This document provides guidance on approaching a poisoned patient. It outlines 7 rules for evaluation and management, including that history is important but may be unreliable, vital signs are vital, the substance ingested is often unknown, most patients only require supportive care, antidotes aren't always needed, activated charcoal should be given if the substance is unknown, and stabilizing the patient is most important. Additional tips are provided on history taking, physical exam, communication, toxin stratification, gastrointestinal decontamination, and common emergency room skills. The overall message is that a systematic approach focusing on stabilization and supportive care is most important for poisoned patients.

1. How to approach a poisoned patient?
By
Kerolus Ekram Gad Shehata
• PGY-III IM Resident, Ain Shams University
• ECFMG certified

2. 
Poisoning is COMMON.
Poisoning is RARELY deadly.
Rule No. 1

3. 
History is EVERYTHING : for any
available meds., missing drugs, time
course, intention…etc.
History is NOTHING : could be
unattainable, unreliable or even
misleading.
Rule No. 2

4. 
Vitals are VITAL
Rule No. 3

5. 
We RARELY know for sure
what has been taken
It will RARELY matter
Rule No. 4

6. 
Most poisoned patients
require only SUPPORTIVE
therapy for recovery
Rule No. 5

7. 
The presence of an antidote
DOESN’T necessarily
mean that you should use it
Rule NO. 6

8. 
If you don’t know anything
about DRUG toxicity, give
ACTIVATED CHARCOAL !!
Rule NO. 7

9. 
The clinical perspective of toxicology is actually
a subspecialty of Emergency Medicine.
You are going to deal with a poisoned patient
not just a poison.
Stabilizing the patient is actually far more
important than knowing what is the type of the
poison ( Remember the ABCD )
General Hints

10. 
Stabilize if not already stable.
Take a well-organized history.
Perform a focused clinical examination.
Order some tests and imaging studies if needed.
Take a final decision.
Step by step approach

11. 
Discharge.
Keep under observation.
Inpatient ward admission.
ICU admission.
Referral.
Your Decision

12. 
Well-focused at
the important
items that will
help you explore
the real
problem(s) and
those which
could change
your decision
regarding the
case.
Most
importan
t is to
gain the
trust of
your
patient.
Be
skilled
enough
to
discover
a fake
history !!
Stress
upon
importan
t items
for more
clarificati
on.
Multi-
directional
approach: If
you still
have doubt,
take it more
than once,
ask the
relatives…et
c.
Could
be
unatta
inable
from
the
start.
History Taking Skills

13. 
General as well as focused.
If it matches the history, Go on to TTT.
If it doesn’t match the history, ask for more
clarification, assure the patient regarding his concerns
and confidentiality before confronting the patient.
Trust your objective findings NOT the subjective pt.’s
history and start your investigations & TTT if
necessary.
Physical Examination Skills

14. 
Establish Confidentiality.
Show your concern toward the Pt.’s health.
Respond to all the Pt.’s concerns.
Never to give false reassurance.
Never lie to the patient.
Respect the Pt.’s decision regarding what is going to be
done to his/her own body.
Communication & Interpersonal Skills

15. 
Safe: Most of them
Potentially dangerous: if exceed a certain toxic dose e.g.
Acetaminophen, salicylate, Iron…etc.
Grossly dangerous: Requires either immediate
intervention in the ER or direct admission even if
asymptomatic e.g. CCBs, Digoxin, B.Bs, Theophylline,
Zinc phosphide, PPD…etc.
Toxin Stratification

16. 
Induction of Emesis using syrup of Ipecac OR rapid
ingestion of large amount of fluids causing gastric
distension with reflex emesis ( double edged weapon).
Gastric lavage: usually done for pt.’s with DCL (preferably
under cover of cuffed ETT).
Activated Charcoal: The universal antidote and
the most safe .
GI decontamination measures

17. 
If you are sure that the Pt. will benefit from that measure e.g.
delay is short (<2 h), large amount ingestion of a toxic substance.
If there are no C/I for emesis or lavage either related to
the substance or to the patient.
Recent guidelines: No emesis once Pt. arrives to ER.
Lavage will remove 50 % in 1st h & 15 % in 2nd h, after that
it is useless.
When ??

18. 
You can still do these measures in some special cases
(they will greatly improve the outcome of the Pt.) esp.
Salicylates, Theophylline & Organophosphorus.
Remember that Activated Charcoal is the most safe &
the most effective broad-spectrum adsorbent. So, if
there are no C/I for its use then GO FOR IT.
BUT !!

19. 
IV cannulation.
Withdraw venous blood
samples.
Withdraw ABG samples.
Endotracheal intubation.
Perform CPR
Main ER skills

20. 
Most common Physical findings

21. 
Most common measures of ER management

22. Questions & Comments