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 · Consider poisoning when confronted with confusing clinical presentations
· Always save and freeze initial urine from suspicious cases · “Munchausen’s by proxy” is now known as “Factitious disorder imposed on another” or “child abuse” and does not require exotic toxins. 
Field treatment: don’t make things worse, get to the nearest hospital In the hospital: 1. ABCs 2. Wound assessment and pain control 3. Labs to assess for coagulopathy and rhabdomyolysis 4. Call poison control – should always talk to toxicologist 5. CroFAB vs observation only - Mild/dry bite: no CroFAB, just observation - Moderate/severe: one or more doses as needed based on wound progression CroFAB is only curative treatment currently but VERY expensive; Currently evaluating anti-TNFa agents TNFa pilot study: active now, enrolling nonpregnant healthy adults  Organophosphates
- Valium - Restore acetylcholinesterase enzyme - 2PAM - bolus then infusion  Mechanisms of hyperthermia
Malignant Hyperthermia - Rare - Increased peripheral muscle activity due to ryanodine receptor issues - genetic component - Only seen with anesthesia - halothane, succinylcholine - Fast onset from exposure, severe and short lived - hyperK, muscle rigidity, autonomic instability, - increased CO2 on capnography Neuroleptic Malignant Syndrome - Due to altered DA transmission - seen with typical antipysch meds, lithium, environmental (heat) - Subacute, severe, lasts day-weeks - Lead pipe rigidity, autonomic instability, AMS Parkinsons Disease - abrupt withdraw of DA agonist therapy can cause hyperpyrexia Cocaine/ Stimulants - Hypothalamic stimulation, vasoconstriction, increased muscle activity - Fast onset, short duration, severe hyperthermia Serotonin Syndrome - Increased central 5HT activity - More common in drug drug interactions - SSRI/SSRI or SSRI & other serotonin agonists - TCA, demerol, linezolid, MAOI, tramadol, dextromethrophan (MAOI activity) - Subacute, moderate severity - AMS, muscle rigidity (LE>>UE), hyperreflexia & rigidity, autonomic instability - NBOME - designer drugs - increased serotonin activity OTHERS: Anticholinergic - increased muscarnic blockade Salicylate toxicity - uncouples cellular respiration Baclofen withdraw Complications from hyperthermia - Resp, PE, rhabdo, hepatic failure, hyperK Treatments - DC offending agents or restart withdrawn med - Physical cooling - Sedation - benzos, non depolarizing blockade - Secondary Treatments > Cyproheptadine - serotonin antagonist (for 5HT syndrome) - PO only > Dantrolene - for malignant hyperthermia - first line agent > Limited evidence for NMS - dantrolene has been tried - don't use as monotherapy > Dopamine agonist - bromocriptine, amantadine - dont use as monotherapy (long time to start acting) > ECT - unknown mechanism 54000 or 800-222-1222 - poison control  Central Cord Syndrome
-Generally caused by hyperextension. Patients with history of central canal stenosis at risk -Upper extremities affected > lower extremities -Distal affected > proximal -Usually bladder dysfunction Opioid Induced Hearing Loss -Occurs <72 hours after use (seen in both acute and chronic users) -MCC is hydrocodone and heroin but seeing more with methadone lately -May be unilateral or bilateral -Most resolve within 72 hours but may be permanent -Treat with cessation of narcotics and possibly cochlear implants if permanent Rhabdomyolysis -Fluids, fluids, fluids as treatment -Diuretics (mannitol) and bicarb are controversial -Risk of AKI is lower when CK <5,000 but can be seen at CK levels of 1,000 -Urine dipstick + for blood with urinalysis - for blood has sensitivity of 80% for diagnosis  Iron
- Metals in salt form cause VOMITING - 2+ ferrous sulfate in absorbable state → 3+ state for storage/transfer Chewable tablets - 10-18mg/tab - Hard to overdose on these - “minimally toxic” Iron carbonyl - elemental iron - low toxicity Iron filings in hand warmers → if ingested, could be toxic Prenatal vitamins - greatest morbidity - look like candy
Injuries
5 stages of toxicity 1. ingestion to 6h - vomiting!! - abd pain - diarrhea - melena/hematemesis - bowel wall necrosis/infarct 2. 6h - 24h - quiescent stage - symptoms appear to resolve - continued worsening acidosis - if ingestion was small → course usually stops here - if ingestion was large → this stage is sometimes skipped and go onto more badness 3. 12h - 48h - crash - CV, Liver, GI, ARDS, CNS lethergy/coma, Acidosis 4. 2d - 3d - independent of severity of stage 3 - fulminant hepatic failure - >1000 iron level 5. weeks later - mucosal injuries/strictures Iron Levels
Workup - electrolytes -- AGMA - coags if bleeding - LFTs if sick - APAP level for intentional ingestion -- think about synergy - x-rays -- abd → see pills sometimes Management
use: hx of sxs, pos xrays, super high iron level 100mg binds 10mg iron IV admin -- 15mg/kg/hr for rate but may not get in enough Side Effects: hypotension, tachycardia, diuresis visual/ototoxicity, abd pain, fever, diarrhea increased risk for yersenia enterocolitica sepsis stop when acidosis resolves Core Concepts: elemental dose is what’s toxic no charcoal for tx look for anion gap metabolic acidosis check an xray for pills, but if it’s negative doesn’t mean pt isn’t sick there’s a quiescent phase of toxicity deferoxamine is an option for iron chelation pay attention to units used to quantify iron --usually in dL  Dens fracture
> Type I: Extends through the tip of the dens > Type II: Extends through the base of the dens - unstable > Type III: Extends through vertebral body of axis - can be unstable Geriatric Trauma - Falls - leading cause of injury - Frequently fail to mount a tachycardic response TB meningitis
> If lymphocytic meningitis, likely not viral if low glucose - LOW GLUCOSE IS NOT NORMAL FOR VIRAL MENINGITIS > Absence of fever doesn't exclude TB > Cranial nerve 6 = most common nerve palsy in meningitis Chronic Acetaminophen Toxicity - Can't use nomagram with chronic ingestions - NAC - replenished and maintains glutathione stores - also thought to have a role in free radical scavenging; IV or PO acceptable - If unknown ingestion time and LFTs or APAP elevated  Mechanism of GI injury
Damage is due to multiple factors: - tissue contact time - pH and concentration - ability of caustic to penetrate tissues - presence of absence of food in stomach - titratable acid/allkaline reserve (TAR) - amount of neutralizer needed to titrate pH of caustic to physiologic pH of tissues - higher TARs produce more damaged tissue Alkalis - injury is due to LIQUEFACTION NECROSIS - bad because injury keeps penetrating until neutralized or penetration of organ occurs - can get esophageal and gastric injuries > Sodium hydroxide > Sodium hypochlorite (household bleach) - worry about ingestion of larger amounts or higher concentrations > Ammonium hydroxide (toilet bowel cleaner) > Household detergents - usually dont cause GI injury but massive ingestions can be bad Acids - + ion causes COAGULATION NECROSIS - ulceration and perforation can occur; can get gap or nonanion gao acidosis; both esophageal and gastric injuries as well as pylorospasm Classification of caustic injury of esophagus Grade I - hyperemia - diet as tolerated, early D/C (likely need to be brought in initially for obs) Grade II - ulcerations and exudates Grade III - necrosis and deep ulcerations * Be aware - these people can have an initially benign presentation * Don’t use presence or absence of oral pharyngeal lesions to determine damage distally Management - Hydration - Steroids for airway edema (not research base) - CBC, lytes, VBG, coags - Not unusual to have GI bleed early on, but check type and cross - Airway - manage early (WEAR MASK), get good visualization - No NG tube for alkali ingestions, but with acid ingestions use w/in 30-60 min, don't do charcoal unless bad ingestion (ex, Zinc Chloride) - Endoscopy for all intentional ingestions - perform in first 12-48 hrs, up to 96 hrs is safe - unless they ingest very concentrated products or large amounts - then scope immediately - If you do not scope - observe for 6-12 hrs with serial exams and small sips of water - Contraindications to endoscopy - perforation, supraglottic or epiglottic burns (concern for perforation if you scope) - if can’t do endoscopy - perform esophagram and upper GI series 24 hrs after ingestion - use water soluble contrast initially Sequelae - scarring - motility issues - gastric outlet obstruction - tracheoesphogeal fistulas - strictures which SIGNIFICANTLY increases risk for Cancer - need lifelong monitoring  Cyanide
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