Snapshot A 30-year-old woman self-presents to the ED, reporting that she ingested an entire bottle of pills less than an hour ago. She refuses to disclose the type of pill. She has a sweet scent to her breath. She is escorted to the trauma bay, where her blood pressure is 130/80 mmHg, pulse is 90/min, respirations are 24/min, and SaO2 of 96% on room air. ECG reveals no unusual dysrhythmias. Large-bore IVs are inserted. Thiamine is provided, followed by D5 1/2 NS. The patient undergoes gastric lavage, followed by a single dose of activated charcoal. Abdominal radiograph is unremarkable. ASA/acetaminophen levels are unremarkable. The patient remains hemodynamically stable. She is admitted to the psychiatry inpatient service for further monitoring. Introduction Poisoning and overdose cause more deaths than firearms and motor vehicle accidents Leading cause of nontraumatic cardiac arrest General approach to undifferentiated overdose/poisoning patient involves trauma risk management including the following resuscitation screening (clinical evidence of toxidromes) decrease absorption of drug increase elimination of drug Specific toxin search is secondary Presentation When to suspect overdose/poisoning altered mental status/coma young patient with life-threatening dysrhythmia trauma patient bizarre/unusual patient presentation History age weight past medical history medications substance and dose amount time since exposure determines prognosis and need for decontamination route (PO, IV, IM) intention (accidental,suicidal,homicidal) Evaluation and Management Primary survey with resuscitation ADD: (Universal) Antidotes, Draw bloods, Decontamination (universal) Antidotes: DON'T not considered harmful, high benefit profile Dextrose any patient with AMS Oxygen intubate if apneic / unconscious Naloxone usually given in emergent setting given high prevalence of prescription opioid abuse in United States Thiamine (before dextrose) any patient with AMS prevention/treatment of Wernicke's encephalopathy Draw bloods essential tests CBC, electrolytes, BUN/Cr, glucose, INR/PTT, serum osmolality calculate anion gap and plasma osmolar gap ABG, SaO2 ASA, acetaminophen, EtOH levels useful/nonessential tests drug levels Ca2+, Mg2+, Phos protein, albumin, lactate, ketones, liver enzymes, CK negative drug screens/levels do NOT rule out toxic overdose specific drugs tested were not detected in specimen Decontamination and elimination gastrointestinal prior to decontamination, secure airway to prevent aspiration if ingestion is known to be within 1 hour: gastric lavagefollowed by activated charcoal only for noncaustic agents (not acidic or alkaline) if ingestion is known to be> 1 hour ago: activated charcoal not for heavy metals (e.g., iron, lithium), alcohols, caustic agents contraindicated in known small bowel obstruction/perforation can be given in multiple doses due to low side effect profile if ingestion includes drug packets, enteric-coated/sustained-release pills, and/or cannot be absorbed by activated charcoal: whole bowel irrigation contraindicated in known SBO, perforation, GI hemorrhage methods no longer used (i.e., wrong answers on USMLE) syrup of ipecac forced diuresis cathartics ocular and dermal remove any accessories and irrigate with saline urine alkalization for aspirin, methotrexate, barbiturate, chlorpropamide, TCA overdose pH > 7.5 traps weak acids in urine to increase elimination hemodialysis when all other routes of decontamination / elimination fail for toxins with low Vd, high water solubility, low molecular weight, low protein binding alcohols lithium phenobarbital carbamazepine valproate methotrexate Secondary survey physical exam with search for toxidromes AMPLE history to identify toxin vitals, ECG, Foley, radiographs Specific antidote discussed elsewhere Disposition strongly consider admission due to delayed onset of many side effects arrange psychiatric evaluationafterpatient is medically optimized