RESUSCITATION OF THE POISONED PATIENT

RESUSCITATION OF THE

POISONED PATIENT

Dr Andy McClellandDept. of Emergency Medicine

Auckland Hospital

5 YR TOXICOLOGY 2003 2

COMMON POISONINGS1. Substance abuse - ‘recreational’

Alcohol's, narcotics, sedatives, stimulants, hallucinogens

2. Intentional overdoseSuicide / Parasuicide

3. AccidentalMislabelled containers / paediatric age

group

4. Toxic exposuresGases , sprays, house fires


A journey into the unknown?


EVALUATION

1. Recognition of poisoning

2. Identification of the poison

3. Prediction of toxicity

4. Assessment of severity


MANAGEMENT5. Supportive care

6. Prevention of poison absorption

7. Administration of antidotes

8. Enhancement of elimination

9. Prevention of re-exposure

10.Treat associated conditions/injuries

11.Disposition of the patient

“ The surest poison is time.”

Ralph Waldo Emerson (1803-1882)


Suspect overdose / poisoning in any patient with

• altered level of consciousness

• unexplained signs & symptoms


CLINICAL COURSE

•Non-toxic ingestion

•Acute toxicity

•Delayed toxicity


INITIAL PATIENT MANAGEMENT

1. Condition upon arrival

2. Likely course of the poisoning

3. Other injuries / medical conditions

4. Patient compliance


INITIAL PATIENT MANAGEMENT- if unwell

‘Team approach’



Initial stabilisation

i. Triage

ii. Position patient

iii. A, B, C, D

iv. Blood glucose, Temperature

v. Monitor – SaO2, ECG, BP, LOC


INITIAL PATIENT MANAGEMENT- if unwellAirway

• Adequacy, protection Breathing

• Always 0XYGEN; intubation/ventilation

Circulation • Large bore IV’s• Low BP due to decreased vascular

tone will respond to IV fluids /inotropes



• Correct

• Hypoxia• Fluid balance• Electrolyte abnormalities• Acid / base abnormalities



‘Coma cocktail’

50 mls 50% dextrose

naloxone 2 mg thiamine 100 mg


POISONS INFORMATION

Ask a senior colleague!


POISONS INFORMATION

• Text books– Ellenhorn– Haddad– Goldfrank

• On-line resources– Substance database (National Poisons Centre)– Poisindex– Toxindex


AVOID INJURY TO STAFF

1. Barrier precautions where applicable

2. External decontamination

3. Adequate ventilation

4. Avert / control violent behaviour

5. Exclude at risk staff


EVALUATION 1

•History

•Toxidromes


EVALUATION 2- History

• Circumstances of discovery • Mental illness / suicide attempts• Reason for overdose

• Recreational• Self harm• Depression

• Additional injuries• Past medical history• Social history / family history


EVALUATION 3- prediction of toxicity

1. The substances ingested

2. The quantities ingested

3. The time since ingestion

4. Any treatment to date

5. Concurrent medical conditions


EVALUATION 4 - History

• Intoxicated patients can be unreliable historians

• 70% of intentional overdoses involve more than 1 substance

• Always consider substances which patients may not think are harmful

examples: aspirin, paracetamol, antihistamines


EVALUATION 5- assessment of severity

• Vital signs• Physical examination

– Eyes• Pupillary size, nystagmus

– Neurological• Focal deficit is rare in overdose patients

– Skin– Odors

• Toxidromes


EVALUATION 6- toxidromes1. Anticholingeric2. Cholingeric3. Sympathomimetic4. Narcotic5. Sympatholytic6. Extrapyramidal movement disorders7. Haemoglobinopathies8. Metal fume fever


EVALUATION 7- Diagnostic testing 1

• ECG• Blood tests

– Paracetamol level for all patients– Arterial blood gas if unwell– U + E, glucose, anion gap, osmolar gap– FBE– Drug levels

• Urine drug screens


EVALUATION 7-Diagnostic testing 2:

• Harrisons text


EVALUATION 8- Diagnostic testing 3Consider specific tests

• CXR for pulmonary aspiration / oedema

• LFT’s / coagulation for liver damage

• Creatinine kinase for rhabdomyolysis

• Cervical spine XR / CT head for injury

• AXR for radio-opaque substances

PREVENTION OF POISON ABSORPTION

‘Decontamination’

Note - staff may be at risk


DECONTAMINATION 1• Skin

• Remove contaminated clothing / wash skin

• Gastrointestinal Activated charcoal (in 1st hour post

ingestion)x Emesis (‘ipecac’ ) – rarely usedx Gastric lavage – rarely used Cathartics / whole bowel irrigation

• Eyes


DECONTAMINATION 2- activated charcoal

• 1 gram / kg• Does not absorb

– Lithium– Heavy metals - iron– Alcohols/Solvents/

hydrocarbons– Caustics/strong acids– Cyanide– Pesticides

• Recovers 60% of poison if administered within the first hour


DECONTAMINATION 3- cathartics

• Reduced gastrointestinal transit time => reduced time for drug absorption

• Osmotic agents – sorbitol, mannitol, MgSO4

• Contraindications – ileus / bowel obstruction– electrolyte imbalance

• Indication = debatible


DECONTAMINATION 4-whole bowel irrigation

• May be useful for concretions &sustained-release preparations

• Polyethylene-glycol solution

• Administer at 1000 mls/hour until effluent is clear

• Rarely done but may be life saving if SR overdose


ANTIDOTES

• Useful in < 5% of overdoses

• Know which antidotes are stocked

• Know how to get advice


ANTIDOTES – some examples

Poison1. Paracetamol2. Narcotics3. Oral anticoagulants4. Carbon monoxide5. Organophosphates6. Betablockers7. Ca channel blockers8. Iron 9. Digoxin10. Methanol, ethylene glycol11. Cyanide

Antidote1. N-acetyl cysteine2. Naloxone3. FFP, Vitamin K4. oxygen5. Atropine, oximes6. Glucagon, insulin/glucose7. Calcium8. Desferrioxamine9. Digoxin Fab fragments10. ethanol, fomepizole11. Vit. B12, E-L kit,

Kelocyanor


ENHANCEMENT OF ELIMINATION

1. Diuresis2. Multiple-dose activated charcoal3. Urinary pH manipulation

- salicylate4. Haemodialysis

- small molecules, low protein binding - e.g. salicylate, Lithium

5. Charcoal haemoperfusion- theophylline/barbiturates/carbamazepine


TREAT ASSOCIATED CONDITIONS

• Trauma

• Chronic illness

• Environmental


MONITORING

• Clinical observation– i.e. neurological assessments

• Pulse oximetry

• ECG monitoring– Minimum 6 hours if cardio-active drug– >24 hours if delayed release

preparation


DISPOSAL 1

• Discharge

• Admission


DISPOSAL 2• DischargePrerequisites:

1.Medical fitness

2.‘Safety check’

Formal assessment of suicide

and self-harm risk


DISPOSAL• Admission 4

•Critical Care unit


DISPOSAL 5• Admission

•Psychiatric unit


DISPOSAL 6• Admission

•General Medical unit


DISCHARGE ADVICE• COUNSELLING

– Community and alcohol counselling contacts for recreational drug abuse

• EDUCATION– Care-giver education for accidental

ingestion's• LEGAL

– OSH contact for work-related toxic exposures


SUMMARY 1• Consider poisoning in any patient with

– ALOC– Unexplained signs and symptoms of any

nature

• Supportive care is the primary objective– TSS ‘Think simple stupid’

–A–B–C


SUMMARY 2

• Evaluation of the patient

– Is thorough history taking from all sources

– Is occasionally aided by ‘toxidrome’ recognition

– Do not rely on toxicology screening tests


SUMMARY 3• Management of the patient

– Depends on your assessment of A B C D

– Treating the patient not the poison

– Initiating clinically indicated treatment early

– Asking advice early


Any questions?

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RESUSCITATION OF THE POISONED PATIENT

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