Toxidrome Recognition in Chemical-Weapons Attacks
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Methamphetamine Presentations to an Emergency Department: Management and Complications
Isoardi Katherine (Orcid ID: 0000-0002-1176-7923) Abstract Objective: There is little recent published data characterising methamphetamine intoxication. This study aims to describe the clinical effects, management, complications and disposition of patients with methamphetamine exposure. Methods: This is a retrospective review of patients presenting with methamphetamine intoxication to an Emergency Department in 2016. All presentations were extracted from a relational database and each medical record reviewed. Demographics, clinical features, complications and disposition were extracted. Results: There were 378 presentations of 329 patients (234 males [71%]), median age 31 years (range 16-68 years). The commonest clinical effect was acute behavioural disturbance, occurring in 295 (78%) presentations. This was successfully managed with oral sedation alone in 180 (61%) patients with the remainder receiving parenteral sedation. Other effects included tachycardia in 212 (56%), hypertension in 160 (42%) and hyperthermia in 17 (4%) presentations. No antihypertensives were given. One patient was actively cooled. Complications included 21 (30%) presentations with rhabdomyolysis and 43 (11%) presentations with acute kidney injury. There were two seizures, three intracranial bleeds and one myocardial infarction. The majority of This is the author manuscript accepted for publication and has undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/1742-6723.13219 This article is protected by copyright. All rights reserved. patients (310 [82%]) were managed solely within the emergency department. The median length of stay was 14 hours. There were 41(11%) mental health admissions. -
Unintentional Fentanyl Overdoses Among Persons Who Thought They
Morbidity and Mortality Weekly Report Notes from the Field Unintentional Fentanyl Overdoses Among emergency departments; 2) holding a multiagency press Persons Who Thought They Were Snorting conference; 3) conducting media interviews; 4) informing Cocaine — Fresno, California, January 7, 2019 law enforcement, prehospital providers, and the public about Patil Armenian, MD1; Jeffrey D. Whitman, MD2; Adina Badea, PhD2; naloxone distribution and use; 5) educating persons on Whitney Johnson, MD1; Chelsea Drake, MS1; Simranjit Singh Dhillon3; the proper disposal of old or new but unused medications Michelle Rivera3; Nicklaus Brandehoff, MD1; Kara L. Lynch, PhD2 through the Fresno County Department of Behavioral Health/ California Health Collaborative drop-off containers§; and On January 7, 2019, three patients arrived at the Community 6) publicizing the California Central Valley Opioid Safety Regional Medical Center emergency department in Fresno, Coalition webpage,¶ which provides information about California, after snorting (i.e., nasally insufflating) white pow- naloxone and substance use disorders. der they thought was cocaine. One (patient A) was in cardiac On January 12, 2019, a similar drug overdose incident was arrest, and two (patients B and C) had opioid toxidrome reported in Chico, California, in which postmortem toxicol- (miosis, respiratory depression, and depressed mental status) ogy testing for one person confirmed fentanyl (1). Fourteen (Table). After spontaneous circulation was reestablished in other persons at the same event were hospitalized with opioid patient A, he was admitted to the intensive care unit, where toxidrome and later released. They reported thinking they he was pronounced brain-dead 3 days later. Patients B and C were snorting cocaine,** but confirmatory toxicology results responded to naloxone, but repeated dosing was required to are unavailable. -
Approach to the Poisoned Patient
PED-1407 Chocolate to Crystal Methamphetamine to the Cinnamon Challenge - Emergency Approach to the Intoxicated Child BLS 08 / ALS 75 / 1.5 CEU Target Audience: All Pediatric and adolescent ingestions are common reasons for 911 dispatches and emergency department visits. With greater availability of medications and drugs, healthcare professionals need to stay sharp on current trends in medical toxicology. This lecture examines mind altering substances, initial prehospital approach to toxicology and stabilization for transport, poison control center resources, and ultimate emergency department and intensive care management. Pediatric Toxicology Dr. James Burhop Pediatric Emergency Medicine Children’s Hospital of the Kings Daughters Objectives • Epidemiology • History of Poisoning • Review initial assessment of the child with a possible ingestion • General management principles for toxic exposures • Case Based (12 common pediatric cases) • Emerging drugs of abuse • Cathinones, Synthetics, Salvia, Maxy/MCAT, 25I, Kratom Epidemiology • 55 Poison Centers serving 295 million people • 2.3 million exposures in 2011 – 39% are children younger than 3 years – 52% in children younger than 6 years • 1-800-222-1222 2011 Annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System Introduction • 95% decline in the number of pediatric poisoning deaths since 1960 – child resistant packaging – heightened parental awareness – more sophisticated interventions – poison control centers Epidemiology • Unintentional (1-2 -
Pre-Hospital Use and Administration of Naloxone
Opioid Toxicity and Naloxone: Implications for the K-12 Population Elizabeth J. Scharman, Pharm.D., DABAT, FAACT, BCPS Director, West Virginia Poison Center Professor, WVU School of Pharmacy Outline • Definitions • Patterns of opioid exposure grades K-12 • Opioid Toxicology I. Opioid toxidrome II. Pharmacologic differences: effect on toxicity III. Designer opioids: what this means for WV • Naloxone I. Mechanism details II. Potential adverse effects III. Meaning of “response” to naloxone Definitions • Opioid – A drug that works by binding to the opioid receptors • Opioid receptors are where the body’s “natural” painkillers (endorphins for example) attach to decrease the perception of pain – Examples: morphine, hydrocodone, heroin, oxycodone • Naloxone – Opioid antidote • Competitively takes the place of the opioid on the opioid receptor 1 Young Opioid Abusers • Survey of 50 injection drug users 16-25 years – Hydrocodone/acetaminophen, oxycodone, oxycodone/acetaminophen most common initial opioid drugs misused • Average age first use = 14.5 years • Obtained from family member, their own Rx, friend/contact • Oral = 41, Sniffing/snorting = 8, Injecting = 1 – Followed initial use of alcohol (avg 12.8 years of age), marijuana (avg 12.5 years of age), Rx stimulants (avg 14.1 years of age) • Opioid misuse prior to heroin (n = 43) – Average age of first use = 16.1 years WV Poison Center Data 2014 2015 ≤ 5 years 6 – 19 years ≤ 5 years 6 – 19 years Heroin 1201 Single Opioid 59 30 64 21 Comb. Opioid 18 41 21 27 Acetaminophen 83 88 Non-steroidal 120 -
The Anticholinergic Toxidrome
Poison HOTLINE Partnership between Iowa Health System and University of Iowa Hospitals and Clinics July 2011 The Anticholinergic Toxidrome A toxidrome is a group of symptoms associated with poisoning by a particular class of agents. One example is the opiate toxidrome, the triad of CNS depression, respiratory depression, and pinpoint pupils, and which usually responds to naloxone. The anticholinergic toxidrome is most frequently associated with overdoses of diphenhydramine, a very common OTC medication. However, many drugs and plants can produce the anticholinergic toxidrome. A partial list includes: tricyclic antidepressants (amitriptyline), older antihistamines (chlorpheniramine), Did you know …… phenothiazines (promethazine) and plants containing the anticholinergic alkaloids atropine, hyoscyamine and scopolamine (Jimson Weed). Each summer, the ISPCC receives approximately 10-20 The mnemonic used to help remember the symptoms and signs of this snake bite calls, some being toxidrome are derived from the Alice in Wonderland story: from poisonous snakes (both Blind as a Bat (mydriasis and inability to focus on near objects) local and exotic). Red as a Beet (flushed skin color) Four poisonous snakes can be Hot as Hades (elevated temperature) found in Iowa: the prairie These patients can sometimes die of agitation-induced hyperthermia. rattlesnake, the massasauga, Dry as a Bone (dry mouth and dry skin) the copperhead, and the Mad as a Hatter (hallucinations and delirium) timber rattlesnake. Each Bowel and bladder lose their tone (urinary retention and constipation) snake has specific territories Heart races on alone (tachycardia) within the state. ISPCC A patient who has ingested only an anticholinergic substance and is not specialists have access to tachycardic argues against a serious anticholinergic overdose. -
Critical Care Management of Chemical Exposures 4 the Patients Were Decontaminated Prior to Arriving at the Hospital
Chapter 4: CRITI C AL CARE MANAGE M ENT OF CHE M I C AL EXPOSURES James Geiling, MD, FCCM Vincent M. Nicolais, MD, FCCM Gregory M. Susla, PharmD, FCCM The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. Objectives ■ Review measures of preparedness and planning. ■ Describe the purpose of decontamination. ■ Discuss how to evaluate whether a patient has been adequately decontaminated to enter the emergency department (ED), hospital, or intensive care unit (ICU). ■ Summarize the steps necessary to protect hospital staff: decontamination, personal protective equipment (PPE). ■ Review specific agents: diagnosis, identification, and management. If supposedly civilized nations confined their warfare to attacks on the enemy’s troops, the matter of defense against warfare chemicals would be purely a military problem, and therefore beyond the scope of this study. But such is far from the case. In these days of total warfare, the civilians, including women and children, are subject to attack at all times. Colonel Edgar Erskine Hume, Victories of Army Medicine, 1943 Fundamental Disaster Management Case Study A young couple was transported to your hospital’s ED from a local cinema. You have been told there are many others who are being cared for by the emergency medical services and are en route. The 18-year-old male and 17-year-old female were admitted to your ICU after intubation and placement on mechanical ventilation. They are unresponsive and diaphoretic, and they have constricted pupils with excessive lacrimation, vomiting, diarrhea, and restlessness. -
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Terrorism WHAT CLINICIANS and NEED TO Disaster KNOW Sarin Sponsored for CME Credit by Rush University Medical Center Release Date: April 1, 2005 Expiration Date: March 31, 2007 errorism WHAT T CLINICIANS and NEED TO Disaster KNOW SERIES Uniformed Services University Guest Faculty EDITORS Health Sciences Ronald E. Goans, PhD, MD, MPH* Bethesda, Maryland Clinical Associate Professor Rush University Tulane University School of Public Health & David M. Benedek, MD, LTC, MC, USA Medical Center Tropical Medicine Associate Professor of Psychiatry Chicago, Illinois New Orleans, LA Stephanie R. Black, MD* Steven J. Durning, MD, Maj, USAF, MC* Sunita Hanjura, MD* Assistant Professor of Medicine Associate Professor of Medicine Rockville Internal Medicine Group Section of Infectious Diseases Rockville, MD Department of Internal Medicine Thomas A. Grieger, MD, CAPT, MC, USN* Associate Professor of Psychiatry Niranjan Kanesa-Thasan, MD, MTMH* Daniel Levin, MD* Associate Professor of Military & Director, Medical Affairs & Pharmacovigilance Assistant Professor Emergency Medicine Acambis General Psychiatry Residency Director Assistant Chair of Psychiatry for Graduate Cambridge, MA Department of Psychiatry & Continuing Education Jennifer C. Thompson, MD, MPH, FACP* Gillian S. Gibbs, MPH* Molly J. Hall, MD, Col, USAF, MC, FS* Chief, Department of Clinical Investigation Project Coordinator Assistant Chair & Associate Professor William Beaumont Army Medical Center Center of Excellence for Bioterrorism Department of Psychiatry El Paso, TX Preparedness Derrick Hamaoka, MD, Capt, USAF, MC, FS* Faculty Disclosure Policy Linnea S. Hauge, PhD* Director, Third Year Clerkship It is the policy of the Rush University Medical Educational Specialist Instructor of Psychiatry Department of General Surgery Center Office of Continuing Medical Paul A. Hemmer, MD, MPH, Lt Col, USAF, MC* Education to ensure that its CME activities Associate Professor of Medicine are independent, free of commercial bias AUTHORS and beyond the control of persons or organi- Rush University Benjamin W. -
The Clinical Toxicology of Gamma-Hydroxybutyrate, Gamma-Butyrolactone and 1,4-Butanediol
Clinical Toxicology (2012), 50: 458–470 Copyright © 2012 Informa Healthcare USA, Inc. ISSN: 1556-3650 print / 1556-9519 online DOI: 10.3109/15563650.2012.702218 REVIEW ARTICLE The clinical toxicology of gamma-hydroxybutyrate, gamma-butyrolactone and 1,4-butanediol LEO J SCHEP 1 , KAI KNUDSEN 2 , ROBIN J SLAUGHTER 1 , J ALLISTER VALE 3 , and BRUNO MÉGARBANE 4 1 National Poisons Centre, Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand 2 Department of Anesthesia and Intensive Care Medicine, Surgical Sciences, Blå Stråket 5, Sahlgrenska University Hospital, Gothenburg, Sweden 3 National Poisons Information Service (Birmingham Unit) and West Midlands Poisons Unit, City Hospital, Birmingham, UK; School of Biosciences and College of Medical and Dental Sciences, University of Birmingham, Birmingham,UK 4 Hôpital Lariboisière, Réanimation Médicale et Toxicologique, INSERM U705, Université Paris-Diderot, Paris, France Introduction. Gamma-hydroxybutyrate (GHB) and its precursors, gamma-butyrolactone (GBL) and 1,4-butanediol (1,4-BD), are drugs of abuse which act primarily as central nervous system (CNS) depressants. In recent years, the rising recreational use of these drugs has led to an increasing burden upon health care providers. Understanding their toxicity is therefore essential for the successful management of intoxicated patients. We review the epidemiology, mechanisms of toxicity, toxicokinetics, clinical features, diagnosis, and management of poisoning due to GHB and its analogs and discuss the features and management of GHB withdrawal. Methods. OVID MEDLINE and ISI Web of Science databases were searched using the terms “ GHB, ” “ gamma-hydroxybutyrate, ” “ gamma-hydroxybutyric acid, ” “ 4-hydroxybutanoic acid, ” “ sodium oxybate, ” “ gamma-butyrolactone, ” “ GBL, ” “ 1,4-butanediol, ” and “ 1,4-BD ” alone and in combination with the keywords “ pharmacokinetics, ” “ kinetics, ” “ poisoning, ” “ poison, ” “ toxicity, ” “ ingestion, ” “ adverse effects, ” “ overdose, ” and “ intoxication. -
Toxicological Profile for Acetone Draft for Public Comment
ACETONE 1 Toxicological Profile for Acetone Draft for Public Comment July 2021 ***DRAFT FOR PUBLIC COMMENT*** ACETONE ii DISCLAIMER Use of trade names is for identification only and does not imply endorsement by the Agency for Toxic Substances and Disease Registry, the Public Health Service, or the U.S. Department of Health and Human Services. This information is distributed solely for the purpose of pre dissemination public comment under applicable information quality guidelines. It has not been formally disseminated by the Agency for Toxic Substances and Disease Registry. It does not represent and should not be construed to represent any agency determination or policy. ***DRAFT FOR PUBLIC COMMENT*** ACETONE iii FOREWORD This toxicological profile is prepared in accordance with guidelines developed by the Agency for Toxic Substances and Disease Registry (ATSDR) and the Environmental Protection Agency (EPA). The original guidelines were published in the Federal Register on April 17, 1987. Each profile will be revised and republished as necessary. The ATSDR toxicological profile succinctly characterizes the toxicologic and adverse health effects information for these toxic substances described therein. Each peer-reviewed profile identifies and reviews the key literature that describes a substance's toxicologic properties. Other pertinent literature is also presented, but is described in less detail than the key studies. The profile is not intended to be an exhaustive document; however, more comprehensive sources of specialty information are referenced. The focus of the profiles is on health and toxicologic information; therefore, each toxicological profile begins with a relevance to public health discussion which would allow a public health professional to make a real-time determination of whether the presence of a particular substance in the environment poses a potential threat to human health. -
Introduction to Emergency Management Second Edition
Introduction to Emergency Management Second Edition Introduction to Emergency Management Second Edition George D. Haddow Jane A. Bullock With Contributions by Damon P. Coppola Amsterdam • Boston • Heidelberg • London • New York • Oxford • Paris San Diego • San Francisco • Singapore • Sydney • Tokyo Elsevier Butterworth–Heinemann 30 Corporate Drive, Suite 400, Burlington, MA 01803, USA Linacre House, Jordan Hill, Oxford OX2 8DP, UK Copyright © 2006, Elsevier Inc. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher. Permissions may be sought directly from Elsevier’s Science & Technology Rights Department in Oxford, UK: phone: (+44) 1865 843830, fax: (+44) 1865 853333, e-mail: permissions@elsevier. co.uk. You may also complete your request on-line via the Elsevier homepage (http://elsevier.com), by selecting “Customer Support” and then “Obtaining Permissions.” Recognizing the importance of preserving what has been written, Elsevier prints its books on acid-free paper whenever possible. Library of Congress Cataloging-in-Publication Data Haddow, George D. Introduction to emergency management / George D. Haddow, Jane A. Bullock. — 2nd ed. p. cm. Includes bibliographical references and index. ISBN 0-7506-7961-1 (hardcover : alk. paper) 1. Emergency management. 2. Emergency management—United States. I. Bullock, Jane A. II. Title. HV551.2.H3 -
Toxidromes Toxi-What?
Toxidromes Toxi-what? • Toxidrome – Portmanteau of “toxic syndrome” – It is a constellation of commonly seen features and exam findings that are typical for certain types of poisonings Toxidrome Symptoms History & Signs Vital signs Labs & Imaging OMG! Toxidromes r my fav! • Interesting physical exam findings • A careful history & physical usually gives enough clues to get the answer • Don’t require labs, CTs, MRIs, or tricorders Poison versus Medicine • The dose is the difference…alcohol! • Nearly all medications are poisons that are sometimes helpful at a very low dose – Diphenhydramine (Benadryl) – anti-cholinergic – Aspirin – blocks the COX enzyme, poisons platelets Philip Theophrastus Bombast von Hohenheim aka PARACELSUS (1493-1541) “What is there that is not poison? All things are poison and nothing [is] without poison. It is only the dose determines whether something is or is not a poison.” Poison versus Venom Taipan Snake Goals • Overview of the most • Diagnostic pitfalls of common toxidromes toxidromes • Excited Delirium • Working as a team for patient care – History – Vitals – Treatment Anticholinergic Syndrome Cholinergic Syndrome Sympathomimetic Syndrome Opioid / Ethanol / Sedative Toxidrome First Case – Rave Gone Bad 20ish year old female brought in by ambulance from a party/rave. No eyewitnesses to events (they all fled). Patient is very confused and all of her muscles are rigid. PMH/PSH: Unknown Meds: Unknown Allergies: Unknown All other questions: Unknown Case 1: Physical Exam VS: T 41.4 HR 180 BP 196/130 HEENT: Pupils -
Evaluation of Poisoning and Drug Overdose
Evaluation of Poisoning and Drug Overdose Kara Lynch, PhD, DABCC University of California San Francisco San Francisco, CA Learning Objectives • Understand the laboratories role in the diagnosis and treatment of toxicology cases • Review the pathophysiology of toxic exposures • Identify the common toxidromes • Calculate the osmolar gap and anion gap • Be able to recognize drug overdoses Paraclesus – “father of toxicology” • “All things are poison, and nothing is without poison; only the dose permits something not to be poisonous.” • “The dose makes the poison.” • substances considered toxic are harmless in small doses, and an ordinarily harmless substance can be deadly if over-consumed Paraclesus, 1490 - 1541 Definition of “Poisoning” • A poisoning occurs when a person’s exposure to a natural or manmade substance has an undesirable effect - CDC • Poisonings can be classified as: – Self-harm or suicide – Assault or homicide – Unintentional or accidental, when no harm was intended – includes overdoses resulting from drug misuse, drug abuse or taking too much of a drug for medical reasons Monitoring Poisonings • AAPCC – American Association of Poison Control Centers – – National poison data system (NPDS) annual report • DAWN – Drug Abuse Warning Network • SAMHSA World Drug Report – Substance Abuse and Mental Health Services Administration • CDC – Center for Disease Control – National Vital Statistics System (NVSS) Poisoning / Overdose Trends Poisoning / Overdose Trends AAPCC: Top 25 human exposures AAPCC: Top 25 pediatric exposures Increase