Approach to the Poisoned Patient

What are the steps when assessing a poisoned patient?

1. Critical stabilization

2. Patient history

3. Objective assessment

What makes up the critical stabilization step of patient assessment?

ABCs (+DE)

Vitals/ECG

Mental status

Address ALL parts before moving to the next two steps

What makes up the patient history step of patient assessment?

Medications

PMH

Ingestion details

What makes up the objective assessment step of patient assessment?

Physical exam

Lab testing

What does ABCDE stand for in a poisoned patient?

A = airway

B = breathing

C = circulation

D = dextrose

E = ECG

Define airway in ABCDE

The actual ability to safely move air in and out of the body

What are we looking for when assessing the airway?

Airway obstruction

Airway protective reflex

Define breathing in ABCDE

The actual process of moving oxygen in and moving CO2 out

How can we monitor breathing in a poisoned patient?

Respiratory rate

Oxygen saturation

End title CO2

Define end title CO2 (ET CO2)

Tells us how much CO2 is left in the lungs at the end of the breath

Interpret an ET CO2

If high = patient is retaining a lot of CO2

If low = patient is blowing off too much CO2

Define circulation in ABCDE

Whether a patient is appropriately getting oxygenated blood to where it needs to go

How can we monitor circulation in a poisoned patient?

Measure BP

Feel for cold extremities

Dizziness/lightheadedness

Urine output

Define dextrose in ABCDE

Blood glucose level

How do we monitor blood glucose level in a poisoned patient?

Every patient who comes in for a suspected toxicology issue will receive a fingerstick glucose test

Define ECG in ABCDE

Electrocardiogram to see electrical activity of the heart

Why do all poisoned patients receive an ECG?

There can be dangerous changes in an ECG even without clinical signs and symptoms

What cardiovascular vital signs should be monitored in a poisoned patient?

HR + rhythm, BP

What specific aspects of HR + rhythm should be monitored?

QRS/QTc

What is a normal QRS complex length?

< 120 mg

What is a normal QTc interval length?

< 450 ms (males)

< 460 ms (females)

What specific aspects of BP should be monitored?

MAP, perfusion/capillary refill

Define mean arterial pressure (MAP)

The pressure forcing blood into tissues, averaged over cardiac cycle

One number that is a combination of systolic and diastolic pressure

What is the goal MAP?

> 65

What respiratory system vital signs should be monitored in a poison patient?

RR/effort

Ventilatory status

What specific aspects of RR/effort should be monitored?

Labored breathing / accessory muscles

Respiratory depth / regularity

Cyanosis (varies with skin color/tone)

What specific aspects of ventilatory status should be monitored?

O2 / ET CO2

VBG/ABG (if you don't have access to an ET CO2 test)

What temperatures should be monitored in a poisoned patient?

Core temperature AND peripheral temperature

Which routes measure a patient's core temperature?

Rectal temperature or Foley catheter

Define a Foley catheter

Indwelling catheter retained in the bladder by a balloon inflated with air or fluid

Measures the temperature of the bladder = core temperature

Which routes measure a patient's peripheral temperature?

Oral, tympanic, otic, etc.

Anything that isn't rectal or a Foley catheter

Which temperature is more reliable?

Core temperature is more reliable than peripheral temperature

What aspects of patient history are important to collect in a poisoned patient?

Age

PMH / medications

Reason for exposure

How does age correspond to fatality risk?

Older age = increased fatality risk

What is important to ask about when assessing PMH / medications?

OTC, dietary supplements, non-prescribed drugs

Why is important to ask about the reason for exposure when collecting patient history?

To determine whether the exposure was intentional vs unintentional

What is important information to collect regarding medications when taking patient history?

Time of exposure

Dose/quantity

Formulation

Prescribed medications + available medications

What are the goals of gastrointestinal decontamination?

Remove drug ingestion

Decrease drug absorption

Enhance drug elimination

What is the preferred method of GI decontamination?

Activated charcoal

How does activated charcoal work?

Adsorbs to drugs in the GI tract to limit absorption

What does activated charcoal NOT bind to?

Metal salts like iron, lithium, or potassium

Heavy metals

What is the dosing of activated charcoal?

1 g/kg

When are multiple doses of activated charcoal used?

Multi-dose used for large ingestions or enterohepatic / enteroenteric recirculation

A patient MUST have bowel sounds to receive multiple doses

What are indications for activated charcoal?

Ingestion of a potentially toxic amount of drug

Patient presents shortly after the ingestion occurred (1-2 hours)

Patient ingested a drug(s) that delays absorption, a SR product, or a drug with delayed absorption kinetcs

What are contraindications to activated charcoal?

Patient does not have airway protective reflexes and is not intubated

Ingestion of a drug that does not adsorb to charcoal

Ingestion with high aspiration risk, a caustic agent, or the need for diagnostic endoscopy

What is the procedure for taking activated charcoal?

1. Prepare 1 g/kg of activated charcoal for oral administration in chocolate milk or another liquid

2. Administer in a closed container with a straw

3. Provide antiemetics as needed for N/V

What are two other methods of GI decontamination?

Whole-bowel irrigation

Orogastric lavage

Describe whole-bowel irrigation

Rapid administration of a continuous infusion of polyethylene-glycol electrolyte solution (Golytely) to "flush" GI tract

When is whole-bowel irrigation used?

Massive/life-threatening ingestions

When a patient has overdosed on one of the three salts that charcoal does not stick to

Describe orogastric lavage

OG tube to instill fluid and remove stomach contants

When is OG lavage used?

Limited utility = small pill size, gastric emptying (only works within 60 min)

Used for massive/life-threatening ingestions

What basic labs should all poisoned patients have done?

Glucose, CMP, VBG, CK

beta-hcG if patient has a uterus

What toxicology labs should all poisoned patients have done?

Acetaminophen/aspirin, ethanol (especially if patient is altered), "level-able" medications