Toxicology

“ABCD3EFG” of toxicology:

  • A        Airway (consider stabilizing the C-spine)
  • B        Breathing
  • C        Circulation
  • D1     Drugs (universal antidotes)
  • D2     Draw bloods
  • D3     Decontamination (↓ absorption)
  • E        Expose\Examine (look for toxidromes)
  • F        Full vitals, ECG monitor, Foley, X-ray
  • G       Give specific antidotes and treatments

D1: Universal antidotes: will not harm pts. “DONT”

  • Dextrose: give to any pt w\ altered LOC
  • Oxygen
  • Naloxone: for opioids, both diagnostic and therapeutic
  • Thiamine: for Wernicke’s encephalopathy. Given w\ glucose to all pts

Toxicology 2


D2: Draw bloods:

  • Essential tests: CBC, electrolytes, BUN\Cr, glucose, INR\PTT, osmolality, ABG, pO2.
  • ASA, acetaminophen, EtOH levels (are measured in all pts!)

D3: Decontamination (enhanced elimination):

1) GI decontamination:

  • Single dose activated charcoal:
    • Adsorption of toxin -> prevents availability
    • Contraindications: caustics, small bowel obstruction, perforation
  • Multidose activated charcoal:
    • For toxins which undergo enterohepatic circulation -> removes the drug that has already been absorbed by drawing it into the GIT
    • Carbamazepine, phenobarbital, theophyllineToxicology 6
  • Induced vomiting by Ipecac:
    • Used prior coming to the hospital
    • Needs 15-20 mins to work -> delays admin of antidotes
  • Gastric lavage:
    • Attempted up to 2 hrs after ingestion -> will remove 50% of pills at one hour and 15% at 2 hours
    • Contraindications: caustics, altered mental status, acetaminophen overdose
  • Whole bowel irrigation:
    • 2 L\hr of Polyethylene glycol via NGT until clear effluent per rectum
    • Contraindications: ileus, obstruction, perforation

2) Urine alkalinization:

  • Weakly acidic substance trapped in alkali urine to increase elimination
  • ASA, methotrexate, phenobarbital, chloropropamide

3) Hemodialysis:

  • Low molecular weight, low protein binding, water soluble, small volume distribution (high conc in blood)
  • Methanol, ethylene glycol, salicylates, lithium, phenobarbital, theophylline, carbamazepine, valproate, methotrexate

E: Expose\Exam for toxidromes:


F: Full vitals, ECG monitor, Foley, X-ray:

  • Abdominal X-ray:
    • Indications: Chips: Calcium, Chloral hydrate, CCI4, Heavy metals, Iron, Potassium, Enteric coated Salicylates
  • ECG:
    • TCA: tachycardia, prolonged QRS\QT, R in aVR
    • Digoxin: scooped T waves, multiple dysrhythmias
    • Calcium channel\beta blockers: bradycardia, PR prolongation, AV block

Toxicology 14


G: Give specific antidotes and treatments:

 

 


Download the PDF version: here


References:

  • First aid step 2 CK
  • Toronto notes
  • The Johns Hopkins Internal Medicine Board Review
  • Master the boards

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