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Tox Overview EMERGENCY MEDICINE PRACTICE AN EVIDENCE-BASED APPROACH TO EMERGENCY MEDICINE August 2001 Toxicology Update: A Rational Volume 3, Number 8 Approach To Managing Authors Timothy B. Erickson, MD, FACEP, FACMT Department of Emergency Medicine; Director, Section The Poisoned Patient of Toxicology, University of Illinois, Chicago, IL. Steven E. Aks, DO, FACMT Fellowship Director, Toxikon Consortium; Cook County “What is it that is not a poison? Hospital, University of Illinois Hospital, Rush- All things are poison and nothing is without poison. Presbyterian-St. Luke’s Medical Center, Chicago, IL. It is the dose only that makes a thing not a poison.” Leon Gussow, MD, ABMT —Paracelsus (1493-1541), Department of Emergency Medicine, Cook County Hospital, Chicago, IL. the Renaissance “Father of Toxicology,” in his Third Defense.1 Robert H. Williams, PhD, DABCC, FACMT Department of Pathology, University of Illinois, Chicago, IL. OXIC overdose can present with a great variety of clinical symptoms— Peer Reviewers from minor presentations such as nausea and vomiting, to the calamitous, T William Kerns II, MD, FACEP including altered mental status, seizures, cardiac dysrhythmias, hypotension, Emergency Medicine and Medical Toxicology, Carolinas and respiratory depression. In the patient with altered mental status, there may Medical Center, Charlotte, NC. be few clues to diagnosis at the time of initial assessment and management. The Peter Viccellio, MD, FACEP diagnosis may be complicated by the ingestion of multiple drugs. Professor of Emergency Medicine, SUNY at Stony Brook, The clinical course of a poisoned patient depends largely on the specific Stony Brook, NY. Marianne C. Burke, MD toxicity of the agent and the quality of care delivered within the first several Emergency Medicine Consultants, Glendale, CA. hours. Fortunately, in most instances, the drug or toxin can be quickly identified CME Objectives by a careful history, a directed physical examination, and commonly available laboratory tests. Attempts to identify the poison should, of course, never delay Upon completing this article, you should be able to: life-saving supportive care. Once the patient has been stabilized, the physician 1. form a differential diagnosis after presentation of needs to consider how to minimize the bioavailability of toxin not yet absorbed, clinical scenarios involving toxicology; which antidotes (if any) to administer, and whether other measures to enhance 2. discuss the management (including antidote use) of a variety of specific poisonings; 2 elimination are necessary. 3. identify the utility of laboratory data and other aids for diagnosis of poisoned patients; Clinical Practice Guidelines And Systematic Reviews 4. determine by critical evaluation the validity of previously rigid standards of care in toxicology; and There are several published position statements,3-7 practice guidelines, and 5. evaluate the role of various poisoning treatment consensus statements8 regarding the management of overdoses. However, the modalities using evidence-based medicine. majority of the toxicology literature is based on retrospective case series Date of original release: August 3, 2001. analysis or isolated case reports (Class III evidence) with isolated animal/bench Date of most recent review: August 1, 2001. research. Investigations regarding gastric decontamination either involve adult See “Physician CME Information” on back page. Editor-in-Chief Medicine, The University of Center, Atlantic Health System; School of Medicine; Attending University of Florida; Orlando New Mexico Health Sciences Vice-Chairman, Department of Physician, UCLA Emergency Regional Medical Center; Medical Stephen A. Colucciello, MD, FACEP, Center School of Medicine, Emergency Medicine, Morristown Medicine Center; Co-Director, Director of Orange County Assistant Chair, Director of Albuquerque, NM. Memorial Hospital. The Doctoring Program, Emergency Medical Service, Clinical Services, Department of W. Richard Bukata, MD, Assistant Michael A. Gibbs, MD, FACEP, UCLA School of Medicine, Orlando, FL. Emergency Medicine, Carolinas Clinical Professor, Emergency Residency Program Director; Los Angeles, CA. Alfred Sacchetti, MD, FACEP, Medical Center, Charlotte, NC; Medicine, Los Angeles County/ Medical Director, MedCenter Air, John A. Marx, MD, Chair and Chief, Research Director, Our Lady of Associate Clinical Professor, USC Medical Center, Los Angeles, Department of Emergency Department of Emergency Lourdes Medical Center, Camden, Department of Emergency CA; Medical Director, Emergency Medicine, Carolinas Medical Medicine, Carolinas Medical NJ; Assistant Clinical Professor Medicine, University of North Department, San Gabriel Valley Center; Associate Professor of Center, Charlotte, NC; Clinical of Emergency Medicine, Carolina at Chapel Hill, Chapel Medical Center, San Gabriel, CA. Emergency Medicine, University Professor, Department of Thomas Jefferson University, Hill, NC. Francis M. Fesmire, MD, FACEP, of North Carolina at Chapel Hill, Emergency Medicine, University Philadelphia, PA. Chapel Hill, NC. of North Carolina at Chapel Hill, Director, Chest Pain—Stroke Corey M. Slovis, MD, FACP, FACEP, Associate Editor Chapel Hill, NC. Center, Erlanger Medical Center; Gregory L. Henry, MD, FACEP, Department of Emergency Assistant Professor of Medicine, CEO, Medical Practice Risk Michael S. Radeos, MD, MPH, FACEP, Andy Jagoda, MD, FACEP, Professor Medicine, Vanderbilt University UT College of Medicine, Assessment, Inc., Ann Arbor, Attending Physician in Hospital, Nashville, TN. of Emergency Medicine; Director, Chattanooga, TN. MI; Clinical Professor, Department Emergency Medicine, Lincoln International Studies Program, Valerio Gai, MD, Professor and Chair, of Emergency Medicine, University Hospital, Bronx, NY; Research Mark Smith, MD, Chairman, Mount Sinai School of Medicine, Department of Emergency of Michigan Medical School, Ann Fellow in Emergency Medicine, Department of Emergency New York, NY. Medicine, University of Turin, Italy. Arbor, MI; President, American Massachusetts General Hospital, Medicine, Washington Hospital Center, Washington, DC. Michael J. Gerardi, MD, FACEP, Physicians Assurance Society, Ltd., Boston, MA; Research Fellow in Editorial Board Clinical Assistant Professor, Bridgetown, Barbados, West Indies; Respiratory Epidemiology, Thomas E. Terndrup, MD, Professor Medicine, University of Medicine Past President, ACEP. Channing Lab, Boston, MA. and Chair, Department of Judith C. Brillman, MD, Residency and Dentistry of New Jersey; Jerome R. Hoffman, MA, MD, FACEP, Steven G. Rothrock, MD, FACEP, Emergency Medicine, University Director, Associate Professor, Director, Pediatric Emergency Professor of Medicine/ FAAP, Associate Professor of Alabama at Birmingham, Department of Emergency Medicine, Children’s Medical Emergency Medicine, UCLA of Emergency Medicine, Birmingham, AL. volunteers taking sub-toxic amounts who receive decon- significance of urine or plasma drug levels. Toxicokinetics tamination at a set post-ingestion time, or involve mildly to may also be used to predict the onset of symptoms and moderately poisoned patients, excluding those with duration of toxicity.17 significant overdoses. Very few children have been included in these trials. Differential Diagnosis Well-controlled, randomized, human trials with adequate sample sizes are infrequent. The conflicting Toxins may cause fever, headache, and abdominal pain; literature regarding the utility of hyperbaric oxygen (HBO) indeed, any symptomatic patient can be a potential drug therapy in carbon monoxide (CO) poisoning is one example overdose. Altered mental status, GI complaints, cardio- where the absolute conviction of various experts is out- vascular compromise, and seizures can all be toxin- weighed only by the paucity of good data.9 related. Some toxins produce subtle effects, such as the The American Association of Poison Control Centers “flu-like” symptoms seen with CO poisoning, or cases of provides annual reports based on data from Regional digitalis overdose, which may mimic intrinsic heart Poison Centers.10 However, poison center data may not disease. Furthermore, when faced with any known accurately reflect current reality. Under-representation may overdose, the clinician should also consider agents that occur in the case of lethal agents, because the majority of have similar effects or may be found on the same shelf in poisoning deaths never arrive at hospitals (instead, they the bathroom cabinet. That is, with acetaminophen, think become cases for the medical examiner).11 On the other aspirin; with digitalis, add ß-blockers and calcium- hand, emergency physicians treat most minor ingestions channel antagonists to the list of suspects. without consulting a Poison Center. Well-designed forensic toxicology data are rare. Prehospital Care There are few well-controlled trials that examine the Epidemiology And Etiology impact of prehospital care on the poisoned patient. It is Descriptions of poisonings come to us from ancient times. taken for granted that medics should perform basic (Some even come from the future. An investigation of the stabilization measures such as providing oxygen when logs of the Enterprise obtained from the original “Star needed, employing cardiac monitoring for those with Trek” television series revealed that 35% of the episodes unstable vital signs and cardiotoxic overdoses, and involved toxin-related incidents.12 These toxic mishaps establishing venous access in those who may require usually
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