Toxicology

ETOH Intoxication

Management:

Symptoms:

1. Tremulousness (6-12 hours after last drink)

2. Seizures

3. Delirium Tremens - autonomic instability with fluctuating mental status. 2-7 days after last drink, usually with visual hallucinations, perspiration, fever, tachycardia, hypertension. This is a medical emergency. mortality is approx. 5%

Other toxic alcohols:

References:
Kraut JA, Kurtz I. Toxic alcohol ingestions: Clinical features, diagnosis, and management. Clin J Am Soc Nephrol 2008 Jan;3(1!):208-25.
Goldfrank's Toxicology Emergencies, 9th ed 2010.
Poisoning and Drug overdose, 6th ed. 2012.
UpToDate. (2022). https://www.uptodate.com/contents/management-of-moderate-and-severe-alcohol-withdrawal-syndromes.



Acetaminophen Overdose

Check Acetaminophen levels and urine toxicology for co-ingestions

  1. Call poison control
  2. NGT, lavage with 2 L NS
  3. Activated charcoal: Give a single dose of activated charcoal at 1 g/kg p.o. via NG tube within 4 hours of ingestion
  4. N–Acetylcysteine: Passive given within 8 hours of ingestion and before ALT begins to rise, can give a charcoal
  5. Oral dosing of acetylcysteine: 140 mg/kg loading dose followed by 17 doses of 70 mg.kg every 4 hours.  If patient vomits within 1 hour administration give full dose again
  6. Give acetylcysteine based on the nomogram.  If unable to obtain level just treat.
  7. Follow acetaminophen levels q4h, LFT, PT/PTT
  8. Evaluate potential need for liver transplant; pH < 7.3, Cr > 3.4, INR >6.5

References:

1. Hospitalist Handbook, iPhone App

2. UpToDate -- Acetaminophen Overdose

3. NCBI

 

Salicylate Overdose

Check salicylate level and check urine toxicology for co-ingestions. Try to determine whether salicylate was regular or enteric-coated (Affects pharmacokinetics).

  1. Call poison control
  2. NGT, lavage with 2L NS
  3. Intubate for respiratory depression if indicated
  4. Activated charcoal, if indicated. 1g/kg po/per NGT q2-4h
  5. Alkalinize plasma/urine with a bolus of 1 to 2 Amps of sodium bicarb, then start 2 Amps of sodium bicarb per 1 L of D5 ¼ NS.  Run this at approximately 4 mL/kg/hr.  Do not use acetazolamide.  Caution in elderly and renal failure as aspirin can cause pulmonary edema
  6. Replete potassium to maintain normal serum levels otherwise alkalinization will be difficult to achieve
  7. Be sure to treat concurrent hypoglycemia and coagulopathy if present
  8. External cooling if febrile (no acetaminophen)
  9. Hemodialysis indicated if level > 100mg/dL - level checked 6 hours after ingestion, refractory acidosis, persistent CNS symptoms, and/or if renal failure.

References:

1. Hospitalist Handbook, iPhone App

2.UpToDate -- Salicylate Toxicity

TCA Overdose

Call poison control. 

References:

1. Hospitalist Handbook, iPhone App

2. UpToDate -- TCA

 

Cocaine Overdose


Diagnosis

Management

Source: Uptodate: Cocaine Overdose

Hospitalist Handbook



Opiate Overdose

Effects

Diagnosis

Treatment

Source: Uptodate: Opiate overdose


Carbon Monoxide Inhalation

Symptoms depend on CO level (carboxyhemoglobin)

Diagnosis

Management

Source: Uptodate: CO poisoning