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
- Section Editor
- Stephen J Traub, MD
Stephen J Traub, MD
- Section Editor — Toxicology
- Associate Professor of Emergency Medicine
- Mayo Medical School
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Adult and Pediatric Emergency Medicine
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- 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) .
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- 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