Tox ACLS. Sophie Gosselin MD FRCPC

Transcription

1 Tox ACLS Sophie Gosselin MD FRCPC 1

2 Objectives discuss the ACLS guidelines for poisoned patients list two situations requiring resuscitative antidotes list indications for lipid emulsion therapy digoxin-specific antibodies sodium bicarbonate insulin-glucose list the mechanisms and therapies for toxic convulsions. 2

3 TOX-ACLS: Toxicologic-Oriented Advanced Cardiac Life Support 2001 ACLS 1st resuscitation guidelines. Albertson TE et al. TOX-ACLS: toxicologic-oriented advanced cardiac life support. Ann Emerg Med 2001;37:S78-S Guidelines 2005 for cardiopulmonary resuscitation and emergency cardiovascular care. Part 10: advanced challenges in resuscitation: section 2: toxicology in ECC. The American Heart Association in collaboration with the International Liaison Committee on Resuscitation. Circulation 2005; 112 (24 Suppl): IV Vanden Hoek TL et al. Part 12 ACLS. Cardiac Arrest in Special Situations. Circulation 2010 vol 112; 19: S3. 3

4 How do put all these recommendations together? Other pearls not addressed in ACLS-guidelines 28

5 Important principles Goal of resuscitation keep alive until the toxic agent is eliminated from the body. Primary cellular toxin special antidote ASAP 29

6 Acute intoxication Detection and correction of vital functions failures Airway (Intubate) Respiratory (hyperventilate) Cardio-circulatory (fluids then assess the problem) Neurological (seizures) Thermal (external cooling, rewarming) 30

7 Tox Threats to 7

8 Airways- Laryngeal obstruction Ingestion of corrosives substances Inhalation of toxic substances Intubate early if symptoms Coma is a threat to airway protection Intubate to decontaminate or wait for loss of airway protection then decontaminate? Neurovitals 31

9 Tox Threats to 9

10 Ventilation - Metabolic acidosis Hyperventilation MUST be maintained Before, during & after intubation Avoid fatal exacerbation of metabolic acidosis cyanide salicylates toxic alcohols metformin 32

11 BENZODIAZEPINES 2010 No role for flumazenil Maybe excessive procedural sedation 22

12 Ventilation CNS & Respiratory β- blockers Carbon monoxide Calcium channel blokers Opiates SSRIs Antipsychotics PCP Ethanol Methanol Oral hypoglycemics Benzodiazepine/ GHB Carbamazepine, valproate, barbiturates 33

13 Tox Threats to 13

14 BRADYCARDIA 2005 Atropine Organophosphates, carbamates, nerve gas Doubling doses 2-4 mg Digoxin specific antibodies Digoxin related bradycardia or arrest Chinese herbs with digitalis glycosides 13

15 TACHYCARDIA 2005 can lead to ischemia, high output failure 1st Benzodiazepine if sympathomimetic agents? physostigmine for (pure) anticholinergic cautiously to avoid opposite effect cholinergic bradycardia if QRS/QT normal Adenosine contraindicated CCB contraindicated 15

16 2005 DRUG-INDUCED HYPERTENSIVE EMERGENCIES 1st choice benzodiazepine decrease effect of endogenous catecholamine release 2nd choices Hydralazine, Phentolamine, nitroprusside (short-acting) β-blocker can worsen hypertension (contraindicated) 16

17 DRUG-INDUCED ACS 2005 Cocaine or other sympathomimetics Reversal of cocaine-induced vasoconstriction 1 st, 2 nd, 3rd agents benzodiazepine 17

18 DRUG-INDUCED VT and VFIB 2005 Instability and polymorphic VT unsynchronised high energy defibrillation Stability lidocaine 1st choice monomorphic VT- effectiveness not demonstrated. ANY type 1A or 1C is contraindicated (antagonise Na channel) phenytoin for TCA not recommended 18

19 DRUG-INDUCED VT and VFIB 2005 Torsade de pointes Magnesium sulfate even if serum [Mg] is normal Overdrive pacing at bpm Isoproterenol as pharmacological overdrive 19

20 DRUG-INDUCED SHOCK 2005 Hypovolemic shock FLUID CHALLENGE and verify preload Vasopressors Distributive shock Vasopressors,? Cardiogenic shock mix of agents. no specific recommendation 20

21 Circulation - V fib after HF burn Severe hypocalcemia Defibrillation alone might not work Aggressive calcium repletion 60 ml of calcium gluconate 10% q 2 minutes until ROSC Topical, intravenous, intraarterial 35

22 Circulation - Theophylline induced SVT Bad prognosis Arrhythmias Hypotension Convulsions Only hope is early hemodialysis Beta blockers can be useful as a bridge while organizing for dialysis ( metoprolol, esmolol) 36

23 Circulation - Wide QRS Cocaine and other Na channel antagonist: Sodium bicarbonate Sodium bicarbonate Sodium bicarbonate Intralipid 37

24 2010 DIGOXIN DIGOXIN and other cardiac glycosides There are no data to support the use of specific antidotes in digoxin-induced cardiac arrest. Severe life-threatening toxicity K > 5.0 meq/l Empiric dosage 10 vials for acute ingestion (380 mg) 5 is probably enough 5 vials for chronic intoxication 2-3 probably enough 5 extra vials extra if no response after 20 minutes. 24

25 2010 LOCAL ANESTHETICS Lipid emulsion Weinberg protocol 1.5 ml/kg of 20% maximum 8-12mL/kg BMV hyperventilation 26

26 Sudden Sniffing Death Beta blockade Epinephrine will kill them (again).. 26

27 Think differently Standard ACLS originally for ISCHEMIC event can CPR alone overcome pharmacological toxicity? Aggressive alkalinization of serum digoxin-specific antibodies ECMO if available in your centre. Hydroxocobalamin +/- thiosulfate Lipid emulsion 41

28 DRUG-INDUCED CARDIAC ARREST 2005 Prolonged efforts ECMO has been used successfully 21

29 Post resuscitation care Decontaminate more toxin might be lurking in the GI track IV fluids check preload with US IVC filling Urinary output Serum levels (APAP, ASA, EtOH) Dialyse what you can Call your Poison Control 42