Over the past several decades, the use of the intensive care unit (ICU) and its attendant resources has led to improved patient survival from many serious conditions. This is the direct result of the ability to pay meticulous attention to supportive care, continuously monitor physiologic parameters, and use the most modern medical technology and treatment. Most critically ill poisoned patients have acutely reversible conditions that will clearly benefit from ICU intervention.55
Unlike many patients with diseases managed in the ICU, poisoned patients often do not have a well-recognized clinical course or predictable complications. More than almost any other disease managed in the ICU, uncertainties typify toxicologic emergencies. A patient's history is often unreliable with regard to the kind of xenobiotic ingested, time of ingestion, and amount ingested. The xenobiotic may have unknown or unpredictable toxic effects. The therapies, antidotes, and complications of acute poisoning may be unfamiliar to the ICU staff. These uncertainties challenge healthcare providers and influence decisions about admitting patients to the ICU.
Often a patient is admitted to the ICU for observation and monitoring, not for intervention.71 Of the 12.5 million reported xenobiotic exposures reported in the American Association of Poison Control Centers (AAPCC) National Poison Database System from 2003 to 2007, only 5% were admitted to the hospital (Chap. 135).7 In addition, fewer than 25% of those hospitalized required specific treatments or antidotes other than gastrointestinal (GI) decontamination.6,7,71 Many physicians elect to observe poisoned patients in an ICU in anticipation of possible delayed, unrecognized life-threatening toxicity. The ICU provides necessary monitoring and individual nursing care that can help in the early recognition of developing toxicity. ICUs give healthcare providers the best opportunity to minimize morbidity and decrease mortality. However, ICU care is very expensive and has contributed significantly to the escalation of healthcare costs.
The ICU admission guidelines presented in this chapter are intended to encourage effective use of ICU resources without compromising patient care. Effective guidelines must consider the unique characteristics of a xenobiotic, the capabilities of the hospital, and all realistic alternatives for managing and observing poisoned patients without compromising care. Current medical literature allows us to develop only very general guidelines. Future clinical studies addressing the use of healthcare resources for poisoned patients will allow refinement of these guidelines. Although it is impossible to be all-inclusive, this chapter provides a decision-making strategy for most xenobiotics discussed in this text.
Most critically ill poisoned patients have acutely reversible conditions that will clearly benefit from meticulous supportive care, continuous physiologic monitoring, and the use of the most modern medical technology and treatment. It seems reasonable to assume that a patient's signs and symptoms can be used to decide the need for ICU admission. The presence of certain signs, symptoms, or abnormal diagnostic test results requires ICU observation or intervention, whatever the toxic exposure. This approach is most consistent with the philosophy of ...