What is the initial management for a patient presenting with unknown poisoning?

Initial Management of Unknown Poisoning

Immediately prioritize airway, breathing, and circulation (ABCs) with standard resuscitation protocols, while simultaneously contacting poison control (1-800-222-1222 in US) for expert guidance—do not delay treatment waiting for toxin identification. 1, 2

Immediate Stabilization (First 5 Minutes)

Scene Safety and Self-Protection

• Ensure scene safety first: assess for toxic fumes, chemical hazards, or environmental dangers before approaching 2
• Use appropriate personal protective equipment (gloves, protective clothing) when handling the patient or contaminated materials to prevent secondary contamination 1, 2
• Remove all contaminated clothing and jewelry immediately to prevent continued absorption 3, 2

Primary Survey (ABCs)

• Airway: Open and secure the airway; prepare for early intubation if mental status is declining 1
• Breathing: Provide rescue breathing or bag-mask ventilation if respiratory arrest is present 1
• Circulation: Assess pulse and blood pressure; initiate CPR if cardiac arrest, focusing on high-quality compressions plus ventilation 1
• For altered mental status: Administer oxygen, naloxone (if opioid suspected), glucose (if hypoglycemia possible), and thiamine 1

Activate Emergency Response

• Call emergency services immediately—do not delay while awaiting response to interventions 1
• Contact poison control center (1-800-222-1222) for real-time expert guidance on evolving management 1, 3, 2

Toxidrome Recognition (Minutes 5-15)

Rapidly assess for common toxidromes to guide empiric antidote therapy:

Opioid Toxidrome

• Clinical features: Respiratory depression, pinpoint pupils (miosis), decreased consciousness 2
• Action: Administer naloxone immediately if definite pulse present but no normal breathing 1, 2
• Caveat: If cardiac arrest, prioritize CPR over naloxone—no proven benefit during arrest 1

Cholinergic Toxidrome (Organophosphates/Carbamates)

• Clinical features: Bronchorrhea, bronchospasm, bradycardia, miosis, hypersalivation, lacrimation, urination, diarrhea (SLUDGE syndrome), seizures 1, 2
• Action: Give atropine immediately for severe symptoms (1-2 mg IV, double every 5 minutes until atropinization achieved) 1
• Add pralidoxime for organophosphate poisoning (not carbamate) 1
• Benzodiazepines for seizures and agitation 1
• Early intubation recommended for life-threatening cases 1

Sympathomimetic Toxidrome

• Clinical features: Agitation, tachycardia, hypertension, hyperthermia, mydriasis 2
• Action: Benzodiazepines for extreme agitation or hyperthermia 2

Anticholinergic Toxidrome

• Clinical features: Altered mental status, mydriasis, dry skin, urinary retention, hyperthermia, tachycardia 1
• Action: Supportive care; consider physostigmine only in consultation with toxicology 1

Decontamination (Concurrent with Stabilization)

External Decontamination

• Remove chemical powders with gloved hands before water irrigation to prevent exothermic reactions 2
• Copious water irrigation for skin exposures after powder removal 2
• Eye exposure: Flush with tepid water for at least 15 minutes 4

Gastrointestinal Decontamination

• Activated charcoal (1 g/kg) if ingestion within 1 hour and airway protected 1
• Do NOT give charcoal for caustic substances, metals (iron, lithium, lead), or hydrocarbons 1
• Do NOT induce vomiting—contraindicated in modern practice 1, 4

Specific Antidotes Based on Clinical Presentation

Administer empirically when clinical suspicion is high—do not wait for confirmatory testing:

• Cyanide poisoning (fire exposure + severe metabolic acidosis): Hydroxocobalamin 2
• Calcium channel blocker/beta-blocker: High-dose insulin therapy early 2
• Benzodiazepine overdose: Flumazenil only if no contraindications (seizure history, chronic use) 2
• Hyperkalemia or hypermagnesemia: Calcium chloride 10% (5-10 mL IV) or calcium gluconate 10% (15-30 mL IV over 2-5 minutes) 1
• Hypomagnesemia with torsades: Magnesium sulfate 1-2 g IV push 1

Critical Monitoring and Supportive Care

Continuous Assessment

• Vital signs: Monitor for bradycardia, tachycardia, hypotension, hypertension, respiratory depression 1, 2
• ECG monitoring: Indicated for chest pain, dyspnea, or suspected cardiotoxic ingestions (tricyclic antidepressants, beta-blockers, antidysrhythmics) 5
• Laboratory studies: Electrolytes, creatinine, bicarbonate, anion gap calculation based on presentation 5
• Arterial blood gas: If severe metabolic acidosis or respiratory compromise 1

Advanced Interventions for Refractory Cases

• Consider VA-ECMO early for cardiogenic shock or refractory dysrhythmias from cardiotoxic poisoning 2
• Hemodialysis for specific toxins (salicylates, lithium, methanol, ethylene glycol) 6
• Lipid emulsion therapy for severe local anesthetic toxicity (bupivacaine), amitriptyline, or bupropion 6

Critical Pitfalls to Avoid

• Do NOT delay treatment waiting for specific toxin identification—treat the patient, not the poison 2
• Do NOT use succinylcholine or mivacurium in organophosphate/carbamate poisoning (metabolized by cholinesterase) 1
• Do NOT forget multiple drug exposures are common in intentional overdoses 2, 6
• Do NOT contaminate yourself or other healthcare providers—maintain barrier precautions throughout 1, 2
• Do NOT give oxygen liberally in paraquat poisoning—target SpO2 85-88% only 3
• Do NOT administer anything by mouth unless specifically advised by poison control 4