TOXICOLOGY

DR FRED JOHN
KIMS HOSPITAL BANGALORE
A 31 year male patient presented to the ER at 11pm on 17/10/17 with
alleged history of consumption of 60 unknown tablets around 9:30pm
at his residence.

c/o giddiness and chest pain following intake.

 AIRWAY : PATENT , CLEAR,

 BREATHING : SPONTANEOUS ,REGULAR, RR: 12 CPM

 CIRCULATION : PULSE 52BPM,N VOL, REGULAR,

BP –120/70 mmHg
SPO2 97% IN ROOM AIR
PERIPHERAL PULSES – FELT AND EQUAL
CAPILLARY REFILL <3sec

 DISABILITY : GCS E4V5M6

GRBS 125mg/dl

 EXPOSURE : NOTHING SIGNIFICANT

AFEBRILE/NO PALLOR/NO ICTERUS/NO CYANOSIS /

NO OEDEMA/NO LYMPHADENOPATHY

NO DIAPHORESIS

SYSTEMIC EXAMINATION

RS : NVBS, NO ADDED SOUNDS

CVS : S1S2 HEARD, NO MURMUR

CNS : CONSIOUS OBEYS TO COMMANDS, GCS E4V5M6

PUPILS – 2mm BILATERAL REACTING TO LIGHT
PLANTARS –BILATERAL FLEXROR
NO MOTOR SENSORY DEFICITS
SWAYING GAITS++
HORIZONTAL NYSTAGMUS++
SLURRING OF SPEECH

P/A : SOFT , NO ORGANOMEGALY AND BOWEL SOUNDS HEARD

NO ALLERGY HISTORY

NO HISTORY OF DIABTETES, HYPERTENSION,SEIZURE

NO FALL /TRAUMA /ALCOHOL INTAKE

NO HISTORY OF ANY OTHER DRUG CONSUMPTION

NO HISTORY OF PREVIOUS SUICIDAL ATTEMPTS

Patient sensorium deteriorated over the course of time
Differential
ORGANOPHOSPHORUS
(Bradycardia, Miosis, salivation, lacrimation, GI motility, fasiculation)

CLONIDINE
(Bradycardia, Miosis , Resp depression, Coma, Hypothermia, N/low BP ,)

OPIODS
(Miosis, Resp depression, Coma, Hypotension)

BETA BLOCKERS
(Bradycardia, Hypotension, Hypoglycemia, Arrhythmia, Blocks, delirium,
coma, seizures,)

CCB
(Bradycardia , Hypotension, Hyperglycemia, Arrhythmia, Blocks,)
Digitalis
(Bradycardia, nausea, vomiting, photophobia, drowsiness, hallucinations,
delirium, arrhythmia)

Bradyarrhytmia
(Blocks)

ANTI PSY
(Tachycardia, Hypotension Miosis, Mydriasis, Resp depression, Slurred
speech, EPS)

TCA
(Tachycardia, Hypotension, Mydriasis, Miosis, Resp depression, Arrhyt)

CVA
(difficulty in breathing, speaking, swallowing, paralysis, blurred
vision, Dizziness and vertigo)
 11:10PM GASTRIC LAVAGE WAS GIVEN F/B 50 GM ACT..CHARCHOL
THE SAMPLE WAS DRAWN FOR TOXICOLOGY ANALYSIS
PATIENT STARTED BECOMING DROWSY,
WITH RAPID FALL IN SENSORIUM OVER 30 MIN.
Pulse 48bpm, BP130/70mmHg, RR 14cpm
GCS E2V4M5
ECG: BRADYCARDIA

 11:30PM SHIFTED TO EM ICU

Pulse 48BPM BP130/70mmHg , RR 14cpm, Spo2 80%
ABG

 12 AM Pulse 38bpm , BP 130/70 mmHg, RR 12cpm

Atropine .6mg iv stat , f/b repeated twice 5 min interval
pulse picked up to 70bpm
Calcium gluconate 10 ml 10% IV 5min stat
IN VIEW OF LOW GCS E1V2M4
PATIENT WAS INTUBATED VETILATOR P A/C.
 1AM Pulse 80 bpm, BP 130/70 mmHg, RR 12bpm
E1VTM3
THERE WAS NO SPONTANEOUS BREATH ON P A/C MODE

 PATIENT REMAINED SATUS QUO TILL NEXT DAY 6AM

WITH GCS E1VTM3 , PULSE 90 bpm, BP120/80 mmHg
WHEN THE ATTENDERS brought empty sheets of Arkamin 100mcg

 6AM NALOXONE WAS CONSIDERED.

INJ NALOXONE .4MG IV STAT WAS GIVEN,
FOLLOWING WHICH PATIENT BECAME AGITATED, IRRITABLE
GCS E4VTM6

 6:30AM PLANED FOR EXTUBATION

 7AM PATIENT SENSORIUM DETERIORATED AFTER EXTUBATION.
NALOXONE WAS REPEATED EVERY 5MIN .4MG
TILL RESPONSE IMPROVED, AROUND 5 DOSES WAS GIVEN.

 7:30AM PULSE 100BPM BP110/70MMHG RR 18CPM

PATIENT WAS DROWSY BUT AROUSABLE &
RESPONDS TO PAIN

 PATIENT SENSORIUM IMPROVED, AND WAS HEMODYNAMICALY

STABLE ,LATER WAS SHIFTED TO WARD AND DISCHARGED
DISSCUSION
Adverse Effects
 1. Dry mouth, drowsiness, orthostatic hypotension, insomnia,
agitation

2. Abrupt withdrawal of clonidine can be life-threatening.

Withdrawal effects include agitation, tremor, palpitations,
insomnia, severe hypertension, nausea, and vomiting. Even
otherwise, rebound hypertension is common.
 Usual therapeutic equal to 4 mcg/L.
 Toxic effects generally occur within 30 minutes to 4 hours after
overdose and usually resolve within 24 to 72 hours.

 presynaptic α2 receptors in the vasomotor center in

the brainstem. This binding decreases
presynaptic calcium levels, thus inhibiting the release
of norepinephrine (NE). The net effect is a decrease in
sympathetic tone.
 Opiod agonist activity at mu receptors

 But in high doses result in peripheral post synaptic alpha 2

stimulation thus increase BP
clinical

 Hypothermia, bradycardia, normal or low blood pressure, slow, shallow

respiratory rate
 CNS: Lethargy, coma, hypotonia and hyporeflexia include impaired
consciousness
 Pupils: Pinpoint
 Skin: Cool, pale or moist.
 Misc: Hyporeflexia, seizures ,dysrythmias
 0.1 to .4 mg IV if patient breath spontaneous, and may be repeated at 2
to 3 minutes intervals.
 2mg IV if patient is apneic, and may be repeated at 2 to 3 min .

Infants and children from birth to 5 years of age or 20 kg of body weight

naloxone is 0.1 mg/kg

Children olden than 5 years of age or weighing more than 20 kg naloxone

2.0 mg is given.

 Endotracheal (this is the least desirable): 2-2.5 times (0.8-5 mg) initial IV
dose

 For chronic opioid abuse, use smallest doses (0.1-0.2 mg) to avoid acute
withdrawal

 Following reversal, additional dose(s) may need to be administered at later

interval (ie, 20 to 60 min) depending on type and duration of opioid
 Inhalation via Nebulization
2mg as inhalation via nebulization; later Switch to IV or IM
administration when possible

 Evzio Auto-Injector
0.4 mg or 2 mg IM/SC into anterolateral aspect of the thigh

NALTREXONE PO ROUTE LAST 24hrs

NALMEFENE IV ROUTE LAST 4HRS

 Alpha-adrenergic antagonists such as tolazoline may have antidotal
action in clonidine poisoning. The recommended dose is 5 to 10 mg
as IV infusion every 15 minutes (upto a maximum of 40 mg).

 Yohimbine, a CNS alpha2-adrenergic antagonist, has been used for

treatment of clonidine overdose.

 Haemodialysis, Haemoperfusion and forced diuresis are not likely to

significantly enhance the elimination of this drug
Adverse Reactions

Rapid opiate withdrawal may also cause:

 Agitation, irritability, and violent behavior
 Restlessness and nervousness
 Runny nose, watery eyes
 Excessive sweating
 Shaking, trembling, quivering
 Sneezing, yawning, muscle aches
 Rapid heart rate
 High or low blood pressure
 Gowing L, Farrell M, Ali R, White JM. Alpha₂-adrenergic
agonists for the management of opioid
withdrawal. Cochrane Database Syst Rev. 2016 May 3.
CD002024. [Medline].
 Roberge RJ, McGuire SP, Krenzelok EP. Yohimbine as an
antidote for clonidine overdose. Am J Emerg Med. 1996
Nov. 14 (7):678-80
 Ahmad SA, Scolnik D, Snehal V, Glatstein M. Use of
naloxone for clonidine intoxication in the pediatric age
group: case report and review of the literature. Am J
Ther. 2015 Jan-Feb. 22 (1):e14-6.
THANK YOU