Prise En Charge Des Intoxication .pdf

Prise en charge
des
Intoxications
Pr. E. Roupie

Table des Matières
• Le primum movens
• Vision
• Vision
• Vision des réanimateurs

Généralités de CAT
• Intoxications : motif de recours fréquent
(#10% ?), ne sont pas de la psychiatrie ...!!!
• Toujours à évoquer devant des situations
peu « évidentes » d’emblée (comme le
médicaments…)…
• Aspect circonstanciel : majeur
• Urgence à la prise en charge immédiate
• 3 situations

3 situations
• I. Produit connu mais pas symptomatique
• II. Produit connu et symptomatique
• III. Patient symptomatique, intoxication
suspectée, mais pas d’orientation initiale

I. Produit connu mais pas
symptomatique
• I°) Connaître : risque toxique, dose et délai. Si
doute : centre anti-poison +++.
• II°) Attention : toxiques à intervalle libre
(cardiotropes : pas de signe avant-coureur)
• III°) Phase initiale : priorité donnée à la
« décontamination » + anti-dotes efficaces ?
Ex : Paracétamol, chloroquine …

II. Produit connu et
symptomatique
• I°) Priorité : correction des défaillances
vitales
• II°) Classes pharmacologiques
(toxidrome…) ?
• III°) Anti-dote ?
• IV°) Épuration si pt stabilisé…

III. Patient symptomatique,
intoxication suspectée, mais pas
d’orientation initiale
• I°) Priorité : correction des défaillances
vitales
• II°) Toxidrome : évocation de la substance
Anamnèse, antécédent, BSPP, témoins …
• III°) Analyse biologique prime sur
toxicologie (gds, NFS, TP, iono …).
• IV°) Antidotes si suspicion

Exemple de toxidrome
• Myosis, hypoventilation, coma =
• Mydriase, agitation-coma, sécheresse des
muqueuses =

Exemple de toxidrome
• Myosis, hypoventilation, coma =
morphiniques
• Mydriase, agitation-coma, sécheresse des
muqueuses =

Exemple de toxidrome
• Myosis, hypoventilation, coma =
morphiniques
• Mydriase, agitation-coma, sécheresse des
muqueuses = syndrome atropinique
(ADT, atropine …).

TOXIDROMES
• E. Roupie MD, PHD
• Henri Mondor Hospital,
• University of Paris XII

Rechercher la clef du toxique!

PHYSICAL EXAMINATION
•
•
•
•
•

Neurologique
Yeux
Peau
Hémodynamique
(ECG)

PHYSIOLOGIC STIMULANTS

PHYSIOLOGIC DEPRESSANTS



OTHERS



PHYSIOLOGIC STIMULANTS
•
•
•
•
•

1°) Anticholinergiques
2°) Sympathomimetiques (ex. cocaine)
3°) Hallucinogènes
4°) Drug withdrawal (sevrages OH etc ...)
5°) Miscellaneous (Thyroid hormones)

1°) ANTICHOLINERGIQUES
• ANTIHISTAMINES
• ANTIPSYCHOTICS
• BELLADONNA
ALKALOIDS
• CYCLIC
ANTIDEPRESSANT
• CYCLOBENZAPRINE

• PARKINSON’S DZ
DRUGS
• GI/GU
ANTISPASMODICS
• MYDRIATRICS
• PLANTS/
MUSHROOMS

ANTICHOLINERGIQUES
=
ATROPINE
• CLINICAL PRESENTATION
– “Hot as a hare, dry as a bone, mad as
a hatter”
– Dryness of mouth
– flushed, hot, dry skin
– dilated and nonreactive pupils
– tachycardia
– hallucinations, restlessness

2°) COCAINE
(Sympatomimétiques)
• CLINICAL PRESENTATION
– tachycardie, HTA, arhythmies
– can get hypotension and reflex bradycardia
– CNS stimulation +++

• TREATMENT
–
–
–
–

CNS sedation
Labetolol
Treat hyperthermia
? Parlodel or desipramine

ECG +++

3°) Hallucinogènes
• Stimulation du système serotoninergique
• Hallucinations, Délires, sueurs, tachycardie,
dilatation pupillaire
• Surveillance 12 heures
• No true withdrawal state
• Treatment
– Generallement pas de traitement medical
– benzodiazepines pour agitation
– Reduire les stimuli
– Discontinuation can result in dysphoria from reduced
serotonin activity.

PHYSIOLOGIC
DEPRESSANTS 
•
•
•
•
•

Cholinergiques
Narcotiques
Symphatholytiques (cyclic antidepressants)
Sedative-hypnotiques
Miscellaneous (carbon monoxide)

1°) CHOLINERGIQUES
• BETHANACOL
• CARBAMATE
INSECTICIDES
• MYASTHENIA
GRAVIS DRUGS
• EDROPHONIUM
• PHYSOSTIGMINE

• PILOCARPINE
• NICOTINE



CHOLINERGICS: CLINICAL
PRESENTATION
•
•
•
•
•
•
•
•

DEFECATION
URINATION
MIOSIS
BRONCHOCONSTRICTION
BRADYCARDIE
EMESIS
LACRIMATION
SALIVATION



CHOLINERGICS
• TREATMENT
–
–
–
–
–
–

Gastric decontamination
Respiratory support
Atropine
[Pralidoxime (Contrathion°)]
Cardiac monitoring
Ttt seizures avec benzodiazipines



OPIATES
• CLINICAL
PRESENTATION
–
–
–
–
–
–
–

Pinpoint pupils
Respiratory depression
Bradycardia
Hypotension
Hypothermia
Pulmonary edema
Seizures



CYCLIC ANTIDEPRESSANTS
• CLINICAL PRESENTATION
– Most are combination anticholinergic and
sympatholytic
– Coma
– Seizures and or agitation
– Hypotension
– Cardiac dysrhythmias



• TREATMENT
– Gastric decontamination
– Treat cardiac dysrhythmias
– Treat seizures

OTHER DRUGS
• DISSOCIATIVE
DRUGS
• ACETOMINOPHEN
• SALICYLATES
• DIGOXIN

• SEROTONIN
SYNDROME
• LITHIUM
• “CLUB DRUGS”



DISSOCIATIVE DRUGS
• Ketamine, Phenycyclidine (PCP),
Phenylcyclohexylpyrolidine (PHP)
• Acts on all six neurotransmitter systems
– Anticholinergic: dry skin, miosis
– Dopamine/norepinephrine:agitation, delusions
– Opioid : pain perception alterations
– Serotonin: perceptual changes
– GABA receptor inhibition: excitation
•

Treatment
– Haloperidol
• Presynaptic dopamine antagonist
• Shifts the dopamine-acetylcholine activity ratio in the limbic system
• Therefore can counteract the dopamine stimulation and cholinergic
antagonism of the drug

ACETAMINOPHENE
• CLINICAL PRESENTATION
– No specific symptoms or signs

• TREATMENT
– Gastric decontamination
– N-acetylcysteine

SALICYLATES
• CLINICAL PRESENTATION
– Mixed acid-base disturbances
– GI: N/V, abdominal pain
– CNS: tinnitus, lethargy seizures, cerebral
edema, irritability
– Resp: pulmonary edema
– Coagulation abnormalities

DIGOXINEs
• CLINICAL PRESENTATION
– Nausea/vomiting
– Mental status changes
– Cardiovascular symptoms

• TREATMENT
– Gastric decontamination
– Fab fragments

SEROTONIN SYNDROME
• CLINICAL PRESENTATION
– Neurobehavioral: mental status changes, agitation,
confusion, seizures
– Autonomic: hyperthermia, diaphoresis, diarrhea,
tachycardia, HTA, salivation
– Neuromuscular: myoclonus, hyperreflexia, tremor,
muscle rigidity
• TREATMENT
– Respiratory support
– Temperature control
– Sedatives
– Muscle relaxants

LITHIUM
• Symptoms
– GI: vomiting, diarrhea
– Neuro: tremors, confusion,
dysarthria, vertigo,
choreoathetosis, ataxia,
hyperreflexia, seizures,
opisthotonis, and coma
– Labs: decreased anion gap

• Treatment
– Levels >2.5 meq/L
– Gastric lavage
– Urinary alkalinization
• Not very effective

– Aminophylline
– Hemodialysis !!!
• >3.5 mEq/L (acute)
• >2.5 w/ chronic
ingestion or renal
insufficiency

“CLUB DRUGS”
• Rave parties
increasing in
popularity
• Drugs meant to
intensify sensory
experience of
lights/music, facilitate
prolonged dancing

MDMA “Ectasy”
• Structurally resembles
amphetamine (stimulant)
and mescaline
(hallucinogen)
• SX: trismus, bruxism,
tachycardia, mydriasis,
diaphoresis, hyperthermia,
hyponatremia, hepatic
failure, CV toxicity
(tachycardia, HTN)

• Treatment
–
–
–
–

Mainly supportive
Benzodiazepines
Calm environment
Avoid beta-blockers
• Can result in unopposed
alpha effect
• If essential consider
labetolol

GHB: Date rape drug
“Georgia homeboy, liquid ectasy, or grievous bodily
harm”
• Developed as anesthetic
agent. GABA analog
• Symptoms
–
–
–
–
–
–

Bradycardia
Hypothermia
hypoventilation
Somnolence
Vomiting
Myoclonic jerking

• Treatment
– Conservative mgmt
– Intubation
– Careful exam for
sexual assault

Ketamine: “K”, “special K”
• Developed as an
anesthetic, structurally
resemble PCP
• Symptoms
–
–
–
–

Nystagmus
Tachycardia
HTN
vomiting

• Treatment
–
–
–
–

Benzodiazepines
Supportive care
IV
Can consider urine
alkalinization