Drug Overdose

“All substances are poisons. The right dose

differentiates a poison and a remedy.”

(Fallopius von Hohenheim-Paracelsus 1493-1541)

Adapted from source

Drug Overdose

Objectives
Determine a systematic approach

Discuss high profile toxidromes

Discuss some specific overdoses

Drug Overdose

• 20 y male, unresponsive, GCS 3/15

• Vodka
• QAS assessment
Drug Overdose

• Guedel.
• RR 14/min, shallow, SpO2 99% @ 6 l/m,
no cyanosis.
• P 110/min, CRT <2 sec, BP 100/60 mmHg.
• Pupils equal and reactive, mid range.
• 37 °C.
Drug Overdose

• ECG
• Glucose
• IV access and bloods
• Search clothing
• Antidotes -
• Toxicology
• Secondary survey
mechanism/AMPLE
Drug Overdose

needle track marks

Drug Overdose

Mnemonic: COPS
• Cholinergic toxicity
• Clonidine
• Opiates
• Organophosphates
• Phenothizines
• Pilocarpine
• Pontine haemorrhage
• Sedative hypnotics
Drug Overdose

Mnemonic: CAAAS
• Carbon monoxide
• Anticholenergic
• Antihistamines
• Antidepressants
• Sympathomimetics
Drug Overdose
Risk Assessment
Takes into account
•Patient
•Agent
•Dose
•Time since ingestion

History from patient T/F

Trivial poisonings reassurance, decon, Ix, LOS

Lee V. et al, Emerg.Med. 2001;13:37-42
Drug Overdose
Risk Assessment
Eg Valproic acid
<200 mg/kg drowsiness, ataxia
200-400 mg/kg CNS depression
>400 mg/kg fatalities

~39% unintentional OD – more likely to be hospitalised

Warfarin and Insulins ~16% of ADRs overall and 33% in those

>50yrs
Budnitz, et al. Annals of Emerg Med. 2005. 45(2).
 Drug Overdose
Gastrointestinal decontamination
Gastric lavage TCA, Ca++, β
anticholenergics, recent, slow release, not adsorbed
conditions

Activated Charcoal (C*) 10:1 or 1g/kg

conditions

Whole Bowel Irrigation Go-Lytely 1-2 l/hr

Cathartics
Drug Overdose

5 Toxidromes:

Cholenergic
Anti-cholenergic
Sympathomimetic
Opioid
Sedative-hypnotic
Drug Overdose

Cholenergic
Organophosphates, carbamate insecticides, sarin

Miosis
Bradycardia, bronchospasm, bronchorrhoea, salivation, lacrimation
Vomiting, diarrhoea, urination
Drug Overdose

Cholenergic
Organophosphates, carbamate insecticides, sarin

Miosis
Bradycardia, bronchospasm, bronchorrhoea, salivation, lacrimation
Vomiting, diarrhoea, urination

Atropine pralidoxime diazepam

“dumbells”
Drug Overdose

Anti-cholenergic
Tricyclics, phenothizines, antihistamines
belladonna, scopolamine, datura

Mydriasis
Dry membranes, dry flushed skin, tachycardia, hypertension
Absent bowel sounds, urinary retention
Drug Overdose

Anti-cholenergic
Tricyclics, phenothizines, antihistamines
belladonna, scopolamine, datura

Mydriasis
Dry membranes, dry flushed skin, tachycardia, hypertension
Absent bowel sounds, urinary retention

Supportive (physostigmine) benzos, nitrites, α/β

“hot, dry, red, blind, mad”

Belladonna atopa

Nightshade family
Drug Overdose

Sympathomimetic
Amphetamines, cocaine, decongestants
caffeine

Mydriasis
Sweaty, hyperthermia, tachycardia, hypertension
Hyperactive bowel sounds, urinary retention
Agitation seizures, myocardial infarction, rhabdomyolysis
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Sympathomimetic
Amphetamines, cocaine, decongestants
caffeine

Mydriasis
Sweaty, hyperthermia, tachycardia, hypertension
Hyperactive bowel sounds, urinary retention
Agitation seizures, myocardial infarction, rhabdomyolysis

Supportive benzos, nitrites, α/β

Drug Overdose

Opioid
Heroin, morphine, methadone, fentanyl, oxycodone, imidazoles

Miosis
Analgesic, euphoric, sedative, anxiolytic
Hypothermia, bradycardia, hypotension, pulmonary oedema
Drug Overdose

Opioid
Heroin, morphine, methadone, fentanyl, oxycodone, imidazoles

Miosis
Analgesic, euphoric, sedative, anxiolytic
Hypothermia, bradycardia, hypotension, pulmonary oedema

Naloxone

addict, ½
Drug Overdose

Sedative-hypnotic
Benzodiazepines, barbiturates, GHB

Normal eyes and vital signs

Striated muscle relaxation, sedative, anxiolytic

Supportive C* (Flumazenil)
Drug Overdose

• Paracetamol
• Tricyclics
• Calcium channel blockers
• Iron
Drug Overdose
Paracetamol
Hepatic metabolism ~90% is converted to nontoxic
glucuronide and sulfate conjugates

<5% is excreted unchanged in the urine

~5% metabolised via c-P450 to NAPQI which

combines immediately with glutathione

If glutathione depleted, NAPQI binds to cellular

macromolecules that contain cysteine
centrilobular hepatocellular damage
Drug Overdose

N-acetyl cysteine?

• NAC converted to cysteine

converted to glutathione within hepatocytes

• NAC acts as a direct substitute for glutathione,

• And NAC acts as a sulfur donor in the formation of the

nontoxic sulfate metabolite of acetaminophen
Drug Overdose
• All patients with serum paracetamol on or above the lower line
(≥150 μg/mL) after an acute ingestion.

• History (or suspicion) of overdose requires NAC until plasma levels

are known – can wait up to 8 hours

• Delayed presentation >24 hr post ingestion

if paracetamol measurable or transaminases are elevated

• Chronic ingestion
treat for 24 to 36 hr, then reassess levels

• Progressive hepatotoxicity requires NAC until INR <2

Drug Overdose

• CI
• IV NAC 150mg/kg over 15 minutes
50-100mg/kg
• Anaphylactoid 20%
• Cost $207.90
Drug Overdose
BUT

if ingested 200mg/kg or less

STOP
2nd level not required
don’t move nomogram
reportable
Drug Overdose

Tricyclics
Mydriasis
Dry membranes, dry flushed skin, tachycardia, hypertension
Absent bowel sounds, urinary retention

Decontaminate C*
Intubate
Acidosis Seizures Hypotension
QRS >120msec Sodium bicarbonate 2meq/kg
Drug Overdose
Calcium channel blockers
QRS width blocks AV and SA nodes
vasodilatation
bradycardia hypotension

Correct pH gastric lavage C*

Ca++ loading
Glucagon
Insulin

Atropine, inotropes
Drug Overdose

Fe-poisoning
gastro-enteritis, vomiting, metabolic acidosis, cardiotoxic

AXR Count tablets

Whole bowel irrigation no C*

20mg/kg do nothing
40 mg/kg vomit, gastr
60 mg/kg toxic 100 mg/kg lethal
desferrioxamine
Drug Overdose

?
Drug Overdose

Objectives
Determine a systematic approach

Discuss high profile toxidromes

Discuss some specific overdoses

Drug Overdose

Management principles
• Resuscitation
• Risk assessment
• Supportive care
• Decontamination
• Antidotes
• Enhanced elimination
• Ongoing monitoring/supportive/disposition
Drug Overdose

www.worstpills.org

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