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

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

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

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.

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health, a Clinical Adjunct Associate Professor at Monash University, and the Chair of the Australian and New Zealand Intensive Care Society (ANZICS) Education Committee. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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