IM 665 Approach to the Toxicologic Emergency

Mary Hughes DO 1 of 7

A GENERAL APPROACH TO THE TOXICOLOGIC EMERGENCY

I. INTRODUCTION

The emergency medicine specialist is the expert in managing the acute poisoning. No other medical specialty
possesses that level of expertise. However, once a patient is admitted to the hospital, treatment of the poisoned
patient usually is the concern of the internist, pediatrician or family practitioner. Therefore, an academic knowledge
base and practical clinical approach concerning toxicologic emergencies is required of all physicians. The purpose
of this lecture is to provide an introduction to the management of the acutely poisoned patient.

II. OVERVIEW

A. Toxicology is a study of poisons and their antidotes.

B. Poisonings are the exposure to non-pharmacological substances. Overdose is the

exposure to pharmacological substances, intentional or unintentional.

C. 30,000 patients commit suicide by ingestion annually. 50% of adult overdoses are mixed
ingestions. Approximately 10% of ambulance calls are poison related and 80% of all
poisoning victims are children. 80-90% of childhood poisonings occur in children less than 5 years of age,
and, in fact, child abuse should be suspected in a child with normal intellect over the age of 5 who is the
victim of poisoning. Approximately 2-5% of all pediatric admissions are for toxicological ingestions. In
persons over 65 years of age, 9.4% of admissions to a hospital are drug induced.'

III. ROUTES OF EXPOSURE

A. Ingestion
B. Inhalation
C. Injection
D. Absorption

IV. BASIC APPROACH TO THE POISONED PATIENT

A. EMS Evaluation

The survey of the scene is extremely valuable in the initial management of the patient who suffers from
poisoning or overdose. EMS personnel are well trained to survey the scene at the time they are stabilizing
the victim. A complete history and physical examination should be performed as soon as possible and
measures should be taken to reduce absorption. This may include giving the patient a shower and washing
their hair prior to transporting to the hospital if the means of exposure is skin related. General supportive
care should be provided to all poisoned patients.

As with all patient presentations, an accurate history should be attempted. In poisonings this is often difficult or next
to impossible for several reasons:

1. The patient is too young to tell what they did.

2. The overdose is not witnessed.
3. The patient is uncooperative and refuses to give accurate information.
4. The patient is comatose.
5. The patient has no idea what they took.
6. The patient lies to deceive the care-giver in a direct attempt to prolong time to accurate treatment in hopes
that they will die first.

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It is always important to find out who accessed the healthcare system and why. It is imperative to know
what has already been done prior to arrival of the patient and vigorous attempts should be made to speak
to any witnesses that were at the scene or talked to the patient prior to their presentation to the hospital to
validate stories.

B. Initial Management

The principles of managing the acute overdose or poisoning are axiomatic, and include a) addressing the ABCs, b)
identifying the offending agent, c) removing or neutralizing the toxin, and d) administering antidotal therapy is
always prescribed. These will be discussed in further detail.

1. Addressing the ABCs

As hopefully you all know, ABCs stands for Airway, Breathing and Circulation. The adequacy of airway should be
determined. Quite often simple maneuvers such as the jaw thrust can provide a patent airway. An oral airway
should be avoided unless the patient is comatose. Ventilation is usually easily accomplished by a bag valve mask
with supplemental oxygen. Definitive airway management is intubation, especially if there is significant risk of
aspiration or an absent gag reflex in a comatose patient. Not all conscious patients have a gag reflex, so the mental
status in conjunction with the presence or absence of gag reflex is an important combination to be assessed for. The
circulatory status is rapidly assessed by the pulse and blood pressure. A rhythm strip may be useful and an EKG is
often required. Hypotension is initially addressed by a fluid bolus of normal saline. Occasionally vasopressors may
be needed to correct hypotensive problems. Hypertensive problems may be managed by antihypertensives as
appropriate.

The next decision point is to evaluate the patient's mental status. In the general approach to the patient who is
comatose, the DON'T therapy is often utilized. This is also called the “Coma Cocktail.”

D = Dextrose - Adults: 1 amp D50/W (Children: D25/W: lgm/Kg) –if you have a normal accucheck you do not
need to give dextrose solution
0 = Oxygen - high flow oxygen should be given – even if saturation is normal, until carbon monoxide is ruled out as
a cause
N =Narcan 1-2 mg IV, IM, sub Q, IO, endotracheally or sublingually should be given. No side effects and life-
saving is an acute narcotic overdose, although sometimes larger doses will need to be given to see an effect.
T =Thiamine - generally l00 mg is given IM or IV if the patient is a chronic alcoholic and nutritionally depleted. The
oral route may also be used in patients who are not vomiting, and often a multivitamin is used. 'Thiamine should be
given prior to glucose to preclude the precipitation of Wernicke's encephalopathy. '' This old dictum has being
replaced by the recommendation that both be given in a timely fashion in the ED. (Greene)

Flumazenil is not routinely given as patients on chronic benzodiazepines are likely to have a seize when
given this medication.

All patients who are poisoned and compromised should have at least 1 intravenous line of normal saline
started, be placed on high flow oxygen if they are not in need of intubation and be placed on a cardiac
monitor. Blood should be drawn for labs which will be discussed a little later in the lecture. THE
PATIENT MUST BE CONTINUALLY REASSESSED AS MOMENTARY CHANGES IN
VITALS, MENTAL STATUS OR ABCs MAY OCCUR AND MAY NEED TO BE ADDRESSED.

The patient should be completely undressed and a core temperature should be obtained in all patients who are
poisoned. A close inspection for trauma is mandatory in all of these patients. Be sure to log roll and look at the
back.

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2. Identification of the Poison

Identification of the agent or agents ingested, inhaled, injected or absorbed is important for the definitive
treatment of the patient. There are several helpful sources of information which may include:

a. Patient or the family.

b. The containers with labels.
c. The pills themselves which may be identified through the pharmacy, internet, PDR or other mechanisms.
d. Radiographs: several agents are radiopaque and will show up on plain radiographs of the abdomen. Patients
who body pack often will have evidence of the same on x-ray.
e. Toxicology screens: These are often only the drugs of abuse and often take more than an hour to get back
from the laboratory. Generally you need urine and serum specimens and most often they only provide
qualitative rather than quantitative results initially. In addition, some tests will be falsely positive with routine
administration of Rx medications.
f. Indirect screens such as arterial blood gases, serum osmolarity, (calculated versus actual) to look for an
osmolar gap and general labs to look for anion gaps also may be clues to the type of ingestion. Often
important to determine the acid base status of the patient in serial fashion.

Vital signs are very often a telltale sign of the class of agent that the patient ingested. This will be discussed in detail
a little further in the lecture.

The criteria used to determine whether the exposure is nontoxic are: (1) an unintentional exposure to a clearly
identified single substance, (2) where an estimate of dose is known, and (3) a recognized information source (e.g., a
poison control center) confirms the substance as nontoxic in the reported dose.

3. Removal of the Toxin

Over the last several years there has been much debate over the appropriate agent to use to remove the toxin from the
stomach. Generally if the patient presents less than 1 hour from the time of ingestion, especially of a potentially
toxic dose of a compound, or up to 2 hours with toxic compounds that slow gastric empytying, then gastric emptying
is important. The typical method is gastric lavage, but this does not work for all items, and sometimes cathartics
given with charcoal, and/or whole bowel irrigation are used. Syrup of ipecac is no longer recommended.

'Gastric decontamination may be considered in individual patients after a three-question risk-benefit analysis: (1) Is this exposure
likely to cause significant toxicity? (2) Is gastrointestinal decontamination likely to change clinical outcome? (3) Is it possible that
gastrointestinal decontamination will cause more harm than good?' (Greene)

a. Lavage: Depending on the type of agent, gastric lavage, which is accomplished through a large tube placed
through the mouth and into the stomach, is used for this task. Lavage should be performed in the follow manner:

1) Protect the airway.

2) Select the proper size tube and mark the proper length of the tube to be passed prior to insertion.
3) Confirm tube placement prior to placing any irrigating fluids or connecting to suction.
4) Place the patient in Trendelenburg and left lateral decubitus positions to help prevent aspiration.
5) Lavage with saline using 200 cc aliquots in adults and 50-100 cc aliquots in children.
6) Use the tube to place activated charcoal, cathartic or antidote also once it has been placed for lavage.

b. Activated Charcoal: Activated charcoal is produced by distilling various organic materials and then
removing previously absorbed materials and reducing particle size. Activated charcoal adsorbs a number of
drugs and most organic and inorganic compounds. Multidose activated charcoal increases elimination of
toxins with enteroenteric, enterohepatic, or enterogastric recirculation. It is most often given as a water slurry
through either a lavage tube or a separately placed nasogastric tube into the stomach as it is almost intolerable
for patients to drink any amount. Occasionally children will drink charcoal without much difficulty, especially
if mixed with ice cream. Activated charcoal can be flavored with cherry syrup, chocolate syrup, ice cream or

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Mary Hughes DO 4 of 7

sherbet. Activated charcoal is not recommended with the ingestion of certain agents which are beyond the
scope of the general lecture. Activated charcoal does not effectively adsorb metals, corrosives, and alcohols
(Greene)

Activated charcoal also acts as gastrointestinal sink and the term "gastrointestinal dialysis", is sometimes
used. Frequent doses are extremely effective in treating both acute and chronic toxicity states of some
medications. The initial recommended loading dose is 1 gram per kilogram in adults followed by 20-60
grams every 4-6 hours. Paradoxically, the presence of food in the stomach at the time of ingestion may
enhance the effect of charcoal by slowing gastric emptying time and giving the activated charcoal more time
to adsorb drugs while they are in the stomach. Most often it is mixed with sorbitol, which acts as a cathartic.
The cathartic is only given with the first dose of activated charcoal.

c. Cathartics: Often cathartics are used to enhance transit time of poison through the gastrointestinal tract.
Often sorbitol 70% solution is incorporated with the charcoal to speed transit. One should be aware that when
using repeated doses of charcoal that it should be plain charcoal and not the type with Sorbitol already added.
The patient should get 1 dose at most of a cathartic agent.

d. Whole Bowel Irrigation: Occasionally this is necessary to remove toxins – expecially used for body stuffers
to attempt to remove packets intact, and for heavy metals, Lithium, Iron and sustained released products. It is
accomplished by instilling polyethylene glycol at a rate of 2 liters/hour until rectal effluent is clear in adults
and therer is no radiographic evidence of foreign objects if they were present before. Doses are available for
children as well.

e. Skin Decontamination: Agents that are absorbed through the skin are best removed by showering and using
copious amounts of soap and water to remove them. One should be very cautious not to contaminate the
caregiver while attempting to decontaminate the victim. The victim’s clothes should be removed and placed
in a separate container. Some chemicals are activated by water to cause a thermal reaction, and therefore
before automatically dousing a patient with water, you must look it up first in a reference to make sure it is
safe for the patient and caregive assisting.

4. Antidotal Therapy

Unless you treat large numbers of poisoned patients on a daily basis, nearly all ingestions must be looked up in some
sort of a reference to verify appropriate therapy. Calling the poison control center for your area will allow you
access to a toxicologist as well, which is often very helpful. They will log the patient into their data base, and follow
the patient to final disposition. Very often multiple drugs are ingested and you must take into account the indications
of each type of therapy in conjunction will all the other medications the patient may have ingested. There are several
references that are used for this type of information. One is the Poisondex or textbooks that contain information on
toxicology of various compounds. Lastly (only because very few hospitals have them) is a consult with a
toxicologist if they are available to your area. This would be first if you have an available toxicology service to
consult with. Certain sub-specialists also act as consultants to identify certain types of plants, mushrooms,
poisonous snakes or other animals that may cause toxicologic problems for the patient. When working in the ED, you
should have ready access to these types of information.

V. GENERAL LABORATORY TESTS TO ORDER

Although there are no specific laboratory tests for many of the toxicologic emergencies that are seen, routine
laboratory studies are generally indicated. These would include a complete blood count with differential, urinalysis
with a urine toxicology screen (you must be aware of what the urine toxicology screen provides or analyzes for in
your institution as this does vary from institution to institution), electrolytes, BUN, creatinine, glucose, serum
osmolarity and specific drug levels when indicated. Certain drugs such as alcohol, methanol, carboxyhemoglobin,
acetaminophen, salicylic acid, digoxin, theophylline, quinidine, phenytoin or fosphenytoin, phenobarbitol and
lithium all have readily available levels that can be checked in a routine hospital laboratory. Arterial blood gases are

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Mary Hughes DO 5 of 7

very often useful in determining whether the patient suffers from an acidosis or alkalosis which may point to a
particular type of ingestion. Calculating the anion gap and the osmolar gap will also help guide the clinician in
making the right diagnosis for an unknown ingestion. With so many medications affecting the QT interval, it is
important to obtain and interpret a 12 lead EKG as well.

VI. THINGS VITAL SIGNS CAN TELL YOU

As mundane and simplistic as it may seem, keen attention to the vital signs and serial evaluation of the vital signs
may reveal critical information allowing an accurate diagnosis to be made. They may also be the most important
measures of therapeutic effect of your treatment.

A. Respiration

Establishing an airway and assessing the respiratory status are always the first steps in treating an overdose victim.
The three things that commonly cause tachypnea are aspiration, toxic exposure to hydrocarbons, and CNS
stimulants. However, with CNS depressants, tachypnea may occur, rapidly followed by bradypnea. This
progression of fast to slow breathing is also seen with cyanide and carbon monoxide toxicity. In addition, tachypnea
is seen as a late effect in poisonings by agents producing a metabolic acidosis such as methanol and ethylene glycol.

Agents Commonly Causing Hypoventilation: Anesthetics, carbon monoxide, clonidine, cyanide, ethanol, opioids,
sedative hypnotics.

Agents Commonly Causing Hyperventilation: Amphetamines, CNS stimulants, cocaine, ethanol, ethylene glycol,
hydrocarbons, methanol, salicylates, theophylline, carbon monoxide (early) , quinidine, camphor and withdrawal
states. In addition, any compound that causes a metabolic acidosis will cause the patient to hyperventilate to attempt
to compensate.

B. Pulse

The pulse rate is an indicator of the balance between adrenergic and cholinergic tone. If there is an abnormal rate,
the offending agent must have some affect on this balance. Many cardiac drugs cause bradycardia (beta blockers,
calcium channel blockers, quinidine, digitalis, clonidine). Mushrooms containing muscarine can have a similar
effect. Organophosphates and carbamate insecticides also cause bradycardia.

Tachycardia is produced by sympathomimetics. Drugs that cause release of catecholamine such as amphetamines,
caffeine, cocaine, nicotine and theophylline cannot be differentiated from anticholinergics such as atropine,
scopolamine and tricyclic antidepressants by the pulse alone. Diaphoresis and increase bowel sounds suggest
adrenergic toxicity whereas decreased sweating and absent bowel sounds help to diagnosis anticholinergic toxicity.
In addition, withdrawal from ethanol, opioids or sedative hypnotics can cause increased adrenergic tone.

Agents Commonly Associated with Bradycardia: Beta blockers, calcium channel blockers, quinidine, digitalis,
gasoline, mushrooms, opioids, organophosphates, clonidine, sedatives, hypnotics.

Agents Commonly Associated with Tachycardia: Amphetamines, anticholinergic agents, antihistamine, arsenic,
atropine, caffeine, cocaine, cyanide, ethanol, hypoglycemics, nicotine, salicylates, sympathomimetics, theophylline,
tricyclic antidepressants and withdrawal states.

C. Blood Pressure

The blood pressure is most completely assessed by orthostatic measurement in the overdose victim, if possible. One
must interpret the blood pressure in light of concomitant clinical factors such as blood loss and diabetes.
Hypotension is caused by three main mechanisms.

1. Decreased peripheral resistance.

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2. Decreased myocardial contractility.

3. Dysrhythmia.

Some drugs can cause orthostatic hypotension without an initial supine hypotension. These agents are most
commonly cardiovascular drugs, tricyclic antidepressants, CNS depressants and antipsychotics. It should be
emphasized that in the hypotensive patient, a nontoxic etiology for the hypotension should be ruled out.

Hypertension is caused by CNS stimulants. Some agents such as monoamine oxidase inhibitors and clonidine cause
hypertension early on but then are followed by hypotension.

Agents Often Associated with Hypotension: Antihypertensive agents, antipsychotics, beta blockers, calcium
channel blockers, diuretics, ethanol, nitrates, opioids, sedatives, hypnotics, thiamine deficiency, tricyclic
antidepressants and monoamine oxidase inhibitors as a late finding.

Agents Often Associated with Hypertension: Amphetamines, cocaine, lead, monoamine oxidase inhibitors
(early), nicotine, phencyclidine, sympathomimetics, tricyclic antidepressants.
D. Temperature

Temperature is the most often overlooked vital sign. The safest method to obtain a temperature is to use a rubber
protected rectal probe or thermistor Foley Catheter. Hyperthermia is produced by a number of mechanisms
including muscle hypertonicity, peripheral and central thermogenic mechanisms and uncoupling of oxidative
phosphorylation.

Hypothermia is often caused by exposure. Some toxins which produce metabolic failure decrease temperature.
Other drugs cause hypothermia by affecting the hypothalamic axis.

Agents often Associated with Hypothermia: Antipsychotics, carbon monoxide, quinidine, cyanide, ethanol,
hydrogen sulfide, hypoglycemia, opioids, sedative hypnotics, thiamine depletion.

Agents Often Associated with Hyperthermia: Amphetamines, anticholinergic agents, antihistamines, cocaine,
ethanol withdrawal, LSD, sympathomimetics, tricyclic antidepressants.

VII. OTHER MARKERS THAT WILL HELP DETERMINE WHAT THE TOXIC AGENTS MAY BE:

A. Urine

Urine is typically yellow but may be almost any color. Clear urine often suggests over hydration or
ethanol, but diabetes mellitus or diabetes insipidus is also a consideration. An overdose of diuretics
would also cause clear urine. Dehydration alone can cause the urine to become dark orange. Red urine
may result from red cells, hemoglobinuria, myoglobinuria, chronic mercury or lead toxicity. Reddish-
brown urine suggests porphyria. Foods and other pharmacological substances may cause the urine to
change many shades of color.

B. Odors

Some toxins possess characteristic odors. Only the most common will be listed.

Garlic: DMSO, arsenic, organophosphates, phosphorus

Shoe polish: nitrobenzene
Bitter Almonds: cyanide, laetrile, apricot pits
Violets: turpentine
Rotten Eggs: hydrogen sulfate, sewer gas
Pears: chloral hydrate
Peanuts: vacor which is a rodenticide that damages the pancreas
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Mary Hughes DO 7 of 7

Acetone: isopropyl alcohol, ethanol, lacquer, chloroform, DKA and salicylate intoxication
Moth Balls: camphor

C. Eye Findings:

Looking at the eye including the pupils and movement will often give one more clue as to the possible agent or
agents.

Pupils mydriasis: mushrooms, withdrawal states. Anticholinergics, sympathomimetics.

Pupils miosis: Cholinergics, narcotics, nicotine, PCP, insecticides, mushrooms, clonidine.
Nystagmus: Agents that cause the eyes to have nystagmus include alcohols, barbiturates, phenytoin (Dilantin) , PCP
and carbamazepine (Tegretol).

VIII. The PRAGMATIC APPROACH TO THE PATIENT WHO HAS BEEN POISONED BY AN
UNKNOWN AGENT

Now that you have been completely overwhelmed by the multitude of toxicological problems that you may face, the
following is a general approach that you can use in all patients.

A. Follow the ABCs.

B. Focus on neurological and cardiovascular examinations and reassess these frequently Always pay attention to
the QRS width and the QTc interval..
C. If gastric emptying is desired, lavage should be strongly preferred.
D. In most overdoses, RAPID instillation of activated charcoal is the cornerstone of therapy.
E. If cathartics are to be used, avoid Sorbitol in young children and magnesium in adults. One dose is all that is
necessary.
F. Always consult the Poisondex or some other reference source such as a poison control center. Then you must
put together the pieces of the puzzle taking into account the patient, their underlying disease states, the
combination of medications that may have been the cause of their problem and the combination of treatments
necessary to see them through this event. In using one's pharmacology and medical knowledge, do what you
think is best.
G. The most aggressive approach in a seriously poisoned patient is management of vital signs, airway protection
followed by charcoal followed by lavage, followed by reinstallation of charcoal.

REFERENCES

http://www.lifeinthefastlane.com for ekgs

Greene S. General Management of Poisoned Patients. In: Tintinalli JE, Stapczynski J, Ma O, Cline DM, Cydulka
RK, Meckler GD, T. eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. New York, NY:
McGraw-Hill; 2011.
http://accessemergencymedicine.mhmedical.com/content.aspx?bookid=693&Sectionid=45915515. Accessed
September 08, 2014.

Hack JB, Hoffman RS: Thiamine before glucose to prevent Wenicke encephalopathy: Examining the conventional
wisdom. JAMA 1998; 279: 583.

Schabelman E, Kuo D: Glucose before thiamine for Wernicke encephalopathy: a literature review. J Emerg Med
November 19, 2011.

IM 665 Approach to the Toxicologic Emergency handout.doc