1. Stabilize

2. Clinical and lab data

3. Decontaminate

4. Decrease absorption of toxin

5. Increase elimination of toxin

6. Treat with antidote

7. Determine appropriate disposition

1. ABCs

2. DONT

3. Seizure control

Treatment for altered mental status

1. Dextrose: Hypoglycemia

2. Oxygen

3. Naloxone

4. Thiamine

1. Benzodiazepine

2. Barbituate

3. Propofol

--NO phenytoin

--NO Flumazenil (benzodiazepine antagonist) because it may unmask tendency for seizures

Substrate response

History

Observations at scene

Rule-Out non toxic causes

Toxidromes

EKG

e.g. MI, CVA, sepsis, meningitis, trauma.

-Altered Mental Status: Stroke

-Hypotension: MI

Head CT: For any altered mental status of uncertain etiology

EKG: Provide clues if someone has an MI

-One of the fastest tests to do in ER (along with finger stick)

1. Acetaminophen

2. Alcohol

3. Arterial Blood Gas

4. Anion Gap

5. Aspirin

1. Most common pharm toxin.

2. No reliable clinical signs

3. Can result in hepatic failure

4. Nomogram:

-Above 200 line = risk for hepatic toxicity

-US also treats those who are at the 150 line and above.

5. Excellent antidote biut it must be given in time

NAC

1. Acts as a sulfhydryl donor, substitutes for hepatic glutathione and detoxifies the toxic metabolite.

2. Most effective when given within 8 hours but may reduce hepatotoxicity up to 24-36 hours.

1. Common cause of ams

2. Needed to calculate osmol gap

3. Continue to look for other co-exisiting problems (e.g. intracranial bleed)

1. Need to identify and correct acidosis early

2. Clues about salicylate poisioning

3. Obtain for any patients with abnormal respirations

*Shows if they need more oxygen, need to be intubated, or need to be treated for aspirin overdose

1. Basic metabolic panel gives anion gap, measured bicarbonate, and calculated osmolality

2. Most causes of metabolic acidosis have an increased (wide) anion gap usually with low HCO3

AnGap = Na - (Cl + HCO3)

Normal = 8-12 mmol/L

Measured osmolality (by freezing point depression) -  calculated osmolality

-Normally: 5-10

-If large, then something is osmotically active (usually toxic alcohol)

MEDIE

Methanol

Ethanol

Diuretic

Isopropanol

Ethylene Glycol

1. TCAs

2. Sympathomimetics

3. Cocaine

4. Theophylline

5. Anticholinergics

1. Beta-blockers

2. Calcium channel blockers

-Normal is less than 120s

-Suggests a Na channel problem (longer period of depolarization)

1. TCAs

2. Propafenone

3. Flecainide

4. Quinidine

5. Procainamide

6. Disopyrmide

1. Digoxin

2. Beta blockers

3. Ca++ Channel Blockers

Sometimes useful in diagnosis (abd films)

CHIPES

Chloral hydrate, carbon tetrachloride

Heavy metals

Iron, Iodine

Penothiazine, Packers

Enteric coated packets

Sustained release

1. Prevent further absorption

2. Increase elimination

1. Ipecac

2. Gastric Lavage

3. Activated charcoal

4. Cathartic

5. Whole Bowel Irrigation

6. Polyethylene Glycol Solution

1. One hour window between overdose and use

2. Studies show no difference in outcome as compared to charcoal

1. Binds to most drugs and toxins, except metals

2. Promotes transluinal efflux of selected drugs

Used for drugs where there is enterohepatic cycling

1. Theophylline

2. Phenobarbital

3. Carbamazepine

4. Quinine

5. Dapsone

6. Salicylate

1. Forced diuresis

2. Alkaline diuresis

3. Acid diuresis

4. Hemodialysis

5. Hemoperfusion

1. IV saline + furosemide

-Used for lithium

IV sodium bicarbonate, K+

1. Ion trapping of salicylates, phenobarbital based on pka

2. Potassium is the key to successful urinary alkalinization

-Hepatic and renal faiulre

1. Li+

2. ASA

3. Theophylline

4. Ethylene Glycol

5. Methanol

1. Opiate

2. Amphetamine

3. PCP

4. TCA

5. Benzodiazepine