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Kent R. Olson, MD
Medical Director California Poison Control System San Francisco Division
Lesson:
Best antidote is good supportive care
Case 1:
Young woman found unconscious, several empty pill bottles nearby Unresponsive to painful stimuli Shallow breathing
Airway issues
Risks:
Floppy tongue can obstruct airway Loss of protective reflexes may permit pulmonary aspiration of gastric contents
Alternatives
Breathing
Assess visually pCO2 reflects ventilation - ABG useful pulse oximetry provides convenient, noninvasive evaluation of O2 saturation
Pitfalls
pO2 measures dissolved oxygen
can be normal despite abnormal hemoglobin states, eg COHgb, MetHgb
Interventions
Endotracheal intubation
Protects airway Allows for mechanical ventilation
Reverse coma?
Naloxone: note T = 60 min Flumazenil?
Case, continued
The patient has no gag reflex, and does not resist intubation. She remains unconscious and on a ventilator overnight Awakens and extubated the next day Dx: mixed sedative drug overdose
Case 2
47 year old man calls 911, suicidal BP 70/50, HR 50/min Junctional rhythm Hx: uses an antihypertensive
Circulation = plumbing
Pump working? Enough volume (is it primed)? Adequate resistance (no leaks)?
Management of Hypotension
Hypovolemia?
IV fluid challenge
Pump?
Dopamine
Antihypertensives
Diuretics Beta blockers Calcium channel blockers ACE Inhibitors Centrally acting agents Vasodilators
HR AV Block
CO
SVR
SHOCK
Case 3:
An 18 month old takes some of his grandmothers sleeping pills Brought to the ER after a seizure HR 150/min Pupils dilated, skin flushed, mucous membranes dry
Tricyclic antidepressants
Anticholinergic syndrome Seizures Cardiotoxicity
Treat cardiotoxicity
Sodium bicarbonate 1 mEq/kg IV IV fluids Dopamine and/or NE
Drug-induced Hyperthermia
Heat Stroke Malignant Hyperthermia Neuroleptic Malignant Syndrome Serotonin Syndrome
Malignant hyperthermia
Rare, familial myopathy Triggered by general anesthesia
Succinylcholine Inhalational agents (eg, Halothane)
Serotonin Syndrome
Current hot diagnosis Serotonin-enhancing Rx
SSRIs in OD or multiple combos MAOI + serotonin-ergic drug
Hyperthermia treatment
Act quickly!
Remove clothing spray and fan Sedation and anticonvulsants PRN Neuromuscular paralysis if T >40 C Dantrolene if NM paralysis ineffective Consider bromocriptine, cyproheptadine
Ipecac-induced emesis
Easy to perform, but not very effective Contraindicated:
Comatose/convulsing Ingested corrosive or hydrocarbon
Gastric lavage
May stimulate gagging, vomiting Risky if airway reflexes dulled Lack of proven efficacy Bottom line: used only rarely
Activated charcoal
Finely divided powdered material
Huge surface area
Activated charcoal
More effective than SI, GL First choice for most ODs
Good for:
Iron Lithium Sustained-release pills, foreign bodies
Antidotes:
The best antidote is supportive care Examples of antidotes:
Digoxin-specific antibodies Atropine & 2-PAM N-acetylcysteine Vitamin B-6 (pyridoxine)