GENERAL APPROACH TO THE POISONED PATIENT - rEMERGs

emoved or effluent clearIncreased Elimination(1) Dialysis(2) Forced Diuresis(3) Alkalinization of serum‣ TCA example: changing pH from 7.45 to 7.50 increasesalbumin binding from 95 - 96% of drug :. free drug (whichis active) goes from 5% to 4% which is a 20% reduction inthe amount of free drug.‣ Alkalinization also changes the intracellular pH and allowsthe open of H/M ? gates of the Na+ channel and release ofthe TCA(4) Alkalinization of the urine‣ Ion Trapping of ASA in the urine b/c the alkalinized formis not reabsorbed as well.Supportive Care(1) Oxygen, IV, Monitor(2) Management of Respiratory Complications‣ Airway protection: intubation if necessary‣‣Ventilation may be necessaryARDS: high-flow oxygen, +ve pressure ventilation,consider PEEP(3) CV Complications‣ arrythmias as per ACLS‣ hypotension: fluids only (vassopressors rare)‣ hypertension: nitroprusside, CCBs(4) Neuro Complications‣ coma: airway etc‣ seizures: very dangerours, standard tx w/ benzos andphenobarb, paralyzing agents may be needed initially tocontrol prolonged sz (pancuronium)‣behavioural abnormailities: chemical sedation is dangerousb/c of cardioresp compromise :. use physical restraints ifpossible: ativan and haloperidol are effective if necessaryDiagnostic Studies‣ Drug Screens: urine and blood‣ Routine labs‣ ABGs importantDefinitive Care‣ Antagonists: see table 129-2, pp740‣ All poisoned pts should get oxygen, glucose, and naloxozone (narcan)‣ Elimination: example is alkalinization of urine in ASA od