1. No category

Diagnosis of Poisoning
Dag Jacobsen MD, PhD, FAACT
Director & Professor
Department of Acute Medicine
Oslo University Hospital, Ulleval
Diagnostic challenges
• The comatose patient
– Confirms the ultimate clinical statement ”in medicine you only find
what you are looking for..”
• The patient with metabolic acidosis of unknown origin
• If something/everything is strange – think poisoning (!)
• Early sepsis diagnosis – therefore SSC
– Why isn’t this patient septic?
• The ”ultimate imitators”: PE & endocarditis….
NN 35, slight fatigue & dyspnea
• Asthma, regular (normal) drinker, full job
• Last 1-2 days abdominal discomfort & slight
shortness of breath (’asthmatic’)
• ER: hyperventilation (26/min), slight abdominal
tenderness, astmatic pulmonary sounds
• Better following inhalation treatment – sent home…
• Found dead in bed next morning
• Diagnosis?
Poisoning – diagnosis disposition
• Anamnesis
– Munchausen syndrome (self-injury for secondary gain)
& MS by proxy
– Be curious – ask why… even about wines… if
something is strange (!)
• Clinical diagnosis
– Toxicological syndromes (”toxidromes”)
• Pharmacological diagnosis
– Naloxone, flumazenil, physostigmine
• Laboratory (direct or indirect methods)
• Other investigations (X-ray, hair..)
Clinical diagnosis
• Miosis, coma & respiratory depression = ?
• Coma, respiratory depression & bradyarrhythmias = ?
• Hyperventilation (metabolic acidosis)
– Methanol
– Ethylene glycol (’antifreeze’)
– Others; salicylates, cyanide, metformine…
• Coma, seizures & arrhythmias = ?
• Pink skin color
– Cyanide
– CO
• Chocolate cyanosis = ?
Methemoglobinemia
HbFe++
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•
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•
HbFe+++
Isobutyl nitrite (abuse)
Amyl nitrite (’Poppers’)
Dapsone
Others
Methylene blue reduces MetHb back to
OxyHb; repeated injections often necessary
Solheim L et al. Tidsskr Nor Laegeforen 2000; 120: 1549
Solheim L et al. 2000
Toxidromes
• Anticholinergic syndrome
– Mushrooms, atropine, antihistamines, TCA
• Cholinergic syndrome
– Nerve gas agents, OP, mushrooms
• Neuroleptic malignant syndrome
– Rigidity, confusion, hyperthermia, rhabdomyolysis…
• Serotonin syndrome
– Restlessness, hyperreflexia, clonus…
• Others
Cholinergic syndrome –
mnemonics – DUMBELS*
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Diarrhea
Urination
Miosis
Bronchospasm
Emesis
Lacrimation
Salivation
*Cholinergic crisis – Organophosphate exposure
K 18 (I)
• På by’n med venninner lørdag kveld
• Plutselig fjern & rar på utested, synkope/koma,
ambulanse til sykehus
• Resp insuff – ingen effekt naloxon eller flumazenil
iv i ambulansen
• Intuberes, respirator
• Bradyarytmi (26/min) & hypotensiv
• Diagnose – tiltak ?
K 18 (III)
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På by’n med venninner
Plutselig fjern & rar på utested, synkope/koma, ambulanse til sykehus
Resp insuff – ingen effekt naloxon eller flumazenil iv i ambulansen
Intuberes, respirator
Bradyarytmi (26/min) & hypotensiv
• Komparentopplysninger
– Foreldre fortvilet & uforstående – tidl frisk
– Venninner uforstående…
• Diagnose – tiltak ?
GHB – gamma-hydroxybyturate –
19 cases treated in MICU
• Respiratory depression: 19
(9 on ventilator)
• Bradyarrhythmias: 19
(atropine in 6)
• Coma: 19
• Aspiration pneumonia: 6
• No deaths in this series of
patients
Coma + respiratory depression + bradyarrhytmias = GHB
The lady with blue hair…(I)
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F80 admitted comatose with ”stroke”
Normal clin exam - except coma (normal CCT)
Gradually worsening of respiration…
Mechanical ventilation?
• Any witnesses? No
• Any relatives? YES
The lady with blue hair…(II)
• F80 admitted comatose with ”stroke”
• Normal clin exam - except coma (normal CCT)
• Gradually worsening of respiration…
• Mechanical ventilation? NO
• The new study drug? YES
The lady with blue hair…(III)
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F80 admitted comatose with ”stroke”
Normal clin exam - except coma (normal CCT)
Gradually worsening of respiration…
Mechanical ventilation? NO
The new study drug? YES
• Result: Seizures & opisthotonus….
NON-TRAUMATISK KOMA –
alder vs diagnose
Intox 80 %
<40 år (n=206)
>60 år (n=458)
Andre 20 %
Intox 11 %
Andre 89 %
Forsberg S et al. Emerg Med J 2009;26:100-2.
NON-TRAUMATISK KOMA ÅRSAKER & PROGNOSE
Intox 352 (38 %)
( 3 %)
Koma 938
(GCS < 10)
Andre 586 (62 %)
( 39 %)
Fokal nevrologi 24 %
Metabolsk/diffus 21 %
Epilepsi 12 %
Psykogen 1 %
Uavklart 4 %
Forsberg S et al. Emerg Med J 2009;26:100-2
Poisoning –
pharmacological diagnosis
• Naloxone (Narcanti)
• Flumazenil (Anexate)
• Physostigmin (Antilirium)
• Atropine
In-hospital antidote use in Oslo
Antidote(s)
Flumazenil
1980*
2003**
2008***
21%
39%
38%
220 (23%)
207 (19%)
-
Naloxone
137 (12%)
130 (14%)
186 (17%)
NAC
34 (1%)
125 (13%)
120 (11%)
Physostigmine
46 (4%)
3
8
Vitamin K
16
3
4
Fomepizole
-
6
1
Other
9
5
9
*Jacobsen
D et al. Hum Toxicol 1984;3:93
**Heyerdahl F et al. Clin Toxicol 2008;46:42
***Lund C et al. Scand J Trauma Resusc Emerg Med 2012;20;49
Poisoning - diagnostikk
• Anamnese
• Klinisk diagnostikk
• Farmakologisk diagnostikk
• Laboratoriediagnostikk (direkte/indirekte)
– S-paracetamol & etanol er vanligste prøver, lokale
variasjoner spiller inn
– Vurder toksikologisk blindprøve (!) – ev samle døgnurin
– Anion & osmolalt gap ved uklare tilstander/metabolsk
acidose av ukjent årsak (S-metformin?)
Behandlingsnomogram paracetamol
2014*
Antidot indisert
Ikke antidot
* www.helsebiblioteket.no/forgiftninger/paracetamol
Poisoning - diagnosis
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Anamnesis
Clinical diagnosis
Laboratory (direct or indirect methods)
Pharmacological diagnosis
• Other investigations (X-ray, hair..) especially if something is strange…
Arsenic concentration in hair
mg/Kg
60
50
40
30
20
10
9.
19.
7
10
.4
-1
1.
3
12
.0
-1
2.
8
13
.8
-1
4.
5
7.
78.
4
6.
57.
2
5.
56.
0
4.
55.
0
3.
54.
0
2.
53.
0
1.
52.
0
0.
01.
0
0
Distance from hairroot (cm)
Stenehjem A et al. Clin Toxicol 2007; 45; 424
Take home message
Poisoning - diagnosis
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•
Anamnesis
Clinical diagnosis
•
Pharmacological diagnosis
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•
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– Toxicological syndromes (”toxidromes”)
– Naloxone, flumazenil, physostigmine
Laboratory (direct - or indirect methods)
Other investigations (X-ray, hair…)
Always consider poisoning:
– Comatose patients (<50 yrs)
– Metabolic acidosis of unknown origin
– If something is strange…