Cnndvc.unmc.edu

8401 W. DODGE RD., SUITE #115, OMAHA, NE 68114; 1-800-222-1222; (402) 955-5555 Steven A. Seifert, MD, Medical Director Nebraska Regional Poison Center _____________________________________________
The Emergency Department is often the front line in dealing with significant toxic exposures. Here’s an
update.
1) We’ve had a name and sponsorship change. We are now the Nebraska Regional Poison Center and are
sponsored by The Nebraska Medical Center, Creighton University Medical Center and University of
Nebraska Medical Center. Our phone numbers, staff and services have not changed. We will continue to
provide the same high quality poison center services to Nebraska and Wyoming.
2) A new topical agent, Zanfel, an abrasive agent that is also a mix of alcohol solubles and anionic
surfactants, was shown to be effective in preventing or ameliorating the signs and symptoms of urushiol-
induced (poison ivy, poison oak, poison sumac) dermatitis in 24 volunteers. It was effective at improving
reaction and itch scores when applied at 48, 96 and 144 hours after exposure. (Davila, et al. Annals of
EM, 2003;42(4):S98)
3) A new drug of abuse, “Foxy” or “Foxy Methoxy” has been reported in Michigan and several other
Midwestern states. It is a synthetic tryptamine. Patients presented with hallucinations, hypertension,
tachycardia, mydriasis, and waxy plasticity. Bear in mind that street drugs are notoriously impure,
misrepresented and often combined, with unpredictable effects. Treatment is symptomatic and supportive.
(Smolinske, et al. J Toxicol Clin Toxicol 2003;41(5):641)
4) As a first line agent, we recommend using benzodiazepines in the agitated ED patient, especially when
the history is unknown and/or multiple substances may be involved. There is little downside to even high-
dose benzos, as hemodynamic effects are minimal and excessive sedation can be managed with proper
airway support. Flumazenil (Romazecon®) is contraindicated in most such cases, as seizures may be
precipitated, unmasked or made more difficult to manage.
5) A number of ED’s have started using IM ziprazadone (Geodon®) as an alternative to droperidol
(Inapsine®) in the management of agitated patients unresponsive to high dose benzodiazepines.
Although several small case series have shown effectiveness and not demonstrated adverse effects, it is
known that ziprazadone prolongs the QTc interval, just as droperidol and haloperiodol (Haldol®).
Although there is no “black box” warning on ziprazadone, it would be prudent to have a pre-treatment
ECG with a normal QTc on any agitated, possibly polysubstance-using patient when contemplating using
any agent known to prolong QTc. When a pre-dose ECG cannot be obtained, a risk-benefit analysis must
be done before giving these medications. An ECG should be obtained at the earliest opportunity
following the use of these drugs and patients should be monitored for several hours following use. The
physician should be prepared to manage Torsades de Points should it occur (IV magnesium, lidocaine,
overdrive pacing, DC shock).
SPONSORED BY: THE NEBRASKA MEDICAL CENTER; CREIGHTON UNIVERSITY MEDICAL CENTER; UNIVERSITY OF NEBRASKA MEDICAL CENTER
8401 W. DODGE RD., SUITE #115, OMAHA, NE 68114; 1-800-222-1222; (402) 955-5555 6) Airway management in the overdose setting can be challenging. The need for intubation to protect the airway, either during lavage or later in the course of CNS depression, is not uncommon. Anticipation of the need for intubation and advance preparation can help turn a crash intubation into a semi-elective one. Some points to keep in mind: • Emptying the stomach first via an NG may decrease the risk of emesis and aspiration. • Have all equipment and personnel assembled prior to initiation of intubation. • Have back-up plans in place (e.g. alternative airways, anesthesiology, surgical options). Call for help early in a difficult intubation. • Select appropriate Rapid Sequence Intubation (RSI) drugs and know the proper doses, • Here is a partial list of useful RSI agents: • Atropine 0.01 mg/kg IV (Minimum dose: 0.1 mg) • Prevents vagally stimulated bradycardia • Consider the need for increased intracranial pressure management • Lidocaine 1 mg/kg IV (Prevents ICP rise) • Fentanyl 3 ug/kg IVP • Consider vecuronium 1 mg as a defasciculating agent • Sedation • Etomidate 0.2-0.3 mg/kg IVP • Midazolam (Versed®) 0.1 mg/kg IVP • Propofol (1-3 mg/kg IV) • Thiopental (Pentothal®) 3-5 mg/kg IVP • Ketamine 1-2 mg/kg IV • Diazepam (Valium®) (0.2-1.0 mg/kg IV) • Succinylcholine 1-1.5 mg/kg IV, 2-4 mg/kg IM • Vecuronium (Norcuron®) 0.1 mg/kg IV • Pancuronium (Pavulon®) 0.1 mg/kg IV • Select the proper blades and tubes for your patient. Patient positioning, good lighting and adjunctive support (e.g. suction, cricoid pressure) are important. • Hyperoxygenate the patient prior to your attempt. Stop to reoxygenate when saturations drop. • Confirm the proper positioning of the tube. Listen for breath sounds. Expired CO2 monitoring devices are most useful. CXR confirms proper depth of tube placement. SPONSORED BY: THE NEBRASKA MEDICAL CENTER; CREIGHTON UNIVERSITY MEDICAL CENTER; UNIVERSITY OF NEBRASKA MEDICAL CENTER

Source: http://cnndvc.unmc.edu/App_Files/docs/ToxUpdate_10_03.pdf