CLINICAL TOXICOLOGY LABORATORY

EXPERIMENT 2:
MANAGEMENT OF POISONING/OVERDOSED PATIENT

INTRODUCTION

A poisoning occurs when exposure to a substance adversely effects the function of any system
within organism.

CLASSIFICATION:
 Based on exposure: occupational, environmental, recreational, or medicinal
 Based on route of administration: inhalation, isufflation, ingestion, cutaneous and mucous
membrane exposure and injection

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.

Parenteral exposure is also common through intravenous or subcutaneous injection of

medications or drugs of abuse.

A poison may affect the normal activity of an organism in a variety of ways.

It may inhibit or alter cellular function, change organ function, or may change uptake or transport
of substance into, out of, or within the organism.

The toxin may prevent the organism from obtaining or utilizing essential substrates from the
environment.

Poison centers are an integral part of the management of potentially exposed patients.

These centers are typically staffed with specialists trained in the management of poisoned
patients, who have extensive reference material at their disposal.

Poison centers have immediate access to medical toxicologists if more extensive evaluation is
required.

Routine consultation in cases where toxic exposure is suspected can help focus diagnosis and
treatment and may reduce costs and unnecessary hospitalizations.

SYSTEMIC APPROACH TO POISONED PATIENT

 Resuscitation and stabilization of the patient (ABCDE)
A-Airway
B-Breathing
C-Circulation
D-Disability
E-Exposure

PROTOCOL
 Obtaining patient history
 Physical assessment and examination
 Laboratory and Diagnostic Assay
 Decontamination
 CLINICAL TOXICOLOGY LABORATORY
 Preventing drug absorption
 Enhance Elimination
 Administration of antidote
 Supportive care
 Clinical follow up

A. RESUSCITATION
 Diagnosis and resuscitation proceed simultaneously
 The first priorities are always the ABCs (airway, breathing, and circulation)
 Once the airway and respiratory status is secured, abnormalities of blood pressure, pulse,
rectal temperature, oxygen saturation and hypoglycemia must be corrected

A: airways
 Check for: voice, breath sounds
 Perform: head tilt, chin lift
 oxygen suction
 Provide one if the patient’s upper airway is obstructed
 Protect the airway if the cough and gag reflexes are obtunded and secure the airway, when
necessary, with tracheal intubation (this may include patients with marginally adequate
protective reflexes who require gastric lavage)

B: breathing
 Check for the respiratory rate (12-20/minute)
 Chest wall movements
 Chest percussion
 Lung auscultation
 Pulse oximetry (97-100%)

 Assess the ventilatory efforts and assist where necessary

 Asses gas exchange
 Look for evidence of aspiration of gastric contents, toxic gases or foreign substances
 Possible treatment:
1. Let the patient seat comfortably
2. Rescue breathe of the patient if breathing is abnormal
3. Administer inhaled medication if needed
4. Bag-mask ventilation
5. Consider pneumothorax

C: circulation
 Observe for:
 Skin color
 Capillary refill time (<2s)
 Palpate the pulse (96-100 minutes)
 Heart auscultation
 Blood pressure
 ECG monitoring
 Establish I.v. access early. Assess peripheral perfusion and begin resuscitation as required
 Connect electrocardiographic monitoring and examine a rhythm strip
 Possible treatment:
1. Stop the bleeding
2. Elevate the legs
3. Intravenous access
4. Infusion of saline solution (NSS, D5NS, D5W with 0.45%, NaCl, D5W in 0.25% NaCl)
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D: disability
 Check for:
 Level of consciousness (AVPU) - alert, voice responsive, pain responsive, unresponsive
 Limb movement
 Papillary light reflexes
 Blood glucose monitoring
 Possible treatment:
1. Secure airway, breathing, and circulation
2. Turn patient intro recovery position
3. Administer glucose for hypoglycemia

E: exposure
 Check for
 Exposed skin
 Temperature
 Possible treatment:
1. Remove all the things that can interfere in the assessment of the patient
2. In case of gas poisoning, expose the patient in an area where he/she can breath free air

NOTE:
 Although the proper use of antidotes is essential in the treatment of poisoned patients, only in
very rare incidences (such as cyanide poisoning) would the administration of an antidote
take precedence over completing the primary evaluation and normal attempts to stabilize the
ABCs
 Patients may be unresponsive or have an altered mental status for many reasons. Four
possible etiologies (hypoxia, opioid intoxication, hypoglycemia and Wernicke’s
encephalopathy) are readily treated by the administration of specific antidotes

Within the first few minutes after the patient’s arrival, the administration of empiric antidotes (the
“coma cocktail”), including supplemental oxygen, naloxone, 50 ml D50W for adults and 1g/kg
glucose for children, and 100 mg thiamine in adults should be considered after taking into account
the medical history, vital signs and laboratory data immediately available.

These treatments are simple, inexpensive, and generally without undue risk of an adverse reaction
when used appropriately.