• Toxic alcohol ingestion
  • will see serum osmolal gap first
  • anion gap happens once the alcohol is metabolized
  • thus, early in ingestion, may not see anion gap but should see osmolal gap
  • no osmolal gap and normal anion gap rules out a toxic alcohol ingestion
  
  

  Posted 10/05/16 11:00:46 AM by Anna Krigel

• Narcan (naloxone) 
  • used for opiate toxicity reversal
  • typical starting dose is 0.4mg, but it is a good idea to start even lower at 0.04mg and then titrate up as needed
  
  

  Posted 10/05/16 11:33:40 AM by Anna Krigel

• Activated charcoal
  • used for tablet ingestions
  • not good for toxic alcohol or organophosphate ingestion as these are absorbed too quickly
  • should not be used in patients with poor mental status who cannot protect their airway (significant aspiration risk)
  
  

  Posted 10/05/16 11:36:08 AM by Anna Krigel

• Organophosphates and carbamates
  • potent cholinesterase inhibitors (bind to acetylcholinesterase and render the enzyme non-functional)
  • cause increased acetylcholine levels leading to severe cholinergic toxicity following cutaneous exposure, inhalation, or ingestion
  • organophosphate = permanent inhibitor, carbamate = transient inhibitor, thus carbamate toxicity tends to be of shorter duration
  • Muscarinic signs of cholinergic excess (DUMBELS)
    • D - defecation
    • U - urination
    • M - miosis
    • B - bronchorrhea/bronchospasm/bradycardia
    • E - emesis
    • L - lacrimation
    • S - salivation
  •  Found in many pesticides and insecticides
    • rodent killer containing carbamate from the Dominican Republic called "Tres Pasitos" can be found in the US, especially in the Washington Heights neighborhood
  
  

  Posted 10/05/16 11:56:18 AM by Anna Krigel

• Organophosphate and carbamate toxicity management
  • Atropine - reverses cholinergic symptoms, start with 1mg and double the dose every 5 minutes until secretions dry up
    • look out for delirium with atropine
  • Pralidoxime (2-PAM) - cholinesterase reactivating agent, used as a weight-based continuous infusion (30mg/kg)
    • has poor CNS penetration, thus must be used with atropine 
  
  

  Posted 10/05/16 02:24:43 PM by Anna Krigel

• For further reading...

  Predicting the Clinical Course in Intentional Drug Overdose (JAMA Internal Medicine) 
  Differentiating between organophosphate and carbamate poisoning
  
  

  Posted 10/05/16 02:31:59 PM by Anna Krigel

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