Treating the Poisoned Patient

Barbara M. Kirrane, M.D., and Robert S. Hoffman, M.D.

Dr. Kirrane is an Assistant Professor, Section of Emergency Medicine, Department of Surgery, Yale University School of Medicine, and Dr. Hoffman is Associate Professor of Emergency Medicine and Medicine, NYU School of Medicine, and Director, New York City Poison Control Center.

What happens when a patient shows up at the emergency room exhibiting signs and symptoms of poisoning? The attending physician in the ER may not immediately know what type of toxin the patient was exposed to. Exposure to toxic compounds — what we tend to call poisoning — may be due to a variety of agents: pharmaceutical drugs, illegal drugs, or even environmental toxins. Poisoning may occur for many different reasons: intentional harm (suicide), deliberate misuse (recreational drug abuse), accidental use (such as ingestions by small children exploring their environment), or by a prescribed dose that causes a toxic reaction.

[I]t is useful to know the established guidelines for treatment that the doctor may follow in order to arrive at the best possible outcome.

Poison Control Centers estimate approximately two million exposures to toxins per year(1); this may be an underestimate of actual exposures, since not all are reported to officials. Some antidotes exist for certain drugs, but if the patient's symptoms are not clear-cut, it is often necessary, and quite possible, to treat the patient with basic supportive care such as IV fluids or vasopressors. Given how relatively common poisoning is, it is useful to know the established guidelines for treatment that the doctor may follow in order to arrive at the best possible outcome. Some of these are described below.

First Steps

Physicians generally evaluate the patient right off the bat for certain basic body functions. Some assessments include the degree to which airways are open or closed, the rate and depth of breathing, and circulation (heart rate, blood pressure, etc.). If the patient appears to have been exposed to a toxin externally (i.e., via the skin), then measures are taken immediately to decontaminate the skin of the toxic substance.

Looking for Clues

Once basic body functions have been deemed stable, the doctor may be able to determine what class of toxin is responsible for the poisoning. One method is to look at pupil size, which can be enlarged in response to certain toxins, or constricted in response to others. Skin texture — wet/moist skin vs. dry, flushed skin — can also be a signal as to what type of toxic substance has been ingested. Patients who are showing clear signs of altered mental status are given a test to determine glucose level, since this is the brain's only nourishment. If the glucose level is low, then doctors will give the patient an IV drip of fluid containing dextrose, a sugar solution.

Electrocardiogams (ECG or EKG) are performed on all patients who exhibit exposure to toxic compounds, as they may be good indicators of the type of toxin involved. For example, a specific change in the pattern of the ECG can indicate the presence of tricyclic antidepressants. Doctors can then treat the patient accordingly and do a repeat ECG to monitor the patient's progress and recovery.(2)

Low Blood Pressure and Poisoning

While many people may be familiar with the risks of hypertension in everyday life, hypotension "or low blood pressure" is a common symptom in poisoned patients and can result from a variety of factors, including dehydration or anaphylaxis (severe allergic reaction). In cases of hypotension, doctors will begin a specific type of IV drip and monitor the patient closely. If the patient does not respond to the IV, a vasopressor "a compound that constricts the blood vessels to increase blood pressure" should be administered. It is important for the physician to keep in mind that the patient may be on prescription antidepressants, which would determine what type of vasopressor is administered.(3)(4)(5)

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