NOVEMBER 20, 2015
APPROACH TO THE
POISONED PATIENT
Steven Smith
Kristian Richardson
WHAT IS A
POISON?
POISON
A poison is a chemical or physical
agent that produces an adverse,
sometimes
lethal,
response
in
biological organisms.
What is there that is not poison? All
things are poison and nothing without
poison. Solely, the dose determines
that a thing is not a poison.
Paracelsus
POISON
Poisoning may be intentional or unintentional
and may have various portals of entry or
routes.
The setting of poison exposure may be:
R Recreational
O Occupational
M Medicinal
E Environmental
EPIDEMIOLOGY
EPIDEMIOLOGY
According to the World Health Organization (WHO), the
global incidence of poisoning is not known.
The Institute of Medicine estimates that the incidence of
poisoning in the United States is approximately 4 million
cases per year, with 300,000 cases leading to
hospitalization, and approximately 30,000 deaths.
EPIDEMIOLOGY
Each year in the United States,
more than 1 million poison
exposures among children younger
than six years of age are reported
to the American Association of
Poison Control Centers (AAPCC).
EPIDEMIOLOGY IN JAMAICA
The incidence of accidental poisoning from a retrospective
study conducted in 2006 in 22 Jamaican hospitals
(excluding UHWI) by Dr. Erica Reynolds revealed:
Between 1075 and 1431 cases were reported to the
Accident and Emergency Department between 19992005
On average 78% of these cases were males
90% of the cases were in the age group 0-5
EPIDEMIOLOGY IN JAMAICA
The study also revealed that the four most common
poisons responsible for approximately 80% of the
poisonings were
Bleach
Kerosene
Pharmaceuticals
Pesticides
EPIDEMIOLOGY IN JAMAICA
In a three-year retrospective review (2009-2011) of acute
poisonings in the emergency department at UHWI (Dr.
Nickecia Campbell et al) revealed:
0.13% of patients presented to the ED in the study period.
92.1% were self-inflicted and 58.6% were intentional.
Ingestion was the most common route (88%)
Only 12.4% received a specific antidote
EPIDEMIOLOGY IN JAMAICA
In a three-year retrospective review (2009-2011) of acute
poisonings in the emergency department at UHWI (Dr.
Nickecia Campbell et al) revealed:
Pharmaceutical agents notably analgesics were the most commonly
used
Bleach was the most frequently used non-pharmaceutical agent
Non-pharmaceuticals agents were more commonly used by children
aged 15 and under.
EVALUATION OF
THE POISONED
PATIENT
RESUSCITATION
Stabilization before addressing the underlying problem is
key.
Consider the ABCD3EFG of Toxicology
RESUSCITATION
The first priority in treating poisoned patients is assessment
and stabilization of cardiopulmonary function.
Once the airway and respiratory status, blood pressure, and
pulse are stabilized, abnormalities of core (rectal)
temperature, oxygen saturation, and hypoglycemia are
addressed.
RESUSCITATION
Hypoglycemic patients may appear
to be intoxicated and it may be
difficult to initially differentiate them
from a poisoned patient.
In a patient with depressed mental
status, physicians should check the
serum
glucose
and
administer
intravenous
dextrose
when
necessary.
RESUSCITATION
THE COMA COCKTAIL
An Acquired Taste
Dextrose (Adults 50ml of 50% dextrose,
Children 1ml/kg of 50% dextrose)
Thiamine (100 mg IM or IV infusion)
especially in alcoholics
Naloxone (0.4-2 mg IV)
Supplemental Oxygen
Flumazenil**
HISTORY
After initial stabilization of a critically ill patient, specific
antidote therapy is administered while a more detailed
history and physical examination are performed.
A thorough history is one of the most important factors in
adequately managing a poisoned patient.
HISTORY
In an unconscious patient or one who is unable to
accurately recount the events the history should be taken
from relatives or witnesses.
The history should elicit:
Demographics and comorbidities
The source of the agent
What and how much was taken/ time of exposure
When and why was it taken / why exposure occured
The route and additional substances taken with it
HISTORY
Obtain all prescription bottles and other containers when
possible. Search the patients belongings for drugs or drug
paraphernalia.
Contact prescribing physician or pharmacy and retrieve old
notes to determine previous overdoses. Identify underlying
medical and psychiatric disorders and medication allergies.
Elicit any history of smoking , alcohol or chronic illicit drug
abuse.
In cases of occupational exposure, obtain a description of the
CLINICAL EXAMINATION
Once the patient is stabilized, a thorough physical examination
should be done to provide direction for future therapeutic
interventions. It will also provide objective evidence to
corroborate the history obtained and indicate the use of
additional substances in the case of polyagent poisoning.
Serial examinations are also beneficial to determine a
prognostic trajectory.
CLINICAL EXAMINATION
Approach to examination
Vitals
General assessment
Toxidromes identification
VITALS
In many cases,
the clinician
may be able to
deduce the
class of drug or
toxin taken
simply by
means of the
patients vital
signs.
General Assessment
Check the patient's clothing for
objects still retained in the pockets or
substances hidden on the patient's
body (waistband, groin, or between
skinfolds).
Search clothing and belongings with
care to avoid being injured by
uncapped needles or sharp objects.
Any odors on the patient's clothes or
from mouth should be noted.
General Assessment
EXAMINATION OF THE EYES
Pupillary size and reactivity to light
Nystagmus
Horizontal
Lithium,
Antiepileptic
Vertical or Rotatory - PCP
Decreases visual acuity
Direct ophthalmoscopy
Evidence of Optic Neuritis
Barbiturates,
General Assessment
EXAMINATION
SKIN
OF
THE
Color and Temperature
Dry or Diaphoretic
Bites , wounds or
needle tracks
Rash or bullae
Burns
or
corrosive
lesions
Mees
lines
(leukonychia striata)
General Assessment
CARDIOVASCULAR EXAMINATION
Signs of shock assessed in resuscitation
New onset murmur
RESPIRATORY EXAMINATION
Elevated rate, depth and effort
Abnormal breath sounds on auscultation
Wheezing or rales hydrocarbons aspiration, toxic gases
Evidence of pulmonary oedema opioids, TCAs, cholinergic agents
General Assessment
GASTROINTESTINAL EXAMINATION
Residual fragments
Odours
Burns and drooling (with a Hx of dysphagia)
Bite marks on tongue
Bowel sounds
Hyperactive Organophosphates, Arsenic, Iron
Diminished Anticholinergics, Opioid, Sedatives
DRE suspicion of foreign body or drug packets
General Assessment
NEUROLOGICAL EXAMINATION
Focal neurological deficits often suggests a structural lesion rather than
toxic or metabolic encephalopathy.
Be aware that significant barbiturate poisoning can cause profound
neurological depression, causing a flaccid coma with absent reflexes and
even an isoelectric EEG. This may be mistaken for brain death.
Seizures may occur with certain drug overdoses. Other neurological signs
also include muscle fasciculations , rigidity, tremors and dystonic
posturing.
Toxidromes
A collection signs and symptoms
associated with certain classes of
substance
intoxication.
These
findings are useful in diagnosis of
unknown overdoses and help to
anticipate other symptoms.
In the face of polyagent poisoning
toxidrome identification may pose
a
diagnostic
challenge,
as
conflicting effects may cloud the
clinical picture.
Toxidromes
INVESTIGATIONS
GENERAL
Complete Blood Count
Urea and Electrolytes
Liver Function Tests
Glucose
INR/PT/PTT
ABG
Urinalysis
SPECIFIC
Toxicology Screen
Phenothiazines
Sedative-hypnotic drugs
Stimulants
Tricyclic antidepressants
Alcohols
Analgesics
Anticonvulsants
Others
TOXICOLOGY SCREENING
Should be used to confirm suspected diagnosis but
immediate resuscitation, stabilisation and
management is of paramount importance
Of significance in the evaluation of children where
positive results for a controlled or illegal substance
should prompt further investigation
TOXICOLOGY SCREENING LIMITATIONS
Does not contribute significantly in patient
management in the acute setting
Positive results may arise depending on chronicity of
use and may be unrelated to acute symptoms
Negative results may be due to sampling error or
assay specificity
TOXICOLOGY SCREENING LIMITATIONS
Comprehensive toxicology screens specifically detect
only a small percentage of the thousands of possible
available substances
Tests tend to be time consuming and results may not
be immediate
If screening is done too soon, results may be
inaccurate
CLINICAL TESTS AND INVESTIGATIONS FOR THE POISONED PATIENT
CBC
U+Es
LFT
PT/PTT
ABG
Glucose
Osmolality
Urinalysis
ECG
CXR
TEST ABNORMALITIES OBSERVED IN THE POISONED PATIENT
ECG abnormalities
Wide QRS complex
TCAs, quinidine, Class Ia and Ic antidysrhythmic agents
Prolonged QT interval
Terfenadine, antipsychotics
AV block
Ca channel antagonists, digitalis glycosides,
phenylpropanolamine
Evidence of myocardial ischemia or infarction
Carbon monoxide, cocaine
TEST ABNORMALITIES OBSERVED IN THE POISONED PATIENT
Glucose
Hypoglycaemia
Insulin overdose
Sulfonylureas
Anti-diabetic drugs
Salicylates
Ethanol
Hypoglycin (Ackee)
HyperglycAemia
Methanol*
Salbutamol
Propanolol
ABG analysis
Respiratory acidosis and
hypoxia
Hypnotics/ sedatives/
antipsychotics/ opioids
Respiratory alkalosis
Salicylates (can cause
mixed)
Wide AG metabolic
acidosis
Normal AG metabolic
acidosis
TEST ABNORMALITIES OBSERVED IN THE POISONED PATIENT
Hyperkalemia
Atenolol
Ibuprofen
Potassium chloride
Fluoride
Digoxin
Hypokalemia
Barium salts
Diuretics
Insulin
Magnesium sulphate
Nifedipine
Caffeine
Theophylline
-adrenergic agents
TEST ABNORMALITIES OBSERVED IN THE POISONED PATIENT
Plasma Osmolality and Osmolal Gap
Acetone
Ethanol
Ethylene Glycol
Methanol
2-Propanol
1,2-Propanediol
TEST ABNORMALITIES OBSERVED IN THE POISONED PATIENT
Oxygen Saturation Gap
Difference between O2 saturation calculated from ABG and
O2 saturation measured by pulse oximetry
Some causes include:
Carbon monoxide
Methaemoglobinaemia
Hydrogen sulphide
MANAGEMENT
Resuscitation
Stabilization
Supportive care
Decontamination
Antidotes
Enhanced elimination
SUPPORTIVE MANAGEMENT
Facilitate prevention and/or limitation of RS,
CVS, and CNS complications
Oxygen mask, IV access, Monitors, Medication,
Ventilatory assistance
Anticipate complications
BE PREPARED
DECONTAMINATION
Dermal exposure
Remove all clothing
Irrigate skin with copious amounts of water for at least 30
minutes
Avoid forceful washing which may further increase absorption
Ensure proper protection of medical personnel
Ocular exposure
Copious irrigation of the conjunctiva with 2L of sterile water or
N/S for at least 30 minutes
Remove particulates with moistened cotton swab or forceps
DECONTAMINATION
Gastrointestinal Exposure
Gastric Emptying
Emesis
Orogastric lavage
Toxin adsorption in the gut
Activated charcoal
Multiple-Dose Activated Charcoal
Cathartics
Whole Bowel Irrigation
EMESIS
Achieved by administration of syrup
of ipecac
Active agents include emetine and
cephaeline
Induces vomiting
Dosage
15mL for paediatric group >2yrs
30mL for adult group
Patient vomits 3-5 times and
symptoms usually resolve in
approximately 2 hours
EMESIS
INDICATIONS
Extremely limited
RECENT ingestion of
substances not
expected to
compromise airway,
lead to altered mental
status, haemodynamic
derangement or seizure
CONTRAINDICATIONS
Convulsions
Corrosives
Altered mental status
Decreased gag reflex
Recent surgical
intervention
Haemorrhagic tendencies
Previous significant
vomiting
Less than 6 months of age
Sever cardiovascular
EMESIS
COMPLICATIONS
Mallory-Weiss tear
Aspiration
Boerhaave syndrome
Has not been demonstrated to alter outcome when
compared to activated charcoal and cathartics
Minimal health benefits
Associated with misuse
No longer used
OROGASTRIC LAVAGE
Principle method for gastric emptying
Only effective less than an hour after ingestion
Lavage with room temperature water until effluent is
clear
Indication
Recent ingestion of a toxin that requires ventilatory
support because of depressed mental status or risk
of seizures
OROGASTRIC LAVAGE
COMPLICATIONS
Laryngospasm
Aspiration
Hypertension
Tachycardia
Mechanical trauma
Entry of tube into
trachea
CONTRAINDICATIONS
Corrosive substances
Froth producing
substances
Oesophageal varices or
peptic ulcer
Airway not protected
Comatose patient
Convulsions
ACTIVATED CHARCOAL
Allows adsorption of a variety of
drugs and chemicals
Remains undigested and decreases
toxin concentration on movement
through GI tract
Adult dose is 1g/kg and can be given
with a cathartic (sorbitol or Mg
citrate) to decrease GI transit time
and is believed to decrease toxin
bioavailability
SUBSTANCES NOT ADSORBED BY ACTIVATED CHARCOAL
Corrosives
Alcohols
Cyanide
Oils
Glycols
Metals (Iron, Lithium, Lead, Mercury)
Petroleum distillates
Sodium chloride
Sodium hypochlorite (Bleach)
ACTIVATED CHARCOAL
COMPLICATIONS
Aspiration
Intraluminal impaction
in patients with
abnormal gut motility
Ineffective on patient
outcome when given
>1hr post ingestion
CONTRAINDICATIONS
Oesophageal or gastric
perforation
Substances which it
cannot adsorb
If an oral antidote is
administered
Intestinal obstruction
MULTIPLE-DOSE ACTIVATED CHARCOAL
Defined as the
administration of more than
2 doses of activated
charcoal
Dosage:
First dose up to 1g/kg
(usually given with
cathartic)
Subsequent doses of 0.25
to 0.50 g/kg at intervals
ranging from 1 to 4 hours.
Recommended indications
include
If patient has ingested a
life threatening amount of
carbamazepine,
dapsone, phenobarbital,
quinine or theophylline
Alternative treatments are
ineffective
Benefits outweigh the risks
CATHARTICS
Substances which decrease the transit time of material
through the GI tract and presumably decrease toxin
bioavailability
Osmotic cathartics
Increase osmotic pressure within the
Magnesium sulphate)
Irritant cathartics
Increase intestinal motility (e.g. Castor Oil)
lumen
(e.g.
CATHARTICS
Complications
Nausea
Vomiting
Abdominal pain
Electrolyte imbalances
Sever volume depletion
Hypermagnesemia in
patients with renal
compromise
Contraindications
Ingestion of a substance
which will result in
diarrhoea
Patients with renal failure
Intestinal obstruction
Ingestion of caustic
substance
Children < 5 years
WHOLE BOWEL IRRIGATION
Involves administration of polyethylene glycol in an
electrolyte solution
Has the advantage of avoiding both fluid and electrolyte
shifts
End point is clear rectal effluent
Dosage:
Adult 2L/hr
Child 500mL/hr
WHOLE BOWEL IRRIGATION
Involves administration of polyethylene glycol in an
electrolyte solution
Has the advantage of avoiding both fluid and electrolyte
shifts
End point is clear rectal effluent
Dosage:
Adult 2L/hr
Child 500mL/hr
WHOLE BOWEL IRRIGATION
Indications
Ingestion of large amounts of drugs that may form
bezoars of concretions
Ingestion of toxin which is poorly adsorbed by AC
Removal of ingested packets of drugs
Ingestion of sustained release preparations
WHOLE BOWEL IRRIGATION
Contraindications
Ingestion expected to result in significant diarrhoea
Intestinal obstruction
Perforation
Complications
Bloating
Cramping
Rectal irritation from frequent bowel movements
ENHANCED ELIMINATION
Urinary Alkalinization
Forced Diuresis
Acidifcation of Urine
Haemodialysis/Haemoperfusion
ENHANCED ELIMINATION
Acidification of urine
Not used because the risks outweigh the benefits
Forced diuresis
Has never been shown to be effective
URINE ALKALINIZATION
IV administration of sodium
bicarbonate (1 to 2 mEq/kg)
Results in a decrease in
toxin serum half-life due to
increased urinary excretion
Ideal for toxins that are
weak
acids
(ASA,
methotrexate,
phenobarbital)
HAEMODIALYSIS/HAEMOPERFUSION
INDICATIONS
Toxins that have a high water solubility, low protein
binding(haemodialysis),
low
molecular
weight
(haemodialysis), low volume of distribution, adsorb well
to activated charcoal(haemoperfusion)
Clinical deterioration despite medical support
Prediction that the drug/metabolite will have toxic effects
Impairment of normal routes of elimination
Removal of already absorbed toxins
HAEMODIALYSIS/HAEMOPERFUSION
COMPLICATIONS
Hypotension, bleeding tendency, electrolyte imbalance,
air embolism, infection
CONTRAINDICATIONS
Poor vascular access, haemodynamic instability, bleeding
diathesis
ANTIDOTES
Definitive patient care involves
adequate knowledge/ evidence of
the agent to be used in order to
administer the correct antidote
when indicated
ANTIDOTES
In weighing the benefits and risks of
giving a particular antidote, consider
the patients clinical status, laboratory
values, the expected pharmaceutical
action of the toxin, and possible
adverse reactions associated with the
antidote.
DISPOSITION
If health care facilities are inadequate consider
transfer in the following circumstances:
Inability to stabilize patient
Deteriorating patient
Resource limitations including staff, timely diagnostic
testing and monitoring equipment
Clinical judgement suggests a need for transfer
Inability to provide patient with ongoing maintenance;
Lack of availability of toxin-specific therapy
DISPOSITION
Management
and
disposition
of
patients
following
decontamination of toxin is patient specific, occasionally
requiring interventions such as dialysis, hemodialysis and
haemoperfusion.
Most patients require only minor supportive care and recover
without sequelae.
Patients with uncomplicated acetaminophen ingestions requiring
N-acetylcysteine antidote administration can be managed locally.
All patients who have taken a suicidal ingestion require
assessment of suicidal risk prior to discharge via psychiatry
consult.
PATIENT EDUCATION
Prevention is better than cure
Educate patients, parents and caregivers about:
Proper storage of chemicals, medication and other
hazardous substances
Ensuring proper labelling of bottles and containers
Ensuring that all potentially hazardous substances are
kept out of childrens reach
Any substances used by children are correctly portioned
for use
SUMMARY
Patient resuscitation and stabilization
Careful history
Physical exam
Vitals
Toxidromes
Complications
Evaluation of underlying disease
Supportive Management of RS, CVS and CNS
Antidotes if applicable
Elimination if applicable
Appropriate referrals/transfer where necessary
Patient education
REFERENCES
Cahill, J. (n.d.). Approach to the Poisoned Patient. Updates in Emergency
Medicine, 109-116.
Hedmann, E. (n.d.). Epidemiology Of Poisoning in Jamaica. Retrieved
November 20, 2015, from
http://www.carpin.org/p_General/EpidemiologyOfPoisoningInJamaica.pdf
Rosen, P. (2006). Rosen's emergency medicine: Concepts and clinical
practice. (6th ed.). Philadelphia, Pa.: Mosby Elsevier.
Tintinalli, J. (2011). Tintinalli's emergency medicine: A comprehensive
study guide (7th ed.). New York: McGraw-Hill.
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