Page 235 - TNFlipTest

Toronto Notes 2019 Toxicology
■ treatment
◆ urgent hemodialysis required
◆ fomepizole 15 mg/kg IV bolus (treatment of choice) or EtOH 10% IV bolus and infusion to
achieve blood level of 22 mmol/L (EtOH loading may be done PO)
◆ consider folic acid for methanol, and pyridoxine and thiamine for ethylene glycol – both help
reduce conversion to active metabolites
• otherabnormalitiesassociatedwithalcohol:hypomagnesemia,hypophosphatemia,hypocalcemia,
hypoglycemia, hypokalemia
Gastrointestinal Abnormalities
• gastritis
■ common cause of abdominal pain and GI bleed in chronic alcohol users
• pancreatitis
■ serum amylase very unreliable in patients with chronic pancreatitis, may need serum lipase ■ hemorrhagic form (15%) associated with increased mortality
■ fluid resuscitation very important
• hepatitis
■ AST/ALT ratio >2 suggests alcohol as the cause as well as elevated GGT with acute ingestion
• peritonitis/spontaneousbacterialperitonitis
■ leukocytosis, fever, generalized abdominal pain/tenderness
■ occasionally accompanies cirrhosis
■ paracentesis for diagnosis (common pathogens: E. coli, Klebsiella, Streptococcus) ■ albumin shown to improve outcomes in SBP patients
• GIbleeds
■ most commonly gastritis or ulcers, even if patient known to have varices ■ consider Mallory-Weiss tear secondary to retching
■ often complicated by underlying coagulopathies
■ minor: treat with antacids
■ severe or recurrent: endoscopy
Disposition
• beforepatientleavesEDensurestablevitalsigns,canwalkunassisted,andfullyoriented
• offersocialservicestofindshelterordetoxprogram
• ensurepatientcanobtainanymedicationsprescribedandcancompleteanynecessaryfollow-up
Approach to the Overdose Patient
History
• age,weight,underlyingmedicalproblems,medications
• substance,route,andquantity
• timeandsymptomssinceexposuredeterminesprognosisandneedfordecontamination • route
• intention, suicidality
Physical Exam
• focuson:ABCs,LOC/GCS,vitals,pupils
Disposition from the Emergency Department
• methanol,ethyleneglycol
■ delayed onset, admit and watch clinical and biochemical markers
• TCAs
■ prolonged/delayed cardiotoxicity warrants admission to monitored (ICU) bed
■ if asymptomatic and no clinical signs of intoxication: 6 h ED observation adequate with proper
decontamination and no ECG abnormalities
■ sinus tachycardia alone (most common finding) with history of overdose warrants observation in
ED
• hydrocarbons/smokeinhalation
■ pneumonitis may lag 6-8 h
■ consider observation for repeated clinical and radiographic examination • ASA, acetaminophen
■ if borderline level, get second level 2-4 h after first
■ for ASA, must have at least 2 measurements showing decreasing toxin serum concentration before
discharge (3 levels minimum) • oralhypoglycemics
■ admit all patients for minimum 24 h if hypoglycemic and 12 h after last octreotide dose ■ observe asymptomatic patient for at least 8 h
Psychiatric Consultation
• oncepatientmedicallycleared,arrangepsychiatricinterventionifrequired • beware–suicidalideationmaynotbeexpressed
Emergency Medicine ER55
Indications to Suspect Overdose
• Altered LOC/coma
• Young patient with life-threatening
dysrhythmia
• Trauma patient
• Bizarre or puzzling clinical presentation