This document provides guidance on what not to do in various aspects of toxicology and poison management, including resuscitation, risk assessment, supportive care, investigations, decontamination, enhanced elimination, antidotes, and disposition. It advises against becoming distracted from resuscitation, rushing intubation, giving up too early in cardiac arrest, being lazy in seeking information, expecting toxidromes to fit in mixed overdoses, performing unnecessary procedures like gastric lavage or giving activated charcoal within 1 hour as routine. It also cautions against forgetting important investigations like glucose, overdosing on naloxone, and failing to consider psychosocial factors in patient disposition.

1. TOXICOLOGY…
WHAT NOT TO DO
Chris Nickson FACEM FCICM
Intensivist, The Alfred ICU

2. Financial
Conflicts of InterestNO!
http://litfl.org/CONCEPTOS

3. Resus
RSI DEAD

4. Resuscitation
Risk Assessment
Supportive care & monitoring
Investigations
Decontamination
Enhanced elimination
Antidotes
Disposition

5. RESUSCITATION
(WHAT NOT TO DO)

6. Do not get distracted…
resuscitation comes first!
RESUSCITIATION

7. Do not intubate based on !
risk assessment alone when!
there are no signs of toxicity!
RESUSCITIATION

8. Do not rush to intubate a
salicylate overdose patient
lightly or allow respiratory
acidosis to develop!
RESUSCITIATION

9. Do not use phenytoin
for toxin-induced seizures!
RESUSCITIATION

10. Do not give up too early!
in cardiac arrest !
RESUSCITIATION

11. RISK ASSESSMENT
(WHAT NOT TO DO)

12. Do not be lazy…!
seek more information
RISKASSESSMENT

13. Do not be reassured by!
the apparently well patient
RISKASSESSMENT

14. Do not expect toxidromes!
to “fit” in a mixed overdose
RISKASSESSMENT

15. Do not get your !
calculations wrong
RISKASSESSMENT

16. Do not ignore phone advice,
but do not forget you are !
the one at the bedside!
RISKASSESSMENT

17. SUPPORTIVE CARE &
MONITORING
(WHAT NOT TO DO)

18. Do not forget to !
observe and monitor !
in an appropriately !
staffed and equipped
environment
SUPPORTIVECARE

19. INVESTIGATIONS
(WHAT NOT TO DO)

20. Do not ever forget glucose
INVESTIGATIONS

21. Do not rely on “gaps”!
to diagnose !
toxic alcohol poisoning
INVESTIGATIONS

22. Osmolar gap Anion gap

23. Do not order!
drug levels unless you !
can interpret them and they
will change management
INVESTIGATIONS

24. Do not perform !
urine drug screens
INVESTIGATIONS

25. DECONTAMINATION
(WHAT NOT TO DO)

26. Do not perform !
gastric lavage
DECONTAMINATION

27. Eddleston et al (2007), PMCID: PMC1941903!

28. Do not administer!
activated charcoal
‘within 1 hour’ as a routine
DECONTAMINATION

29. Do not ‘freak out’ about
organophosphate poisoning!
DECONTAMINATION

30. ENHANCED ELIMINATION
(WHAT NOT TO DO)

31. Do not hesitate to call in the
renal team when
hemodialysis is indicated!
ENHANCEDELIMINATION

32. ANTIDOTES
(WHAT NOT TO DO)

33. Do not overdose your !
patients with naloxone
unless they are !
apneic or peri-arrest!
RESUSCITIATION

34. Do not forget octreotide for
sulfonylurea-induced
hypoglycemia
ANTIDOTES

35. Do not give flumazenil
ANTIDOTES

36. Do not give glucagon
ANTIDOTES

37. Do not be afraid of
physostigmine for
anticholinergic delirium
ANTIDOTES

38. Do not stop !
N-acetylcysteine for
anaphylactoid reactions
ANTIDOTES

39. Do not forget transporting!
the antidote to the patient!
is an option
ANTIDOTES

40. DISPOSITION
(WHAT NOT TO DO)

41. Do not forget!
self-poisoning is a “snapshot”
of a psychosocial disorder
DISPOSITION

42. Resuscitation
Risk Assessment
Supportive care & monitoring
Investigations
Decontamination
Enhanced elimination
Antidotes
Disposition

43. http://litfl.org/CONCEPTOS