General approach to drug poisoning in adults
- Sean H Rhyee, MD, MPH
Sean H Rhyee, MD, MPH
- Assistant Professor of Emergency Medicine, Division of Medical Toxicology
- University of Massachusetts Medical School
Accidental and intentional poisonings or drug overdoses constitute a significant source of aggregate morbidity, mortality, and health care expenditure worldwide. Millions of poisonings and drug overdoses occur annually in the United States alone [1,2].
The general approach and initial management of patients with suspected or confirmed poisoning will be reviewed here. Specific issues relating to the management of common drug overdoses are discussed separately (see appropriate topic reviews). A topic devoted to the management of the critically ill patient with an unknown overdose is found separately. (See "Initial management of the critically ill adult with an unknown overdose".)
Accidental and intentional poisoning from both licit and illicit substances remains a major cause of morbidity and mortality worldwide [3-7]. In the United States, the American Association of Poison Control Centers (AAPCC) reported over 2.1 million human exposure calls in 2014. While the overall mortality rate reported by the AAPCC was 0.07 percent, 28.3 percent of cases required management at a health care facility and 7.9 percent of cases required hospital admission . Between 2008 and 2011 in the United States, there were an estimated 1.1 million annual emergency department (ED) visits related to drug poisoning, or 35.4 visits per 10,000 persons; 24.5 percent of these patients presenting with drug poisoning required hospital admission, compared with 12.7 percent for non-poisoning related presentations . Rates of poisoning cases among ED patients appear similar in other industrialized nations .
As of 2008, poisoning has become the leading cause of injury-related death in the United States, surpassing motor vehicle collisions. The majority of poisoning fatalities were related to drugs, with 36,500 cases in 2008 ; most overdoses involved prescription drugs . Patients aged 35 to 54 years accounted for the highest number of poisonings, but patients between the ages of 18 and 20 had the highest rate. The contribution of poisoning to suicide cases varies by region: suicidal poisoning is especially prevalent in Scandinavian countries and the United Kingdom, while the burden of suicidal poisonings is relatively less in most of Eastern Europe and Central and South America .
Among adults, the AAPCC reported the most common exposures were due to analgesics (11.3 percent), sedatives and antipsychotics (5.9 percent), and antidepressants (4.4 percent). A review of a toxicology case registry noted similar findings, with sedatives, analgesics and antidepressants accounting for the most frequently mentioned exposures . Reviews of self-poisoning cases in the United Kingdom and Spain found that analgesics, benzodiazepines, and antidepressants were the most commonly encountered drugs [9,14]. However, trends vary in other geographic regions. In a study of Norwegian patients, the most prevalent drugs (aside from ethanol) were acetaminophen, opioids, and gamma hydroxybutyrate (GHB) . A German study of intensive care unit (ICU) admissions found benzodiazepines, antidepressants and antihistamines were the most commonly encountered drugs, again excluding ethanol . A report of Israeli poison center data found that antimicrobials were the most frequently reported drugs, second only to analgesics (including opioids) .
- McCaig LF, Burt CW. Poisoning-related visits to emergency departments in the United States, 1993-1996. J Toxicol Clin Toxicol 1999; 37:817.
- Mowry JB, Spyker DA, Brooks DE, et al. 2014 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 32nd Annual Report. Clin Toxicol (Phila) 2015; 53:962.
- Gjersing L, Jonassen KV, Biong S, et al. Diversity in causes and characteristics of drug-induced deaths in an urban setting. Scand J Public Health 2013; 41:119.
- Gallagher LM, Kappatos D, Tisch C, Ellis PM. Suicide by poisoning in New Zealand--a toxicological analysis. N Z Med J 2012; 125:15.
- Sinyor M, Howlett A, Cheung AH, Schaffer A. Substances used in completed suicide by overdose in Toronto: an observational study of coroner's data. Can J Psychiatry 2012; 57:184.
- Susnjara IM, Smoljanović A, Gojanović MD. Drug related deaths in the Split-Dalmatia County 1997-2007. Coll Antropol 2011; 35:823.
- Liu Q, Zhou L, Zheng N, et al. Poisoning deaths in China: type and prevalence detected at the Tongji Forensic Medical Center in Hubei. Forensic Sci Int 2009; 193:88.
- Albert M, McCaig LF, Uddin S. Emergency department visits for drug poisoning: United States, 2008-2011. NCHS Data Brief, no. 196. Hyattsville, MD: National Center for Health Statistics. 2015.
- Burillo-Putze G, Munne P, Dueñas A, et al. National multicentre study of acute intoxication in emergency departments of Spain. Eur J Emerg Med 2003; 10:101.
- Warner M, Chen LH, Makuc DM et al. Drug poisoning deaths in the United States, 1980-2008. NCHS data brief, no. 81. Hyattsville, MD: National Center for Health Statistics. 2011.
- Centers for Disease Control and Prevention (CDC). Vital signs: overdoses of prescription opioid pain relievers---United States, 1999--2008. MMWR Morb Mortal Wkly Rep 2011; 60:1487.
- Ajdacic-Gross V, Weiss MG, Ring M, et al. Methods of suicide: international suicide patterns derived from the WHO mortality database. Bull World Health Organ 2008; 86:726.
- Rhyee SH, Farrugia L, Campleman SL, et al. The Toxicology Investigators Consortium Case Registry--the 2014 Experience. J Med Toxicol 2015; 11:388.
- Camidge DR, Wood RJ, Bateman DN. The epidemiology of self-poisoning in the UK. Br J Clin Pharmacol 2003; 56:613.
- Hovda KE, Bjornaas MA, Skog K, et al. Acute poisonings treated in hospitals in Oslo: a one-year prospective study (I): pattern of poisoning. Clin Toxicol (Phila) 2008; 46:35.
- Sorge M, Weidhase L, Bernhard M, et al. Self-poisoning in the acute care medicine 2005-2012. Anaesthesist 2015; 64:456.
- Bentur Y, Lurie Y, Cahana A, et al. Poisoning in Israel: annual report of the Israel Poison Information Center, 2007. Isr Med Assoc J 2008; 10:749.
- Erickson TB, Thompson TM, Lu JJ. The approach to the patient with an unknown overdose. Emerg Med Clin North Am 2007; 25:249.
- Boyer EW. Management of opioid analgesic overdose. N Engl J Med 2012; 367:146.
- Schabelman E, Kuo D. Glucose before thiamine for Wernicke encephalopathy: a literature review. J Emerg Med 2012; 42:488.
- Tate JR, Nixon PF. Measurement of Michaelis constant for human erythrocyte transketolase and thiamin diphosphate. Anal Biochem 1987; 160:78.
- Soslow AR. Acute drug overdose: one hospital's experience. Ann Emerg Med 1981; 10:18.
- Wright N. An assessment of the unreliability of the history given by self-poisoned patients. Clin Toxicol 1980; 16:381.
- Pohjola-Sintonen S, Kivistö KT, Vuori E, et al. Identification of drugs ingested in acute poisoning: correlation of patient history with drug analyses. Ther Drug Monit 2000; 22:749.
- Linden CH. General considerations in the evaluation and treatment of poisoning. In: Intensive Care Medicine, Rippe JM, Irwin RS, Fink MP, Cerra FB. (Eds), Little Brown and Company, Boston 1996. p.1455.
- Olson KR, Pentel PR, Kelley MT. Physical assessment and differential diagnosis of the poisoned patient. Med Toxicol 1987; 2:52.
- Yates C, Manini AF. Utility of the electrocardiogram in drug overdose and poisoning: theoretical considerations and clinical implications. Curr Cardiol Rev 2012; 8:137.
- Savitt DL, Hawkins HH, Roberts JR. The radiopacity of ingested medications. Ann Emerg Med 1987; 16:331.
- Kurt TL, Anderson RJ, Reed WG. Rapid estimation of carboxyhemoglobin by breath sampling in an emergency setting. Vet Hum Toxicol 1990; 32:227.
- Taftachi F, Sanaei-Zadeh H, Zamani N, Emamhadi M. The role of ultrasound in the visualization of the ingested medications in acute poisoning - a literature review. Eur Rev Med Pharmacol Sci 2012; 16:2175.
- Nordt SP, Campbell C, Medak A, et al. Ultrasound visualization of ingested tablets: a pilot study. Pharmacotherapy 2011; 31:273.
- Sporer KA, Khayam-Bashi H. Acetaminophen and salicylate serum levels in patients with suicidal ingestion or altered mental status. Am J Emerg Med 1996; 14:443.
- Sorisky A, Watson DC. Positive diphenhydramine interference in the EMIT-st assay for tricyclic antidepressants in serum. Clin Chem 1986; 32:715.
- Brett AS. Implications of discordance between clinical impression and toxicology analysis in drug overdose. Arch Intern Med 1988; 148:437.
- Kellermann AL, Fihn SD, LoGerfo JP, Copass MK. Impact of drug screening in suspected overdose. Ann Emerg Med 1987; 16:1206.
- Hammett-Stabler CA, Pesce AJ, Cannon DJ. Urine drug screening in the medical setting. Clin Chim Acta 2002; 315:125.
- Hawley PC, Falko JM. "Pseudo" renal failure after isopropyl alcohol intoxication. South Med J 1982; 75:630.
- Litovitz TL, Klein-Schwartz W, Rodgers GC Jr, et al. 2001 Annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 2002; 20:391.
- Watson WA, Steele MT, Muelleman RL, Rush MD. Opioid toxicity recurrence after an initial response to naloxone. J Toxicol Clin Toxicol 1998; 36:11.
- Isbister GK, Downes F, Sibbritt D, et al. Aspiration pneumonitis in an overdose population: frequency, predictors, and outcomes. Crit Care Med 2004; 32:88.
- Tran TP, Panacek EA, Rhee KJ, Foulke GE. Response to dopamine vs norepinephrine in tricyclic antidepressant-induced hypotension. Acad Emerg Med 1997; 4:864.
- Buchman AL, Dauer J, Geiderman J. The use of vasoactive agents in the treatment of refractory hypotension seen in tricyclic antidepressant overdose. J Clin Psychopharmacol 1990; 10:409.
- Hollander JE. The management of cocaine-associated myocardial ischemia. N Engl J Med 1995; 333:1267.
- Lange RA, Cigarroa RG, Flores ED, et al. Potentiation of cocaine-induced coronary vasoconstriction by beta-adrenergic blockade. Ann Intern Med 1990; 112:897.
- Blake KV, Massey KL, Hendeles L, et al. Relative efficacy of phenytoin and phenobarbital for the prevention of theophylline-induced seizures in mice. Ann Emerg Med 1988; 17:1024.
- Battaglia J, Moss S, Rush J, et al. Haloperidol, lorazepam, or both for psychotic agitation? A multicenter, prospective, double-blind, emergency department study. Am J Emerg Med 1997; 15:335.
- Burns MJ, Linden CH, Graudins A, et al. A comparison of physostigmine and benzodiazepines for the treatment of anticholinergic poisoning. Ann Emerg Med 2000; 35:374.
- Laskowski LK, Landry A, Vassallo SU, Hoffman RS. Ice water submersion for rapid cooling in severe drug-induced hyperthermia. Clin Toxicol (Phila) 2015; 53:181.
- Brett AS, Rothschild N, Gray R, Perry M. Predicting the clinical course in intentional drug overdose. Implications for use of the intensive care unit. Arch Intern Med 1987; 147:133.
- Lee HL, Lin HJ, Yeh ST, et al. Presentations of patients of poisoning and predictors of poisoning-related fatality: findings from a hospital-based prospective study. BMC Public Health 2008; 8:7.
- OVERVIEW OF APPROACH
- INITIAL EVALUATION AND TREATMENT
- DIAGNOSIS OF POISONING
- Physical examination
- Radiographic studies
- Toxicology screens (drug testing)
- Other laboratory studies
- POISONING MANAGEMENT
- Enhanced elimination techniques
- Supportive care
- ADDITIONAL RESOURCES
- SUMMARY AND RECOMMENDATIONS