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Toxicology – APPROACH TO THE POISONED PATIENT
ABC’s:
As with all emergency department patients, first ensure the patient has a patent airway, is breathing, and has a pulse. Immediate intervention is required if any or all of these are absent.
Vital Signs:
Temperature, heart rate, blood pressure, respiratory rate, and O₂ saturation will help guide the diagnosis and help categorize the intoxication or overdose into one of the more common toxidromes.
History:
Attempt to get a good history using collateral sources if possible, as the poisoned patient is often unreliable or containers altered. EMS, family members, occupation, past medical records, and empty pill bottles can provide insight into the potential toxin or overdose.
Physical:
In addition to vital signs, physical examination will help tease out the clinical toxidrome.
PEARLS
ABC’s:
As with all emergency department patients, first ensure the patient has a patent airway, is breathing, and has a pulse. Immediate intervention is required if any or all of these are absent.
Vital Signs:
Temperature, heart rate, blood pressure, respiratory rate, and O₂ saturation will help guide the diagnosis and help categorize the intoxication or overdose into one of the more common toxidromes.
History:
Attempt to get a good history using collateral sources if possible, as the poisoned patient is often unreliable or containers altered. EMS, family members, occupation, past medical records, and empty pill bottles can provide insight into the potential toxin or overdose.
- What: Consider what medications the patient has access to including his or her own, as well as those of parents, friends, significant others, children and visiting relatives. Ask if the drug is an immediate-release or sustained-release product.
- When: A time frame of suspected ingestion can influence treatment options and patient disposition. For example, some toxins have a delayed onset and some antidotes must be given within a specific time frame.
- Dose: Assume that any unreliable patient took the highest possible dose. Count the number of pills remaining in their prescription bottles and subtract that amount from the initial number prescribed. Assume all missing pills were taken as a single overdose.
- Why: Was this an accidental ingestion, a therapeutic misadventure in pursuit of a “high” or in pursuit of better treatment outcomes, or was it a suicide attempt? The answer will help determine the patient’s disposition.
- Coingestions: Multiple drug ingestions are common; alcohol is the most common coingestion.
Physical:
In addition to vital signs, physical examination will help tease out the clinical toxidrome.
- Mental Status: Agitation / somnolence / paranoid / obtunded / comatose
- Skin: Wet / dry / cyanotic / erythematous / pale / hot / cold
- Eyes: Miosis / mydriasis / nystagmus / conjunctival injection / jaundice
- Mucous Membranes: Wet and salivating / dry and chapped
- Heart/EKG: Tachycardia / bradycardia / QRS widened / QT prolongation
- Lungs: Tachypnea / bradypnea / rales / wheezing / crackles
- Bowel Sounds: Hyperactive / normal / absent
- Neurological: Hyperreflexia / hyporeflexia
PEARLS
- US Poison Control Center: 1-800-222-1222
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