Name the Toxidrome
Shallow respirations, bradycardia, altered mental status & miosis. What is this toxidrome?
Opiate Toxidrome!
Treatment - Naloxone
15 year old patient ingested 50 tabs of Acetaminophen 500 mg. What medication should you start in the ED?
N-Acetylcysteine (NAC)
In Arizona, a patient presents after feeling a sharp pain in her arm. She is febrile, tachycardic, restless, with her arms and legs jerking in multiple directions. She also has dilated pupils, nystagmus and rotary eye movements.
What is the culprit of her symptoms?
A Scorpion! Minor bites result in local pain and swelling. However more severe poisoning causes neurologic signs including muscle jerks and rotary nystagmus. This patient was bit by a Bark Scorpion.
Your best friend was stung by a jellyfish? What do you do to help?
Pour some vinegar (acetic acid) on it! This will deactivate the nematocysts that are left and help with the pain!
Don't pee on it!
In caustic ingestions, severe and life-threatening esophageal injuries are more likely with acidic or alkali materials?
Alkali materials! These cause liquefactive necrosis when ingested.
Patient presents with hypertension, tachycardia, hyperthermia, hyperreflexia, agitation, dilated pupils, diaphoresis, hyperactive bowel sounds
Sympathomimetic Toxidrome
Examples: Amphetamines, theophylline, synthetic cannabinoids
Treatment: Treat the agitation, seizures with benzodiazepines. IV fluids and supportive care.
Avoid Beta Blockers
A 16 month old presents after accidentally ingesting grandma's Valium? What is the reversal agent if this patient develops respiratory depression or apnea?
Flumazenil!
Flumazenil is a selective competitive antagonist of the gamma-aminobutyric acid (GABA) receptor and is the only available specific antidote for benzodiazepine toxicity. In most cases, supportive care measures are adequate if the patient is hemodynamically stable and breathing!
An 8 year old was playing in a dark closet and felt a pinch! Later that night, a blister with redness and swelling appeared and a few days later the blister progressed to hemorrhagic vesicles.
What guidance do you give the family about what will happen next with the wound?
A black eschar with central necrosis will develop.
This is a brown recluse spider bite (Loxosceles Species). The wounds eventually develop ulceration and necrosis. Follow up with Plastic Surgery is always recommended.
An 8 year old girl ate Mani Mani for dinner. She starts to feel flushing and breaks out in hives. In time develops nausea and headache.
She eats Mani Mani all the time and never had any reactions? What do you suspect is happening tonight?
Scromboid poisoning (histamine fish poisoning) - usually from improperly stored fish. Bacteria have histidine carboxylase enzymes that convert naturally occurring histidine in fish to histamine! This is why it produces similar symptoms to an allergic reaction! Treated the same with Benadryl or Epi if severe.
An 18 month old comes in vomiting and drooling. You see the remnants of a laundry pod in the emesis. Soon he becomes very somnolence, with slight movement and no eye opening. Only opening to pain.
HR 120 - RR 28 - BP 95/50
Ph 7.02 pCO2 38 pO2 94 HCO3 10
What's the best intervention for this patient?
Secure the airway -- Intubation!
Laundry Pods specifically cause metabolic academia, coma and respiratory depression in addition to the caustic effects on the esophagus. This can develop into ARDS.
Patient presents with hypertension, tachycardia, agitation, dilated pupils, urinary retention, dry skin
What is Anticholinergic Toxidrome! Very similar to Sympathomimetic toxidrome -- both with altered mental status, agitation, dilated pupils, hypertension.
"Blind as a bat, mad as a hatter, red as a beet, hot as a hare, dry as a bone, bowl and bladder lose their tone, and the heart runs alone"
Examples - Scopolamine, atropine, antihistamines, antidepressants
Treatment: Mostly supportive. Benzodiazepines help with agitation. Physostigmine for the delirium (check an EKG first)
A 3 y/o was found in her garage and presents with somnolence, Kussmaul breathing, anion gap acidosis, and urine that fluoresces with a wood’s lamp. What is the antidote?
What is fomepizole? Prior to 1998 - it was Ethanol!
Patient ingested Antifreeze which contains Ethylene. Glycol. Ingestion can cause severe lactic acidemia, hypotonia, hypocalcemia, AKI.
EMS calls about a 10 year old who was bit by a rattlesnake. As medical command, what directions do you give on how to take care of the wound prior to transport?
(Their ETA is 60 minutes.)
Immobilize the extremity and keep it dependent. You want to prevent lymphatic drainage of the toxin centrally. Tourniquets or suction are no longer recommended.
After eating fish for lunch 6 hours ago, a 12 year old has sudden onset vomiting, diarrhea, and abdominal pain. She also complains of pain in her teeth, numbness and painful tingling in her extremities.
What is the diagnosis?
A 4 year old boy weighing is brought in for seizures after being found with an open bottle of glipizide. The patient is comatose and persistently hypoglycemic. In addition to your routine resuscitation and IV dextrose boluses - what medication will you administer?
Octreotide! This is the treatment of hypoglycemia from ingestion of sulfonylurea diabetic medication. Glipizide causes increased pancreatic insulin release. Octreotide prevents the pancreas from releasing insulin.
Patient presents with diarrhea, urination, mitosis, emesis, lacrimation, sweating? What is the toxidrome?
Cholinergic Toxidrome -- This is the DUMBELS acronym!
Don't forget the killer B's -- Bronchospasm, Bradycardia, Bronchorrhea from muscarinic activation. Atropine if the patients have these symptoms.
Always decontaminate these patients prior to bringing them into the ED.
A 15 year old female intentionally overdosed on her migraine medication Amitryptiline, and presents with altered mental status, hypotension, and a wide QRS on EKG. What do you administer?
What is Sodium Bicarbonate?
TCA overdose - as little as 5 mg/kg can cause toxicity in children. TCA's are sodium channel blockers
A rattlesnake bit the hand of an 11 year old. She has oozing from the wound, pain, and a progressively swollen hand.
STAT labs are remarkable for: WBC 19, Hb 11, Platelets 95, PT 18, PTT 45.
What is your next step in management?
CroFab (pit viper antivenin) can be administered for worsening symptoms of labs. In stable patients, you can recheck labs in 1 hour prior to administration.
Fun Fact: CroFab is now sheep derived instead of horse derived. No longer associated with serum sickness.
Dosing - same for adults and kids. You're treating the venom not the person! Administered IV not in the wound.
Pit Viper Bites - local injury, coagulopathy, hypotension, DIC, altered mental status.
What is the most important thing to do in her management?
Place the leg in hot water! She was stung by a sting ray and stingray venom is heat labile - inactivated in 43-45 degrees C. Inactivate the venom prior to pulling out the barbs.
2 year old male comes in with Grandma after she found one of her extended release metoprolol tablets missing. He is sleepy.
Temp 37 - HR 52 - RR 16 - BP 50/38 - SpO2 100%. D-stick is 88. You give two fluid boluses and atropine but no improvement of HR or BP.
What do you give next?
Glucagon IV is the treatment for beta-blocker poisoning. Glucagon increases intercellular cAMP which is the same as beta receptor stimulation without relying on beta receptors! Atropine is unlikely to work in these patients - be careful of repeat doses causing anticholinergic symptoms. Be wary of repeat boluses as well.
Pinpoint pupils, shallow respirations, bradycardia, and improves initially with Naloxone... However symptoms return after a few minutes. UDS negative.
Clonidine! Alpha 2 agonist that is commonly prescribed for HTN.
Patient who was treated with Dapsone for a brown recluse spider bite in Mexico now presents with severe generalized cyanosis. Pulse oximetry is 85-90%, arterial blood is a chocolate brown color when a-line is placed.
What is the antidote?
What is Methylene Blue (Methemoglobinemia from Dapsone ingestion)
Neurologic symptoms - altered mental status and cranial nerve palsy. This is a CORAL snake. To deliver venom they have to bite and chew because they have short fangs.
Muscle weakness can impact respiratory muscles as well.
The King snake is close and harmless. Remember Red on Black - Venom lack. Red on yellow kills a fellow.
A 3 year old was stung by a Portuguese man of war. Despite immersion of the wound in hot water at an OSH, she continues to have severe pain and decreased level of alertness. What is the appropriate treatment to prevent sequelae of severe envenomation?
Fluid boluses! Portugese Man of War toxin is heat labile and causes severe pain. It causes headache, myalgia, fever, N/V, respiratory distress, hemolysis, AKI, diarrhea and hypotension. You also want to immerse the wound in hot water to deactivate the toxin (the OSH already did that in this patient).
14 year old boy comes in after swallowing some gasoline. He says he was coughing for a few minutes, then had some epigastric and chest burning. Now he is feeling better, only coughing twice in the room. Vitals are normal and he has no respiratory distress. CTA bilaterally.
What's the management plan?
Observe for 6 hours, and then get a CXR.
Hydrocarbon ingestion can cause pneumonitis and acute lung injury. You should always order a CXR even for asymptomatic patients to look for infiltrates.