Overdose

1
Overdose

• Marie-Martine Logvinoff, M.D.

2
Decontamination

• Toxic inhalation
• Air skin decontamination useful
• Dermal (insecticide, organophosphate)
• (protocol for rescuer themselves)

3
Gastro-intestinal Decontamination

• (ipecac, charcoal, bowel irrigation) not shown
  to change the outcome, follow regional poison
  center
• (National 800-222-1222)

4
Syrup of Ipecac

• Within 30 min of ingestion
• For low risk substance
• In alert, responsive victim

5
Activate Charcoal

• Absorbs numerous drugs
• ? the bioavailability by
• 70 within 30 minutes of ingestion
• 30 within 60 minutes of ingestion

6
Activated Charcoal contd

• 1 gm/kg up to 1 year
• 25 50 gm 1 12 years
• If stable airway, with protective reflex
• Contraindicated if no bowel sound
• (TCA Ca blocker Opiate)

7
Gastric Lavage

• Complication hypoxia pneumothorax GI
  perforation

8
Antidote
9
Cocaine / Crack

• 1/3 fatal injury in young adults
• Absorbs from mucous mbr, IV onset 1-2 minutes ½
  life 60 min
• Small children ingest crack ? shock ALTE
  passive inhal./breast milk ? seizure

10
Cocaine / Crack contd

• ? blocks reuptake of neurotransmitters on presyn,
  nerves (Accumulation of Epi, Nor, Dopa, Serot)
• ? and is a fast Na channel blocker (prolongs QRS)
  (lidocaine, ß blocker, procainamide, propranolol,
  quinidine, carbamazepine, doxepin)

11
Cocaine / Crack, Clinical

• CNS mood elevation, exhilaration,
  hallucination, movement disorder, tremor, hyper
  ?, mydriasis
• Resp.CV Hypertension, ACS (Acute Coronary
  Syndrome) ? 02 demand, coronary artery const.
  Myocardial infarction, chest pain. Prolonged
  QRS, QT, VT, VF
• Platelets Aggregation, activation

12
Cocaine / Crack Treatment

• Phentolamine
• 0.05 mg/kg
• ASA / Heparin
• Na H CO3 1 2 mcg/Kg
• No ß-blocker (antagonize cocaine ß adrenergic
  stimulation and vasodilation)

• AW, V, O2
• ECG monit (troponin)
• Benzodiazepine (no phenothiazine)
• MONA greets all patients Morphine, O2,
  Nitroglycerin
• 0.2 0.5 mcg/kg/min

13
Ca Channel Blockers

• Affect transmembrane, and intracellular movement
  of Ca
• ? Conduction in slow channel (SA, AV node)
• ? Myocardial excit contract
• ? Vascular smooth muscle tone

14
Ca Channel Blockers contd

• Bradyarrhytmia / Hypotension
• Pulm-edema, ? GI mobility CNS (coma, syncope)
• Immediate
• Delayed (slow release)

15
Ca-Channel Blockers Treatment contd

• CaCl 10 20mg/kg, infusion, monitor Ca
• Insulin/Glucose (0.5 g/kg) 0.1u/kg Glucagon
  0.05-0.1mg/kg bolus, infusion 01.mg/kg/hr
• Cardiac pacing, ECMO
• Isopro/Abropine/Dopamine Amrinore

• AW V O2
• ECG monit
• Vascular access
• (treat shock)
• N/S small bolus 5-10 ml/kg
• High dose Epi/Nor

16
ß-Adrenergic Blockers

• Compete with sympathetic (Epi, Nor) neurot. At
  receptor sites
• (ß1 Cardiac, renal adipose
• ß2 Lower airway, vessels, GI)
• ? intracellular CAMP (brady, ? contractility)
• ? release of Ca from endo retriculum
• (? conduction)

17
ß-Blocker- Cardio-Vasc Toxicity

• Propranolol-atenolol-metroprolol 90
• Bradycardia, hypotension
• Prolonged PR, QRS, block
• Intravent conduction defect
• Acebutolol ? torsade de pointe, VF- asystole
• Na blocking effect (propan. sotalol)
• Prolonged QRS - QT

18
ß-Blocker, Clinical

• CNSaltered mental status, seizures,coma
• (2o to hypoperfusion, high lipid solubility
  (propranolol)
• CV/ECG
• - Brady hypot
• - Prolonged QRS, QT block
• - arrhythmia
• - ? contractility
• Resp bronchospasm
• Hypoglycemia

19
ß-Blocker Treatment

• AW, O2, V
• ECG monitor
• Vascular Access (Treat shock)
• Epinephrine infusion high dose
• Glucagon 0.05 to 0.1 mg/kg up to 1
  mg (? phenol)
• Glucose / insulin
• Nabic
• Ca?
• Cardiac pacing - ECMO

20
OPIOD OD

• Recreational
• Analgesic
• Morphine, codeine, hydrocodone, fentanyl patch
  25-100 ?g/hr (2.5mg 100mg)
• Dm cough syrup
• Methadone (long ½ life)
• Clonidine (central a2 agonist)

21
OPIOD OD contd

• Respiratory depression-apnea-non cardiogenic pulm
  edema (inhibition of medulla receptors)
• Coma, seizure (meperidone)
• Miosis pin-point)
• Hypotension-brady/tacky-cardiac arrest
• GI delay
• Potentiated by benzodiazepine-alcohol
  (glutamate-GABA neurotransm)

22
Pediatrics

• Drug / Coma / Miosis
• 88 narcotics
• 72 phenothiazine
• 35 ethanol
• 31 barbiturate

23
OPIOD OD, Treatment

• AW V O2 (Correct CO2)
• ECG monitoring (treat arrhythmia)
• Vascular Access (treat shock)
• Naloxone (0.1 mg/kg up to 2 mg for 2 hours)
  short ½ life
• Now. GO-SLOW. GO-LOW
• (1)

24
OPIOD OD, Treatment contd

• Naloxone (0.1 mg/kg up to 2 mg for 2 hours)
  short ½ life
• Now. GO-SLOW. GO-LOW
• (1) Normaliza pCO2 (to prevent ? epinephrine)
• (2) 0.01 mg/kg up to 0.4 mg Naloxone
• IM, SC, IV, ET
• Narcan drip 6-48 hrs (if methadone OD) watch for
  cyclical emesis, coma, hypo/hypertension, pupil
  dilation, pulm edema, arrhythmia

25
Tricyclic Antidepressant (and other Na blocker)

• TCA (Three C, A, coma, convulsion, cardiac
  arrhythmia, acidosis)
• Na blocker
• Propranolol, sotalol
• Procain, quinidine
• Lidocaine / cocaine
• Antiarrhythmic
• Benadryl - doxepin

26

• 2 Effects
• Anticholinergic (mad as a hatter, red as a beet,
  blind as a bat, hot as a hare, dry as a bone)
• Na blocker quinide like on myocardium K blocker
• First anticholin effect ? CNS stim agitation,
  confusion, hallucination. Seizure, ?? - coma
• CV sinus tacky, then wide complex QRS 0.1.
  Sec, brady, block, VF ? wave lead a VR 3mm
• RESP Pulm edema

27
Tricyclic Antidepressant, Treatment

• AW, V, O2
• ECG monitor
• Vascular Access (Shock) Epin
• Nabic 1 meq/kg/bolus inusion (ph7.45-7.5)
• Benzodiazepine no physostigmine
• no phenytoin

28
Anticholinergic Mydriasis

• Antihistamine
• Antiparkinson
• Belladone
• Jimson weed
• Carbamazepine - phenothiazine