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54: The Poisoned Patient

Sean M. Bryant, MD

Key Points

  • A thorough history of present illness including information gathered from available friends, family, and emergency medical service personnel can be invaluable in the management of poisoned patients.

  • Perform a comprehensive physical exam including a full set of vital signs to help classify the patient's clinical presentation into a particular toxidrome.

  • Always focus on supportive measures first in the clinical management of poisoned patients.

  • Consult your regional poison center (1-800-222-1222) to ensure the appropriate management of poisoned patients.

Introduction

More than 2 million toxic exposures and poisonings are reported to U.S. regional poison centers annually. Consequently, all emergency physicians should possess a basic fundamental comprehension of emergency toxicology and a sound clinical approach for managing the poisoned patient. Depending on the absolute dose and/or duration of exposure, all substances have the potential for harm. Factors including the absorption, distribution, and elimination rate of the inciting agent help determine its overall toxicity. In poisoned patients, the pharmacokinetic features of the toxin (eg, circulating half-life) can be markedly prolonged secondary to extended absorption times and the saturation of metabolizing enzymes. These toxicokinetic principles often result in an unpredictable onset of symptoms and overall duration of toxicity.

The initial goal in managing a poisoned patient is to provide excellent supportive care. Contact your regional poison center (1-800-222-1222) early in the management of your patient as they can provide invaluable support. To aid in making the diagnosis, attempt to classify the patient's clinical presentation into a specific toxidrome (a syndrome complex that characterizes certain classes of poisonings) (Table 54-1). Only by following the preceding guidelines will certain patients be suitable for decontamination measures and possibly focused antidotal care.

Table 54-1.

Common toxidromes.

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Table 54-1.

Common toxidromes.
Toxidrome Representative agent(s) Most Common Findings Additional Signs/Symptoms Potential Interventions
Opioid Heroin, morphine CNS depression, miosis, respiratory depression Hypothermia, bradycardia, respiratory arrest, acute lung injury Ventilation or naloxone
Sympathomimetic Cocaine, amphetamine Psychomotor agitation, mydriasis, diaphoresis, tachycardia, hypertension, hyperthermia Seizures, rhabdomyolysis, myocardial infarction, cardiac arrest Cooling, sedation with benzodiazepine, hydration
Cholinergic Organophosphate insecticides, carbamate insecticides Salivation, lacrimation, diaphoresis, nausea, vomiting, urination, defecation, muscle fasciculations, weakness, bronchorrhea Bradycardia, seizures, respiratory failure Airway protection and ventilation, atropine, pralidoxime
Anticholinergic Scopolamine, atropine AMS, mydriasis, dry/flushed skin, urinary retention, decreased bowel sounds, hyperthermia, dry mucous membranes Seizures, dysrhythmias, rhabdomyolysis Physostigmine (if applicable), sedation with benzodiazepine, cooling, supportive management
Salicylates Aspirin, oil of wintergreen AMS, respiratory alkalosis, metabolic acidosis, tinnitus, hyperpnea, tachycardia, diaphoresis, nausea, vomiting Low-grade fever, ketonuria, acute lung injury MDAC, alkalinization of the urine with K+ repletion, hemodialysis, hydration
Hypoglycemia Sulfonylureas, insulin AMS, diaphoresis, tachycardia, hypertension Paralysis, slurring of speech, seizures Glucose, octreotide
Serotonin syndrome Meperidine or dextromethorphan and MAOI; SSRI and TCA; SSRI/TCA/MAOI and amphetamines; SSRI alone AMS, increased muscle tone, hyperreflexia, hyperthermia Intermittent whole-body tremor Cooling, sedation with benzodiazepine, supportive management

AMS, altered mental status; CNS, ...

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