Drugs of Abuse – Stimulants and Opiates

Be alert in patients presenting with psychotic symptoms for toxicologic emergencies. Scrutinize vital signs and ECGs, and be concerned in patients with new onset psychotic symptoms, especially if age >40, or if they report visual, tactile or olfactory hallucinations.

 St, Mungo's Toxicology

Knowing your toxicological examination is key to knowing how to treat your patients. The patient may not be able to tell you which substances they have taken, so being familiar with the common toxidromes is very important. Check out these resources to brush up:

 The Approach to the Poisoned Patient

Most toxicologic exposures involve ingestions or localized chemical/biologic exposures involving single individuals with limited risk to medical personnel. In the uncommon event of an exposure which could be transmitted to emergency personnel, be sure to perform decontamination FIRST and OUTSIDE of the Emergency Department in order to not contaminate your personnel or life-saving equipment.

 Toxicology Airway Tips • When intubating- use rocuronium

When intubating- use rocuronium. Do not use succinylcholine in case of cholinergic toxicity. • In salicylate poisoning, avoid intubation. The hyperventilation is beneficial and difficulty to replicate. • If a patient is compensating for a metabolic acidosis, i.e., toxic alcohol, and begin to tire or have a seemingly normal. pCO2, then intubate.

A Basic, Practical Approach to Toxicology

Common toxidromes include sympathomimetic, anti-cholinergic, sedative-hypnotic, and opioid. They can be thought of as 2 larger classes, the ‘fast and furious’ and ‘downers’:

Drug Overdose in the Emergency Department

Discuss manifestations of drug intoxication in patients presenting to ED...

EKG Toxicology

Evaluation of these patients always includes a history and physical, but further testing can provide valuable information. Blood work is often be needed, but an EKG is a faster, cheaper tool that can provide key pieces of information prompting early interventions.

EM@3AM: Overdose

Most initial therapy is supportive rather than having a specific antidote; however toxicology is largely about anticipation of symptoms that may occur (such as seizures) to prevent decompensation.

Opiate Overdose in the ED. St.Emlyn’s

Opiate overdose is a common presentation to the ED. It has a significant mortality in the drug using population and although there are antidotes available the traditional approach to reversal may in itself cause harm.

Opioid Overdose: Emergency Treatment Is Crucial, but It's Not Enough

The opioid-blocking drug naloxone is a crucial first step, but there must be immediate follow-up to keep the cycle of addiction from continuing.

Poisonings

While looking for clues to aide in the diagnosis, there are a few classic “doorway diagnoses” where “toxidromes” are easily recognizable... Remember that patients my ingest several medications which may mask or blunt the toxidrome.

The Approach to the Patient with an Unknown Overdose

The following should be considered together as possible culprits: acetaminophen and salicylates, methanol and ethylene glycol, digitalis and beta-blockers and calcium channel antagonists.

Toxicologic Hyperthermic Syndromes, Part 1

It is important to refer to these patients as hyperthermic rather than febrile. The mechanism of temperature increase is different than in a febrile patient, and antipyretics such as acetaminophen do not work in managing the hyperthermia.

Toxicology

Accidental – cyanide from burning furniture, an accumulation of toxic levels of a prescription drug, accidentally ingested by a child.  Social drug use.  Deliberate self harm.  Attempts to harm others.

Toxicology: General management principles

Supportive measures should supersede all other considerations in the management of the poisoned patient. The ABC's always come first. Subsequently, the focus may switch to confirmation of a toxic ingestion and specific management issues. The majority of poisoned patients only require supportive therapy alone in order to recover. Supportive measures alone (Scandinavian method) including mechanical ventilation and circulatory support will permit survival of most patients who are alive upon arrival at the hospital. In general, the use of antidotes or specific measures should be limited to those patients with clear indications.