Critical Care Toxicology: What Did My Patient Take? 1/2

Surprisingly, patients aren’t entirely truthful about what they may have ingested to make them sick. Or, they might be in a state where they can’t share the information due to their medical condition. This can put the medical team in a worse case scenario where if they knew what the patient took . . . they might be able to offer the right antidote.

Without the information it can seem like a shot in the dark to try and reverse the effect the substance is having on the individual.

Recently, I heard a fascinating lecture given by a doctor of toxicology who gave some guidelines, based on the patient’s signs, as to what that drug might be and I thought I’d share them with you for some great writing details.

Let’s first assume that we at least know the patient likely ingested something. They’re discovered by EMS in their home with an array of alcohol, pills, and drug paraphernalia. A good EMS team will try and take stock of what they see and report to the ER what they found. They’ll likely not grab illegal drugs like weed or powders (this would be for the police to confiscate) but they may bring unidentified pills and prescription bottles to help us. This can help narrow down what the person might have taken.

The opposite is finding someone unconscious in the middle of the street with nothing around them and the police call EMS for transport.

Or, even better, a teen has been involved in a “pharming party” where they raid every medicine cabinet they have access to and dump all they find into a punch bowl. Then proceed to swallow a handful of these pills with a bunch of alcohol. I have had cases like this where EMS grabbed the bowl and brought it with them. I mean, a punch bowl filled with prescription drugs but no boxes or labels. Even if we have the pills– it takes time to identify what they might be.

Time the patient might not have.

Scenario #1:

The patient presents with low heart rate and low blood pressure.

First, why would we think this may be a drug ingestion? The body’s normal response to low blood pressure is to increase your heart rate– not lower it– as a mechanism to prevent shock.

There’s only one other medical state I can think of that would mimic this and that would be a spinal cord injury. When the spinal cord is damaged, you lose nerve innervation that would help increase blood pressure. So, in absence of a traumatic event, a spinal cord injury would be ruled out. However, an unconscious person can’t tell us if they’ve been injured which further complicates the picture.

Drugs that can create this picture could be the following:

1. Beta-blocker. Your heart has beta receptors. When these are stimulated, say by a release of adrenaline in your body, the heart contracts harder and beats faster. A beta-blocker “blocks” these receptors so the opposite happens. Propranolol is beta blocker.

2. Clonidine. Clonidine is a sympatholytic medication meaning it blocks the flight or fight response. It’s used to treat high blood pressure but also ADHD and anxiety disorders. Personally, I’ve seen quite a few of these ingestions and they tend to be very unpredictable. The child can be fine one minute and then, with little warning, have a very slow heart rate and be unarouseable.

3. Baclofen: A muscle relaxer.

4. Calcium Channel Blocker. These drugs do what they say– block the flow of calcium from entering heart cells and those that line your blood vessels. Calcium acts to contract things so blocking its flow has the opposite effect. They are used to treat high blood pressure, migraine headaches and Raynaud’s disease. Verapamil would be a drug in this class.

5. Digoxin: I talk extensively about digoxin toxicity in this post.

How do we treat? With the exception of digoxin, there is no specific antidote so it is largely symptomatic support.

1. Give IV fluids. This will help support and raise the blood pressure.

2. Give Calcium. This helps things contract– thereby raising the blood pressure as well.

3. Give a Vasopressor. Vasopressors work to contract blood vessels to raise blood pressure. These would be drugs like dopamine and epinephrine (adrenaline).

There are a few other things to be done but this will give you plenty to write a scene that involves this type of drug ingestion.

Have you written a medical scene that dealt with a drug overdose in your novel?

General Treatment of Ingested Drugs

One thing that has evolved a lot in medicine is the general treatment of drug overdoses. 

Early in my nursing career, I worked in a community ER. In this setting we saw both adult and pediatric patients. One day, three young boys were brought in after they’d gotten into grandma’s medicine cabinet and sampled a multitude of pills. 

In those days, if the ingestion was within one hour, we did use Syrup of Ipecac to induce vomiting and each of these boys got a dose and a big bucket. Syrup of Ipecac is more effective the more water you drink. All three children were lined up next to one another, each on their own gurney, and I walked down the line encouraging each of them of drink. 
Soon enough, one of them began to vomit. One of the other boys proclaimed that wasn’t going to happen to him and I simply gave him another glass of water to drink. After he saw his second sibling throw up, he said to me, “I don’t want any more water.” 
That didn’t keep him from the invetible. 
What we learned is that causing patient’s to throw up increased their risk of more serious complications– like aspiration pneumonia. It is a risk that while vomiting, you’ll inhale some of that material. 
Then there was “stomach pumping.” There’s a lot of confusion about what this actually is and the last time I did it was over twenty years ago. A large (literally garden size hose) is inserted down the patient’s mouth into their stomach and then, through a pumping action, the stomach contents are washed out with large amounts of saline.
The problem with this therapy became the electrolyte shifts that can happen when replacing stomach contents with saline and this practice has been largely abandoned as well. Also, having a large tube put down into your stomach also increases your risk for vomiting and the same risk discussed above still applies.

What has remained is the use of activated charcoal. Activated charcoal literally looks like ground up charcoal. It is a thick, sludge like material that is sweetened to make is more palatable. In kids– we usually put it in a covered up Styrofoam cup so they can’t see it. If they won’t initially drink it we may flavor it with chocolate milk. The problem becomes that whatever it is diluted in they have to drink all of in order to get the full dose.

Activated charcoal works by binding the drug to make it inactive. If the effects of the drug would be more detrimental to the patient (versus just observing and offering symptomatic support) then we’ll generally try to give it if the patient comes in within one hour of the overdose.

With any ingestions, we usually follow the direction of our Poison Control Center.

If your child has ingested anything of concern, I highly recommend you call them first at 1-800-222-1222.