3/16/2023

GENERAL ED APPROACH TO THE POISONED PATIENT

JOHN PAUL E. NER, MD, FPCEM
TOXICOLOGY REFERRAL AND TRAINING CENTER- NATIONAL SPECIALTY CENTER FOR TOXICOLOGY

OUTLINE
•Modified ABCDE for poisoned patients
•Toxidromes / Toxic Syndromes
•Methods of Decontamination
•Enhanced Elimination
•Antidotal Therapy
•Disposition

GENERAL ED APPROACH TO THE POISONED PATIENT

General ED
Approach to
the Poisoned
Patient

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•Consider corrosive agents and direct airway injury

•Stridor, dysphagia, dysphonia
•Threats to airway from CNS depression
•Excess secretions from cholinergic agents
•Consider early intubation

Poisoned patients are at risk due to the dynamic nature of toxin metabolism

GENERAL ED APPROACH TO THE POISONED PATIENT

•Consider compensatory respiratory alkalosis in tachypneic

patients in methanol, ethylene glycol, salicylates
•Opioids causing respiratory depression
•Cholinergic crisis may lead to respiratory failure

Poisoned patients are at risk due to the dynamic nature of toxin metabolism

GENERAL ED APPROACH TO THE POISONED PATIENT

•Rate, rhythm, blood pressure, cardiac monitoring

•IV access and fluid resuscitation

Poisoned patients are at risk due to the dynamic nature of toxin metabolism

GENERAL ED APPROACH TO THE POISONED PATIENT

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•Seizures – May require use of benzodiazipines. Common with

sodium channel blockade and serotonin agents.
•Hypoglycemia – if serum glucose is less than 4.0mmol/L give
Poisoned patients are at risk due to the dynamic nature of toxin metabolism
50ml of 50% dextrose IV.
•Hyper/hypothermia

GENERAL ED APPROACH TO THE POISONED PATIENT

•Sodium Bicarbonate (TCA overdose)

•Naloxone (Opioid overdose)
Poisoned patients are at risk due to the dynamic nature of toxin metabolism
•Atropine (Organophosphate Poisoning)
•Glucose
•Digoxin specific antibodies

GENERAL ED APPROACH TO THE POISONED PATIENT

•Use
•Ask •What is the the latest possible •Vital signs
•Comorbidities
•Toxidromes
worst case time of ingestion •Hepatic and
•Check •Does the clinical
scenario dose? •Paracetamol– Renal Function
Always consider the worst case scenario when conducting thepresentation match
risk assessment.
•Correlate •Count missing estimate
the stated
•Age
the earliest time •BMI
•Consider tablets toxicant?
of ingestion

GENERAL ED APPROACH TO THE POISONED PATIENT

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SEDATIVE-HYPNOTIC
TOXIDROME
Toxidrome includes
◦ CNS depression, respiratory depression
◦ Normal pupils, normal vital signs
Agents include
◦ Benzodiazepines, barbiturates, ethanol
Other problems include
◦ Skin bullae for barbiturate overdose
Treatment
◦ supportive therapy
◦ Flumazenil for benzo but use with caution
GENERAL ED APPROACH TO THE POISONED PATIENT

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The aim is to optimise organ function and minimise secondary complications from the poisoning, the
coma or the hospital admission

GENERAL ED APPROACH TO THE POISONED PATIENT

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•Removal of a drug from the body BEFORE it has been absorbed

•Gastrointestinal and Dermal are the two main types
•Activated Charcoal
•The benefit of giving charcoal must outweigh the risk of complications from
administration.
•Administration is of benefit in certain situations in the 1st hour, or where a large pill
bolus may remain in the GI tract following massive overdose. Consider delayed
charcoal in massive ingestions of slow-release preparations
• No benefit in
• Hydrocarbons and alcohols
• Metals
• Corrosives

GENERAL ED APPROACH TO THE POISONED PATIENT

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•Multiple-dose activated charcoal

•Urinary Alkalinization – phenobarbital, salycilates
•Extracorporeal elimination techniques – lithium, metformin, potassium, toxic alcohols,
valproic acid, theophylline, salycilates

GENERAL ED APPROACH TO THE POISONED PATIENT

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MULTIPLE DOSE ACTIVATED CHARCOAL (MDAC)

MDAC helps create a form of “gut hemodialysis” by decreasing the

amount of unbound drug in the gut lumen and drawing the drug from the
circulation.
Charcoal may also be helpful in enhancing elimination for drugs that have
enterohepatic / enteroenteric recirculation.
Indications:
❏ Aminophylline/theophylline
❏ Barbiturates
❏ Concretion forming drugs (salicylates) or carbamazepine
❏ Dapsone
❏ Quinine

Note: MDAC is dosed similar to single dose activated charcoal for the
initial dose (05.- 1 g/kg) and then ~50% of the initial dose every 4 hrs .

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URINARY ALKALINIZATION

Alkaline urine favors ionization of acidotic drugs within renal tubules, preventing
resorption of the ionized drug back across the renal tubular epithelium and enhancing
elimination through the urine

GENERAL ED APPROACH TO THE POISONED PATIENT

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Toxicant requirements for Dialysis

❑Low volume of distribution

❑Low protein binding
❑Low plasma clearance
❑Low molecular weight

Other indications for dialysis include

severe acid-base or electrolyte derangements

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ANTIDOTES

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DISPOSITION Observation may be limited to 6 hours if:

• Peak toxicity is expected to be reached
within that time
• Overall level of toxicity is predicted to be
low
• Patient remains asymptomatic
• Patient has received a psychiatric consult (if
intentional)

Longer observation (> 24 hours) in the

following situations:
• Substance-related: extended-
release formulation, delayed peak effects,
delayed toxicity ,or active metabolites
• Patient-related: Symptoms do not resolve
with supportive treatment or complications
occur

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SUMMARY

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