TY - CHAP M1 - Book, Section TI - Toxicology in Adults A1 - Nguyen, HoanVu A1 - Comstock, Grant A1 - Pitotti, Christopher A1 - Lavonas, Eric A2 - Schmidt, Gregory A. A2 - Kress, John P. A2 - Douglas, Ivor S. PY - 2023 T2 - Hall, Schmidt and Wood’s Principles of Critical Care, 5th Edition AB - KEY POINTSInitial Approach to a Poisoned PatientPoison control center consultation may aid in determining appropriate laboratory testing, patient disposition, management, and need for specific targeted treatments; the US national toll-free emergency phone number is 1-800-222-1222.Initial management of poisoned patient should be targeted to addressing immediate life threats: airway management, breathing and ventilation, and cardiovascular support.Cardiopulmonary resuscitation and advanced cardiac life support may be extended in some poisoned patients with good neurologic recovery.Intubation is a clinical decision, and gag reflex should not be elicited to make this determination.For ventilator management, special attention must be paid to toxins that have differential tissue distribution based on tissue pH (eg, salicylates).Xenobiotic-induced bradycardia can be addressed with atropine, sympathomimetic pressors, transcutaneous or transvenous pacing, as well as specific antidotes: calcium, glucagon, sodium bicarbonate, naloxone, and digoxin-specific antibodies, in appropriate situations.Xenobiotic-induced QT prolongation and polymorphic ventricular tachycardia can be addressed by optimizing electrolytes, avoiding other QT-prolonging agents, and potentially intravenous magnesium, isoproterenol, and overdrive electrical pacing.Xenobiotic-induced hypertension can be addressed by targeting the underlying cause, typically by using sedating medications; otherwise, short-acting titratable agents such as nitroglycerin, nitroprusside, or phentolamine.Naloxone reversal of opioid poisoning should begin with low doses (eg, ≤0.4 mg IV) and titrated to restore protective airway reflexes and adequate spontaneous minute ventilation unless apneic; failure to respond to naloxone beyond 10 mg should prompt search for alternative causes.Cautious administration of flumazenil (0.2 mg test dose) can be considered in patients with suspected benzodiazepine-mediated central nervous system (CNS) depression without history or presence of benzodiazepine dependence, seizure, tachycardia, myoclonus, or hyperreflexia.Evidence-based pharmacologic options to address acutely agitated, violent, or patients suffering from psychoses who do not respond to de-escalation techniques include ketamine, midazolam, droperidol, haloperidol, and olanzapine.Benzodiazepines are first-line treatment for common xenobiotic-induced seizures, followed by barbiturates or propofol, and escalating to general sedation; traditional second-line therapies (eg, phenytoin, levetiracetam) are not expected to be as beneficial; pyridoxine is utilized for certain xenobiotic-induced seizures.Xenobiotic-induced alterations in temperature must be treated aggressively to minimize life-threatening complications using external cooling, sedating medications, and/or neuromuscular blockade for hyperthermia, and rewarming for hypothermia.Diagnosis of Toxic ExposureClassic collections of symptoms in toxicologic syndromes (toxidromes) are specific, but not sensitive; they can be confused, and absence of a toxidrome has not been shown to reliably exclude the possibility of exposure.Osmolar gap must be ordered and interpreted with caution and should not be used as a general screening test.Oxygen saturation gaps between calculated saturation on arterial blood gas compared to pulse oximetry may suggest the presence of abnormal hemoglobin (eg, methemoglobin).Urine drug screens can provide evidence of exposure but are limited by false positive, false negatives, and inability to provide timing of exposure information.Routine testing for acetaminophen and/or salicylates ingestion in all patients with intentional overdose is recommended due to the ubiquity of these compounds in many households.Whole bowel irrigation and/or surgical consultation may be considered in cases of patients who have ingested large quantities of packaged substances (“body packers”).DecontaminationGastric lavage is rarely used in modern poisoning treatment, though may be considered in ... SN - PB - McGraw Hill CY - New York, NY Y2 - 2024/10/05 UR - accesssurgery.mhmedical.com/content.aspx?aid=1201812004 ER -