GENERAL APPROACH TO THE POISONED PATIENT - rEMERGs

‣ I Iron‣ L Lithium, Lead‣ E EthanolMultidose Activated Charcoal (MDAC)‣ Doses and frequency varies with indication‣ Can be given by continuous NG infusion‣ Massive ingestion: one dose won’t be enough‣ Sustained release: delayed release of drug‣ Gastric concretions‣ Enhanced elimination: prevents enterohepatic reabsorption of active drugor metabolites?Contraindications‣ Caustic ingestions: doesn’t bind, obscures endoscopy‣ Unprotected airway‣ Hydrocarbons: increased risk of aspiration and ARDSComplications‣ Very safe‣ GI upset‣‣Bowel obstruction: case reports with MDACAspiration is biggest risk­ Trivial aspiration very common­ Significant aspiration rare­CATHARTICS Purpose = increase GI transit speed, decrease transit time No proven benefit Effect on activated charcoal: occasionally benefitial, usually no effect, occasionallyharmful Only three used with any frequency: sorbital, magnesium sulfate, magnesium citrate Sorbital: 1 gm/kg; repeat dose X 1 only at 0.5 mg/kg with MDAC if no ileus/obstruction No evidence of harm for single use if no contraindications Complications: dehydration, electrolyte changes, GI upset, abdominal distension Children have more problems with fluid and electrolyte shifts Relative contraindications:‣ Bowel obstruction‣ Ileus (absent bowel sounds)‣ Diarrhea (uneccessary)‣ Infants and young childrenWHOLE BOWEL IRRIGATION General‣ More effective than clearing bowel than cathartic‣ PEG-ELS solution is electrolyte and osmolarity balanced thus nofluid/electrolyte shifts (isotonic components); huge volumes are notdangerous‣ Components are not absorbed‣ Mechanical washout of bowel (doesn’t draw in fluid or stimulate motility) Indications for WBI: serious overdoses, poor binding to charcoal, sustained release