What is the initial management for a patient with unknown poisoning, vomiting, and a history of alcoholism?

From the Guidelines

The initial management for a patient with unknown poisoning, vomiting, and a history of alcoholism should focus on stabilization, supportive care, and specific antidotes when appropriate, prioritizing airway management, breathing, and circulation (ABCs) as outlined in the 2023 American Heart Association guidelines 1.

Initial Assessment and Stabilization

The patient's airway, breathing, and circulation should be assessed and secured. Given the patient's history of vomiting, there is a risk of dehydration and potential electrolyte imbalances.

• Administer supplemental oxygen if needed, and establish IV access for fluid resuscitation with normal saline or lactated Ringer's solution.
• Obtain vital signs, including pulse, blood pressure, and respiratory rate, and perform a focused physical examination looking for signs of specific toxidromes, as suggested by the guidelines for managing patients with cardiac arrest or life-threatening toxicity due to poisoning 1.

Laboratory Tests and Antidotes

Laboratory tests should include:

• Complete blood count
• Comprehensive metabolic panel
• Blood alcohol level
• Acetaminophen and salicylate levels
• Arterial blood gases Consider administering thiamine 100 mg IV before glucose to prevent precipitating Wernicke's encephalopathy in this alcoholic patient, as alcoholism increases the risk of thiamine deficiency.
• Naloxone 0.4-2 mg IV/IM/intranasal should be given if opioid toxicity is suspected, given its potential to reverse opioid-induced respiratory depression.
• Activated charcoal 1 g/kg orally may be administered if the ingestion was recent (within 1-2 hours) and the airway is protected, though it's contraindicated if the patient has decreased consciousness or is actively vomiting, as per the guidelines on managing poisoning 1.
• Specific antidotes like N-acetylcysteine for acetaminophen toxicity should be given if indicated by toxicology screening.

Ongoing Management

Benzodiazepines such as lorazepam 2-4 mg IV may be needed to manage alcohol withdrawal symptoms.

• Continuous cardiac monitoring and frequent reassessment are essential as the clinical picture evolves, ensuring timely intervention for any potential complications. Given the complexity of managing unknown poisoning, consultation with a regional poison center, such as those available in the United States (1-800-222-1222) or Canada, can provide expert guidance tailored to the specific case, as recommended by the American Heart Association guidelines 1.

From the Research

Initial Management

The initial management for a patient with unknown poisoning, vomiting, and a history of alcoholism involves several key steps:

• Airway, breathing, circulation (ABCs) is central to the management of unknown poisoned patient 2
• Taking a systematic approach to consider key additional history, possible toxidrome, and data in the form of vital signs, physical examination, laboratory analysis, ECG, and imaging 2
• Implementing life-support measures, gathering and communicating prognostic information and details of any treatments to the ambulance crew or hospital team 3
• Considering the patient's history of alcoholism and the potential for alcohol withdrawal symptoms, which can range from mild to life-threatening 4

Supportive Care

Supportive care with attention to the body systems at risk from the poisoning is the mainstay of therapy:

• Activated charcoal can reduce the gastrointestinal absorption of some drugs and should be given as soon as possible, preferably within 2 hours after ingestion 3
• Gastric lavage carries a risk of serious adverse effects and is only justified in rare cases where the patient's life is at risk 3
• Intravenous naloxone is useful for respiratory depression due to opioid poisoning, but its duration of action is often shorter than that of opioids, making continuous monitoring necessary 3

Consultation and Disposition

Consultation with a medical toxicologist or regional poison control center can positively impact diagnosis, management, and disposition of poisoned patients:

• Hospital monitoring is warranted in case of potentially severe poisoning, including patients at increased risk or those having taken a potentially lethal substance at a toxic or unknown dose 3
• The patient's history of alcoholism and potential for alcohol withdrawal symptoms should be considered when determining disposition, and hospital admission may be necessary to manage these symptoms and prevent complications 4