From the Guidelines
The initial treatment approach for a patient with unknown poisoning should prioritize stabilization and supportive care, focusing on airway management, hemodynamic support, and correction of critical vital sign and metabolic derangements, as outlined in the 2023 American Heart Association guidelines 1. The treatment of poisoning includes prevention of additional exposure, removal of the poison when possible, provision of supportive care, and administration of medications that reverse or bypass the effect of the poison on its molecular target (antidotes) 1. Some key considerations in the initial treatment approach include:
- Ensuring the patient's airway, breathing, and circulation are maintained, providing supplemental oxygen and intravenous access as needed
- Continuously monitoring vital signs
- Considering activated charcoal (1 g/kg orally) if the patient presents within 1-2 hours of ingestion and is alert with a protected airway, though this should be avoided if the substance is caustic or petroleum-based
- Administering specific antidotes when indicated by clinical presentation, such as naloxone 0.4-2 mg IV for opioid overdose, glucose for hypoglycemia, or N-acetylcysteine for acetaminophen toxicity
- Obtaining relevant laboratory tests including electrolytes, glucose, renal and liver function, and toxicology screens
- Considering gastric decontamination through lavage in rare cases of life-threatening poisonings within one hour of ingestion
- Utilizing enhanced elimination techniques like hemodialysis for certain toxins, as mentioned in the 2023 American Heart Association guidelines 1. This approach allows for the treatment of life-threatening conditions while diagnostic work continues to identify the specific poison, enabling more targeted interventions as information becomes available.
From the Research
Initial Treatment Approach
The initial treatment approach for a patient with unknown poisoning involves several key steps:
- Assessing the airway, breathing, and circulation (ABCs) to ensure the patient's stability 2, 3, 4
- Taking a thorough history to gather information about the potential poison and the patient's symptoms 2, 4
- Considering possible toxidromes, which are constellations of symptoms commonly encountered with certain drug classes 3, 4
Stabilization and Supportive Care
Stabilization involves providing oxygen, naloxone, glucose, and thiamine to patients with altered mental status 3 Supportive care is crucial in managing patients with unknown poisoning, as most cases are not fatal and can be managed with supportive measures unless a specific antidote is available 4
Decontamination and Antidotes
Decontamination methods include:
- Activated charcoal, which is a useful adsorbent for gastric decontamination 3, 5, 6
- Whole bowel irrigation, which is useful for iron, lead, and lithium poisoning and for the body packer phenomenon 3
- Emesis by means of syrup of ipecac is rarely used for in-hospital gastric decontamination 3 Antidotes may be available for specific poisons, and their use can be beneficial in improving outcomes 2, 6
Enhanced Elimination Techniques
Enhanced elimination techniques include:
- Multiple doses of activated charcoal 3
- Hemodialysis or charcoal hemoperfusion 3, 6
- Urinary alkalinization for salicylate ion trapping 6
- Intravenous lipid therapy for poisoning from certain medications 6
- Chelators for binding toxic metals 6
- Displacers with hemodialysis to augment clearance of protein-bound toxins 6