Acute poisonings and Acute poisonings and comatous statecomatous state

Classification, clinic and diagnostics Classification, clinic and diagnostics of comaof coma

Classification, clinic and diagnostics of coma.Classification, clinic and diagnostics of coma. Coma is a complete depression of consciousness with lack of pain Coma is a complete depression of consciousness with lack of pain

sensitivity and reflexes, general muscular relaxation and violated vital sensitivity and reflexes, general muscular relaxation and violated vital functions.functions.

   Classification of consciousness levels according to Bogolepow, 1982.Classification of consciousness levels according to Bogolepow, 1982. Conscious (normal)Conscious (normal) ConfusedConfused StuporousStuporous SoporousSoporous Comatose: moderateComatose: moderate                                     deepdeep                                     terminalterminal Each level has its own diagnostic criteria; you can find them in the Each level has its own diagnostic criteria; you can find them in the

table below.table below.

Classification of coma according to etiology and pathogenesis.Classification of coma according to etiology and pathogenesis. Coma of central genesis (epileptic, traumatic, apoplectic). Coma of central genesis (epileptic, traumatic, apoplectic). Coma caused by visceral organs dysfunctions and endocrine glands Coma caused by visceral organs dysfunctions and endocrine glands

disorders (diabetic, hypoglycaemic, thyrotoxic, myxedemic, disorders (diabetic, hypoglycaemic, thyrotoxic, myxedemic, hypopituitary, hypocorticoid, hepatic, uremic, hypochloremic, anaemic, hypopituitary, hypocorticoid, hepatic, uremic, hypochloremic, anaemic, alimentary-distrophic ). alimentary-distrophic ).

Infectious coma (in case of pneumonia, malaria, neuronal infections, Infectious coma (in case of pneumonia, malaria, neuronal infections, etc.). etc.).

Acute toxic coma (poisonings with alcohol and its surrogates, Acute toxic coma (poisonings with alcohol and its surrogates, medicinal poisonings, carbon monoxide poisonings). medicinal poisonings, carbon monoxide poisonings).

  Coma caused by physical factors ( caused by electric injury, Coma caused by physical factors ( caused by electric injury, hypothermic and hyperthermia coma, radiation coma, etc.). hypothermic and hyperthermia coma, radiation coma, etc.).

Sometimes it is very hard to find the reason of the coma, so detailed Sometimes it is very hard to find the reason of the coma, so detailed anamnesis (interview relatives and witnesses) and clinical anamnesis (interview relatives and witnesses) and clinical observations are very important.observations are very important.

First of all ask about the duration of unconsciousness and was it lost First of all ask about the duration of unconsciousness and was it lost suddenly or there were other levels of altered consciousness. Ask suddenly or there were other levels of altered consciousness. Ask about the events prior to incident: did the patient fell and was there a about the events prior to incident: did the patient fell and was there a chance of head injury? Did he have fever, flu or jaundice? Are there chance of head injury? Did he have fever, flu or jaundice? Are there any sings of chronic diseases like diabetes, epilepsy, hypertonic any sings of chronic diseases like diabetes, epilepsy, hypertonic disease? Have the patient ever suffered from similar unconsciousness disease? Have the patient ever suffered from similar unconsciousness episodes? Were there any suicide attempts? If the comatose condition episodes? Were there any suicide attempts? If the comatose condition was not sudden, have the patient complained of vomiting, was not sudden, have the patient complained of vomiting, convulsions? Pay attention to the personal things of the patient: you convulsions? Pay attention to the personal things of the patient: you can find medical documents, medicine packages, diabetic bracelets or can find medical documents, medicine packages, diabetic bracelets or necklaces, etc.necklaces, etc.

If the anamnesis failed to reveal the coma etiology, concentrate on If the anamnesis failed to reveal the coma etiology, concentrate on objective symptoms.objective symptoms.

Skin colour: extreme paleness can be a sign of great blood loss, circulatory Skin colour: extreme paleness can be a sign of great blood loss, circulatory collapse, blood diseases. Cyanosis is a symptom of hypercapnic coma caused collapse, blood diseases. Cyanosis is a symptom of hypercapnic coma caused by respiratory failure or asphyxia (hanging, drowning, convulsions). by respiratory failure or asphyxia (hanging, drowning, convulsions). Hyperaemic face allows you to think about atropine and carbon monoxide Hyperaemic face allows you to think about atropine and carbon monoxide poisonings, hyperglycaemic coma or infectious disease.poisonings, hyperglycaemic coma or infectious disease.

Head position: tilted back head is a sign of meningitis, tetanus, hysteria; head Head position: tilted back head is a sign of meningitis, tetanus, hysteria; head turned aside can be the symptom of stroke. turned aside can be the symptom of stroke.

Pathological types of breathing are also helpful in coma diagnostics: Cheyne-Pathological types of breathing are also helpful in coma diagnostics: Cheyne-Stokes breathing (periods of apnoea, which are followed with chaotic frequent Stokes breathing (periods of apnoea, which are followed with chaotic frequent breathing) and Biot’s breathing (periods of apnoea which are followed with breathing) and Biot’s breathing (periods of apnoea which are followed with breathing of equal amplitude) show deep affection of central nervous system. breathing of equal amplitude) show deep affection of central nervous system. Kussmaul breathing (deep and laboured) proves accumulation of acid Kussmaul breathing (deep and laboured) proves accumulation of acid metabolites (metabolic acidosis) of exogenous (in case of poisonings) or metabolites (metabolic acidosis) of exogenous (in case of poisonings) or endogenous (diabetic ketoacidosis) nature. Fever and rapid deep breathing are endogenous (diabetic ketoacidosis) nature. Fever and rapid deep breathing are probable signs of infectious coma. Remember that per each excess body probable signs of infectious coma. Remember that per each excess body temperature degree there are 5-7 excess breathes and 10 excess heart beats. temperature degree there are 5-7 excess breathes and 10 excess heart beats.

Generally when you are coming to the patient with consciousness disorders try Generally when you are coming to the patient with consciousness disorders try to do this from the side of patient’s head (nape): this way you can easily to do this from the side of patient’s head (nape): this way you can easily improve airways patency if necessary (thrust the jaw forward for example) and improve airways patency if necessary (thrust the jaw forward for example) and avoid accidental injuries from the patient if his moves are uncontrolled.avoid accidental injuries from the patient if his moves are uncontrolled.

You can always identify simulation or hysteric coma by opening the eyes of the You can always identify simulation or hysteric coma by opening the eyes of the patient: in case of simulating conscious patients or hysteric patients you will patient: in case of simulating conscious patients or hysteric patients you will feel the resistance of the eyelids. Unconscious patients never resist when you feel the resistance of the eyelids. Unconscious patients never resist when you try to open their eyes.try to open their eyes.

Pressing the eyeballs toy can evaluate their tone: “soft” eyeballs with Pressing the eyeballs toy can evaluate their tone: “soft” eyeballs with decreased tone are the symptom of hypovolemia (bleeding, dehydration) or decreased tone are the symptom of hypovolemia (bleeding, dehydration) or shock condition. However they can also be part of hyperglycaemic coma clinic.shock condition. However they can also be part of hyperglycaemic coma clinic.

The depth of coma is assessed with the reflexes reduction. If patient reacts to The depth of coma is assessed with the reflexes reduction. If patient reacts to the external stimuli - it’s a moderate coma. If corneal reflexes are preserved the external stimuli - it’s a moderate coma. If corneal reflexes are preserved with depressed other reflexes – it’s a deep coma. Lack of photoreaction is a with depressed other reflexes – it’s a deep coma. Lack of photoreaction is a symptom of terminal coma.symptom of terminal coma.

Identification of intoxicationIdentification of intoxicationSuspition of intoxication

Vilnius toxikology clinic 2003

Preliminary CNS evaluation

SuppressionAgitation

Opioids

THC

EthanolPsichostimulants

Midriasis, normal photoreaction Normal pupils, photoreaction Myosis, no photoreaction

OpioidOpioidssNatural(opiates)

MorphineCodeine

SemisyntheticHeroinHydromorphoneOxymorphoneOxycodone

SyntheticMethadoneMeperidineLevorphalFentanyl3-methylfentanylPropoxypheneTramadol

Opioids Opioids PPharmacologyharmacology

Generally, all opioid agonist drugs exert Generally, all opioid agonist drugs exert the same pharmacological effects in the same pharmacological effects in the CNS and periphery, but differ in the CNS and periphery, but differ in pharmacokinetic propertiespharmacokinetic properties, , e.g. e.g. duration of action, potency, ability to duration of action, potency, ability to cross blood-brain-barriercross blood-brain-barrier

Opioid overdoseOpioid overdoseCNS CNS SymptomsSymptoms I I

Respiratory depressionRespiratory depression, i, intensive ntensive central central cyanosiscyanosis (bradipnoe 2-4/min.)(bradipnoe 2-4/min.)

Sedation and drowsinessSedation and drowsiness, unconsciousness , unconsciousness up to cup to comaoma

MiosisMiosis HypothermiaHypothermia

Opioid overdoseOpioid overdoseCNS CNS SymptomsSymptoms II II

Suppression of coughSuppression of cough Suppression of painSuppression of pain Nausea and vomitingNausea and vomiting Euphoria or dysphoriaEuphoria or dysphoria SeizuresSeizures

Opioid overdoseOpioid overdose Periphery Periphery SymptomsSymptoms

CardiovascularCardiovascular: vasodilatation: vasodilatation, h, hypotensionypotension Urinary tractUrinary tract: urinary urgency and retention: urinary urgency and retention SkinSkin: urticaria from histamine release : urticaria from histamine release GI tractGI tract: constipation: constipation UterusUterus: decreased contractions: decreased contractions

Opioid overdoseOpioid overdoseTreatmentTreatment

CPR (cardiopulmonary resuCPR (cardiopulmonary resusscitation) citation) Naloxone Naloxone – – bolus bolus 2 mg I/V (0,4-2mg) to 2 mg I/V (0,4-2mg) to

10 mg10 mg ( (If no I/V access - sublingual,If no I/V access - sublingual, endotracheal, i/mendotracheal, i/m), c), continous infusionontinous infusion

In-patient monitoring at leastIn-patient monitoring at least 12 hours12 hours HeatingHeating

CocaineCocaine Neurochemical actions Neurochemical actions

Blockade of reuptake of NE, DA and Blockade of reuptake of NE, DA and serotoninserotonin::– Low dose: preferential action on NE reuptakeLow dose: preferential action on NE reuptake– Moderate dose: NE Moderate dose: NE andand DA reuptake DA reuptake– High doses: NE, DA High doses: NE, DA andand serotonin reuptake serotonin reuptake

Local anesthetic action:Local anesthetic action:– blockade of sodium channelsblockade of sodium channels

CocaineCocaine Neurotransmission I Neurotransmission I

http://drugabuse.govhttp://drugabuse.gov

CocaineCocaine Neurotransmission II Neurotransmission II

http://drugabuse.govhttp://drugabuse.gov

CocaineCocaine Neurotransmission III Neurotransmission III

http://drugabuse.govhttp://drugabuse.gov

Cocaine overdoseCocaine overdoseSymptomsSymptoms I I

Agitation to psychosisAgitation to psychosis HalucinationsHalucinations MydriasisMydriasis Hypertermia (>41Hypertermia (>41OOC)C) Hypertension Hypertension TachycardiaTachycardia SeizuresSeizures ComaComa

Cocaine overdoseCocaine overdoseSymptomsSymptoms II II

Ischemic complications (vasospasm)Ischemic complications (vasospasm)– Myocardial infarction, cerebral infarction, etc.Myocardial infarction, cerebral infarction, etc.

Haemorrhagic complications Haemorrhagic complications (hypertension)(hypertension)– Subarachnoid, intracerebral hemorrhage, Subarachnoid, intracerebral hemorrhage,

aortic dissection, etc.aortic dissection, etc.

Dysrhytmias to ventricularDysrhytmias to ventricular

fibrilationfibrilation

Cocaine overdoseCocaine overdoseTreatmentTreatment No antidotesNo antidotes

CPRCPR Agitation, psychosis, seizures, hypertension, Agitation, psychosis, seizures, hypertension,

tachycardia tachycardia BZD (Diazepam 10-100 mg)BZD (Diazepam 10-100 mg)

Hyperthermia Hyperthermia external cooling (<41external cooling (<41OOC)C)

Severe hypertension Severe hypertension phentolamin, nitroprusidephentolamin, nitropruside

SVT - SVT - Ca antagonistsCa antagonists

VT - VT - lidocainelidocaine

No β-blockersNo β-blockers

HeroinHeroin++Cocaine overdoseCocaine overdoseSymptomsSymptoms

Changing clinical signs (swing)Changing clinical signs (swing)

Cocaine Cocaine ↔↔ opioids opioids

ComaComa Respiratory depressionRespiratory depression MidriasisMidriasis TachycardiaTachycardia

HeroinHeroin++Cocaine overdoseCocaine overdoseTreatmentTreatment

CPRCPR NaloxoneNaloxone:: bolus bolus 2 mg 2 mg ii//v v ++ c continousontinous infusion infusion

In-patient monitoring at leastIn-patient monitoring at least 12 hours12 hours Symptomic treatmentSymptomic treatment BenzodiazepinesBenzodiazepines

Body packing and stuffing Body packing and stuffing Is it the same? Is it the same?

Packing – action, when Packing – action, when a person transports a person transports illicit drugs in a body illicit drugs in a body orifice. The risk of orifice. The risk of package rupture is package rupture is more remote.more remote.

Stuffing – action, when a Stuffing – action, when a person places drugs in a person places drugs in a body orifice in a moment of body orifice in a moment of imminent danger. In this imminent danger. In this case drugs are not well case drugs are not well packaged for packaged for transportation, hence the transportation, hence the high risk for leakagehigh risk for leakage

Body packing and stuffingBody packing and stuffing Investigations Investigations

UltrasonographyUltrasonography Contrast X-ray of Contrast X-ray of

the bowelthe bowel Computerized Computerized

tomographytomography Drug detection in Drug detection in

urine and bloodurine and blood

Clinical observationClinical observation Light solid dietLight solid diet Free assumption of Free assumption of

liquidsliquids Surgical removal, if Surgical removal, if

mechanical obstruction mechanical obstruction occursoccurs

Treatment of systemic Treatment of systemic symptoms symptoms

Body packing and stuffingBody packing and stuffing Investigations Investigations

Study Study IndicationsIndications SensivitySensivity CommentsComments

Plain Plain abdominal abdominal radiographyradiography

Screening testScreening test 85-9085-90%% Sensivity for finding small Sensivity for finding small numbers of packets may be numbers of packets may be lower. May miss substantial lower. May miss substantial numbers of packetsnumbers of packets

UltrasonograUltrasonographyphy

Screening testScreening test No No establishedestablished

Has the potential to be very Has the potential to be very useful, large studies neededuseful, large studies needed

CTCT Used if equivocal results Used if equivocal results obtained on initial screening obtained on initial screening test. Used to document that test. Used to document that GT is clearGT is clear

No No establishedestablished

Large studies neededLarge studies needed

Contrast Contrast enhanced enhanced abdominal abdominal radiographyradiography

Used if equivocal results Used if equivocal results obtained on initial screening obtained on initial screening test. Used to document that test. Used to document that GT is clearGT is clear

9696%% Reported sensitivity based Reported sensitivity based on 1 studyon 1 study

Radiographic Approaches to the Identification of Body packing

Body packing and stuffingBody packing and stuffing Levels of packages security Levels of packages security

I - 1 protective layerI - 1 protective layer II - 2 protective layers; II - 2 protective layers;

in our casein our case III – machine-made (4-7 III – machine-made (4-7

protective layers)protective layers)

Body packing and stuffing Body packing and stuffing First detected case in Lithuania First detected case in Lithuania

A 31 year old male was brought to the A 31 year old male was brought to the Department of Toxicology by customs Department of Toxicology by customs officers after disembarking at the Vilnius officers after disembarking at the Vilnius International Airport suspecting of cocaine International Airport suspecting of cocaine transporttransport

Body packing and stuffing Body packing and stuffing First detected case in Lithuania First detected case in Lithuania

There were no any complaints and examination There were no any complaints and examination of patient didn’t show any pathologyof patient didn’t show any pathology

All blood tests were normalAll blood tests were normal Patient refused endoscopy, but agree to Patient refused endoscopy, but agree to

contrast X- ray investigationcontrast X- ray investigation Foreign bodies were detected in the Foreign bodies were detected in the

gastrointestinal tract by X-ray photographygastrointestinal tract by X-ray photography Toxicological analysis for narcotics of urine and Toxicological analysis for narcotics of urine and

blood were doneblood were done

Body packing and stuffing Body packing and stuffing First detected case in Lithuania First detected case in Lithuania

Observation (blood pressure, heart Observation (blood pressure, heart frequency, temperature, neurological frequency, temperature, neurological assessment every hour)assessment every hour)

Mild laxative in conjunction with sufficient Mild laxative in conjunction with sufficient beveragesbeverages

Body packing and stuffing Body packing and stuffing First detected case in Lithuania First detected case in Lithuania

“double condom’’ signFill defects

Body packing and stuffing Body packing and stuffing First detected case in Lithuania First detected case in Lithuania

39 packets were excreted on the first day, 10 – on 39 packets were excreted on the first day, 10 – on the second day, 3 – at the third daythe second day, 3 – at the third day

X-ray 3 days later revealed foreign bodies in the X-ray 3 days later revealed foreign bodies in the gastrointestinal tract (“double condom’’ sign)gastrointestinal tract (“double condom’’ sign)

Because of customs officers demand the patient was Because of customs officers demand the patient was transferred to the Hospital of Prison, despite staff transferred to the Hospital of Prison, despite staff objection. 62 cocaine packets were excreted objection. 62 cocaine packets were excreted during the next 3 daysduring the next 3 days

Body packing and stuffing Body packing and stuffing First detected case in Lithuania First detected case in Lithuania

Condoms were filled with 3-8 g of cocaine eachCondoms were filled with 3-8 g of cocaine each 114 packages, weight 114 packages, weight 438,63 g438,63 g,purity – 57%,purity – 57% 2 of cocaine packets were slightly injured2 of cocaine packets were slightly injured Blood sample – no answer, urine analysis – Blood sample – no answer, urine analysis –

“possibility of cocaine metabolites”“possibility of cocaine metabolites”

Forensic analysis

Body packing and stuffingBody packing and stuffing Management Management

•In no way endoscopic removal of the package should be attempted. The patient in whom only one packet fails to pass the pylorus may be the exception•Conservative management during spontaneous evacuation of the containers is the first choice approach to the body-packing•Surgery is indicated for patients with acute cocaine poisoning or gastrointestinal obstruction or perforation•Observation till the last package removes is obligatory

AmphetamineAmphetamineNeurochemical actionsNeurochemical actions

DDoseose--related increase in release of related increase in release of norepinephrine, dopamine and serotonin:norepinephrine, dopamine and serotonin:– llow dose: preferential action on NE releaseow dose: preferential action on NE release– mmoderate dose: NE oderate dose: NE andand DA release DA release– hhigh dose: NE, DA igh dose: NE, DA andand serotonin release serotonin release

BBlockade of reuptake of NE, DA and serotoninlockade of reuptake of NE, DA and serotonin IInhibition of MAOnhibition of MAO

AmphetamineAmphetamineSymptomsSymptoms

Agitation to psychosisAgitation to psychosis HalucinationsHalucinations MydriasisMydriasis Tachycardia Tachycardia Hypertension Hypertension Mild hypertermiaMild hypertermia SeizuresSeizures ComaComa

AmphetamineAmphetamineTreatmentTreatment

No antidotesNo antidotes CPRCPR GI decontamination GI decontamination gastric lavage, activated charcoalgastric lavage, activated charcoal BenzodiazepinesBenzodiazepines Severe hypertension Severe hypertension phentolamin, nitroprusidephentolamin, nitropruside External coolingExternal cooling SVT SVT Ca antagonistsCa antagonists

VT VT lidocainelidocaine No β-blockersNo β-blockers

““Ecstasy” (MDMA):Ecstasy” (MDMA): a hallucinogenic amphetaminea hallucinogenic amphetamine

Combination of psychostimulant effects with Combination of psychostimulant effects with stronger hallucinogenic effects (serotonin stronger hallucinogenic effects (serotonin component)component)

Common acute adverse effects: muscle Common acute adverse effects: muscle tension and bruxismtension and bruxism

HyperthermiaHyperthermia IIncrease HR and BPncrease HR and BP AAcne-like rashcne-like rash

CannabinoidsCannabinoidsSymptomsSymptoms

Impairment of cognitive function Impairment of cognitive function Disorientation, talkativnessDisorientation, talkativness Anxiety to panicAnxiety to panic HeadacheHeadache ““Exploding chest”Exploding chest” SedationSedation

AtaxiaAtaxia TremorTremor Dry mouthDry mouth TachycardiaTachycardia Injected Injected

conjunctiveconjunctive

CannabinoidsCannabinoidsTreatmentTreatment

BenzodiazepinesBenzodiazepines Symptomic treatmentSymptomic treatment PsychoterapyPsychoterapy

LSD LSD SymptomsSymptoms

Anxiety, agitationAnxiety, agitation Hallucinations Hallucinations Moist and pale skinMoist and pale skin Mild hypertensionMild hypertension TachycardiaTachycardia HypertermiaHypertermia

(Lysergic Acid Diethylamine)

LSD LSD TreatmentTreatment

BenzodiazepinesBenzodiazepines In severe cases – the same as In severe cases – the same as

amphetaminesamphetamines

(Lysergic Acid Diethylamine)

Gamma-hydroxybutyric acidGamma-hydroxybutyric acid SymptomsSymptoms

CNS depressionCNS depression ((GCS of 3 is not uncommonGCS of 3 is not uncommon)) EExtreme combativeness and xtreme combativeness and

agitationagitation BBradycardiaradycardia DDecreased systemic vascular ecreased systemic vascular

resistanceresistance,, hhypotensionypotension PProfound respiratory depressionrofound respiratory depression. .

Gamma-hydroxybutyric acidGamma-hydroxybutyric acid Treatment Treatment

Airway protection and Airway protection and aspiration precautionsaspiration precautions

Use atropine to treat Use atropine to treat symptomatic bradycardia that symptomatic bradycardia that is unresponsive to stimulationis unresponsive to stimulation

SolventsSolvents Symptoms Symptoms

Agitation, joyAgitation, joy Vertigo, coordination damamgeVertigo, coordination damamge Sneeze, hypersalivationSneeze, hypersalivation CNS depressionCNS depression, delusions, delusions Sense of invulnerability Sense of invulnerability RRespiratory depressionespiratory depression TachycardiaTachycardia Seizures, comaSeizures, coma

SolventsSolvents Treatment Treatment

OxygenOxygen CPR CPR (if needed)(if needed)

BenzodiazepinesBenzodiazepines Symptomic treatmentSymptomic treatment

MileMilestones in treatment of stones in treatment of drug overdosedrug overdose

NaloxoneNaloxone

BenzodiazepinesBenzodiazepines

Life support measuresLife support measures