Pocket Emergency Medicine (Pocket Notebook Series) 3rd Ed.

GENERAL APPROACH TO THE INTOXICATED PATIENT

Approach

• (1) ABCs, resuscitate/stabilize → (2) decontaminate (GI tract, skin, eyes)/enhance elimination (charcoal, dialysis) → (3) treat w/ antidote, if available & indicated

• Consider empiric naloxone, dextrose, thiamine in pts w/ depressed MS. Use flumazenil w/ caution as it can precipitate sz.

• Call Poison Control (800)222-1222

History

• Timing, quantity of ingestion/exposure, access to household chemicals/other meds, coingestions, enteric-coated/extended-release substances

Physical Exam

• VS, pupils, skin, neuro findings (AMS, nystagmus, myoclonus, tremor), peristalsis, smell

Evaluation

• ECG, FSG, CBC, chemistries, LFT’s, UA, ABG, hCG, osmolar/anion gap

• Drug levels

• Exposures for which drug level is useful: APAP, salicylates, theophylline, lithium, digoxin, EtOH, carboxyhemoglobin, methemoglobin, iron, methanol, ethylene glycol, lead, mercury, arsenic, organophosphate, anticonvulsants

Treatment

Dermal Decontamination

• Irrigation w/ copious volumes of H₂O (unless metallic Na, K, or phosphorus)

Ocular Decontamination

• Irrigation w/ copious volumes of H₂O

Enhanced Elimination

• Urinary alkalinization w/ NaHCO₃ (eg, salicylates, phenobarbital, formic acid)

• HD (eg, ethylene glycol, methanol, lithium, salicylates)

Disposition

• Admit for any significant ingestion/exposure; consider transfer for complex presentations & inadequate hospital resources

Pearl

• Hospital tox screens vary → learn your hospital’s screen to guide your practice