PADIS MLSCI 466 - Dec 2023 PDF

The what, why, and when… Nicholas Sajko, B.Sc, M.D. Emergency Medicine PGY-5 (University of Alberta) Clinical Pharmacology & Toxicology Fellow (University of Calgary) OBJECTIVES • PADIS Overview – What it is, who we are, and how can we help! • Highlights of toxicologic epidemiology in Canada • Exp...

The what, why, and when… Nicholas Sajko, B.Sc, M.D. Emergency Medicine PGY-5 (University of Alberta) Clinical Pharmacology & Toxicology Fellow (University of Calgary) OBJECTIVES • PADIS Overview – What it is, who we are, and how can we help! • Highlights of toxicologic epidemiology in Canada • Explore some common toxicology cases and what goes into their assessment / management • Recognize the limitations of qualitative drug screening • Open Q/A (Time permitting!) Conflict of Interest • No conflicts of interest to disclose! CASE #1 • 30 year old unknown male, acting bizarre outside • T 40C, HR 149, BP 160/110, RR 30, Sats 95% RA • Extreme agitation and aggression with EMS, requiring multiple (limited) security personnel to hold the patient down on arrival. CASE #2 • 25 yo female took a friend’s “down” • On arrival to the ED: • • • • GCS 3 (nonresponsive) Pinpoint pupils Respirations 6 breaths / minute O2 85% on RA The PADIS Team – Who are we? The PADIS Team • PADIS is staffed by specially trained and certified healthcare professionals. INFORMATION SPECIALISTS (Pharmacists & R.N.s with Subspecialty Training) Dr Morgan Riggan Dr Scott Lucyk Dr Mark Yarema Dr Riley Hartmann Dr Eric McGillis Toxicology Fellowship Training • US Medical Toxicology training • 2 year program • Usually after a 3-5 year Emergency Medicine residency • ONLY Medical Toxicology • Canadian Clinical Pharmacology & Toxicology Training (CPT) • 2 year Royal College Fellowship • CaRMS match via the Medicine Subspecialty Match (MSM) • Entry residency programs include: • • • • FRCPC Emergency Medicine Internal Medicine Anesthesia Pediatrics Dr Nick Sajko Dr Jason Elzinga FIRST YEAR FELLOWS SECOND YEAR FELLOWS Dr Jacqui Hiob Dr Alex Hamelin PADIS Elective Residents • Open to any and all interested residents, from any specialty • Bedside Consults (Usually 1-2x / week, during daytime – depending on cases) • Participate in bedside consultation and patient care Information Specialist Training • 4 month orientation • 3 months of Toxicology • 1 month of Medication Advice training • Didactic, Role Play, Quiz writing • Preceptor buddy shifts • Focus on: Assessment, Documentation, Communication, Resource navigation, Pharmacology, Toxico/Pharmacokinetics The PADIS Team – What is our Role? PADIS Roles • Exposure to drugs, chemicals, or toxins via mouth, lungs, skin, eyes (or any other route possible!) • “I’ve done something I don’t usually do” • “Have I taken too much? I’m concerned I may have poisoned myself…” • “How can I prevent poisoning?” • “I am caring for an overdose / poisoned patient and I want to review management.” PADIS Roles • Day-to-day activities: • Patient Care • Telephone and bedside consultation service (Within Calgary) • Education • General public and health care professionals • Research / Collaboration • Acetaminophen, toxic alcohols, antidotes • Surveillance • Tracking trends / outbreaks in poisoning • Prevention PADIS Roles • Toxicovigilance – the active process of identifying and evaluating the toxic risks existing in a community and evaluating the measures taken to reduce or eliminate them PADIS Roles • Risks of public health concern include poisoning outbreaks due to: • Contamination • Emergency of new drugs • Mass chemical exposures / terrorist events • Unusual patterns or trends The PADIS Team – What do we see? The WEIRD and WONDERFUL So… What happens when I do call PADIS? The Telephone Risk Assessment • Where do we start? • What is the patient’s current clinical status • HPI – what did they take, intent etc. • Physical Exam • Initial Investigations • Toxin specifics… • What was the ingestion? • How much was ingested? • What was the time of the ingestion? Was it staggered or all at once? • Any coingestants? • Access to other medications? • Any self-decontamination events? • Pill counts? How much was patient prescribed and when? • How has their clinical picture changed over time? http://www.litfl.com The Toxicologic Exam • HEENT • Pupils? – reactive, mydriatic, miotic • Rhinorrhea, secretions? • Temperature? • SKIN • Flushed? Dry? Diaphoretic? Discolored? • CNS • • • • • GI Rigidity? Spasticity? Clonus / hyper-reflexia? Altered mentation / delirium? Cerebellar signs? • N/V/D? • Abdominal pain? Bowel sounds? • CVS • Evidence of pulmonary edema / injury? • FULL SET OF VITALS • • • • • • • Temp Glucose HR BP RR O2 sats GCS • Also: What has the trend been? The Toxicologic Workup • What is included in a “Tox Panel” • • • • • • • CBC +diff • What about urine tox screens? Electrolytes + Extended lytes • Rarely helpful in the acute management Creatinine, Urea, eGFR of tox patients VBG/ABG w/ Co-oximetry, lactate* ASA, EtOH, Acetaminophen serum levels Serum osmols LFTs + Transaminases • ECG (What are we looking for here?) – QRS, QTc • +/- CXR The Toxicologic Workup: Urine Screens • Urine drugs of abuse screen = QUALITATIVE testing for: • • • • • • • • • Amphetamines Barbiturates Benzodiazepines Cocaine Cannabinoids Opiates Oxycodone Methadone Etc. The Toxicologic Workup: Urine Screens The Toxicologic Workup: Urine Screens The Toxicologic Workup: Urine Screens Is there a drug present in the patient? v. Is the patient’s signs and symptoms cause by the drug? The ABCs of Toxicology • A: • Airway protection • Secretions? • B: • Breathing • Tachypnea or Bradypnea? • C: • BP, HR, perfusion • Flushed? Dry? Diaphoretic? The ABCs of Toxicology • D - Decontamination? • Is this an overdose or a patient in which we can initiate decontamination? • What factors do we need to consider? • E – Enhanced Elimination? • Is this an overdose where we can ENHANCE the elimination of the compound? • F – FIND AND ANTIDOTE / Initiate specific therapies • Dependent on the ingestion and a BROAD topic Definitions • Decontamination • Process of preventing systemic absorption into the body • Ex: SDAC, Syrup of Ipecac, gastric lavage, WBI • Enhanced Elimination • Process of speeding up metabolism and elimination of an already absorbed substance; can be ex-vivo or in-vivo methods • Ex: Hemodialysis, MDAC, urinary alkalinization, intra-lipid (IV fat emulsion) Back to the patients… CASE #1 • 30 year old unknown male, acting bizarre outside • T 40C, HR 149, BP 160/110, RR 30, Sats 95% RA • Extreme agitation and aggression with EMS, requiring multiple (limited) security personnel to hold the patient down on arrival. CASE #1: The “Hot & Bothered” DDX • What is our DDX for the HIGH TEMP and AGITATED patient • Think both TOX and non-TOX • BONUS: What is the difference between “Fever” and “Hyperthermia” • TOX Sympathomimetics Anticholinergics Serotonergic  Serotonin Syndrome Antipsychotics  Neuroleptic Malignant Syndrome ETC Uncouplers (ASA, DNP) Drugs that predispose to poor environmental responses • Malignant Hyperthermia • • • • • • • INFECTIOUS • STRUCTURAL • ENDO / METABOLIC • ENVIRONMENTAL Central Effects Agitation Increased Temperature ANS SYMPATHETIC STOP “Fight or flight” Mydriasis Slowed GI / Decreased Secretions PARASYMPATHETIC STOP “Rest and digest” EYES Miosis SALIVARY Increased GI / Secretions Bradycardia, Heart Block Tachycardia / Vasoconstriction CVS Dilated Airways LUNGS Constricted Airways SKIN *Our sweat glands are sympathetically driven* Diaphoresis / pale skin / Temp up N/A CASE #1: The “H & B” Management • Sedation is needed  Rigidity and hyperactivity kill! • Benzos, Benzos, Benzos, Benzos • Consider intubation and paralysis • What should be do about the elevated Temp? • Tylenol? NO CASE #1: Hyperthermia KILLS • Hyperthermia KILLS – we need to aggressively cool these patients • Chemical sedation as before will help • Other cooling methods? Body bag + Ice/water Fanning and Misting Exposure Cooled (4C) IV fluids Cool packs to the axilla, groin, neck (major blood vessel highways) Further sedation and PARALYSIS • When do we stop cooling… What are our targets? • <39 Celsius within 20-30 minutes • True EMERGENCY CASE #2 • 25 yo female took a friend’s “down” • On arrival to the ED: • • • • GCS 3 (nonresponsive) Pinpoint pupils Respirations 6 breaths / minute O2 85% on RA CASE #2: Opioids • Common opioids / opioid-like medications • • • • • • • • • Morphine Codeine Fentanyl Dilaudid Oxycontin Heroin Methadone Tramadol Dextromethorphan • Illicit Opioids contain numerous adulterants… • • • • Sulfonylureas Baking soda Xylazine Etc. CASE #2: Opioids • CNS • Drowsy, somnolent • Pupils • Pinpoint (miosis) • CVS • Bradycardia • Hypotension • Respiratory • Bradypnea, hypopnea • Hypoxia (Decreased O2) • Hypercarbia (Increased CO2) CASE #2: Opioids CASE #2: Opioids • Kratom • Tropical evergreen native to SE asia • Ingestion can produce both stimulant and opioid effects – has been touted as a treatment for opioid withdrawal; NO evidence supporting this. • However, not currently illegal; easy to obtain • 27,338 opioid overdose deaths; 152 of which tested positive for Kratom – post-mortem analysis indicates 91 of the 152 cases where Kratom was the responsible agent. CASE #2: Opioids Management • ANTIDOTE: Naloxone OBJECTIVES • PADIS Overview – What it is, who we are, and how can we help! • Highlights of toxicologic epidemiology in Canada • Explore some common toxicology cases and what goes into their assessment / management • Recognize the limitations of qualitative drug screening • Open Q/A (Time permitting!) QUESTIONS? 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