Principles and Practice of Critical Care Toxicology

Principles and Practice of Critical Care Toxicology Editors Omender Singh

md fccm

Director Institute of Critical Care Medicine Max Superspecialty Hospital Saket, New Delhi, India

Deven Juneja

dnb fnb edic fccp ficcm fccm

Associate Director Institute of Critical Care Medicine Max Superspecialty Hospital Saket, New Delhi, India

Foreword Farhad N Kapadia

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Dedicated to Our lovely and enthusiastic colleagues for their motivation and support throughout this endeavor. Our organizations of practice for providing us state of the art infrastructure and resources, and above all we extend profound gratefulness to our patients for their faith in us.

Contributors Akhilesh Singh md Senior Consultant Institute of Critical Care Medicine Max Superspecialty Hospital Saket, New Delhi, India Amit Goel md edic Senior Consultant Institute of Critical Care Medicine Max Superspecialty Hospital Saket, New Delhi, India

Anish Gupta md fnb edic Senior Consultant Institute of Critical Care Medicine Max Superspecialty Hospital Saket, New Delhi, India

Anjali Chaudhari md Fellow Critical Care Institute of Critical Care Medicine Max Superspecialty Hospital Saket, New Delhi, India Anna L Condella md Consultant Harvard Affiliated Emergency Medicine Residency Brigham and Women’s Hospital/Massachusetts General Hospital Boston, Massachusetts, USA

Aruna Dewan md Director CEARCH (Centre for Education, Awareness and Research on Chemicals and Health) Head, Toxicology Division Unipath Specialty Laboratory Ltd Ahmedabad, Gujarat, India Arvinth Soundarrajan mbbs mem Registrar Department of Emergency Medicine Meenakshi Mission Hospital and Research Center Madurai, Tamil Nadu, India Ashish Bhalla md ficcm Additional Professor Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER) Chandigarh, India

Ashwinkumar Patel msc Consultant, Unipath Specialty Laboratory Ltd Ahmedabad, Gujarat, India

Bharat Jagiasi md idccm Head Critical Care, Terna Specialty Hospital and Research Center Mumbai, Maharashtra, India Desh Deepak md fnb edic In-Charge Critical Care Medeor Hospital, VPS Healthcare Dubai, UAE

Deven Juneja dnb fnb edic fccp ficcm fccm Associate Director Institute of Critical Care Medicine Max Superspecialty Hospital Saket, New Delhi, India Dinesh Chaudhari md Associate Consultant Department of Neurosciences Indraprastha Apollo Hospital New Delhi, India Dinesh Khullar mbbs md dm Professor and Head Department of Nephrology Max Superspecialty Hospital Saket, New Delhi, India

Edward W Boyer md phd Director of Academic Development Department of Emergency Medicine Brigham and Women’s Hospital Associate Professor Harvard Medical School Boston, Massachusetts, USA

Farah Dadabhoy md Consultant, Harvard Affiliated Emergency Medicine Residency Program Boston, Massachusetts, USA

Gunjan Chanchalani md fnb idccm ifccm edic Chief Intensivist Nanavati Superspecialty Hospital Mumbai, Maharashtra, India

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Principles and Practice of Critical Care Toxicology Ipe Jacob pgdip fam med ctccm Fellow, Department of Intensive Care Columbia Asia Referral Hospital Bengaluru, Karnataka, India

Nipun Verma md dm

Jamshed Nayer md Assistant Professor Department of Emergency Medicine All India Institute of Medical Sciences (AIIMS) New Delhi, India

Omender Singh md fccm

Jeetendra Sharma md ifccm Director and Head, Critical Care Artemis Hospital Gurugram, Haryana, India

Ponniah Thirumalai Kolundu Subramanian md Head Department of Internal Medicine Chennai Medical College Hospital and Research Center Trichy, Tamil Nadu, India

Jitendra Shukla md dnb Resident, Department of Medicine Maulana Azad Medical College and associated Hospitals New Delhi, India JV Peter md dnb mams fracp fjficm fcicm ficcm Professor Department of Critical Care Medical Intensive Care Unit Christian Medical College Vellore, Tamil Nadu, India

Lalit Kumar mbbs Resident, Department of Medicine Maulana Azad Medical College and associated Hospitals New Delhi, India

Michael E Nelson md ms Consultant, Department of Emergency Medicine Division of Toxicology Cook County Hospital Chicago, Illinois, USA

Mohit Mathur md idccm edic Principal Consultant Department of Critical Care Medicine Max Hospital Gurugram, Haryana, India

Mradul Kumar Daga md frcp fccp

Assistant Professor Department of Hepatology PGI, Chandigarh, India Director Institute of Critical Care Medicine Max Superspecialty Hospital Saket, New Delhi, India

Pradeep Rangappa dnb fjficm edic fcicm pgdipecho mba ficcm pgdmle Consultant Intensivist Department of Intensive Care Columbia Asia Referral Hospital Bengaluru, Karnataka, India

Prakash K Khernar md idccm ifccm Consultant Critical Care Metro Hospital Faridabad, Haryana, India Prashant Nasa md fnb edic Specialist, Critical Care Medicine Head Prevention and Control of Infection Department of Critical Care Medicine NMC Specialty Hospital, Dubai, UAE Prashant Singh md Associate Consultant Institute of Critical Care Medicine Max Superspecialty Hospital Saket, New Delhi, India

Pravin Amin md fccm Consultant, Critical Care Bombay Hospital Mumbai, Maharashtra, India

Director Professor Department of Medicine and Intensive Care Medical ICU Maulana Azad Medical College and associated Hospitals New Delhi, India

Rajesh Chawla md ficcm fccm

Neha Sharma md

Ravi Jain md fnb

Senior Resident Department of Forensic Medicine and Toxicology All India Institute of Medical Sciences (AIIMS) New Delhi, India

Associate Consultant Department of Critical Care Medicine Max Hospital Gurugram, Haryana, India

Senior Consultant Department of Pulmonary Medicine and Critical Care Indraprastha Apollo Hospital New Delhi, India

Contributors Rohit Yadav da idccm

Subramanian Senthilkumaran

Senior Consultant Institute of Critical Care Medicine Max Superspecialty Hospital Saket, New Delhi, India

md dip a&e fccm msc phd Head, Department of Emergency and Critical Care Manian Medical Center Erode, Tamil Nadu, India

Sahil Bagai md dm Associate Consultant Department of Nephrology Max Superspecialty Hospital Saket, New Delhi, India

Sudhir K Gupta mbbs (Gold Medalist) md dnb mnams Professor and Head Department of Forensic Medicine and Toxicology All India Institute of Medical Sciences (AIIMS) New Delhi, India

Sanjay V Patne md

Suneel Kumar Garg md fnb edic fccp Senior Consultant, Institute of Critical Care Medicine Max Superspecialty Hospital Saket, New Delhi, India

Director and In-Charge of Critical Care Unit JJ Plus Hospital Aurangabad, Maharashtra, India

Saswati Sinha md edic Consultant, Critical Care and Emergency Department Advanced Medicare and Research Institute (AMRI) Hospitals Kolkata, West Bengal, India Shivakumar Mutnal md idccm ifccm Registrar Department of Intensive Care Columbia Asia Referral Hospital Bengaluru, Karnataka, India

Shivangi Khanna md Fellow, Critical Care Medicine Artemis Hospital Gurugram, Haryana, India

Shreya Singh md Assistant Professor Department of Medical Microbiology Postgraduate Institute Chandigarh, India Shweta Gupta da dnb mnams fccp Specialist and In-Charge of Pulmonology Dr Baba Saheb Ambedkar Hospital New Delhi, India

Subhash Kumar Todi md mrcp Head Critical Care and Emergency Department Advanced Medicare and Research Institute (AMRI) Hospitals Kolkata, West Bengal, India

Supradip Ghosh dnb edic Director Department of Critical Care Medicine Fortis-Escorts Hospital Faridabad, Haryana, India

Timothy B Erickson md Associate Professor Division of Medical Toxicology Department of Emergency Medicine Brigham and Women’s Hospital Harvard Medical School Harvard Humanitarian Initiative Boston, Massachusetts, USA

Vijay Kumar Agarwal md idccm ifccm Director Critical Care Medicine and Academic Programs Senior Consultant Pulmonology and Sleep Medicine Metro Hospital, Faridabad, Haryana, India

Vikas Suri md Associate Professor Department of Internal Medicine Postgraduate Institute of Medical Education and Research (PGIMER) Chandigarh, India Vinay Amin mbbs Mumbai, Maharashtra, India

Yash Javeri da idccm Director Apex Healthcare Consortium New Delhi, India

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Foreword It gives me great pleasure to review this book Principles and Practice of Critical Care Toxicology by Dr Omender Singh and colleagues. I have been following his work and his presentations on the critical care aspects of toxicology for more than 10–15 years and it is befitting that he has brought out this book with like-minded and vastly experienced colleagues. The authors include international and national experts in the field of toxicology, and the content and depth of the material in each subject only confirm the expertise of the authors and editors. The material is presented in a format, which is easy to read and digest. Despite having a fair bit of basic sciences, this is ultimately a practical bedside book. Readers will easily pick-up the salient aspects of each specific poisoning syndrome and clinicians and ICU residents will be able to use it as a manual to follow when dealing with these patients. I also personally found some of the material novel, specifically the use of Lipid Emulsion Therapy (LET) and the role of Extracorporeal Membrane Oxygenation (ECMO) in acute toxicity. Readers like me, who do a lot of critical care, but only deal infreqeuntly with poisonings, will find this a very useful update on recent advances in the field. The book includes poisoning management ranging from common household poisons to drug overdose, industrial, agricultural, chemical warfare and nerve agent poisonings, from ABC of poisoning to extracorporeal and emerging treatment modalities (LET). I recommend this book be part of each ICU, library and emergency room. The staff of these departments will find it a comprehensive, pragmatic and useful resource.

Farhad N Kapadia MD MRCP DA (UK) EDIC (European Diploma of Intensive Care European Society of Intensive Care Medicine) FRCP (Royal College of Physicians, Edinburgh) Consultant Physician and Intensivist PD Hinduja Hospital Mumbai, Maharashtra, India

Preface

Omender Singh

Deven Juneja

From the beginning of written history, poisons and their effects have been well described. Paracelsus (1493–1541) correctly noted that ‘‘All substances are poisons; there is none which is not a poison. The right dose differentiates a poison…’’ As life in the modern era has become more complex, so has the study of poisons and their treatments. Critical care toxicology is a field of medicine dedicated to the evaluation and treatment of poisoned and envenomated patients. This book to us is about our zeal to practice critical care toxicology and improve outcomes of poisoned patients in the era of complex poisonings with almost negligible evidence-based guidelines in the field of medical toxicology. Over the past decade, the field of Medical Toxicology has grown in conjunction with the emergence of new pharmaceuticals, new drugs of abuse, chemicals within the workplace, environmental toxins and agents of terrorism. The clinical outcome of patients poisoned by a specific agent depends largely on the quality of care delivered within the first few hours in the emergency and critical care setting. This book will highlight the nuances of clinical toxicology with in-depth and most recent management of poisoning. It will serve physicians working in the fields of critical care medicine, emergency medicine, internal medicine and other allied specialties involved in the management of criticallyill poisoned patients. We have made a conscious effort to incorporate the expertise and experience of clinical toxicologists from diverse specialties from across the globe, to author relevant chapters. We commend the authors for providing a single resource that covers a broad spectrum of toxicologic emergencies in a succinct, clinically relevant, and cutting-edge manner. We are confident that this book will be a useful resource for clinicians, leading to improved outcomes of critically-ill poisoned patients. We wish to thank Jaypee Brothers Medical Publishers, New Delhi, India, to bring our skills and ideas to a wide audience, and we are thankful for their collaboration.

Editors

Acknowledgments I owe an enormous gratitude towards many individuals; some of them deserve a special mention. Especially my parents Late Sh. Surendra Pal Singh and my mother Smt. Singari Devi, my wife Rimple Singh and my lovely children Sofiya and Nikshay for allowing me to spend time for this book, which was rightfully theirs. My teacher Dr Farhad Kapadia, and my inspirational mentors Dr Pervez Ahmed and Dr NK Pandey for their guidance and support. I would also like to extend my gratitude to Ms Poonam Joshi for her unconditional support.

Omender Singh

To my parents, Dr BK Juneja and Mrs Kumud Juneja, for being my source of inspiration and encouragement. To my wonderful wife, Payal and my lovely daughters Aanya and Arayna for being my support and tolerating me and my career.

Deven Juneja

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