Chapter 176: General Management of Poisoned Patients

INTRODUCTION

Poisoning is a worldwide problem that consumes substantial healthcare resources and causes many premature deaths. The burden of serious poisoning is carried by the developing world^1,2; however, poisoning-related morbidity and mortality are also a significant public health concern in the developed world.^3–7

Unintentional poisoning deaths in the United States are increasing, especially as a result of prescription analgesics. This increase has been ascribed to increasing prescription rates and aging of the baby-boom population.^8–10 Prevention is the key to reducing unintentional poisoning deaths. Pharmacists can ensure that medications are labeled correctly, anticipate potential drug interactions, and educate patients to use medications safely. Parents have the responsibility to ensure that poisons are placed in childproof, labeled containers stored in adult-only accessible nonfood storage areas to reduce pediatric exposures. Teachers and healthcare providers can provide age-appropriate education to children about the dangers of poisons. After an exposure, poison control centers staffed by highly trained individuals can provide customized advice to healthcare providers and the public. Poison control centers also participate in prevention, education, and toxico-surveillance activities.

Exposures occur most commonly by ingestion; other routes include inhalation, insufflation, cutaneous and mucous membrane exposure, and injection.¹⁰ Some exposures have minimal risk. The criteria used to determine whether the exposure is nontoxic are as follows: (1) an unintentional exposure to a clearly identified single substance, (2) an estimate of the dose is known, and (3) a recognized information source (e.g., a poison control center) confirms the substance as nontoxic in the reported dose. Asymptomatic patients with nontoxic exposures may be discharged after a short period of observation, providing they have access to further consultation and a safe discharge destination.

Serious clinical effects occur in <5% of acutely poisoned patients presenting to developed-world hospitals, and in-hospital mortality rates are <1%.¹⁰

RESUSCITATION

Resuscitation is the first priority in any poisoned patient. After resuscitation, a structured risk assessment is used to identify patients who may benefit from an antidote, decontamination, or enhanced elimination techniques. Most patients only require provision of good supportive care during a period of observation in an appropriate environment.

Treatment of cardiac arrest in poisoned patients follows Advanced Cardiac Life Support guidelines with the addition of interventions potentially beneficial in toxin-induced cardiac arrest (Table 176-1).¹¹ Prolonged resuscitation is generally indicated, as patients are often young with minimal preexisting organ dysfunction. Utilization of extracorporeal cardiac and respiratory assist devices until organ toxicity resolves may be lifesaving.