The Poisoned Patient

Question 1

Approach to the poisoned patient?

Answer 1

RESUS-RSI-DEAD
1. Resuscitation
2. Risk assessment
3. Supportive care and monitoring
4. Investigations
5. Decontamination
6. Enhanced elimination
7. Antidotes
8. Disposition

Question 2

Resuscitation?

Answer 2

1. Airway
2. Breathing
3. Circulation
4. Seizure control
5. Correct hypoglycemia
6. Correct hyperthermia
7. Resuscitation antidotes

Question 3

Resuscitation antidotes?

Answer 3

1. Naloxone: opioids
2. Atropine and pralidoxime: organophosphates
3. Hydroxy cobalamin and thiosulphate: cyanide
4. Sodium bicarbonate: Sodium channel blockers
5. Digi bind: digoxin
6. high dose insulin euglycemic therapy: Calcium cannel
   blockers and beta blockers
7. Intralipid: local anesthetics

Question 4

What is risk assessment?

Answer 4

Cognitive + quantitative process used to predict individualized
likely clinical course and potential complications

Question 5

Considerations in risk assessment?

Answer 5

1. Agent (s)
2. Dose (s)
3. Time since ingestion
4. Current clinical status
5. Patient factors

Question 6

Supportive care and monitoring?

Answer 6

FAST HUGS IN BED PLEASE
1. Feeding/fluids
2. Analgesia, antiemetics
3. Sedation
4. Head up position
5. Ulcer prophylaxis
6. Glycemic control
7. Skin/eye care and suctioning
8. Indwelling catheter
9. Nasogastric tube
10. Bowel cares
11. Environment (temperature,
appropriate surroundings)
12. De-escalation (End of life,
medication no longer needed)
13. Psychosocial support (For
patient, family, staff)

Question 7

Screening investigations?

Answer 7

1. ECG
2. Paracetamol levels
3. Routine toxicology screen not indicated

Question 8

Specific Investigations?

Answer 8

1. Refine risk assessment
2. confirm or exclude an important differential
3. exclude or confirm complication with specific management
4. establish indication for antidote
5. establish indication to institute enhanced elimination
6. Monitor response to therapy

Question 9

Decontamination?

Answer 9

1. GI Decontamination
2. Activated charcoal
3. Gastric lavage
4. Whole bowel irrigation

Question 10

What enhances elimination? What do they eliminate?

Answer 10

1. Multidose activated charcoal
   - carbamazepine, dapsone, phenobarb, theophylline, quinine
2. Urine alkalisation
   - salicylates, phenobarb
3. Exchange transfusion
   - Methb
4. Dialysis
   - Theophylline, metformin, salicylates,
   toxic alcohols, valproate, lithium

Question 11

Antidotal therapy should be reserved for agents that?

Answer 11

1. have an antidote available
2. cause significant toxicity, that exceeds the potential harms of the antidote
3. cannot be managed by standard resuscitation, supportive care and monitoring
4. cannot be safely and effectively decontaminated before absorption
5. are not suitable for enhanced elimination

Question 12

Harms from antidotes?

Answer 12

1. distraction from other management priorities (e.g. resuscitation, supportive care and monitoring)
2. Dosing errors
3. Hypersensivity reactions (e.g. NAC, anaphylactoid reaction to vitamin K,
   allergy to antivenom)
4. specific adverse events (e.g.
5. excessive antidote effect (e.g. benzodiazepine withdrawal from flumazenil, sympathetic crisis and pulmonary edema from naloxone)
6. unanticipated effects in mixed overdoses (e.g. NAC may worsen hypotension in a mixed paracetamol / cardiotoxic overdose)
7. interference with laboratory assays (e.g. digoxin levels increase after digibind; intralipid may cause spurious biochemistry results)
8. Interference with other therapies (e.g. intralipid may decrease the
   effectiveness of lipid soluble therapeutic agents)

Question 13

Specific antidotes?