Initial management of the critically ill adult with an unknown overdose
- Marco L A Sivilotti, MD, MSc, FRCPC, FACEP, FACMT
Marco L A Sivilotti, MD, MSc, FRCPC, FACEP, FACMT
- Professor of Emergency Medicine and of Biomedical & Molecular Sciences
- Queen's University, Kingston Canada
- 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
Poisoning is a leading cause of death especially in the young, in whom it is the leading cause of nontraumatic cardiac arrest under the age of 35 years. Overdose, both intentional and unintentional, has also become the leading cause of injury-related death in the United States, exceeding the number of deaths due to firearms, falls, or motorized vehicle collisions.
Severely poisoned patients may present in extremis. Such patients require an organized, targeted resuscitation despite incomplete, uncertain, or even erroneous information. A "generic" approach based upon the advanced cardiac life support (ACLS) protocols intended for cardiac patients is suboptimal . It can lead to missed opportunities for specific life-saving interventions and may at times be harmful.
This topic will describe an approach to the resuscitation of the critically ill poisoned adult patient when the identity of the agent(s) ingested is initially unknown. The general approach to the poisoned patient and the management of specific poisonings are described separately. (See "General approach to drug poisoning in adults".)
INITIAL DATA ACQUISITION
Any readily available information about the patient and the poisoning should be obtained from prehospital care providers, other first responders (including witnesses, firemen, police, friends, and family), and from medical records. Medication or chemical product containers, material safety data sheets, pharmacy records, and institutional or patient lists of prescribed medication can be helpful. In addition, the setting and circumstances may help to identify the toxin(s) involved and select interventions. As examples, misadventures with recreational drugs of abuse or accidental industrial exposures suggest the need to prepare for multiple victims, whereas a person who rapidly decompensates after being taken into police custody may have "stuffed" (eg, swallowed) large amounts of illicit drugs and immediate removal of the leaking package may be life-saving . (See "General approach to drug poisoning in adults", section on 'History' and "Acute ingestion of illicit drugs (body stuffing)".)
In addition to securing the airway, breathing, and circulation (ABC's) as with any critically ill or injured patient, the resuscitation leader must consider two additional imperatives that may arise with severely poisoned patients: preserving the operational capacity of the emergency health care system and ensuring the safety of health care workers. These priorities are addressed concurrently as part of the primary assessment.
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- INITIAL DATA ACQUISITION
- FIRST PRIORITIES
- RAPID FIRST LOOK: EXAMINATION, MONITORING, AND TESTING
- SYSTEMATIC EVALUATION: THE "ABCDE" APPROACH
- “A”: Airway stabilization
- “B”: Breathing
- “C”: Circulation
- - Asystole and ventricular fibrillation
- - Hypotension
- - Bradycardia with hypotension
- - Monomorphic, wide-complex tachycardia
- - Polymorphic ventricular tachycardia
- - Narrow complex tachycardia
- “D”: Disability and neurological stabilization
- “E”: Exposure and elimination
- CESSATION OF RESUSCITATIVE EFFORTS
- ADDITIONAL RESOURCES
- SUMMARY AND RECOMMENDATIONS