What is the initial management of a poisoning case in the Emergency Room (ER) department?

Initial Management of Poisoning Cases in the Emergency Room

The initial management of a poisoning case in the Emergency Room should follow standard guidelines including airway assessment, administration of 100% oxygen, identification of the poison, and seeking advice from poison control centers while implementing appropriate supportive care and specific antidotes as needed. 1

Primary Assessment and Stabilization

• Airway, Breathing, Circulation (ABC):

  • Ensure patent airway and adequate ventilation
  • Administer 100% oxygen via mask or endotracheal tube 1
  • Establish IV access and monitor vital signs continuously

• Immediate Interventions for Life-Threatening Conditions:

  • For unconscious patients: Place in left lateral head-down position 2
  • For hypoglycemia: Administer glucose
  • For opioid-induced respiratory depression: Naloxone (0.2-2 mg IV/IO/IM for adults) 3
  • For seizures: Diazepam or other benzodiazepines 2
  • For severe bradycardia: Atropine (1-2 mg, doubled every 5 minutes) 3

Poison Identification and Risk Assessment

• Gather Information:

  • History from patient or witnesses about substance, amount, time of exposure
  • Examine environment for evidence (medication bottles, chemicals)
  • Contact poison control center for guidance (US: 1-800-222-1222) 3

• Clinical Assessment:

  • Look for toxidromes (constellation of symptoms indicating specific poisoning)
  • Assess mental status, vital signs, pupil size, skin condition, bowel sounds
  • Consider specific toxins based on presentation (e.g., hyperventilation and tachycardia in cyanide poisoning) 1

Decontamination

• Gastrointestinal Decontamination:

  • Activated charcoal: Administer as soon as possible (preferably within 2 hours of ingestion) if the patient is conscious and the poison is known to be adsorbed by charcoal 2
  • Do not induce vomiting with ipecac syrup under any circumstances 2
  • Gastric lavage: Only in rare life-threatening cases when the poison is not adsorbed by activated charcoal and presentation is within 1 hour 2

• Dermal Decontamination:

  • Remove contaminated clothing
  • Wash skin thoroughly with soap and water or sodium bicarbonate solution 3, 4
  • Use appropriate personal protective equipment to prevent secondary contamination 3

Specific Antidotes and Treatments

• Common Antidotes:

  • Acetylcysteine: For paracetamol/acetaminophen poisoning (within 24 hours of ingestion) 2
  • Naloxone: For opioid poisoning (may require repeated doses) 2
  • Atropine and pralidoxime: For organophosphate poisoning 4
    • Pralidoxime: Initial dose of 1000-2000 mg IV over 15-30 minutes 4
  • Hydroxocobalamin or sodium thiosulphate: For cyanide poisoning 1

• Specific Poisoning Management:

  • β-blocker poisoning: High-dose insulin and vasopressors are recommended; glucagon may be reasonable 1
  • Calcium channel blocker poisoning: Vasopressors, high-dose insulin, and calcium administration are recommended 1
  • Metal toxicities: Chelation therapy with specific agents based on the metal involved 3

Enhanced Elimination

• Multiple-dose activated charcoal: For certain drugs with enterohepatic circulation
• Urinary alkalinization: For certain acidic drugs
• Hemodialysis: Consider for specific toxins (e.g., lithium, methanol, ethylene glycol) 5
• Extracorporeal support: VA-ECMO may be reasonable for life-threatening poisoning with cardiogenic shock refractory to pharmacological interventions 1, 3

Monitoring and Disposition

• Continuous monitoring:

  • Cardiac monitoring for at least 24-36 hours
  • Serial assessment of vital signs and mental status
  • Laboratory monitoring (electrolytes, renal and hepatic function, toxin levels if available) 3

• Disposition criteria:

  • Monitor for at least 48-72 hours in cases of organophosphate poisoning 4
  • Consider psychiatric evaluation in cases of intentional poisoning 2
  • Ensure source of poisoning is eliminated before discharge 1

Special Considerations

• Healthcare provider safety:

  • Use appropriate personal protective equipment
  • Be aware of specific risks with certain toxins (e.g., hydrogen cyanide, hydrogen sulfide) 1
  • Use mask with non-return valve system for ventilation in cyanide poisoning 1

• Common pitfalls to avoid:

  • Failing to identify the source of poisoning
  • Delaying administration of specific antidotes
  • Inadequate monitoring duration
  • Overlooking the need for psychiatric evaluation in intentional poisonings 3

Remember that poisoning management is time-sensitive, and early intervention with appropriate supportive care and specific antidotes when indicated can significantly improve outcomes.