Trauma Surgery [TOXIC INGESTION]

Alcohols
Ethanol is covered in psychiatry. Look for cerebellar Alcohol Source Anion Osmolar Treatment
symptoms, nausea, vomiting, and amnesia. Support their Gap Gap
airway, gives fluids, and then let them sleep it off. Ethanol Beverages No Yes Supportive
Isopropyl Rubbing No Yes Supportive
Isopropyl alcohol can be found in rubbing alcohol. It has alcohol Alcohol,
similar effects to ethanol and can only be treated with Methanol Moonshine Yes Yes Ethanol
Fomepizole
supportive care. The difference is in the osmolar gap
Ethylene Antifreeze Yes Yes Ethanol
(elevated in Isopropyl, not in ethanol).
Glycol Fomepizole
Methanol (causes blindness, comes from moonshine) and
ethylene glycol (kidney failure, comes from antifreeze)
present and are treated similarly. Both yield an anion gap
acidosis and an osmolar gap. Antifreeze has fluorescein
in it to detect radiator leaks, so a Wood’s Lamp can be
used on the urine to make the diagnosis.

The BMP will show whether there’s an anion gap or not. If

no, it’s either Ethanol or Isopropyl - provide supportive
care. If yes, it’s methanol or ethylene glycol; inhibit
conversion to the toxic metabolites by giving Fomepizole
(if not available, alcohol will work).

Acetaminophen
Acetaminophen overdose causes drug-induced liver
injury. Whether it’s by intentional ingestion (a bottle of
pills) or unintentional overdose (narcotics taken together
with acetaminophen), the result is the same. Look for
elevation of liver enzymes (this can be into the thousands).
Obtain an acetaminophen level at 4 and 16 hours. If
they’re above-the-line on the nomograms (don’t worry
about memorizing the numbers), give the antidote called
N-Acetylcysteine (NAC) IV. If they develop fulminant
hepatic failure, transplant may be needed.

Salicylate Toxicity
Aspirin and other salicylate products (Oil of Wintergreen,
or “headache powders”) can cause intoxication. Early in
the disease there’s tinnitus, vertigo and hyperventilation
(look for the respiratory alkalosis). Late in the disease
anion-gap metabolic acidosis predominates; the patient
becomes altered, obtunded, and hyperpyrexia
predominate. Obtain a salicylate level, and treat with
alkalization of the urine and forced diuresis.

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 Trauma Surgery [TOXIC INGESTION]

Carbon Monoxide Poisoning

Because carbon monoxide has a much higher affinity than
oxygen for hemoglobin, inhalation of carbon monoxide
produces carboxyhemoglobin, a hemoglobin that can’t
carry oxygen. And yet, the saturation of hemoglobin is
NORMAL when read by pulse oximetry. Carbon
Monoxide comes from inhaled smoke. Headache, nausea
and vomiting, and delirium are symptoms. When
suspected, a carboxyhemoglobin level must be obtained.
A normal level is < 3%, but smokers may have as much as
10%. The treatment is 100% FiO2 and hyperbaric.

Cyanide Poisoning
In reality, Smoke inhalation is far more common than
medication-induced cyanide poisoning (such as with
nitroprusside). The person is sick as Cyanide converts all
metabolism to anaerobic despite adequate oxygen.
Coma, seizures, hypotension, and heart block are late
symptoms. Look for cherry-red skin color and cherry
red arterial blood. The first line therapy is thiosulfate -
the second line treatment (amyl nitrate) may worsen
Carbon Monoxide poisoning.

Organophosphate Toxicity
Whether used as weapons of terror (VX nerve gas),
medications (Ogilvie’s syndrome, myasthenia), or as S Salivation
pesticides exposure to organophosphates can be fatal. L Lacrimation
Initial exposure reduces the effectiveness of Acetylcholine U Urination
esterase. Eventually it renders it to permanently D Defecation
irreversibly inactivated (“aging”). The presentation can be G Gastrointestinal upset
remembered by the mnemonic SLUDGE, listed to the E Emesis
right. Everything that can secrete something will.
Treatment is with atropine and pralidoxime (“2-pam
chloride”).

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