What is the initial treatment approach for a casualty with suspected poisoning?

Initial Management of Poisoning in Casualty

Immediately activate EMS if the patient shows any life-threatening signs (sleepiness, seizures, difficulty breathing, vomiting), and simultaneously contact Poison Control (800-222-1222 in US) for expert guidance while initiating supportive care. 1

Scene Safety and Initial Assessment

• Ensure your own safety first before approaching the patient—assess for toxic fumes, chemical hazards, or environmental dangers that could harm you or other responders 1, 2
• Remove yourself and the patient from any contaminated environment if safe to do so 1
• Do not place yourself at greater risk than the victim—proper assessment and cooperation with rescue services is essential 1

Immediate Life Support Measures

Airway, Breathing, Circulation Priority

• Establish and maintain a patent airway as the first priority 3, 4
• Provide respiratory support if breathing is inadequate or absent 2, 3
• Position unconscious patients in the left lateral head-down position to prevent aspiration 3
• Start CPR immediately if the patient is in cardiorespiratory arrest 3
• Assess circulation and provide cardiovascular support according to standard ACLS protocols 2

Critical Interventions Based on Presentation

• For respiratory depression with suspected opioid overdose: Administer naloxone IV immediately 2, 5, 3
• For seizures or status epilepticus: Give IV diazepam or other benzodiazepine 2, 3
• For extreme agitation or hyperthermia: Provide sedation with benzodiazepines (diazepam or clorazepate if no respiratory depression risk; otherwise haloperidol) 2, 3
• For severe bradycardia: Administer atropine 3
• For hypotension: Elevate the legs and provide vasopressor support if needed 3
• For unconscious patients: Administer IV glucose to rule out hypoglycemia 3

Decontamination Procedures

Skin and Eye Exposure

• For chemical powders on skin: Brush off with a gloved hand or cloth before any water irrigation 1
• Remove all contaminated clothing immediately, ensuring you do not contaminate yourself in the process 1, 2
• For acid or alkali exposure to skin or eyes: Immediately irrigate with copious amounts of water 1
• For toxic eye injuries: Rinse eyes immediately with copious water unless a specific antidote is available 1
• Use appropriate personal protective equipment (gloves, protective clothing) when handling contaminated patients or materials, especially with corrosive chemicals or organophosphates 1, 6

Ingested Poisons

• Do NOT administer anything by mouth (water, milk, or any substance) unless specifically directed by Poison Control, as this may cause emesis and aspiration 1, 7
• Do NOT induce vomiting or give ipecac—this is contraindicated and provides no clinical benefit while potentially causing harm 1, 3
• Do NOT administer activated charcoal unless specifically advised by Poison Control or emergency medical personnel 1
  • If recommended by Poison Control, activated charcoal (1 g/kg) may be given via nasogastric tube in select cases 7
  • Activated charcoal is most effective within 2 hours of ingestion and only for drugs known to be adsorbed by it 3
  • The patient must be fully conscious and able to swallow safely 3
• Do NOT perform gastric lavage except in rare life-threatening cases where the drug is not adsorbed by activated charcoal 3

Toxidrome Recognition

Identify specific toxidromes to guide targeted therapy:

• Opioid toxidrome: Respiratory depression, pinpoint pupils, decreased consciousness 2
• Cholinergic toxidrome: Bronchorrhea, bronchospasm, bradycardia, miosis, hypersalivation, lacrimation, urination, diarrhea 2
• Sympathomimetic toxidrome: Agitation, tachycardia, hypertension, hyperthermia, mydriasis 2

Specific Antidotes and Treatments

When to Use Specific Antidotes

• For suspected cyanide poisoning (fire victims with severe metabolic acidosis): Administer hydroxocobalamin or sodium thiosulphate 1, 2
• For organophosphate poisoning: Give atropine for bronchospasm, bronchorrhea, seizures, or bradycardia 2
• For benzodiazepine overdose: Consider flumazenil only if no contraindications exist (no seizure history, no chronic benzodiazepine use, no co-ingestion of proconvulsants) 2, 8
• For calcium channel blocker or beta-blocker poisoning: Consider high-dose insulin therapy early 2

Special Considerations for Specific Poisons

• For paraquat poisoning: Administer oxygen ONLY if saturation falls below 85%, and reduce/stop if saturation rises above 88% (target 85-88%) 6
• For hydrogen cyanide poisoning: Use mask and non-return valve system for assisted ventilation to avoid rescuer exposure to exhaled air 1

Critical Pitfalls to Avoid

• Do not delay EMS activation while attempting home interventions 7, 2
• Do not delay treatment waiting for identification of the specific toxin 2
• Do not assume a single toxin—multiple drug exposures are common 2
• Do not use neuromuscular blockers metabolized by cholinesterase in organophosphate poisoning 2
• Do not forget to protect yourself and other healthcare providers from secondary contamination 1, 2
• Do not rush administration of reversal agents like flumazenil or naloxone—patients should have secure airway and IV access, and be awakened gradually 8, 5

Ongoing Management

• Maintain continuous contact with Poison Control for evolving treatment recommendations 1, 6
• Monitor for resedation after naloxone administration, as its duration of action is often shorter than that of opioids 5, 3
• Obtain appropriate laboratory studies based on clinical presentation: electrolytes, serum creatinine, bicarbonate, anion gap calculation 4
• Perform ECG for chest pain, dyspnea, or overdoses of beta blockers, tricyclic antidepressants, or antidysrhythmics 4
• Consider advanced support such as VA-ECMO early for patients with cardiogenic shock or refractory dysrhythmias 2
• Evaluate suicide risk in cases of intentional self-poisoning and consider hospital admission until acute risk subsides 3