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General

Management of
Poisoned
Patients
PWM OLLY INDRAJANI
2013

Introduction

Poisoning occurs when exposure


to a substance adversely affects
the function of any system
within an organism.
The setting of the poison
exposure may be occupational,
environmental,
recreational, or
medicinal.

Poisoning may result from varied


portals of entry, including
- inhalation,
- insufflation,
- ingestion,
- cutaneous
- mucous membrane exposure, and
- injection.
Historically most poisonings have
occurred when substances are
tasted or swallowed

Toxins may be airborne in the form


of gas or
vapors or in a suspension such as
dust.
Caustics, vesicants, or irritants
may directly
affect the skin, or a toxin may pass
transdermally and affect internal
structures
(e.g., methylene chloride, aniline

Resuscitation
The first priority in treating poisoned patients

Patients may have an altered mental


status because of hypoxia, opioid
intoxication, hypoglycemia, and
Wernicke Encephalopathy, conditions
readily treated by specific antidotes.
Empiric administration of antidotes
(the "coma cocktail"), including
supplemental oxygen, naloxone,
glucose, and thiamine, should be
considered after the medical history,
vital signs, and immediately available
laboratory data are taken into
account

The dogma that the administration of


thiamine should precede the administration of
glucose to prevent the precipitation of acute
Wernicke encephalopathy is unfounded.
Naloxone is a competitive opioid antagonist
without any intrinsic toxicity that can be
administered IV or IM and is appropriate to
use in a hypoventilating opioid-intoxicated
patient who is not intubated.
Naloxone may be given to children as a
therapeutic challenge when unintentional or
intentional opioid exposure cannot be
excluded.

Using miosis as the sole


indication for naloxone
administration is unreliable,
because many other toxins can
produce small pupils along with
mental status depression, and
some opioids classically leave
pupil size unaltered (e.g.,
meperidine, propoxyphene).
Naloxone often completely reverses
the effects of the opioid and restores
effective ventilations and mental
status for 20 to 60 minutes, so

The risks of naloxone treatment are


few but include the precipitation of
an acute opioid withdrawal
syndrome.
Although acute withdrawal is never
life-threatening in adults, vomiting
from withdrawal can result in
aspiration.
Thus, the reflexive administration of
large doses of naloxone should be
discouraged

ED Diagnosis History
It is often

Toxicologic Physical Examination

Undress the patient completely.


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)
Assess the general appearance of the
patient and note any agitation, confusion,
or obtundation.
Examine the skin for cyanosis or flushing,
excessive diaphoresis or dryness, signs of
injury or injection, ulcers, or bullae.
Bruising may be a clue to trauma, a
prolonged duration of unconsciousness,
or coagulopathy.

Toxicologic Physical Examination


Examine the eyes for pupil size, reactivity,
nystagmus, dysconjugate gaze, or
excessive lacrimation.
Examine the oropharynx for
hypersalivation or excessive dryness.
Auscultate the lung fields to assess for
bronchorrhea or wheezing, and the heart
for its rhythm, rate, and regularity.
Examine the abdomen, noting the presence
of bowel sounds, enlarged bladder, and
abdominal tenderness or rigidity. Evaluate
the extremities for muscle tone and note
any tremor or fasciculation

Toxidromes

Toxicologic Screen

In
positive
Negative
results
results
Interpretation
Positive
resultsofmay
urine
occur
toxicology
with many
screening
substances
test results
because
requires
they persist
an un

General Decontamination
The general approach to most toxic
exposures the removal of the
patient from the substance and the
substance from the patient.
Toxins on the outside of the body
washed away.
Toxins within the body, either bound
within the gut lumen to make it
unavailable for absorption or
elimination from the gut, blood, or
tissues can be enhanced.

Gross Decontamination

Surface decontamination is achieved by


completely undressing patients and
thoroughly washing them with copious
amounts of water. Patients requiring
assistance should be attended to by properly
gowned staff.
The towels used to dry patients and patients'
clothing, shoes, socks, watches, and jewelry
should be handled as contaminated material.
If possible, surface decontamination should
occur prior to the patient's entry into the ED
or other areas in the hospital.
In mass casualty exposures, this typically
occurs at a staging area adjacent to the ED

Ocular exposures are treated with copious

GI Decontamination

The three general methods of


decontamination:
1. Removing the toxin from the
stomach via the mouth
2. Binding it inside the gut lumen
3. Enhancing transit through the
intestines
GI decontamination should never
be initiated as a punitive action.

Gastric Emptying

Orogastric Lavage

Toxin Adsorption in the Gut


Activated Charcoal
Activated charcoal

Multidose

Enhancement of Bowel Transit


Cathartics
Activated charcoal is often administered with an osmotic cathartic, such as 70%

Whole-Bowel Irrigation
Whole-bowel irrigation is best accomplished by
infusing the polyethylene glycol solution through a
nasogastric tube, although in motivated patients,
oral ingestion can be used. Typical doses are 1.5 to
2.0 L/h in adults, 1 L/h in children 6 to 12 years of
age, and 0.5 L/h in children <6 years of age.
Contraindications include preceding diarrhea,
ingestion of substances that are expected to result
in significant diarrhea (except for heavy metals,
because these substances do not adsorb well to
activated charcoal), and bowel obstruction as
evidenced by lack of bowel sounds.
Complications include bloating, cramping, and
rectal irritation from frequent bowel movements.

The first is that only

Urinary Acidification

Acidification of urine can somewhat


enhance elimination of weak bases,
such as amphetamines, phencyclidine,
and some other drugs. However, the
risks, particularly in relation to
rhabdomyolysis, far outweigh any
benefits
Forced diuresis has never been shown
to be effective for ingestion of any
toxin, with the possible exception of
chlorophenoxy herbicides when
diuresis is combined with urinary
alkalinization

The benefits include the ability to remove toxins that have already been absorbed from