Translating your way through medical toxicology can be somewhat convoluted – especially when presented with a labyrinth of information. From recognizing toxidromes to implementation of management strategies to knowledge of common “street” drug names, the realm of toxicology needs to be translated and broken down into digestible parts.
Translating Toxicology Part 1: The Approach is by no means all-encompassing. It’s meant to introduce the approach to the poisoned patient and how we can be effective in our roles to improve the care delivered to our toxicologic patients. In Translating Toxicology: Part 2 we will focus more on recognizing toxidromes (i.e. how certain poisonings can result in certain presentations). Let’s get started.
A 37-year-old female is found to be acutely altered by family members at home. There is some suspicion of a toxic ingestion. Where do we even begin?
Whether you work predominately in the prehospital or hospital setting, there is one very important concept to keep in mind – not all altered patients are poisoned! Let’s reiterate this point as it’s a very important one – not all altered patients are poisoned. Therefore, it’s important to have an open mind and a broad approach when it comes to any altered patient. One approach is the AEIOU TIPS mnemonic.
Not necessary to memorize but highly useful to refer to, this mnemonic will force you to think of the other possible causes as to why a patient may be altered. Many organic issues, such as alcohol abuse and withdrawal, hepatic encephalopathy, hypoxia or hypercarbia, renal failure and intercranial abnormalities as well as non-organic causes such as psychiatric disorders are just some examples that can result in altered mental status.
Critical Point #1: Keep an open mind and think outside the “toxicology box.” Not all altered patients are poisoned!
Next, how do we begin to assess the toxicologic patient? The traditional approach of obtaining a history (getting a story from the patient), conducting a physical exam, ordering certain investigations, providing treatment and deciding on a disposition may not be possible in these situations. Often, we find ourselves needing to take a different approach, one that may involve resuscitating prior to asking questions. One approach used (as exemplified by the fantastic folks over at Life in the Fast Lane) to the poisoned patient is RRSIDEAD.1
This is simply one approach that gives us an outline of how to manage and assess our poisoned patient.
Critical Point #2: We may need to intervene prior to asking questions!
But wait! Before laying hands on the patient, always remember to protect yourself as a health care provider and protect your patient. Ensure you’ve put on your PPE (Personal Protective Equipment) and decontaminate (in this case, removal of the patient’s contaminated clothing +/- liberal irrigation/flushing/washing) the patient in the appropriate setting (e.g. cholinergic poisonings – more to come on this in a later post).
Critical Point #3: Protect yourself so you can provide quality care to your patient!
Once you’ve done this very critical step you can begin your resuscitation. Here your ABCDEs are key! Don’t forget your IV access, oxygen (for those patients requiring it) and place them on a cardiac monitor. Remember to appropriately correct your abnormal vital signs, treat dysrhythmias as you would according to ACLS (Advanced Cardiac Life Support) protocols and remember to abate seizure activity with appropriate medications at the appropriate dose.
Next, obtain a risk assessment on your toxicology patient. Essentially, this involves obtaining details around the exposure and includes questions like: what was taken? When was it taken? What was the estimated dose? What symptoms have been witnessed? And, is there any other specific information pertaining to the patient (AMPLE history, patient’s weight, etc.) that might be useful? This can prove to be challenging as the patient may not be able to communicate this information to you.
Therefore, make sure to use valuable resources that may help you in obtaining collateral history. Examples include family members/friends, paramedics, the local pharmacy/clinical pharmacist, confiscated pill bottles and remaining tablets/capsules as well as size, shape and colour of the pills. Remember to also be on the lookout for valuable hints in the patient’s history. For example, a patient with known chronic pain may be at risk for an opioid overdose whereas a schizophrenic patient that is taking antipsychotic medications may potentially be at risk for neuroleptic malignant syndrome or serotonin syndrome.
Critical Point #4: Be sure to obtain collateral history from other individuals, pills and pill bottles and from hints found in the patient’s history. Your pharmacist (if you are fortunate to have one in your department) is of crucial importance in this situation.
Once this information is compiled to the best of your ability, remember to make contact with your local poison control centre when necessary. They are an extremely important and helpful resource that can help guide your entire management strategy.
Critical Point#5: Know the number to your local Poison Control Centre, have it posted in your resuscitation area, and enact their help early!
A very focussed physical exam is also of the utmost importance. This can be overwhelming; however, lets emphasize 5 key elements that will help direct your care:
- Slowed respiratory rate/Apnea/Tachypnea
- Mydriasis – Big
- Miosis – Small/pinpoint
- Mental Status
- Agitated/excited delirium
- Sleepy but rousable
- Glucose – although more investigative, obtaining a fingerstick glucose is quick, easy and can allow for a potentially drastic change in early management.
The application of this process will become clearer in a future post; however, take a moment to recite these 3 words in your head multiple times: VITALS, SKIN, PUPILS! Again… VITALS, SKIN, PUPILS! And one more time… VITALS, SKIN, PUPILS! These 3 elements can yield a ton of information when a poisoned patient cannot communicate it to you.
Critical Point #6: When assessing a toxicology patient look closely at their VITALS, SKIN and PUPILS!
After the acute resuscitation phase, poisoned patients will require on-going care. Teamwork and communication is critical when providing supportive care (not to mention critical in all areas of health care). In this case, supportive care may consist of fluid therapy (type and amount), analgesia and sedation, head of bed elevation (30 degrees), indwelling Foley catheter with clear ins and outs, NG/OG tubes and a calm environment. Moreover, ensure to provide psychosocial support for the patient, their family members and/or friends who may be at the bedside.
Clear communication between the health care team is essential when it comes to the management plan. Team handovers would be highly encouraged to communicate a clear plan that may involve on-going therapy, de-escaltion of therapy and/or duration of observation/monitoring.2
Critical Point #7: Team handovers allow for clear management plans and improve the likelihood of delivering quality care to our poisoned patients!
You’re now ready to begin your investigations and the following would be recommended and/or useful:
- CBC and differential
- Electrolytes (possibly extended electrolytes), creatinine, glucose
- Blood Gas
- Acetaminophen, Salicylate levels and serum EtOH
- Serum osmolality
- Urine Drug Screen
Any extra tests would then be directed toward patient specifics (e.g CT head, specific drug screens, lumbar puncture, TSH, carbon monoxide).
Critical Point #8: Now is not the time to debate the utility/disutility of laboratory investigations! Cast a wide net in the hopes of catching valuable biochemical information.
Next, we must consider decontamination of our patient. This can be done in 2 ways. We can either 1) remove the toxin or 2) bind the toxin. I repeat, we can either remove it or bind it!
This is rarely done nowadays as there can be risk to the patient. One way to remove toxin is by administering syrup of IPECAC. This rapid-acting emetic was once widely used (and comedically referenced here) to cause patients to vomit up their potentially toxic ingestion. Its benefit was questionable at best and is no longer used in the care of poisoned patients.3
Critical Point #9: Forget the term IPECAC! IP – what?? Exactly!
Another method of toxin removal is with orogastric lavage – placement of a large tube into the stomach via the esophagus for the purpose of aspirating out stomach contents (i.e. “pumping the stomach”). This too is rare, and if conducted, would likely be done within one hour of ingestion and would never be done without airway protection. Keep in mind that advanced airway management (i.e. endotracheal intubation) would not be indicated purely for the placement of orogastric lavage.
This involves the administration of activated charcoal (AC). AC is a black, gritty substance that is not so tasty. The tiny particles of AC give it an extremely large surface area. For example, a standard 50 gram dose of AC is like putting the surface area of 12 football fields into the patient.4,5 We hope to use this large surface area to bind (or hold onto) particles of toxin within the gut, thereby preventing toxin absorption. Please keep in mind that AC is not for everyone as it can “PHAIL” in certain patients.
If we can’t (or don’t) decontaminate with AC, we can consider enhanced elimination. This is accomplished via whole bowel irrigation (WBI). WBI is an excellent way to make enemies with your nursing colleagues (only half joking here) and involves the administration of polyethylene glycol (PEG) to induce rapid laxation. The hope with WBI is we may prevent significant toxin absorption if we rapidly push the toxin through the gut.
Critical Point #10: Don’t make enemies! Have a shared mental model when it comes to WBI!
ANTIDOTES & DISPOSITION
Our final steps involve administering specific antidotes for specific poisonings (more to come in future posts) and determining a disposition, or a definitive plan for the overall care of our patient. Remember to observe these patients in appropriate care areas. They may require prolonged monitoring and numerous vital sign checks. Unmonitored areas that are located far away from the eyes of the nursing station may be poor locations to place our poisoned patients.
Translating toxicology requires breaking down seemingly large scenarios into more straightforward, digestible and understandable items. This post attempts to focus on the approach to the poisoned patient. Key takeaways include:
- Not all altered patients are poisoned patients! AEIOUTIPS is one tool that can be used to help identify cause of a patient’s altered state.
- We can’t necessarily use a traditional approach in the management of these patients. Consider RRSIDEAD (Resuscitate, Risk Assessment, Supportive Care, Investigations, Decontaminate, Eliminate, Antidotes and Disposition).
- Protect yourself and your patient with appropriate PPE and decontamination.
- Traditional ABCs for supportive care
- Collateral history is key! Get help from all your friends in all health professions.
- Arguably the 3 most important physical exam findings are the VITALS, SKIN, and PUPILS.
- I repeat again…VITALS, SKIN, PUPILS.
- Consider removing, binding or eliminating toxins (where appropriate).
- Observe patients accordingly and determine appropriate and safe disposition plans.
- Iona Vlad, “RRSIDEAD”, available at https://litfl.com/rrsidead-resuscitation/
- Chris Johnson, “Passing the Baton: Patient Handovers in the ED”, posted January 16, 2019. Available at https://emcentered.com/passing-the-baton-patient-handover-in-the-ed/
- Harris PJF, Liu Z, Suenaga K. Imaging the atomic structure of activated carbon. J Phys: Condens Matter. August 2008:362201
- David JuurlinK, “We Need to Talk about Charcoal”, posted December 2, 2019. Available at https://emcrit.org/toxhound/charcoal/
Please remember to check out our upcoming post Translating Toxicology: Part 2 where we will attempt to break down specific drugs and the presentations they may cause.
Emergency Physician in New Brunswick, Canada
Co-creator and administrator/author EMcenterED