Toxicology-What Every

Emergency Physician
Should Know
What is it that is not a poison?
All things are poison and nothing is
without poison.
It is the dose only that makes a thing
not a poison.
Paracelsus (1493-1541), the Renaissance
Father of Toxicology, in his Third Defense.

Presenters
Dr Bob Sweetland
Emergency Medicine
Health Sciences Centre

Dr Michael Ha
University of Manitoba
Section of Emergency Medicine

Dr John Sokal
Emergency Medicine
Health Sciences Centre

CME Objectives

Be familiar with the initial

management and stabilization of toxic
ingestions

Be able to recognize overdoses by

their clinical features

Case
32 Female Comatose
Pupils 2mm GCS = 6 Sp02 = 86%
BP 96/55 HR 120 RR 8
What methods of rapid reversal are
available?
How can we decontaminate her gut?
What approach in case of life threatening
OD?

Her EKG

Coma Cocktail

Consider in all unknown causes of

coma and decreased LOC

D50W unless Accucheck available

Thiamine alcoholics only

Coma Cocktail

Naloxone (Narcan)
0.4 2.0 mg IV, IM, SC, ETT
Duration 1-2 hours
+/- sage at 2/3 bolus / hour
Higher doses with
Pentazocine (Talwin)
Codeine
Diphenoxylate (Lomotil)
Propoxyphene (Darvon)

Case (post Narcan)

32 Female Comatose
Pupils 4mm GCS = 10 Sp02 = 91% (r/a)
BP 96/55 HR 120 RR14
What methods of rapid reversal are
available?
How can we decontaminate her gut?
What approach in case of life threatening
OD?

Toxic Grill
Activated Charcoal will adsorb all the
following meds except:
a. Phenobarbital
b. Theophylline
c. Ferrous sulfate
d. Verapamil
e. Salicylates

Toxic Grill
Activated Charcoal will adsorb all the
following meds except:
a. Phenobarbital
b. Theophylline
c. Ferrous sulfate
d. Verapamil
e. Salicylates

GI Decontamination
Ipecac

No role for Ipecac in management

of overdoses in the ED setting

Gastric Lavage

No evidence of improved outcomes

Contraindicated with corrosives and
hydrocarbons

GI Decontamination
Charcoal 50gm (1g/kg)
First line decontamination method
Doesnt adsorb:
Heavy metals
Hydrocarbons
Acids / Alkalis
Ethanol
Repeated doses for Theophylline

Toxic Grill
Whole bowel irrigation is recommended
in all of the following ingestions
except:
a. Lead paint chips
b. Cocaine packets
c. Button batteries
d. Hydrocarbons
e. Sustained-release lithium tablets

Toxic Grill
Whole bowel irrigation is recommended
in all of the following ingestions
except:
a. Lead paint chips
b. Cocaine packets
c. Button batteries
d. Hydrocarbons
e. Sustained-release lithium tablets

GI Decontamination
Whole Bowel Irrigation
Heavy metals
Sustained-release meds
GoLytely
500 2000 ml/hr
25cc/kg/hr peds
+/- metoclopropamide
4-6 hours duration

Enhanced Elimination
Urinary Alkalinization
Salicylates
1-2 meq/Kg bolus then 3 amps
NaBicarb in 850cc D5W
150 250 cc/hr
Urine pH >7.5
Add 20 40 meq KCl / L

Enhanced Elimination
Hemodialysis and Charcoal
Hemoperfusion
Confer with a Poison Control
Centre, Toxicologist, Nephrologist

ASA, Toxic Alcohols, Lithium

MB PCC 787-2591
Toxicology HSC Paging 787-2071

Management Steps
1.
2.
3.
4.
5.

ABCs
Immediate consideration of Coma
Cocktail treatments
Gather information
Decontaminate GI tract
Support Patient
6. Enhanced Elimination
7. Antidotes

Life Threatening Overdose

Respiratory Depression? Hypoxia?

Assist respirations
Intubate as necessary
Suspected Opiates or Unknown?
Pupils and Respirations
Naloxone 2mg IV

Toxic Grill
All the following drugs can cause miotic
pupils except:
a. Clonidine
b. MDMA
c. Organophosphates
d. Heroin
e. Codeine

Toxic Grill
All the following drugs can cause miotic
pupils except:
a. Clonidine
b. MDMA
c. Organophosphates
d. Heroin
e. Codeine

The Eyes Have It

Miosis

Opiates

BUT dilated with:

Meperidine (Demerol)
Propoxyphene (Darvon)
Hypoxia,
Co-ingestants, Lomotil(mixed agent)

Cholinergics, Phenothiazines
Absence of miosis doesnt rule out opiate
ingestion

The Eyes Have It

Mydriasis
Anticholinergics
Sympathomimetics

Nystagmus

Ethanol, Lithium, Phenytoin,

Carbamazepine, Sedative-hypnotics
Vertical Nystagmus - PCP

Life Threatening Overdose

Evidence of acute cardiac
manifestations?

Chest pain?
EKG and 3-lead rhythm strip

Life Threatening OD - EKG

Very important to do EKG, esp in

TCA, Beta- and Ca-Blockers
TCA:
Tachycardia, QRS widening
Rightward shift of terminal 0.04 s
of frontal plane QRS
ie prominent R in AVR

TCA EKG

Life Threatening Overdose

Wide Complex Tachycardia with

pulse?
EKG evidence of TCA OD?
Sodium Bicarbonate
1-2 meq/kg
Titrate to QRS narrowing or
pH 7.5
If cocaine, may also try lidocaine
AVOID procainamide

Toxic Grill
Bradycardia is commonly associated
with all the following overdoses
except:
a. Clonidine
b. Digoxin
c. Propanolol
d. Methadone
e. Amphetamines

Toxic Grill
Bradycardia is commonly associated
with all the following overdoses
except:
a. Clonidine
b. Digoxin
c. Propanolol
d. Methadone
e. Amphetamines

Life Threatening Overdose

Acute coronary syndrome associated
with Cocaine?
Nitrates
Benzodiazepines
Aspirin
Phentolamine if persistent severe
hypertension

Life Threatening Overdose

Hypotension?
Fluids

Resistant shock?
Epinephrine or norepinephrine

Life Threatening Overdose

Hypotension associated with:
TCA?
Bicarbonate to pH 7.50 7.55
Ca-channel Blocker?
CaCl 1-3 Gms IV
Ca-channel or Beta Blocker?
Glucagon 5-10 mg IV bolus then
hourly drip

Life Threatening Overdose

Status Seizures?
Glucose if hypoglycemia
Lorazepam 0.1 mg/kg IV
Phenobarbital 20-30 mg/kg IV
AVOID phenytoin
Isoniazid?
Pyridoxine 5 gm Adult, 1 gm Ped

Life Threatening Overdose

Profound Coma?
Ensure airway control
Coma Cocktail
Consider CT scan (occult trauma)

Life Threatening Overdose

Severe Metabolic Acidosis?
Bicarb and look for cause
Toxic Alcohols
Salicylates
Iron
Lactic Acidosis from shock
DKA

Elevated AG Metabolic Acidosis

(METAL ACID GAP)
Methanol, Metformin
Ethylene Glycol
Toluene
Alcoholic KA
Lactic
Aminogycosides, other uremic agents
Cyanide, CO
Iron, Isoniazid
DKA
Generalized Seizures
ASA
Paraldehyde

Toxic Grill
All of the following toxins are properly
matched with their associated odour
except:
a. Cyanide / Bitter almonds
b. Methylsalicylate / Oil of Wintergreen
c. Organophosphates / Garlic
d. Mercury / Mothballs
e. Sulfur Dioxide / Rotten eggs

Toxic Grill
All of the following toxins are properly
matched with their associated odour
except:
a. Cyanide / Bitter almonds
b. Methylsalicylate / Oil of Wintergreen
c. Organophosphates / Garlic
d. Mercury / Mothballs
e. Sulfur Dioxide / Rotten eggs

According to Historians:
Sir, if you were my husband, I would
poison your drink.
- Lady Astor to Winston Churchill.

-Winston Churchill in reply:

Madam, if you were my wife,
I would drink it.

Toxidromes
Anticholinergic
dry, tachycardic
mydriasis

Sedative-Opiate
bradycardic
miosis

Sympathomimetic
Cholinergic
wet, tachycardic all wet, bradycardic
mydriasis
miosis

Anticholinergic Toxidrome

Dry mouth and skin

Delirium
Peculiar mumbling speech
Picking finger movements
HR, Temp
Large Pupils
Bowel sounds
Urinary retention

Sympathomimetic
Toxidrome

Delusional / paranoid
Seizures, or postictal confusion
BP, HR, Pupils
Diaphoresis
Normal Bowel sounds

Opiate / Sedative
Toxidrome

Everything
RR, HR, LOC, Temp, DTR,
Bowel Sounds
Usually miosis, but several exceptions

Cholinergic Toxidrome

Confusion Coma Seizures

Weakness, Fasiculations
Diaphoresis
Bradycardia
Miotic pupils

Insecticides
Organophosphates
Carbamates

Cholinergic Toxidrome

Wet Patient, SLUDGE

Salivation
Lacrimation
Urination
Defecation, Diaphoresis
GI Cramps
Emesis

Jimson Weed

Toxic Grill
Mydriasis, tachycardia, urinary retention,
diminished bowel sounds, and dry
mucous membranes would be
expected for all the following except:
a. Jimson Weed
b. TCA
c. Diphenydramine
d. Amphetamines
e. Cogentin

Toxic Grill
Mydriasis, tachycardia, urinary retention,
diminished bowel sounds, and dry
mucous membranes would be
expected for all the following except:
a. Jimson Weed
b. TCA
c. Diphenydramine
d. Amphetamines
e. Cogentin

Toxic Grill
All of the following ingested toxins have
been found to be radiopaque except:
a.
b.
c.
d.
e.

Ferrous Sulfate
Acetaminophen
Lead
Mercury
Cocaine Packets

Toxic Grill
All of the following ingested toxins have
been found to be radiopaque except:
a.
b.
c.
d.
e.

Ferrous Sulfate
Acetaminophen
Lead
Mercury
Cocaine Packets

Iron Pills on Xray

Body Packer

Toxic Grill
All the following toxins are correctly
matched with their respective
antidote except:
a. Cyanide / Methylene Blue
b. Isoniazid / Pyridoxine
c. Ethylene Glycol / 4-Methylprazole
d. Carbon monoxide / Oxygen
e. Acetaminiphen / N-Acetycysteine

Toxic Grill
All the following toxins are correctly
matched with their respective
antidote except:
a. Cyanide / Methylene Blue
b. Isoniazid / Pyridoxine
c. Ethylene Glycol / 4-Methylprazole
d. Carbon monoxide / Oxygen
e. Acetaminiphen / N-Acetycysteine

Antidotes Used in the ED

Toxin

Antidote

Dose

Opiates

Naloxone

2mg

TCA

Bicarb

1-2meq/kg

Calcium
Blocker

Calcium

1gm IV

Calcium
Blocker

Glucagon

5-10 mg
then
infusion

Antidotes Used in the ED

Toxin

Antidote

Dose

Beta
Blocker

Glucagon

5-10 mg then

Cyanide

Na Nitrite

Cyanide
Iron

infusion

10ml of 3%

Na Thiosulfate 50ml of 25%

Deferoxamine

15mg/kg/hr

Antidotes Used in the ED

Toxin

Antidote

Dose

Ethanol

10ml/kg 10%
then 0.15
ml/kg/hr

Toxic
Alcohols

Fomepizole

15mg/kg IV
q12H

Ethylene
Glycol

Pyridoxine

100mg

Methanol

Folate

50mg IV q4h

Toxic
Alcohols

Antidotes Used in the ED

Toxin

Antidote

Dose

Acetaminophen

NAC

IV regime

Insecticides

Atropine

1-2 mg/kg

Protopam

1-2G IV then
500 mg / hr

Insecticides

Disposition of Tox Patient

ICU Admission
Unstable patient
Potentially lethal overdose
Cardiotoxic overdose

Hospital Admission
Moderately symptomatic patient
with low fatality potential

Disposition of Tox Patient

Prolonged Observation (12 - 24 hours)
or Admission
Overdose with delayed onset or
sustained release preparation

ED Observation 4 6 hours
Mild symptoms, low lethality OD
Asymptomatic, unknown OD

Disposition of Tox Patient

Prolonged Observation (12 - 24 hours)
or Admission
Overdose with delayed onset or
sustained release preparation

ED Observation 4 6 hours
Mild symptoms, low lethality OD
Asymptomatic, unknown OD

Excuses That Dont Work

in Court
5. I thought the child was OK since
she only took one pill
Be wary of:
TCAs, Methylsalicylate, Ca-blocker,
Hypoglycemic agents, Lomotil

Excuses That Dont Work

in Court
4. The toxicology screen was
negative, so it couldnt have been an
overdose
High false negative rates

Newer street drugs

Poor timing of OD

Excuses That Dont Work

in Court
3. The guy overdosed on heroin and
woke right after naloxone. He cursed
at me, so I kicked him out.

Naloxone may wear off before the

narcotic. Observe.
If patient wont stay determine
competence and document well.

Excuses That Dont Work

in Court
2. The patient looked great, so I
thought one hour of observation was
enough.

Most overdoses observe 4 6

hours.
Dangerous ODs or sustainedrelease observe 24 hours.

Excuses That Dont Work

in Court
1. The patient said she only took one
pill how was I supposed to know
she ingested the whole bottle?

Overdosers are notoriously

unreliable historians.
Get collateral.
If in doubt observe 4 6 hours.

TAKE HOME MESSAGE

Supportive care is the most important

measure in most serious overdoses
When in doubt observe in the ED
When faced with an unfamiliar or
serious toxic exposure call a Poison
Control Centre or consult with a
toxicologist

MB Poison Control Centre

Children's Hospital Emergency
Department Poison Control Line
204-787-2591

eMEDiUM
Emergency Medicine
in the U of M

emergency.mb.ca

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HSC ED
Maryann Cromwell
MCromwell@exchange.hsc.mb.ca
phone:
fax:

787-2934
787-2231

Department of Emergency Medicine

Health Sciences Centre
GF 201-800 Sherbrook Street
Winnipeg, MB
R3A 1R9

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