Knowledge of appropriate decontamination techniques and timely administration of antidotes coupled with excellent supportive care may positively alter the outcome of poisoned patients.
A detailed history is essential in the evaluation of a potentially poisoned patient. In the conscious, cooperative person, the specific agent(s), time, route, amount, and intent of exposure need to be documented. In the uncooperative or altered patient, adjunctive information from friends, family, prehospital providers, police, or bystanders may provide more accurate details. Environmental clues such as drug paraphernalia, empty pill bottles, odors, or suicide notes may aid in the diagnosis. If available, review hospital records for recent prescriptions or any history of psychiatric illness. Loose pills with imprint codes may be identified by the pharmacy or poison center.
A thorough exam begins with a completely disrobed patient. Search clothing and personal possessions, but remain vigilant while doing so as to avoid potential injury from needles or chemicals. Review vital signs and perform a comprehensive physical examination. Focus on the general appearance, level of consciousness, pupil size, mucous membranes, respiratory rate, breath sounds, presence of bowel sounds, skin temperature, and muscle tone as the combination of findings may suggest a specific toxidrome (Table 100-1).
Table 100-1 Common Toxidromes |Favorite Table|Download (.pdf)
Table 100-1 Common Toxidromes
|Toxidrome||Representative Agent(s)||Most Common Findings||Additional Signs and Symptoms||Potential Interventions|
Central nervous system depression, miosis, respiratory depression
Death may result from respiratory arrest, acute lung injury
Ventilation or naloxone
Psychomotor agitation, mydriasis, diaphoresis, tachycardia, hypertension, hyperthermia
Seizures, rhabdomyolysis, myocardial infarction
Death may result from seizures, cardiac arrest, hyperthermia
Cooling, sedation with benzodiazepines, hydration
Muscarinic effects (salivation, lacrimation, diaphoresis, nausea, vomiting, urination, defecation, bronchorrhea)
Nicotinic effects (muscle fasciculations and weakness)
Bradycardia, miosis/mydriasis, seizures, respiratory failure, paralysis
Death may result from respiratory arrest from paralysis, bronchorrhea, or seizures
Airway protection and ventilation, atropine, pralidoxime
Altered mental status, mydriasis, dry flushed skin, urinary retention, decreased bowel sounds, hyperthermia, dry mucous membranes
Seizures, dysrhythmias, rhabdomyolysis
Death may result from hyperthermia and dysrhythmias
Physostigmine (if appropriate), sedation with benzodiazepines, cooling, supportive management
Oil of wintergreen
Altered mental status, respiratory alkalosis, metabolic acidosis, tinnitus, hyperpnea, tachycardia, diaphoresis, nausea, vomiting
Low-grade fever, ketonuria
Death may result from acute lung injury or cerebral edema
Multidose activated charcoal, alkalinization of urine with potassium repletion, hemodialysis
Depressed level of consciousness, slurred speech, ataxia
Stupor to coma, depressed respirations, apnea, bradycardia
Altered mental status, diaphoresis, tachycardia, hypertension
Paralysis, slurring of speech, bizarre behavior, seizures
Death may result from seizures
Glucose-containing solution IV and oral feedings if possible, frequent glucose measurement, octreotide
Lysergic acid diethylamide
Hallucinations, dysphoria, anxiety
Hyperthermia, mydriasis, nausea, sympathomimetic symptoms
A variety of drug interactions with dextromethorphan, monoamine oxidase inhibitors, tricyclic ...
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