Chapter 4

For almost 5 decades, medical toxicologists and information specialists have used a clinical approach to poisoned or overdosed patients that emphasizes treating the patient rather than treating the poison. Too often in the past, patients were initially all but neglected while attention was focused on the ingredients listed on the containers of the product(s) to which they presumably were exposed. Although the astute clinician must always be prepared to administer a specific antidote immediately in instances when nothing else will save a patient, all poisoned or overdosed patients will benefit from an organized, rapid clinical management plan (Fig. 4-1).

Figure 4-1

This algorithm is a basic guide to the management of poisoned patients. A more detailed description of the steps in management may be found in the accompanying text. This algorithm is only a guide to actual management, which must, of course, consider the patient's clinical status.

Over the past 2 decades, some basic tenets and long-held beliefs regarding the initial therapeutic interventions in toxicologic management have been questioned and subjected to an "evidence-based" analysis. For example, in the mid-1970s, most medical toxicologists began to advocate a standardized approach to a comatose and possibly overdosed adult patient, typically calling for the intravenous (IV) administration of 50 mL of D50W, 100 mg of thiamine and 2 mg of naloxone along with 100% oxygen at high flow rates. The rationale for this approach was to compensate for the previously idiosyncratic style of overdose management encountered in different healthcare settings and for the unfortunate likelihood that omitting any one of these measures at the time that care was initiated in the emergency department (ED) would result in omitting it altogether. It was not unusual then to discover from a laboratory chemistry report more than 1 hour after a supposedly overdosed comatose patient had arrived in the ED that the initial blood glucose was 30 or 40 mg/dL—a critical delay in the management of unsuspected and consequently untreated hypoglycemic coma. Today, however, with the widespread availability of accurate rapid bedside testing for capillary glucose and pulse oximetry for oxygen saturation, coupled with a much greater appreciation by all physicians of what needs to be done for each suspected overdose patient, clinicians can safely provide a more rational, individualized approach to determine the need for, and in some instances more precise amounts of, dextrose, thiamine, naloxone, and oxygen.

A second major approach to providing more rational individualized early treatment for toxicologic emergencies involves a closer examination of the actual risks and benefits of various gastrointestinal (GI) emptying interventions. Appreciation of the potential for significant adverse effects associated with all types of GI emptying interventions and recognition of the absence of clear evidence-based support of efficacy have led to a significant reduction in the routine use of activated charcoal (AC) and almost complete elimination of syrup of ...

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