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THE MORNING REPORT

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Darshak Vekaria, MD
Sep 26, 2023

The Agent / Antidote Game Show

Acetaminophen Overdose

  1. Vitamin K

  2. Glucagon

  3. N-Acetylcysteine

  4. British Anti-Lewisite

  5. All of the Above

  6. None of the above

  • Acetaminophen is metabolized by glucuronidation and sulfuration

  • Metabolized to NAQPI

    • NAQPI is reduced by glutathione to non toxic compounds that are renally excreted

  • Toxicity develops at 140 mg/kg

  • Centrilobular necrosis

    • Elevated levels of NAQPI. Depletes the Glutathione stores

  • NAC repletes glutathione and prevents NAQPI from binding to hepatic macromolecules

  • Rumack-Matthew Nomogram

    • guides indication for NAC usage

    • Used ONLY in acute toxicity

    • measured 4hrs after ingestion

Iron Toxicity

  1. Fomepizole

  2. Glucagon

  3. High Dose Insulin

  4. Calcium Disodium EDTA

  5. Deferoxamine

  • Very common and deadly among children

  • Failure to recognize and appropriately treat → multi organ failure, death

  • Amount ingested depends on the formulation

    • For example: 325 mg ferrous sulfate tablets are 20% elemental iron

      • 0.20 x 325 mg = 65 mg of Iron

  • Direct caustic injury to GI tract.

    • Hemorrhagic necrosis can occur

  • Impairs cellular metabolism in multiple organs

  • Free radical formation → cell death

  • Treatment:

    • Asymptomatic: supportive care

    • Mild symptoms, but hemodynamically stable: observation

    • Unstable + symptomatic → Deferoxamine + ICU admission

Digoxin Toxicity

  1. Methylene Blue

  2. Naloxone

  3. Calcium Channel Blockers

  4. Digi-Fab

  5. N-Acetylcysteine

  • Cardiac Glycoside derived from foxglove

  • Inotropic effects helpful for CHF

  • AV nodal blocker helpful for atrial tachydysrhythmias

  • Toxicity presents w/ hyperkalemia, GI symptoms, visual disturbances, ECG changes

Carbon Monoxide Poisoning

  1. Andexxa

  2. N-Acetylcysteine

  3. Activated Charcoal

  4. Supportive Care, 100% O2 supplementation

  5. Dialysis

  • CO binds to Hgb with affinity 250x that of O2 → reduced Hgb O2 saturation and inability to carry oxygen rich blood to tissues

  • The O2 dissociation curve displaced leftwards making it hard for Hgb to offload O2 to peripheral tissue

  • Vague symptoms.

    • Whole family comes in w/ same symptoms

    • Pet fatality

  • Obtain Carboxyhemoglobin level

    • Normal < 5%

    • Abnormal in non smokers: > 5%

    • Abnormal in smoker: > 10%

  • O2 Half lives

    • Room air ~6hrs

    • 100% FiO2 ~1hr

    • Hyperbaric O2 ~30m

Hyperbaric O2 indications:

  • Hypotensive

  • Coma/Seizures

  • Ischemia/dysrhythmias

  • COHb2 level > 25% or 20% in pregnancy

  • Severe pH < 7.1

  • Greatest benefit w/in 6 hours

RAPID FIRE:


Aspirin

  • Sodium Bicarbonate

    • 3 amps (150 Meqs) of Bicarb in 1000cc D5W

    • Alkalinizes urine and creates ionic trapping for aspirin

    • Need to keep potassium at adequate numbers as this is used for ionic exchange

  • Hemodialysis indications

    • Altered mental status

    • pH < 7.2 despite bicarb therapy

    • Salicylate level > 100mg/dL in acute overdoses

    • Salicylate level > 90mg/dL in acute overdoses with renal dysfunction OR despite fluid resuscitation / alkalinization

    • Salicylate level > 80mg/dL in acute overdoses with renal dysfunction AND despite fluid resuscitation / alkalinization

    • Salicylate level >40-50mg/dL in chronic overdoses (considerable amount of levels within tissue not circulating in blood)

    • Consider hemodialysis in conjunction with Nephrology AND Toxicology

Tricyclic Antidepressants

  • Sodium Bicarbonate

    • Indications

      • Seizures

      • Ventricular Arrhythmias

      • QRS >100ms

      • Hypotension not due to hypovolemia

    • Bicarb Boluses

    • Bicarb Infusions

    • Therapeutic targets

      • QRS <100ms (if able)

      • pH moderately elevated: ~7.5-7.55

Methanol

  • Fomepizole

    • 15mg/kg IV, then

    • 10mg/kg IV q12hrs x4 doses, then

    • 15mg/kg IV q12hrs

    • EXPENSIVE (~$1500 / dose)

  • Ethanol

    • Target blood alcohol 100-150mg/dL

    • Oral dosing

      • Loading dose: 0.8g/kg ethanol

        • volume = loading dose / ABV

      • Maintenance dose

        • ~66-130mg/kg/hr, may be higher for regular drinkers (100-150mg/kg/hr)

        • equates to ~7g/hr (equates to approximately 1/2 of a "standard drink" per hr)

  • Dialysis indications

    • consult Nephrology AND toxicology

    • Acidosis pH < 7.15

    • Anion gap >24

    • End organ damage

    • Methanol level

      • >50mg/dL in absence of EtOH or fomepizole therapy

      • >60mg/dL in contenxt of ethanol therapy

      • >70mg/dL in context of fomepizole therapy

Isoniazid

  • Pyridoxine (B6)

    • 180-600mg daily (PO ro IV)

References

Darshak Vekaria, MD

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