Toxicological

  • Alcohol
    • Ethanol toxicity
    • Ethylene Glycol Toxicity
    • Isopropyl Toxicity
    • Methanol Toxicity
  • Analgesics
    • Acetaminophen Toxicity
    • Nonsteroidal Anti-Inflammatories (NSAIDS) Toxicity
    • Opiate Toxicity
    • Salicylate Toxicity
  • Anticholinergics
    • Antihistamine Toxicity
  • Anticoagulants/Antithrombotics/Antiplatelets
    • Direct Thrombin Inhibitor Toxicity
    • Factor Xa Inhibitor Toxicity
    • Heparin Toxicity
    • Vitamin K Antagonist Toxicity
  • Antidepressants
    • Bupropion Toxicity
    • Selective Serotonin Reuptake Inhibitor (SSRI) Toxicity
    • Tricyclic Antidepressant Toxicity
  • Antimicrobials
    • Isoniazid Toxicity
  • Antipsychotic Toxicity
  • Carbon Monoxide Toxicity
  • Cardiovascular Drugs
    • Digoxin Toxicity
    • Beta Blocker Toxicity
    • Calcium Channel Blocker Toxicity
  • Cholinergics
    • Nerve Agent Toxicity
    • Organophosphate Toxicity
  • Cyanides/Hydrogen
    • Cyanide Toxicity
    • Hydrogen Fluoride Toxicity
    • Hydrogen Sulfide Toxicity
  • Heavy Metal Toxicity
    • Arsenic Toxicity
    • Cadmium Toxicity
    • Lead Toxicity
    • Mercury Toxicity
  • Rodenticide Toxicity
  • Household/Industrial Chemicals
    • Caustic Agents
    • Hydrocarbons
    • Inhaled Irritants
  • Antidiabetic Agent T
    • Insulin Toxicity
    • Oral Antidiabetic Toxicity
  • Lithium Toxicity
  • Local Anesthetic Toxicity
  • Marine Toxins
  • Methemoglobinemia
  • Mushroom Toxicity
  • Plant Toxicity
  • Nutritional Supplements
    • Iron Toxicity
    • Anabolic Steroid Toxicity
  • Recreational Drugs
    • Cannabis Toxicity
    • Synthetic Cannabinoid Toxicity
    • Hallucinogen Toxicity
    • Gamma-Hydroxybutyrate (GHB) Toxicity
  • Sedatives/Hypnotics
    • Benzodiazepine Toxicity
    • Barbiturate Toxicity
  • Stimulant/Sympathomimetic
    • Amphetamine Toxicity
    • Cocaine Toxicity
  • Beta-Blocker Overdose
  • Lithium Overdose

Acetaminophen Overdose

Rapid Review

  • Background
    • Acetaminophen overdose occurs at doses of 150mg/kg within 24 hours,  causing delayed onset of severe liver injury and potentially liver failure due to the production of NAPQI from the parent compound. 
  • Signs/Symptoms
    • Symptoms: Nausea/vomiting at first, progresses to RUQ pain
    • Signs: jaundice, tachycardia, hypotension
  • Diagnosis
    • Acetaminophen (APAP) level; compare with Rumack-Matthew Nomagram
    • Liver function tests
  • Treatment
    • N-acetylcysteine (most beneficial if given within 8 hours of ingestion)
    • Supportive care (IV fluids, antiemetics)
  • Disposition
    • Discharge patients who are asymptomatic, have an APAP concentration of < 150 ug/mL at 4 hours, and do not require N-acetylcysteine. (NAC)
    • Admit any patients requiring NAC

Pearls

  • The Rumack-Matthew Nomagram is only useful for patients with acute poisonings. It cannot be used for chronic or staggered acute poisonings.
  • Patients who present with significant hepatotoxicity at the time of arrival to the ED will require early evaluation by hepatology/transplant service.
Video Credit: LITreviews

Beta-Blocker Overdose

Rapid Review

  • Background
    •  Beta-blockers inhibit epinephrine and norepinephrine adrenergic stimulation on beta receptors; overdose can cause bradycardia, hypotension, and ultimately cardiovascular collapse. 
  • Signs/Symptoms
    • Symptoms: Fatigue, nausea, weakness
    • Signs: (+) Hypotension, (+) bradycardia
  • Diagnosis
    • Clinical diagnosis based on history and clinical features
    • Routine drug screens not usually helpful
  • Treatment
    • Maintain hemodynamics (IV fluids, vasopressors)
    • Consider glucagon and atropine
  • Disposition
    • Any patient with hypotension, bradycardia, or conduction blocks will need to be admitted for at least 24 hours. ICU is required if hemodynamically unstable.
    • Discharge is appropriate for patients who are asymptomatic and have been observed for at least 6-12 hours (time depending on type of BB ingested)

Pearls

  • Certain lipophilic beta-blockers (ex. metoprolol, labetalol, propranolol) are exceptionally toxic to the central nervous system and may present with AMS, seizures, or comatose state.
  • High-dose insulin can be considered for refractory cases, but should be used cautiously, as BB overdose tends to cause hypoglycemia. 
Video Credit: Doctors Writing DW

Lithium Overdose

Rapid Review

  • Background
    • Lithium is used primarily to treat bipolar disorder. Toxicity can cause GI, neurologic, and renal manifestations.
  • Signs/Symptoms
    • Predominantly GI symptoms initially (nausea, vomiting, cramping, diarrhea)
    • Progression of toxicity can cause dystonia, ataxia, hyperreflexia, and cardiac dysrhythmias.
  • Diagnosis
    • Lithium level (may not correlate with clinical symptoms)
    • Consider testing for coingestants (ex. Acetaminophen)
  • Treatment
    • GI decontamination (whole bowel irrigation, gastric lavage)
    • Enhanced elimination (IV fluids, diuretics, hemodialysis)
  • Disposition
    • Admit any patient with chronic lithium toxicity, or those with symptomatic acute lithium toxicity.  May warrant ICU admission if patient presents with seizures or cardiovascular instability.
    • Discharge may be warranted if the patient is asymptomatic, non-suicidal, and serum lithium level < 2 mEq/L

Pearls

  • Activated charcoal has not been shown to be beneficial for lithium overdose, though whole-bowel irrigation ith PEG may have some utility in massive ingestions. 
  • Serum lithium levels may only be slightly elevated in the setting of chronic toxicity. These levels may not necessarily be predictive of the amount of toxicity.
Video Credit: Lecturio