Pr

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Cases from Downunder
Sophie Gosselin.MD,CSPQ,FRCPC Newcastle Mater
Misericordiae NSW, Australia
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Case one Miss R.

• Call at 01h30
• 13 yrs old female brought by police and EMS after
  suspected DSH by ingestion of medication
• Best friend called at 23h and told  good bye
  forever .
• Friend called mother, 000 called and patient ran
  out back door
• Found at 00h30 by EMS and brought to JHH

3
Case one Miss R.

• On arrival
• Alert, oriented 67 kg
• HR 120 NSR
• RR 16
• BP 110/70
• sat 100
• Glucose 5.1
• T 37.8

4
Case one Miss R.

• Took around 22h30
• Prednisone 50mg x 20 1000 mg
• Paracetamol 500 mg x 64 32 gr
• Codeine 30 mg x 24 720 mg
• Pseudoephedrine 60 mg x 24 1440 mg
• Ibuprofen 200 mg x 24 4800 mg
• Medication X 0.5mg x 50-64 25-32 mg
• Dimenhydrate 50 mg x 12 600 mg

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Case one Miss R.

• What would you do next?
• What would you expect to find on physical exam to
  confirm if she did take all these?

6
Case one Miss R.

• Level of counsciousness - belligerant
• Airways - not a problem
• Breathing - not a problem
• Circulation not a problem
• Decontamination
• Gastric lavage?
• Charcoal?
• WBI?

7
Case one Miss R.

• We are 2 hours post ingestion.
• Do we have indications to consider
  decontamination?

8
Case one Miss R.

• Police went home and did medication search.
• We knew then what Medication X was.
• Here is what we did and what happened.
• Can you identify the toxin?
• Note your answers as we go along
• Ask all questions you want
• Do not yell out your answers
• We will poll the assistance at the end and get a
  top 5 lists of toxin

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Case one Miss R.

• 01h15
• Intubated in ED for decontamination
• Charcoal one dose 50 gr
• WBI started
• N-acetylcysteine started empirically pending
  level
• Admitted to ICU
• HR 160 BP 100/60
• ECG sinus tachycardia

10
Case one Miss R.

• 04h00
• Hbg 137
• WBC 4.3
• Platelets 278
• Na 133
• K 3.0
• Creatinine 57
• BUN 3.5
• INR 1.1
• Paracetamol 950 at 3h30
• CK 146
• Troponin negative

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Day one Miss R.

• 04h00
• Sedated
• Vomiting
• Unable to continue charcoal
• HR 160 sinus
• BP 95/60
• 14h00
• No change in status
• Given Neostigmine 2.5 mg IV
• Decontamination continued with charcoal alone
  until black stools

12
Day two Miss R.

• HR 160 sinus
• BP 75/55 started on norepinephrine
• Swan Ganz
• Output slightly decreased
• Systemic vascular resistance decreased
• Labs
• Unchanged except CK 1307
• Which investigation would you want?

13
Day two Miss R.

• Cardiac echo
• Normal valves
• Impaired LV contraction
• EF 35
• No pericardial effusion.

14
Day three Miss R.

• Still requiring inotropes
• Stools black after MDAC
• HR 140 BP with support 105/60
• Hgb 133
• WBC 4.9
• Plat 99
• LFTs and INR unchanged NAC stopped.

15
Day four to six Miss R.

• Still requiring inotropes (dobutamine)
• Still intubated
• Fever 39
• Abdominal distension
• HGB 105
• WBC 2.2
• Platelets 31
• CK 4142
• Troponins 1.87
• Given GCSF for 24h

16
Day six to eight Miss R.

• Weaned off inotropes
• Extubated
• Treated for Aspiration
• Given neostigmine again
• HGB 116
• WBC 9.0
• Platelets 111
• CK 541
• Troponins going down
• Cardiac echo normal EF

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Data on toxin-Miss R.

• Significant toxicity
• Bound by charcoal
• Initial symptoms?
• Pancytopenia in 48h
• Cardiac depression
• Resolution within one week.
• ????

18
Colchicine intoxication

• Patient has gout.
• Took 0.5 mg x 64 32 mg
• Per kg 0.48
• Phase 1
• 0-24h GI, leukocytosis, hypovolemia, DIC
• Phase 2
• 2-7 days bone marrow suppression, cardiac
  depression, hepatic failure, MOF, ARDS
• Phase 3
• Resolution
• Death
• Alopecia

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Colchicine intoxication

• Alkaloid from Colchicum autumnale
• Narrow therapeutic-toxix index
• GI side effects
• High rates of morbidity
• Absorbed 2 h after ingestion
• Not delayed in overdose unless by coingestants
• First pass hepatic metabolism
• Distribution t1/2 45-90 minutes
• Excreted in the bile with enterohepatic
  circulation

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Colchicine intoxication

• Binds to tubulin
• Impairs microtubules formation
• Neutrophils, gastrointestinal musco,
  hematopoeitic cells, hair follicles.
• Toxicity is dose related
• 0.5 mg/kg or less usual recover
• 0.8 mg/kg or more usual die
• 3 stages
• GI 0-24h
• MOF 24-72h
• Recovery 6-8 days p.i.

21
Colchicine intoxication

• Asymptomatic initially
• N/V/D
• GI mucosal damage
• Hypovolemic shock
• Sepsis
• impaired macrophage function
• Cardiogenic shock
• Rhabdomyolysis
• Renal failure
• Seizures, ascending paralysis, transverse myelitis

22
Colchicine intoxication

• Ingestion known
• Asymptomatic drug OD
• Toxic causes of gastroenteritis
• Iron
• Salicylates
• Fluoride
• Caustics
• Cardiac glycosides
• Nicotine
• OPP/carbamates
• Paraquat
• Mushrooms

• Ingestion unknown
• Acute abdomen
• Cardiogenic shock
• Gastroenteritis
• Hypovolemic shock
• Septic shock

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Colchicine intoxication

• Extensive baseline lab studies
• Levels can be done
• Takes a few days
• Retrospective, post mortem
• No increase in AG, osmolar gap
• Acid base abnormality are not specific
• Early, aggressive GI decontamination
• Enhanced elimination not indicated
• Large Vd 21L/kg
• Intracellular binding sites
• GSCF true response versus natural course?
• Death are rarely from marrow aplasia
• No antidotes commercially available

24
Colchicine intoxication

• Fab antibodies
• Similar to digitalis Fab fragment
• Produced in goat immunized with conjugate of
  colchicine and albumin
• Effectively reverse toxicity in mice
• NEJM Mar 15 1995. Baud and al.
• One human case report 27 hrs p.i of 60 mg of
  colchicine 0.98 mg/kg
• Improvement within 30 minutes after Fab
• Severe cardiogenic shock
• Increased the urinary excretion of Fab-colchicine
  compound by 6 fold

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Colchicine intoxication

• Patient has gout.
• Took 0.5 mg x 64 32 mg
• Per kg 0.48
• Phase 1
• 0-24h GI, leukocytosis, hypovolemia,
• Phase 2
• 2-7 days bone marrow suppression, cardiac
  depression, rhabdomyolysis
• Phase 3
• Resolution

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Case 2- Mrs. B

• 45 years old patient found on highway
• After serious MVA
• Transported to Trauma Center

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Case 2- Mrs. B

• A patent
• B GAEB
• C BP 50/ HR 40
• No external wounds
• No other signs of injury
• Normal temperature
• Normal glucose

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Case 2- Mrs. B

• Prolonged QT
• Wide QRS
• Differential diagnosis
• Traumatic injury after OD?
• No traumatic injury but signs are the OD?

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Traumatic vs toxicologic?

• Traumatic
• Single vehicule MVA
• Seatbelt
• No airbag
• Unknown speed
• Damages important

• Toxicologic
• No associated signs of injury

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Case 2- Mrs. B

• How would you manage this patient?

32
Case 2- Mrs. B

• NaHCO3 infusion?
• External pacer
• Extracorporeal support
• Emergency bypass?
• Thoracotomy?
• Transthoracic ultrasound?
• Gastrointestinal decontamination?

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Differential diagnosis?

• Traumatic
• Tamponnade
• Hypovolemic shock?
• Pneumothorax?
• CNS bleed?

• Toxicologic
• Antidysrhythmic
• TCA
• Phenothiazines
• Cocaine
• Amantadine
• Propoxyphene
• Chloral hydrate
• OPP
• Terfenadine
• BB CCB
• Hypokalemia
• Hypocalcemia

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Case 2- Mrs. B

• No significant response to many boluses of NaHCO3
• Normal CXR, Normal FAST
• Normal Hgb
• Acidosis
• High lactate
• Started seizing
• Would you give her amiodarone?
• Would you start pressors and if so which one?

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Vaughan-Williams Classification
Class Effect Clinical Drugs
IA Decreases upstroke Decreased conduction Na and K blockade QT prolongation QRS widening Hypotension Lethargy, coma Quinidine Procainamide
IB Depresses rapid action potential Confusion,Seizures Asystoly, Ventricular Wide QRS Lidocaine
IC Marked depression rapid action potential No K blockade QT prolongation Hypotension,Bradycardia Coma, seizures Propafenone Flecainide
II B receptors blockade Beta-blockers
III K channel blockade Little or no Na blockade Rapid hypotension, QT Increased PR, bradycardia Profound coma, hypotension Sotalol Amiodarone Bretylium
IV L type Ca channel Bradycardia Peripheral D CCB
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Case 2- Mrs. B

• Are you able to tell which one is which?
• Degree of hypotension?
• Degree of bradycardia?
• Anticholinergic features?
• Presence of seizures?

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Treatment

• IA or IC
• Cardiac conduction delay
• NaHCO3 ph 7.5
• Fluid for hypotension
• Norepinephrine
• Magnesium if TDP
• Overdrive pacing
• Isoproterenol

• IB
• Lorazepam for sz
• Phenobarbital
• Fluid for hypotension
• norepinephrine

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Case 2- Mrs. B

• NaHCO3 infusion increasing
• Overdrive pacing
• Norepinephrine increasing doses
• She went in PEA
• Arrested
• Unable to ressuscitate

39
Case 2- Mrs. B

• Police found suicide note
• Empty bottle of flecainide
• Could we have done anything to save her?

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Flecainide overdose

• IC antidysrhythmic
• Na channel blockade
• All condution pathways depressed
• High mortality rate 23 compared with other
  classes
• Quick absorption within 30 minutes
• 95 bioavailability
• Serious cardiac effect 30-120 minutes
• Weak acid Alkalinization
• Vd 9 L/kg dialysis ineffective
• Long half life

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Flecainide overdose

• Hemoperfusion
• A blood pressure is needed
• ECMO
• Critical Care Medicine April 2001
• Case report
• After 8 mg epi, 1.2 mg atropine, 125 mmol NaHCO3
• Epi drip 100 mg/min
• TC pacer to 100 mA
• T pacer to 20 mA asynchronous mode
• Fixed dilated pupils, no palpable pulse, pH 7.26
• Successful recovery after 26 hours

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Australian experience A paramedical case report
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John Hunter Hospital Level 6 trauma center Built
1991 Ressuscitation Room
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Combined pediatric Adult emergency department
One ressuscitation area
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8 monitored bed 18 acute care beds
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Doctors desks
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Isolated Monitored beds
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Longitudinal hall Departments on either sides
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Special 4 isolation ICU type beds  for SARS or
the like 
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Stand-by isolation ward
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