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  • Initial Approach to a Poisoned Patient

    • Poison control center consultation may aid in determining appropriate laboratory testing, patient disposition, management, and need for specific targeted treatments; the US national toll-free emergency phone number is 1-800-222-1222.

    • Initial management of poisoned patient should be targeted to addressing immediate life threats: airway management, breathing and ventilation, and cardiovascular support.

    • Cardiopulmonary resuscitation and advanced cardiac life support may be extended in some poisoned patients with good neurologic recovery.

    • Intubation is a clinical decision, and gag reflex should not be elicited to make this determination.

    • For ventilator management, special attention must be paid to toxins that have differential tissue distribution based on tissue pH (eg, salicylates).

    • Xenobiotic-induced bradycardia can be addressed with atropine, sympathomimetic pressors, transcutaneous or transvenous pacing, as well as specific antidotes: calcium, glucagon, sodium bicarbonate, naloxone, and digoxin-specific antibodies, in appropriate situations.

    • Xenobiotic-induced QT prolongation and polymorphic ventricular tachycardia can be addressed by optimizing electrolytes, avoiding other QT-prolonging agents, and potentially intravenous magnesium, isoproterenol, and overdrive electrical pacing.

    • Xenobiotic-induced hypertension can be addressed by targeting the underlying cause, typically by using sedating medications; otherwise, short-acting titratable agents such as nitroglycerin, nitroprusside, or phentolamine.

    • Naloxone reversal of opioid poisoning should begin with low doses (eg, ≤0.4 mg IV) and titrated to restore protective airway reflexes and adequate spontaneous minute ventilation unless apneic; failure to respond to naloxone beyond 10 mg should prompt search for alternative causes.

    • Cautious administration of flumazenil (0.2 mg test dose) can be considered in patients with suspected benzodiazepine-mediated central nervous system (CNS) depression without history or presence of benzodiazepine dependence, seizure, tachycardia, myoclonus, or hyperreflexia.

    • Evidence-based pharmacologic options to address acutely agitated, violent, or patients suffering from psychoses who do not respond to de-escalation techniques include ketamine, midazolam, droperidol, haloperidol, and olanzapine.

    • Benzodiazepines are first-line treatment for common xenobiotic-induced seizures, followed by barbiturates or propofol, and escalating to general sedation; traditional second-line therapies (eg, phenytoin, levetiracetam) are not expected to be as beneficial; pyridoxine is utilized for certain xenobiotic-induced seizures.

    • Xenobiotic-induced alterations in temperature must be treated aggressively to minimize life-threatening complications using external cooling, sedating medications, and/or neuromuscular blockade for hyperthermia, and rewarming for hypothermia.

  • Diagnosis of Toxic Exposure

    • Classic collections of symptoms in toxicologic syndromes (toxidromes) are specific, but not sensitive; they can be confused, and absence of a toxidrome has not been shown to reliably exclude the possibility of exposure.

    • Osmolar gap must be ordered and interpreted with caution and should not be used as a general screening test.

    • Oxygen saturation gaps between calculated saturation on arterial blood gas compared to pulse oximetry may suggest the presence of abnormal hemoglobin (eg, methemoglobin).

    • Urine drug screens can provide evidence of exposure but are limited by false positive, false negatives, and inability to provide timing of exposure information.

    • Routine testing for acetaminophen and/or salicylates ingestion in all patients with intentional overdose is recommended due to the ubiquity of these compounds in many households.

    • Whole bowel irrigation ...

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