Okay, jumping right into tox, another whole field specialty that we're going to cover in 15 minutes. I want to remind you about scene safety. I think we've all got gotten very good on now or maybe a little bit lax after COVID about donning and doffing and checking for scene safety, but this is vital. Multiple, you'll see on the news where police or EMS have gotten exposed to perhaps fentanyl that have gotten on their skin and they collapse and they come in as a second victim. So, and also exposures such as organophosphates, you want to make sure that you make your staff is safe. Don and doff if you know that you've got some type of potential exposure that is coming in that could harm you or your staff. And I don't know, people do this still. You see on the movies and on TV, there's always the investigator who wants to taste the powder, right? And you've got, you know, and I just don't understand it. So please, if you see like your students that want to try and do that, just tell them no. The other important thing to know is especially fentanyl, don't just use the alcohol hand cleaner because that can drive it in. So soap and water, wash your hands. In tox, there's three kinds of exposures that you're going to get. You're going to have the known overdose that comes in and says, I took X, or the family says, oh, I found a bottle of X. That's pretty rare, right? And even when they say, oh, I took Tylenol, well, it may or may not be Tylenol. I mean, how many times do your patients, oh, I take, you know, the blue pill? I don't know what that is. And they don't either. So if they have the bottle, great, but don't assume that when they say I've taken a bottle of Tylenol that they actually took Tylenol. It may be Tylenol. It could very well be something else. Then there's the individual who come in who don't, who come in as an overdose and don't tell you what they took because they were trying to hurt themselves or they're embarrassed or whatever. And then the most, I think, challenging in some ways is the unintentional overdose who comes in and they don't tell you because you don't know and they don't know. So you have no idea. And this is where you really have to do a good history and a good physical and look at some of these signs and symptoms and lab values to have a clue when things aren't making sense, perhaps this is an unintentional overdose. You see this time and time again. Many of you have probably taken care of liver, people have gone into liver failure from unintentional Tylenol, right? They think Tylenol is an over-the-counter drug. It's safe. They've got a terrible toothache. They've got some other injury. They just take doses and doses and doses of Tylenol and they come in three days after the fact and they're yellow and they're vomiting. And you have to go back through the history and try and figure out why are they now in acute liver failure? Well, it's because they took a bottle of Tylenol because they couldn't afford the dentist. Additional questions in the history to ask. First is if this is a substance use, you want to know did you buy from your usual dealer? And I know that seems kind of odd, but that can help you parse out what you're dealing with. So if they say, yes, I bought from my usual dealer, the next question is, did you do your usual amount? And if they say, yes, they bought from their usual dealer, yes, they did their usual amount, well, that tells you most likely there's something new out on the street because this is capitalism. The dealers want them to come back, right? So if you kill off your customers, unless they haven't paid their bill, you know, if you kill off your customers, you're not going to have a repeat customer. So if they've gone to their usual dealer and they've done their usual amount, there's probably something new out there and get ready for a really rough couple of days. The other thing is you want to know if they bring in the pill bottle or if they know what they took is an extended release. Did they take it as one set of pills or have they been taking it for the last day or two because they've thought that they were going to, they wanted to kill themselves, they took a bunch of pills, it didn't work. A couple hours later, they take another bunch of pills because that's going to affect the pharmacokinetics of the medication. And then the last thing is on physical exam, what are the vital signs? Are they bradycardic? Are they tachycardic? Are they hypotensive? Are they hypertensive? This also applies for withdrawal, can be very helpful looking at that. Then what is the skin? Skin is key. Are they hot? Are they dry? Are they red? Are they blue? Are they cyanotic? Helpful clues. Are they altered? The other thing is pupils. Do they have the wide-eyed medriasis of a sympathomimetic or they have meiosis, very tiny pupils of perhaps an opioid overdose or an aganiphosphate? Everyone should have an ECG. You want to look for arrhythmia. You want to look for blocks and conduction delays and disorders are very common in overdoses. Now we don't see this very often but this is probably a good board question because this still exists, the tricyclic antidepressants. Fortunately and thank goodness that they have rarely see anybody on that because about 20 years ago prior to the SSRIs coming out, we would see a tricyclic overdose. We would see multiple a week and we would have multiple deaths every month from a tricyclic overdose. And then when everyone got switched off of that to SSRIs, it was almost like it disappeared overnight. But pathognomonic for a tricyclic, so if you have someone who comes in who is unresponsive and unstable and you see a terminal R, meaning what looks like a right bundle branch block, an AVR, that is pathognomonic for a tricyclic and these kinds of questions still appear on the boards. And then the answer is going to be tricyclic and then you're going to give sodium bicarb. We'll get to that in a moment. Labs, you need to know what their blood gas is, you need to know what their lactate is, anion gap, did they have one, what's the bicarb, what's the creatinine, did they have an AKI. And if you're worried about overdose, always send a tylenol and acetaminophen level. You cannot determine a tylenol overdose without it. There are nothing that is pathognomonic about it. There is certainly the phases of the tylenol overdose, but you must get a level and that helps you prognosticate and determine what you're going to give and how often. When you're managing these individuals, things to consider, should you be decontaminating them? We talked about exposure, both for the staff and the patient. If it's on the skin, you want to make sure you've washed them down, you want to bag their clothes, you want to make sure your staff is safe. And should you consider GI decontamination? You know, 40, 50 years ago, we all had ipecac at home in case your child took something. Well, we don't want people to vomit in general now. Charcoal, if they've come in within the first, you know, hour or two and they have the ability to protect their airway, you should give them charcoal unless it's an acid that's potentially corroded or a base that's corroded their esophagus. If anyone's ever seen charcoal aspiration pneumonitis, quite ugly. Those patients tend to do very poorly and they tend to not survive. They may have survived their overdose, but they don't survive the charcoal aspiration. Alkaline diuresis of the urine, you're going to need this in salicylate overdoses, both acute and chronic. Same with dialysis. Dialysis is important to remove aspirin and toxic alcohols. And there are many things that have antidotes. Typically, the antidote is given in a bolus, regardless of what it is, be it N-acetylcysteine or pomidronate. They give a bolus and then you're getting dosing every 12, 8 to 12 hours, typically for 48 hours. Why it's always 48 hours, but that just seems to be the case and what they do in toxicology. And if you don't have a toxicologist at your institution, there is a national toxicology number. So you can always call for help to the National Poison Control and they will route you to your local poison control. Every state in the United States has at least one poison control center. So you can get help through this. So that's a number to keep in mind. You can look it up online or write it down. Now, all of these cases are cases that I took care of. All the questions that we're going to have are all cases that I took care of that did not present as overdoses. They were in that unintentional and we had to discover it as we went along. So first question, 70-year-old male. He's admitted he has profuse vomiting, diarrhea, copious respiratory secretions, wasn't able to give us a history. His heart rate is bradycardic at 35. His respiratory rate is 30. Pressure is 108 over 70. SAT is 88% on 100% non-rebreather. Pertinent labs, he's got a lactate of 3.6. PH is 7.25 with a PCO2 of 25. These presenting symptoms and labs suggest which type of toxin? Anyone think salicylism? Anyone think cholinergic? I see lots of nods going on. Anyone think toxic alcohol? No. And or alcohol withdrawal? And many of them will present with similar cases. Let's go back for a minute. So you're correct. It's cholinergic symptom. So here are the keys. You've got that sludge, right? The vomiting, the diarrhea, the copious secretions. He's bradycardic. He's tachypneic. He's got an elevated lactate and they're acidotic. He's got a gap metabolic acidosis. I actually don't think I gave the gap on here, but he's got a metabolic acidosis. So that cholinergic excess, sludge, these are things that you have to know both in real life and for the test. Remember this, the sludge and it also goes with the three Bs, the bronchorrhea, the bradycardia, and the bronchospasm. There's nicotinic effects, which are typically CNS, seizure coma death. There are the cardiac effects where you have any kind of block can occur, ischemic. They can develop cardiac ischemia or they can develop a prolonged QTC. And then the respiratory effects, they can go into overt respiratory failure, both from the excess secretions and the bronchospasm, but also from the neuromuscular weakness. And the treatment is twofold. Now, if you think that you have a cholinergic excess patient, be it organophosphate or poison gas, one of the first calls you make is if you don't have a PharmD with you at that time, is you call your pharmacy because you are going to potentially need all of the atropine in the hospital. And you may or may not have pamidronate, pralidoxine. They may have to call around to a neighboring hospital. Start with the atropine. This is going to help you with the muscarinic effects. And you're going to push dose the atropine. And you're not pushing it for the heart rate. You're giving it to clear secretions. And you must give the atropine first. If you give the pralidoxine first, you have the risk of causing cardiovascular collapse. And this is important because a lot of the poison gases are going to cause this type of effect. The sarin gas poisoning in the Japanese subway, whatever year ago it was, 1,200 people died, of which 90 to 100, there's a discrepancy in the count, were health care workers. So the importance of protecting yourself, protecting your staff. But think about that. If you've got to care for all those people, you're going to need a lot of atropine. So push the atropine. And then the pralidoxine goes second. This is a slow IV, typically over 10 minutes or so for the first bolus. Because even if you give the atropine first, you can precipitate collapse. It's given as a bolus, 30 minutes, excuse me, and then as an infusion. And this is a total infusion usually for 48 hours, but you monitor on the symptoms. So if they're still having symptoms from it, you continue the pralidoxine. So this could go on for days. And we talked about the scene safety. Question two. 70-year-old female is admitted to the ICU with agitation. GCS is 13. Heart rate is 125, sinus tac. Blood pressure is 150 over 90. She's unable to give you a history. And her exam is otherwise non-focal. Pertinent labs. pH is 6.8, the PCO2 of 20. Lactate is 3.6. Anion gap is 25. Bicarb is 10. These presenting symptoms in labs suggest which type of toxin. Salicylism, cholinergic syndrome, toxic alcohol, or alcohol withdrawal. I hear people whispering under their breath, toxic alcohol. Absolutely. So we've talked already about cholinergic syndrome. Things that are pertinent in here. And this could potentially be an early withdrawal other than that pH. So that significantly low acidosis, that low pH, that very high anion gap once you start getting 20 and higher. I didn't give you an osm gap on here, but that very low bicarb, that very high anion gap, and that very low pH are classic for toxic alcohol. And she came and didn't have a history. You know, we just discovered this between exam and looking at her labs. So that's a pattern to recognize both on the boards and in your patients. Very high anion gap, very low bicarb. You have an osm gap as well. You must think toxic alcohol. Now, I don't think that they'll make you calculate the osmol gap on the boards. Maybe they will, but that's the osm gap. And it's in that online talk as well. And the treatment, we used to give IV alcohol. Has anybody given IV alcohol? Not in probably like two decades, but has anybody done it? Well, I know. Yes. And then people would die from the IV alcohol. So it's not easy to titrate and there's as much risk of giving the IV alcohol, but we use now famipazole. Another thing that your pharmacy may or may not have on hand, it's given as a bolus dose. And then every 12 hours for 48 hours, it is affected by dialysis. And these patients do need to be dialyzed. This is just going to block the alcohol dehydrogenase so that to give you time, you do need to dialyze these patients typically. And then you must re-dose your famipazole after you dialyze them because it does clear the famipazole. Last question. Another 70-year-old female is admitted with altered mental status. Heart rate's 118 in sinus tech. Respiratory rate is 24. Temperature's 38 degrees. BP is 150 over 90. Exam is otherwise non-focal. I mean, this could be anything, right? I mean, odds are, think sepsis. This is easily a presentation of sepsis. PH is 748. PCO2 is 32. Lactate is a little bit elevated at 2.8. Anion gap is 16. Bicarb is 18. So which does this suggest? Salicylism? Absolutely. So we won't go through the rest of them, but the things to point out here is, you know, slightly abnormal vital signs, altered mental status, and slightly elevated temperature is common. And the thing is, this patient was chronic salicylism. So there are two phases. There are two types. There's acute. There's chronic. Aspirin is a very common overdose in the United States. More than 25,000 cases per year. Most of them are unintentional, though. For whatever reason, people like to take Tylenol. They don't necessarily take aspirin. I think the trend changed with, you know, in the 70s with Reye's syndrome, people stopped keeping a lot of aspirin at home because of the potential injury to their child. But it's important to know in the formulation that methyl salicylate has a high concentration of aspirin in it. Also, pepto-bismol, bismuth of subsalicylate. That has aspirin in it as well. So it's not uncommon. These patients come in and they've been maybe taking their baby aspirin or full aspirin a day. That's been recommended by their cardiology team. But they've got aches and pains, and they're taking, you know, putting Bengay or other types of products on their body for all the joints that hurt. And they're drinking mint and ginger tea, which has very high rates of salicylate in it. Yeah, you didn't know that, right? So this is more common than you think. So I would recommend in the, think about patients who are in your unit right now. They're a little bit altered. They're a little bit off. So you want to look at patients who come in and you don't have another source, or maybe they've had some neurosepsis or a mild pneumonia and it's cleared, but they're still not right. Think about chronic salicylism. So tachypnea, some type of acid-base disorder. Remember with aspirin, it can be almost anything because you get both a respiratory alkalosis and a metabolic acidosis. And depending on what phase they are in the salicylate toxicity, it can be anything. The other thing is that aspirin levels, unlike tylenol levels, you know, we have that don't nomogram for tylenol acetaminophen. The aspirin levels aren't necessarily helpful. You can get it, but it may be normal, especially in chronic salicylism. They may have just a top normal level. So it's important to know that don't base your treatment on the level, base it on the symptoms for aspirin. And the other is the key of the non-focal neurologic exam. I would urge you, if you don't remember your mud piles from medical school, look it up for the test because half of the things on here are tox related, right? You've got the toxic alcohols, you've got metformin, INH, iron, so just keep that in mind before you take the test. So just refresh yourself. And then the last thing is the therapeutic adjuncts in overdose. If you have an overdose patient and they're having an arrhythmia and they're unstable, remember about sodium bicarb, and you give that by push. And with the tricyclics that I mentioned before, you would watch on the monitor as you push that bicarb, you would see the wide QRS narrow in front of you. And you would just have to keep pushing bicarb to keep their conduction narrow. If they're hypotensive, use either your phenyl sticks or norepinephrine infusion. And I don't think we have, in this day and age, remind people of that so much. In the past when we had dopamine ready to hang, and dopamine used to be the first choice in sepsis, you know, 20-something years ago. So I don't think that's as big of an issue now, but sometimes you will see it on the boards, they still will list the dopamine. And seizures, remember, check an acu-check and give them benzos. So the reminders are it's easy to miss. This is more for your clinical every day-to-day job. If the patients aren't doing what you expect, you need to search for context. Those slightly altered people who come in that have a little bit of an acid-base disorder, that they're tracheotomic, they may have a little bit of a temperature, you find no source, think about that chronic salicylism. So search for context, and don't forget about your toxidrome. So remember, if it looks like sludge or any of those other toxidromes, think you have a potential undiagnosed overdose. With that, thank you for your attention. I'm happy to take any questions.

toxicology

fentanyl exposure

overdose diagnosis

decontamination methods

management protocols

ongoing education