EMERGENCY MEDICINE GUIDEWIRE
  • HOME
  • The Podcasts
    • Core Concepts
    • Critical Care Topics
    • Intern Nuggets
    • Pediatric EM
    • Toxicology
    • Trauma Topics
    • Sports Medicine Corner
  • Cards for EM
    • ECG Monthly Lesson
  • CMC Imaging Mastery Project
    • Adult Chest X-Ray Cases
    • Pediatric X-Ray Cases
    • Pediatric Orthopedic X-Ray Cases
    • Abdominal Imaging Room
    • Implanted Device Radiology Room
    • Condition Specific Radiology
  • Global EM
  • Shownotes
    • Core Concepts ShowNotes
    • Cards for EM ShowNotes
    • Ped EM Morsels ReBaked Shownotes
    • Pediatric EM Shownotes
    • Sports Med Shownotes
    • Toxicology Shownotes
    • Trauma Talks Shownotes
  • Subscribe
    • iTunes
    • Google Play
    • Stitcher
  • About
  • Associated Sites
    • CMCEdMasters
    • CMCECGMasters
    • PedEMMorsels
  • HOME
  • The Podcasts
    • Core Concepts
    • Critical Care Topics
    • Intern Nuggets
    • Pediatric EM
    • Toxicology
    • Trauma Topics
    • Sports Medicine Corner
  • Cards for EM
    • ECG Monthly Lesson
  • CMC Imaging Mastery Project
    • Adult Chest X-Ray Cases
    • Pediatric X-Ray Cases
    • Pediatric Orthopedic X-Ray Cases
    • Abdominal Imaging Room
    • Implanted Device Radiology Room
    • Condition Specific Radiology
  • Global EM
  • Shownotes
    • Core Concepts ShowNotes
    • Cards for EM ShowNotes
    • Ped EM Morsels ReBaked Shownotes
    • Pediatric EM Shownotes
    • Sports Med Shownotes
    • Toxicology Shownotes
    • Trauma Talks Shownotes
  • Subscribe
    • iTunes
    • Google Play
    • Stitcher
  • About
  • Associated Sites
    • CMCEdMasters
    • CMCECGMasters
    • PedEMMorsels
Search by typing & pressing enter

YOUR CART

2/7/2019 0 Comments

Aspirin (ASA) Toxicity


Aspirin Toxicity and its Management in the Emergency Department
 
Mechanism and toxicity:
  • Salicylates irreversible block the COX-1 pathway and modify the COX-2 pathway resulting in a decrease in inflammation and platelet aggregation
  • Salicylate is conjugated in the liver and then excreted in the kidneys, which will be important in toxicity. 80-90% is protein bound, however, in acute toxicity, this decreases and more of the drug is in the non-ionized form. 
  • This non-ionized form interferes with the Krebs cycle, uncouples oxidative phosphorylation and limits ATP production, increases fatty acid metabolism and causes accumulation of pyruvic and lactic acid
 
Effects of toxicity:
  • Direct stimulation of the respiratory center causing hyperventilation
  • Altered mental status and hypoglycemia in the CSF
  • Cerebral edema 2/2 leakage of the BBB
  • Metabolic acidosis and resp alkalosis causes hyperventilation which leads to dehydration, fluid losses and acute kidney injury
  • Alters platelet function
  • Affects cochlear blood flow and membrane permeability outer hair cell organ of corti leading to sensorineural alterations
  • GI isrupts mucosal barrier that protects from acid, ulcers, bleeding 
 
ASA Level and Indications for Dialysis:
  • 100mg/dL for acute ingestion
  • 60mg/dL for chronic ingestion
  • Tinnitus with levels as low as 30mg/dL
  • Also, standard to obtain BMP, ABG, UA and CXR
 
Management in the ED:
  • Start off with the ABCs like any acutely ill patient that presents to the ED
  • Activated charcoal is indicated in acute ingestions
  • Treat hypoglycemia and hypokalemia, quick bedside BMP/glucose testing will be very helpful
  • Most importantly is combating the acidosis and elimination of the drug which includes aggressive use of NaHCO3 and HD when indicated
  • Goal is to alkalize the urine and create ion trapping to assist elimination of the drug
  • Goals for alkalization of urine are usually a pH of 7.5-8.5. The patient will need a foley and constant monitoring of UOP
 
Managing intubation?:
  • Intubation should be avoided at all costs
  • If you intubate, be sure to increase RR, if not, RR will drop causing worsening acidosis likely resulting in cardiac arrhythmias and possible death. 
 
Chronic ASA Toxicity:
  • Patient history is key and we often misdiagnose these patients with sepsis, delirium, fever of unknown origin
  • They may present with mixed acid base picture
  • More common in elderly, which makes the diagnosis even more difficult. Indication for HD 60mg/dL as mentioned before. 

0 Comments

2/3/2019 0 Comments

TOXIDome's Approach to the Agitated Patient


Pharmacologic Interventions for Undifferentiated Agitation 
 
Introduction
  • Agitated delirium also known as excited delirium syndrome – is a mental state characterized by violent behavior, speech changes, acute disorientation and abnormal thought process. 
 
Differential 
  • Agitated delirium in the ED has many etiologies, must consider a very broad differential
    • Psychiatric - Acute psychosis, paranoia
    • Neurologic – intracranial pathology, encephalitis, idiopathic malignant catatonia, 
    • Medical – hypoxia, sepsis, meningoencephalitis, thyroid storm, pheochromocytoma, hypoglycemia, heat stroke
    • Trauma – SDH, SAH, epidural hematoma
    • And of course…Toxicology –sympathomimetic toxicity, anticholinergic syndrome, alcohol or benzodiazepine withdrawal syndromes, salicylate poisoning, serotonin syndrome, neuromalignant syndrome, hallucinogens, malignant hyperthermia
    • Others
 
Initial Approach
  • Attempt to elicit history and physical exam, although may not be feasible
  • Verbal redirection and de-escalation should be attempted first
  • Physical exam and history can clue you in to potential ingestions/toxidromes
 
Pharmacologic Interventions
  • Benzodiazepines and antipsychotics are the drug classes of choice
  • Must consider onset of action, duration and route when making decision around these medications
  • Tradition use of 5mg of IM haloperidol and 2mg of IM lorazepam may not always be the best choice as their onset of action may be delayed and as long as 20-40 minutes
  • Be aware of repeat dosing (stacking of doses), may lead to respiratory depression
  • Consider 5mg IM midazolam, onset usually 1-3 minutes, shorter acting and 2mg lorazepam
  • Must consider side effects of antipsychotics, including QTc prolongation 
 
Ketamine for Acute Agitation
  • Emerging evidence supports ketamine for this indication
  • Dose: 4-6mg/kg IM
  • Consider in patients that may have contraindications for other drug classes 
 
Core Concepts
  • Keep your differential BROAD
  • Attempt to obtain history and physical exam as this will guide your management
  • Consider route, onset of action and duration of the various pharmaceutical options 
  • Traditional 5mg IM Haldol and 2mg IM Ativan may not be best option given delayed onset of action
  • Recommendation for fastest control is 5mg midazolam and 2mg lorazepam or ketamine IM
 

0 Comments

2/3/2019 0 Comments

Toxicology 101 Part 2: Toxidromes


0 Comments

2/2/2019 0 Comments

Toxicology 101, Part 1

0 Comments

    Author

    Join the EMGuideWire Team from CMC EM Residency as they wrestle with Toxicologic clinical questions. Enter the TOXIDome!

    Archives

    February 2019
    January 2019

    Categories

    All

    RSS Feed

EMGuideWire

Picture
From the J. Lee Garvey Innovation Studio in the 
Department of Emergency Medicine
Carolinas Medical Center
Charlotte, NC

Picture
© COPYRIGHT 2015. ALL RIGHTS RESERVED.
LEGAL DISCLAIMER (to make sure that we are all clear about this):The information on this website and podcasts are the opinions of the authors solely.

For Health Care Practitioners: This website and its associated products are provided only for medical education purposes. Although the editors have made every effort to provide the most up-to-date evidence-based medical information, this writing should not necessarily be considered the standard of care and may not reflect individual practices in other geographic locations.

​For the Public
: This website and its associated products are not intended to be a substitute for professional medical advice, diagnosis, or treatment. Your physician or other qualified health care provider should be contacted with any questions you may have regarding a medical condition. Do not disregard professional medical advice or delay seeking it based on information from this writing. Relying on information provided in this website and podcast is done at your own risk. In the event of a medical emergency, contact your physician or call 9-1-1 immediately.