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Updated: Dec 31 2021

Approach to Overdose/Poisoning

  • 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
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