Approach to Acute Poisoning

Reviewed and revised 20 April 2014

OVERVIEW

The patient’s form a heterogeneous group that requires a systematic approach based on early resuscitation where needed, risk assessment to guide further management and early consideration of the underlying psychosocial issues.

Acute poisoning is a dynamic medical illness usually representing an acute and potentially life threatening exacerbation of a chronic underlying psychosocial disorder — Lindsay Murray

GENERAL APPROACH

Remembered by the mnemonic “Resus-RSI-DEAD”

• Resuscitation
  • Airway
  • Breathing
  • Circulation
  • Seizure control
  • Correct hypoglycaemia
  • Correct hyperthermia
  • Resuscitation antidotes
• Risk assessment
• Supportive care and monitoring
• Investigations
  • Screening (ECG, paracetamol)
  • Specific
• Decontamination
• Enhanced elimination
• Antidotes
• Disposition

The nature and timing of management at each step is guided by the risk assessment

RESUSCITATION

• initial assessment and treatment should target potential life threats and occur in an appropriately staffed and equipped resuscitation area
• extended ABC approach with early detection and treatment of seizures, hypoglycaemia and hyperthermia
• occasionally antidotes are useful in resuscitation, especially:
  — naloxone (opiates)
  — digibind (digoxin)
  — NaHCO3 (sodium channel blockers)
  — high dose insulin euglycemic therapy (HIET) (calcium channel blockers and beta-blockers)
  — intralipid (local anesthetics)
  — atropine and pralidoxime (organophsophates)
  — hydroxocobalamin and sodium thiosulfite (cyanide)
• resuscitation should be prolonged in cardiac arrest from toxicological causes and extracorporeal life support should be considered

RISK ASSESSMENT

A distinct cognitive step that is quantitative in nature and takes into account:

• Agent(s)
• Dose(s)
• Time since ingestion
• Current clinical status
• Patient factors

SUPPORTIVE CARE AND MONITORING

• FASTHUGS IN BED Please applies where appropriate

INVESTIGATIONS

• ECG and paracetamol level are the only routine screening tests needed in the Australasian setting.
• further tests are required as indicated by the specific presentation
• urine toxicology screens are of little use in the acute setting

Rationale for investigations in the acutely poisoned patient

• Refine risk assessment or prognosis
• Exclude or confirm an important differential diagnosis
• Exclude or confirm an important specific poisoning
• Exclude or confirm a complication that requires specific management
• Establish an indication for antidote administration
• Establish an indication for institution of enhanced elimination
• Monitor response to therapy or define an endpoint for a therapeutic intervention

DECONTAMINATION, ENHANCED ELIMINATION AND ANTIDOTES

• see appropriate CCC entries for each
• Decontamination — GI Decontamination, Activated Charcoal, Gastric lavage
• Enhanced elimination — Enhanced Elimination
• Antidotes — Antidote Summary

DISPOSITION

• patients need to be admitted to an environment capable of providing an appropriate level of monitoring and supportive care (and occasionally specific antidotal or enhanced elimination therapies)
• options include observation the ED, a ward environment, HDU or ICU level care
• final disposition depends on psychosocial assessment, which should be organised early in patient management

References and Links

LITFL

• Toxicology conundrums (case-based Q&A scenarios)
• Flashcards – Approach to the Poisoned Patient

Journal articles

• Daly FF, Little M, Murray L. A risk assessment based approach to the management of acute poisoning. Emerg Med J. 2006 May;23(5):396-9. PMC2564094.