bowel sounds@ and dry
mucous membranes would bemucous membranes would be
ex#ected for all the followingex#ected for all the following except:except:a<a< Limson /eedLimson /eed
b<b< 8C78C7
c<c< 2i#henydramine2i#henydramine
d<d< 7m#hetamines 7m#hetamines
e<e<
CogentinCogentin
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Toxic &rill
7ll of the following ingested toxins have 7ll of the following ingested toxins have
been found to be radio#auebeen found to be radio#aue except:except:
a<a< !errous Sulfate!errous Sulfate
b<b< 7cetamino#hen 7cetamino#hen
c<c<
4ead4ead
d<d< MercuryMercury
e<e< Cocaine "acetsCocaine "acets
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Toxic &rill
7ll of the following ingested toxins have 7ll of the following ingested toxins have
been found to be radio#auebeen found to be radio#aue except:except:
a<a< !errous Sulfate!errous Sulfate
b<b< 7cetamino#hen 7cetamino#hen
c<c<
4ead4ead
d<d< MercuryMercury
e<e< Cocaine "acetsCocaine "acets
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ron Pills on 6ray
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!ody Pacer
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Toxic &rill
7ll the following toxins are correctly 7ll the following toxins are correctly
matched with their res#ectivematched with their res#ective
antidoteantidote except:except:
a<a< Cyanide + Methylene BlueCyanide + Methylene Blue
b<b< >soniazid + "yridoxine>soniazid + "yridoxine
c<c< Ethylene $lycol + =AMethyl#razoleEthylene $lycol + =AMethyl#razole
d<d< Carbon monoxide + 1xygenCarbon monoxide + 1xygen
e<e< 7cetamini#hen + 9A7cetycysteine 7cetamini#hen + 9A7cetycysteine
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Toxic &rill
7ll the following toxins are correctly 7ll the following toxins are correctly
matched with their res#ectivematched with their res#ective
antidoteantidote except:except:
a<a< Cyanide + Methylene BlueCyanide + Methylene Blue
b<b< >soniazid + "yridoxine>soniazid + "yridoxine
c<c< Ethylene $lycol + =AMethyl#razoleEthylene $lycol + =AMethyl#razole
d<d< Carbon monoxide + 1xygenCarbon monoxide + 1xygen
e<e< 7cetamini#hen + 9A7cetycysteine 7cetamini#hen + 9A7cetycysteine
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2ntidotes 5sed in the ED
ToxinToxin 2ntidote2ntidote DoseDose
$*iates$*iates +aloxone+aloxone 7mg7mg
T#2T#2 !icar"!icar" 8-7me94g8-7me94g
#alcium#alcium!locer !locer
#alcium#alcium 8gm :8gm :
#alcium#alcium!locer !locer
&lucagon&lucagon/-8; mg/-8; mg
thenthenin1usionin1usion
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2ntidotes 5sed in the ED
ToxinToxin 2ntidote2ntidote DoseDose
!eta!eta!locer !locer
&lucagon&lucagon /-8; mg/-8; mg thenthen in1usionin1usion
#yanide#yanide +a +itrite+a +itrite 8;ml o1 <=8;ml o1 <=
#yanide#yanide +a Thiosul1ate+a Thiosul1ate /;ml o1 7/=/;ml o1 7/=
ronron De1eroxamineDe1eroxamine 8/mg4g4hr 8/mg4g4hr
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2ntidotes 5sed in the ED
ToxinToxin 2ntidote2ntidote DoseDose
ToxicToxic2lcohols2lcohols
EthanolEthanol8;ml4g 8;=8;ml4g 8;=
then ;08/then ;08/ml4g4hr ml4g4hr
ToxicToxic2lcohols2lcohols
>ome*i?ole>ome*i?ole8/mg4g :8/mg4g :
987H987H
EthyleneEthylene&lycol&lycol PyridoxinePyridoxine 8;;mg8;;mg
MethanolMethanol >olate>olate /;mg : 9@h/;mg : 9@h
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2ntidotes 5sed in the ED
ToxinToxin 2ntidote2ntidote DoseDose
2cetamino*hen2cetamino*hen +2#+2# : regime: regime
nsecticidesnsecticides 2tro*ine2tro*ine 8-7 mg4g8-7 mg4g
nsecticidesnsecticides Proto*amProto*am8-7& : then8-7& : then/;; mg 4 hr /;; mg 4 hr
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Dis*osition o1 Tox Patient
>CU 7dmission>CU 7dmission
5 Unstable #atientUnstable #atient
5 "otentially lethal overdose"otentially lethal overdose
5 Cardiotoxic overdoseCardiotoxic overdose
Hos#ital 7dmissionHos#ital 7dmission5 Moderately sym#tomatic #atientModerately sym#tomatic #atient
with low fatality #otentialwith low fatality #otential
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Dis*osition o1 Tox Patient
"rolonged 1bservation :. A = hours;"rolonged 1bservation :. A = hours;
or 7dmissionor 7dmission
5 1verdose with delayed onset or1verdose with delayed onset or
sustained release #re#arationsustained release #re#aration
E2 1bservation = 6 & hoursE2 1bservation = 6 & hours
5 Mild sym#toms@ low lethality 12Mild sym#toms@ low lethality 12
5 7sym#tomatic@ unnown 12 7sym#tomatic@ unnown 12
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Dis*osition o1 Tox Patient
"rolonged 1bservation :. A = hours;"rolonged 1bservation :. A = hours;
or 7dmissionor 7dmission
5 1verdose with delayed onset or1verdose with delayed onset or
sustained release #re#arationsustained release #re#aration
E2 1bservation = 6 & hoursE2 1bservation = 6 & hours
5 Mild sym#toms@ low lethality 12Mild sym#toms@ low lethality 12
5 7sym#tomatic@ unnown 12 7sym#tomatic@ unnown 12
Excuses That DonAt Wor
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Excuses That Don t Wor
in #ourt
,<,< “I thought the child was ! since“I thought the child was ! since
she only took one pill” she only took one pill”
Be wary ofDBe wary ofD
5 8C7s@ Methylsalicylate@ CaAblocer@8C7s@ Methylsalicylate@ CaAblocer@
Hy#oglycemic agents@ 4omotilHy#oglycemic agents@ 4omotil
Excuses That DonAt Wor
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Excuses That Don t Wor
in #ourt
=< I=< I"he toxicology screen was"he toxicology screen was
negati#e, so it couldn$t ha#e been annegati#e, so it couldn$t ha#e been an
o#erdose” o#erdose”
High false negative ratesHigh false negative rates
9ewer street drugs9ewer street drugs
"oor timing of 12"oor timing of 12
Excuses That DonAt Wor
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Excuses That Don t Wor
in #ourt
3<3< “"he guy o#erdosed on heroin and“"he guy o#erdosed on heroin and
woke right after naloxone. %e cursedwoke right after naloxone. %e cursed
at me, so I kicked him out.” at me, so I kicked him out.”
5 9aloxone may wear off before the9aloxone may wear off before the
narcotic< 1bserve<narcotic< 1bserve<
5 >f #atient wont stay 6 determine>f #atient wont stay 6 determine
com#etence and document well<com#etence and document well<
Excuses That DonAt Wor
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Excuses That Don t Wor
in #ourt
<< “"he patient looked great, so I“"he patient looked great, so Ithought one hour of obser#ation wasthought one hour of obser#ation was
enough.” enough.”
5 Most overdoses 6 observe = 6 &Most overdoses 6 observe = 6 &
hours<hours<
5 2angerous 12s or sustainedA2angerous 12s or sustainedA
release 6 observe = hours<release 6 observe = hours<
Excuses That DonAt Wor
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Excuses That Don t Wor
in #ourt
.<.< "he patient said she only took one"he patient said she only took one pill & how was I supposed to know pill & how was I supposed to know
she ingested the whole bottle'” she ingested the whole bottle'”
5 1verdosers are notoriously1verdosers are notoriously
unreliable historians<unreliable historians<
5 $et collateral<$et collateral<
5 >f in doubt 6 observe = 6 & hours<>f in doubt 6 observe = 6 & hours<
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T2KE H$ME MESS2&E
Su##ortive care is the most im#ortantSu##ortive care is the most im#ortantmeasure in most serious overdosesmeasure in most serious overdoses
/hen in doubt 6 observe in the E2/hen in doubt 6 observe in the E2
/hen faced with an unfamiliar or/hen faced with an unfamiliar or
serious toxic ex#osure call a "oisonserious toxic ex#osure call a "oison
Control Centre or consult with aControl Centre or consult with a
toxicologisttoxicologist
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M! Poison #ontrol #entre
Childrens Hos#ital EmergencyChildrens Hos#ital Emergency
2e#artment "oison Control 4ine2e#artment "oison Control 4ine
'=A(A,*.'=A(A,*.
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eMEDiUMeMEDiUM
Bac
Emergency MedicineEmergency Medicine
in the U of Min the U of M
emergency0m"0caemergency0m"0ca
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HS# EDHS# ED
Maryann #romwell
M#romwellBexchange0hsc0m"0ca
*hone3 CC-7<@1ax3 CC-77<8
De*artment o1 Emergency Medicine
Health Sciences #entre&> 7;8-;; Sher"roo Street
Winni*egF M!
G<2 8G
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