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wikitox:introduction [2024/04/23 21:58] – kharriswikitox:introduction [2025/02/24 20:45] (current) – kharris
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-\\ +====== The Toxicology Patient ======
-\\ +
-\\ +
- <font 36px/inherit;;#c12b04;;inherit>Approach to The Toxicology Patient</font>+
  
-----+===== Overview ===== 
 + 
 +This section will give a brief overview to the toxicology patient covering initial approach, risk assessment, examination, investigations and treatments. 
 + 
 +Links are provided to more in depth discussion of some topics particularly treatment modalities.
  
 ===== Toxicoepidemiology ===== ===== Toxicoepidemiology =====
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 ===== Approach to the Toxicology Patient ===== ===== Approach to the Toxicology Patient =====
  
-The following paper gives a summary of factors that need to be considered when assessing and manging to toxicology patient.+The following paper gives a summary of factors that need to be considered when assessing and managing to toxicology patient.
  
 Daly FF, Little M, Murray L. A risk assessment based approach to the management of acute poisoning. Emerg Med J. 2006 May;23(5):396-9. doi: 10.1136/emj.2005.030312. PMID: 16627846; PMCID: PMC2564094. {{:wikitox:daly_2006_toxicological_risk_assessment.pdf|PDF}} Daly FF, Little M, Murray L. A risk assessment based approach to the management of acute poisoning. Emerg Med J. 2006 May;23(5):396-9. doi: 10.1136/emj.2005.030312. PMID: 16627846; PMCID: PMC2564094. {{:wikitox:daly_2006_toxicological_risk_assessment.pdf|PDF}}
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   * clinical manifestations since the exposure   * clinical manifestations since the exposure
   * regular medications   * regular medications
-  * relevant co-morbidities+  * relevant co-morbidities - especially renal or liver disease which may affect drug clearance, cardiac or respiratory disease which may increase toxicity for agents that cause cardiac or sedative effects and seizure history.
  
 If the exposure is a deliberate self-poisoning, a mental health risk assessment should also be undertaken. If the exposure is a deliberate self-poisoning, a mental health risk assessment should also be undertaken.
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   * **Blood gas**  analysis to assess gas exchange and metabolic disturbance particularly in patients with altered level of consciousness   * **Blood gas**  analysis to assess gas exchange and metabolic disturbance particularly in patients with altered level of consciousness
 +  * **Blood glucose **especially important in those with an altered level of consciousness
   * **Paracetamol concentration**  is often tested routinely when a patient is not alert enough to give a reliable risk assessment   * **Paracetamol concentration**  is often tested routinely when a patient is not alert enough to give a reliable risk assessment
   * **ECG**  assessing for QT prolongation or evidence of sodium channel blockade   * **ECG**  assessing for QT prolongation or evidence of sodium channel blockade
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   * **Bedside echo**  in patients with haemodynamic instability to determine the contribution of negative inotropy versus vasodilation   * **Bedside echo**  in patients with haemodynamic instability to determine the contribution of negative inotropy versus vasodilation
   * **CT head**  if concerns for concurrent trauma or hypoxic brain injury   * **CT head**  if concerns for concurrent trauma or hypoxic brain injury
 +More in depth description of some investigations can be found in appropriate sections ([[:wikitox:arterial_blood_gases|Bloods Gases]] , [[:wikitox:ecg_changes|ECG]]) or in specific drug monographs.
 +
 ---- ----
  
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 ==== Decontamination ==== ==== Decontamination ====
  
-Decontamination refers to techniques that reduce the exposure to a drug or toxin by reducing absorption. \\ +Decontamination refers to techniques that reduce the exposure to a drug or toxin by reducing absorption. \\ The use of decontamination methods should be based on a risk/benefit assessment. In those cases where the risk of toxicity is high decontamination should be given if the poisoning is amenable to it. Decontamination should always be a lower priority than resuscitation. \\ Methods of decontamination include:
-The use of decontamination methods should be based on a risk/benefit assessment. In those cases where the risk of toxicity is high decontamination should be given if the poisoning is amenable to it. Decontamination should always be a lower priority than resuscitation. \\ +
-Methods of decontamination include:+
  
-•   Activated charcoal \\ +• Activated charcoal \\ • Other binding resins \\ • Whole bowel irrigation \\ • Washing skin after dermal exposure
-•   Other binding resins \\ +
-•   Whole bowel irrigation \\ +
-•   Washing skin after dermal exposure+
  
-In general, decontamination can only be performed on a consenting patient.  If it is felt the risk of the poisoning is so high that good supportive care or antidote therapy won’t result in a safe outcome it may be necessary to perform decontamination procedures even without consent. This would require intubation and ventilation in most cases. \\ +In general, decontamination can only be performed on a consenting patient. If it is felt the risk of the poisoning is so high that good supportive care or antidote therapy won’t result in a safe outcome it may be necessary to perform decontamination procedures even without consent. This would require intubation and ventilation in most cases. 
- <font inherit/inherit;;inherit;;#f39c12>More in depth discussion of decontamination techniques can be found here</font>+ 
 +Further information regarding decontamination techniques can be found [[:wikitox:decontamination|here]].
  
 ==== Enhanced Elimination ==== ==== Enhanced Elimination ====
  
-Enhanced elimination aims to reduce the severity and duration of an intoxication.  As with decontamination, the decision to proceed with enhanced elimination techniques requires a thorough risk/benefit analysis and shouldn’t interfere with resuscitation or good supportive care. It is only available for ingestions with the toxicokinetics amenable to elimination, in particular the volume of distribution and clearance of the drug in question needs to be considered.+Enhanced elimination aims to reduce the severity and duration of an intoxication. As with decontamination, the decision to proceed with enhanced elimination techniques requires a thorough risk/benefit analysis and shouldn’t interfere with resuscitation or good supportive care. It is only available for ingestions with the toxicokinetics amenable to elimination, in particular the volume of distribution and clearance of the drug in question needs to be considered.
  
 Methods of Enhanced Elimination include: Methods of Enhanced Elimination include:
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   * Urinary Alkalinisation   * Urinary Alkalinisation
   * Extracorporeal Techniques   * Extracorporeal Techniques
- <font inherit/inherit;;inherit;;#f39c12>More in depth discussion of enhanced elimination techniques can be found here</font>+ 
 +More in depth discussion of enhanced elimination techniques can be found [[:wikitox:enhanced_elimination|here]].
  
 ==== Antidotes ==== ==== Antidotes ====
  
-Antidotes for poisonings have existed for thousands of years and the term refers to a wide range of substances that ameliorate poisonings. Broad mechanisms of action of antidotes include reducing absorption, restoring function, or treating effects of poisoning. Examples of antidotes used currently are supplied in the following table.+Antidotes for poisonings have existed for thousands of years and the term refers to a wide range of substances that ameliorate poisonings. Broad mechanisms of action of antidotes include reducing absorption, restoring function, or treating effects of poisoning. Examples of antidotes used currently are supplied in the following table (click to enlarge). 
 + 
 +{{  :wikitox:antidotes.png?direct&400  }} 
 + 
 +==== Supportive Treatment ==== 
 + 
 +Good supportive care is the mainstay of managing the poisoned patient. It involves; 
 + 
 +  * Maintaining hydration with IV fluids 
 +  * Placing a urinary catheter if there is urinary retention 
 +  * Treating agitation with sedation (eg benzodiazepines) 
 +  * Adequate thromboprophylaxis 
 +  * Prevent of pressure areas 
 +  * Treating nausea with antiemetics
  
 ---- ----
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   - Buckley NA, Whyte IM, Dawson AH, Isbister GK. A prospective cohort study of trends in self-poisoning, Newcastle, Australia, 1987-2012: plus ça change, plus c'est la même chose. Med J Aust. 2015 May 4;202(8):438-42. doi: 10.5694/mja14.01116. PMID: 25929508. {{:wikitox:buckley_et_al-2015-medical_journal_of_australia.pdf|PDF}}   - Buckley NA, Whyte IM, Dawson AH, Isbister GK. A prospective cohort study of trends in self-poisoning, Newcastle, Australia, 1987-2012: plus ça change, plus c'est la même chose. Med J Aust. 2015 May 4;202(8):438-42. doi: 10.5694/mja14.01116. PMID: 25929508. {{:wikitox:buckley_et_al-2015-medical_journal_of_australia.pdf|PDF}}
   - Assessment and management of the Poisoned Patient Video Summary [[https://vimeo.com/428066691|https://vimeo.com/428066691]]   - Assessment and management of the Poisoned Patient Video Summary [[https://vimeo.com/428066691|https://vimeo.com/428066691]]
-  - +  - Buckley NA, Dawson AH, Juurlink DN, Isbister GK. Who gets antidotes? choosing the chosen few. Br J Clin Pharmacol. 2016 Mar;81(3):402-7. doi: 10.1111/bcp.12894. Epub 2016 Feb 17. PMID: 26816206; PMCID: PMC4767201. {{:wikitox:buckley_et_al-2015-medical_journal_of_australia.pdf|PDF}}
- <font 11.0pt/Calibri,sans-serif;;inherit;;inherit>Buckley NA, Dawson AH, Juurlink DN, Isbister GK. Who gets antidotes? choosing the chosen few. Br J Clin Pharmacol. 2016 Mar;81(3):402-7. doi: 10.1111/bcp.12894. Epub 2016 Feb 17. PMID: 26816206; PMCID: PMC4767201.</font>+