II. History: Approach

  1. Talk to paramedics and family who were at scene
  2. Review pill bottles including OTC agents
  3. Review drug paraphernalia as well as unusual wrappers and containers

III. History (Mnemonic: History MATtERS)

  1. Materials or Medications
  2. Amount and concentration
  3. Time taken
  4. Emesis
  5. Reason
  6. Signs and Symptoms

V. Evaluation: Mass Casualty Exposure

  1. Consider Exposure possibilities
    1. Biological Weapon
    2. Chemical Weapon
  2. Mnemonic: Asbestos
    1. Agents
      1. Type and toxicity of agent
      2. Potential Lethality of exposure
    2. State
      1. Solid or Liquid
      2. Gas, Vapor, or Aerosol
      3. State combination
    3. Body Site
      1. Where exposure occurred
      2. Routes of entry and absorption
    4. Effects
      1. Local
      2. Systemic
    5. Severity
      1. Mild, moderate or severe effects and exposure
    6. Time course
      1. Past: When did symptom onset occur
      2. Present: Getting better or worse?
      3. Future: Prognosis
    7. Other diagnoses
      1. Differential diagnosis
      2. Additional or combination diagnoses
    8. Synergism
      1. Combined effects of multiple exposures

VII. Labs

  1. Complete Blood Count
  2. Comprehensive Metabolic Panel
    1. See Metabolic Acidosis with Anion Gap
    2. Anion Gap calculation is critical
  3. Arterial Blood Gas (ABG) or Venous Blood Gas (VBG)
  4. Serum Osmolality (where available)
    1. Alerts to possible toxic Alcohol ingestion (e.g. Polyethylene glycol)
    2. May indicate starting antidote (e.g. Fomepizole) empirically
  5. Urinalysis
  6. Urine Tox Screen (Urine superior to blood)
  7. Urine Pregnancy Test (if indicated)
  8. Carboxyhemoglobin (Obtain immediately if Carbon Monoxide Poisoning suspected)
  9. Creatinine Phosphokinase (CPK)
    1. Indicated if Rhabdomyolysis suspected
  10. Drug Levels in all Overdose cases
    1. Serum Aspirin Level (obtain 6-12 hours after ingestion)
    2. Serum Acetaminophen Level (obtain 4 hours after ingestion; also consider at 2 hours)
    3. Blood Alcohol level (obtain 0.5 to 1 hour after ingestion)
  11. Drug levels when indicated
    1. Serum Theophylline Level
    2. Serum Digoxin Level (obtain 2-4 hours after ingestion)
    3. Serum Amitriptyline Level
    4. Serum Iron level (obtain 2-4 hours after ingestion)
  12. Consider evaluation for serious infection
    1. See Septic Shock
    2. See Meningitis
    3. See Bacterial Endocarditis (e.g. IV Drug Abuse)
    4. Consider Blood Cultures and Serum Lactic Acid
    5. Consider Lumbar Puncture

VIII. Labs: Red Flags

  1. Metabolic Acidosis with elevated Anion Gap
  2. Elevated Osmolar Gap

IX. Diagnostics: Electrocardiogram

  1. Indicated in all cases (esp. if Tricyclic Antidepressant or Antipsychotic Overdose suspected)
  2. Obtain serial EKGs during emergency department evaluation
  3. Monitor continuous telemetry
  4. Findings suggestive serious cardiotoxicity (and risk of Ventricular Tachycardia or Torsades)
    1. Prolonged QT interval
      1. See Prolonged QT Interval due to Medication
      2. Causes include Antipsychotics, Anticholinergics, Sympathomimetics, Antidepressants
    2. Wide QRS (e.g. Tricyclic Antidepressant Overdose)
      1. Causes include Tricyclic Antidepressants, Cocaine, Diphenhydramine, Antiarrhythmics

X. Imaging

  1. CT Head
    1. Consider in all patients with Altered Level of Consciousness
  2. CT Cervical Spine
    1. Consider at time of CT Head if suspicion for Cervical Spine Injury
    2. Maintain spine precautions until cleared by exam in a CNS intact patient
  3. Chest XRay Indications (indicated in most Altered Level of Consciousness patients)
    1. Chemical pneumonitis
    2. Toxin Induced Pulmonary Edema
    3. Pneumothorax
  4. Abdominal XRay (KUB) Indications
    1. See Radiopaque Toxins

XI. Differential Diagnosis: Toxidromes

  1. Sympathomimetic Toxicity (e.g. Amphetamine, Cocaine, Ephedrine)
    1. Tachycardia, Hypertension, hyperthermia, diaphoresis, Arrhythmia
    2. Mydriasis, Agitation
  2. Cholinergic Toxicity (e.g. Organophosphate, Pesticide)
    1. SLUDGE: Salivation, Lacrimation, urination, Defecation, gastrointestinal, Emesis
  3. Anticholinergic Toxicity (e.g. Diphenhydramine, Atropine, scopolamine, Jimson weed)
    1. Mad as a hatter (altered)
    2. Blind as a bat (Mydriasis)
    3. Red as a beet (flushed)
    4. Hot as a hare (hyperthermia)
    5. Dry as a bone
  4. Opioid Toxicity (e.g. Heroin, Morphine)
    1. Central Nervous System depression (sedation to coma)
    2. Respiratory depression (apnea)
    3. Miosis
  5. Sedative-Hypnotic Toxicity (e.g. Benzodiazepine Toxicity, Barbiturates, anticonvulsants, Alcohol)
    1. Central Nervous System depression (sedation to coma)
    2. Respiratory depression (apnea)
    3. Confusion, Delirium, Hallucinations
  6. Other presentations
    1. Serotonin Syndrome
    2. Drug Withdrawal
    3. Club Drug or Date Rape Drug
    4. Serious Infection ( Septic Shock, Bacterial Meningitis, Bacterial Endocarditis)
  7. References
    1. ACLS (2013) Provider Manual, AHA, p. 282

XIII. Differential Diagnosis: Drugs of Abuse (Intoxication and withdrawal)

  1. See Date Rape Drug
  2. Precautions
    1. Substances of abuse are difficult to distinguish by sight
    2. White powder could be Cocaine, Methamphetamine, synthetic Opioids, NBOMe or bath salts
    3. Crystals could be Crystal Meth, U-47700
    4. Many substances of abuse are reformulated into tablets
      1. Fentanyl may be formed in tablets similar to Oxycodone or Hydrocodone
  3. Alcohol
    1. See Alcohol Abuse
    2. Ethanol-based hand sanitizer (especially in health care centers)
      1. Hand sanitizer can cause significant Alcohol Intoxication (60% Alcohol)
      2. Some abusers of hand sanitizer extract the Alcohol with salt
  4. Cannabinoids (Marijuana, K2, Spice)
    1. See Marijuana (includes Synthetic Cannabinoids such as K2)
    2. Most common drug of abuse in U.S. and progressively increasing annually among grades 8-12
  5. Opioids (e.g. Oxycodone, Morphine, Heroin)
    1. See Opioid Abuse
    2. Opioid Overdose (Narcotic Overdose)
  6. Sedative-Hypnotics
    1. Benzodiazepine Abuse
    2. Benzodiazepine Overdose
    3. Gamma Hydroxybutyrate (GHB)
  7. Stimulants (Sympathomimetics)
    1. Cocaine
    2. Methamphetamine
    3. Synthetic Cathinones (Psychoactive Bath Salts)
    4. Methylenedioxymethamphetamine (MDMA, Ecstasy)
  8. Volatile Inhalants (Sniffing, Huffing, Bagging)
    1. More common drug of abuse in ages 10-14 years old
    2. Risk of Sudden Sniffing Death Syndrome
  9. Hallucinogens
    1. Ketamine Abuse (and Methoxetamine)
    2. Phencyclidine (PCP)
    3. Dextromethorphan Abuse

XIV. Management: General

  1. See Altered Level of Consiousness
  2. Involve poison control early
    1. http://www.aapcc.org/
    2. U.S. Phone: 1-800-222-1222
  3. Consider Coma cocktail (consider for unknown Drug Ingestion with Altered Level of Consciousness)
    1. Dextrose 25% to 50% (for Hypoglycemia demonstrated by Glucometer)
    2. Naloxone 0.4-2 mg IV (for possible Narcotic Overdose)
    3. Other agents to consider
      1. Thiamine (Alcoholic or malnourished patients)
      2. Flumazenil (for possible Benzodiazepine Overdose)
        1. Uncommon emergency use due to the risk of severe Benzodiazepine Withdrawal (e.g. Seizures)
        2. Use only with caution (due to risk of serious withdrawal in Benzodiazepine addiction)
  4. Consider Toxin Antidotes
  5. Consider Gastric Decontamination with charcoal if presentation within 1-2 hours of poison ingestion
    1. See Activated Charcoal for indications and contraindications
      1. Drugs must be bound by charcoal and patient must be alert or with protected airway
    2. Activated Charcoal given within 30 minutes after ingestion: Decreases absorption by 70%
    3. Activated Charcoal given within 30-60 minutes after ingestion: Decreases absorption by 30%
    4. Do not use Gastric Lavage
  6. Consider Decontamination
    1. Protect medical personnel
      1. Liquid toxin
      2. Vapor off-gassing from patient
    2. Protect patient from further injury
  7. Consider Hemodialysis (for drugs cleared by Dialysis)
  8. Supportive Care
    1. ABC Management
    2. IV Access and appropriate hydration
    3. Oxygen Delivery
    4. Control Seizures (see Status Epilepticus)
  9. Advanced Airway (as indicated)
    1. Rapid Sequence Intubation
      1. Rocuronium is preferred paralytic in ingestions
      2. Risk of Hyperkalemia (which would contraindicate Succinylcholine)
        1. Overdosage with ACE Inhibitors or Digoxin
        2. Rhabdomyolysis associated with unconscious from Overdose
  10. Cardiac monitor
    1. Control Dysrhythmias
    2. QRS Widening on EKG
      1. Sodium Bicarbonate 1-2 ampules IV push (requires numerous back-to-back doses until QRS narrows)

XV. Management: Specific Ingestions

XVI. Disposition

  1. See Clinical Sobriety
  2. Indications for emergency department discharge
    1. Return to baseline mental status and
    2. Minimal to no residual symptoms and
    3. Hemodynamically stable Vital Signs and
    4. No psychological safety concerns (not suicidal, and no intentional Overdose)
  3. Resources
    1. National Suicide Prevention lifeline: 1-800-273-TALK
    2. Substance Abuse and Mental Health Referral Hotline (SAMSHA): 1-800-662-HELP

XVII. Prevention: Childhood Poisonings

  1. See Accidental Poisoning Causes for most common childhood Poisonings
  2. See Medication Dosing Errors in Children
  3. Background
    1. Medication Poisonings are responsible for two-thirds of deaths in children under age 5 years old
    2. U.S. and Canadian restrictions in 2008 on OTC medications for infants and children
      1. Has effectively reduced childhood Poisonings
  4. Education
    1. Do not rely on child-resistant medications as sole protection against Poisoning
    2. Store all medications including pill boxes in a safe place after every time they are accessed
      1. See One Pill Can Kill
      2. Purses containing medications should also be kept safely away from toddlers and children
    3. Dispose of medications properly
      1. See Medication Disposal
    4. Talk to children about danger of household products
      1. Medications, laundry pods and dish detergent pods, household cleansers are absolutely not candy
      2. Hand sanitizer contains >60% Alcohol and may result in Alcohol Poisoning in young children
      3. Keep cleaners and disinfectants in their original containers (never store in water or soda bottles)
    5. Dispose of Ipecac syrup if still in household
      1. No longer recommended (risk of harm such as aspiration, not helpful, and may delay definitive care)
    6. Adults should also Exercise caution to prevent their Accidental Ingestions
      1. Read medication bottles carefully to confirm the medication they are taking (and proper dose)
      2. Turn on the light when using toiletries (e.g. confirm toothpaste tube)
    7. Keep critical phone numbers by telephone (consider programming into telephone)
      1. Poison Control Center: 1-800-222-1212

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Related Studies

Ontology: Drug Overdose (C0029944)

Definition (MSH) Accidental or deliberate use of a medication or street drug in excess of normal dosage.
Definition (MSHCZE) Náhodné nebo úmyslné požití léků nebo pouličních drog převyšující normální dávky.
Definition (NCI_NCI-GLOSS) An amount of drug that is more than what should be taken at one time.
Definition (CSP) accidental or deliberate dose of a medication or street drug that is in excess of what is normally used.
Concepts Injury or Poisoning (T037)
MSH D062787
SnomedCT 212498006, 55680006
LNC LA20277-2, LA17978-0
English Overdoses, Overdose of drug, Overdose NOS, drug overdose, drug overdoses, overdoses, overdose, Overdoses, Drug, Overdose, Drug, Drug Overdose [Disease/Finding], Drug Overdose, Drugs--Overdose, OVERDOSE, Drug overdose, Overdose, OD - Overdose of drug, Drug overdose (disorder), Drug overdose, NOS, Overdose, NOS, Drug Overdoses
Italian Sovradosaggio, Sovradosaggi, Sovradosaggio NAS, Overdose di farmaco, Uso improprio di medicinali
Dutch overdosis NAO, overdosis van geneesmiddel, overdoseringen, overdosis
French Surdosage SAI, Surdosage de médicament ou de drogue, Mauvais usage des médicaments prescrits, Mauvaise utilisation des médicaments délivrés sur ordonnance, Mésusage des médicaments délivrés sur ordonnance, Mésusage des médicaments prescrits, Mauvais usage des médicaments délivrés sur ordonnance, Mauvaise utilisation des médicaments prescrits, Overdoses, Surdose
German Ueberdosierung NNB, Medikamentenueberdosierung, Missbrauch verschreibungspflichtiger Medikamente, Ueberdosis, Ueberdosen
Portuguese Sobredosagem NE, Sobredosagem de droga ou de fármaco, Overdose de Drogas, Overdose de Substâncias, Overdose de Medicamentos, Sobredosagem, Sobredosagens
Spanish Sobredosis NEOM, sobredosis de una droga, Sobredosis de un fármaco, Sobredosis de Droga, Overdose de Sustancias, Overdose de Medicamentos, sobredosis de drogas (trastorno), sobredosis de drogas, sobredosis de un medicamento, sobredosis de una droga (trastorno), Sobredosis, Sobredosificación
Japanese 過量投与, 過量投与NOS, カリョウトウヨ, カリョウトウヨNOS, 薬剤過量投与, ヤクザイカリョウトウヨ
Czech Předávkování, Předávkování NOS, Nadměrné dávky, Předávkování drogami, předávkování léky, léky - požití nadměrné dávky
Hungarian Túladagolás k.m.n., Túladagolások, Gyógyszer túladagolás, Túladagolás
Polish Przedawkowanie leków, Przedawkowanie leku
Norwegian Misbruk av reseptbelagte legemidler

Ontology: Poisoning (C0032343)

Definition (MSH) A condition or physical state produced by the ingestion, injection, inhalation of or exposure to a deleterious agent.
Definition (MEDLINEPLUS)

A poison is any substance that is harmful to your body. You might swallow it, inhale it, inject it, or absorb it through your skin. Any substance can be poisonous if too much is taken. Poisons can include

  • Prescription or over-the-counter medicines taken in doses that are too high
  • Overdoses of illegal drugs
  • Carbon monoxide from gas appliances
  • Household products, such as laundry powder or furniture polish
  • Pesticides
  • Indoor or outdoor plants
  • Metals such as lead and mercury

The effects of poisoning range from short-term illness to brain damage, coma, and death. To prevent poisoning it is important to use and store products exactly as their labels say. Keep dangerous products where children can't get to them. Treatment for poisoning depends on the type of poison. If you suspect someone has been poisoned, call your local poison control center right away.

Definition (CSP) condition or physical state produced by the ingestion, injection or inhalation of, or exposure to a deleterious agent.
Concepts Injury or Poisoning (T037)
MSH D011041
ICD10 T65.91
SnomedCT 269262003, 212498006, 75478009
English Poisoning, Poisonings, POIS, poisoning (diagnosis), poisoning, Poisoning [Disease/Finding], poisoning by, by poisoning, poisonings, Poisoning NOS, Poisoning (event), Poisoning by, Poisoning syndrome, Poisoning (disorder), Poisoning syndrome, NOS, Poisoning, NOS
Dutch vergiftiging NAO, vergiftiging, Vergiftiging
French Intoxication SAI, Intoxication
German Vergiftung NNB, Vergiftung
Italian Avvelenamento NAS, Avvelenamento
Portuguese Intoxicação NE, Intoxicação, Envenenamento
Spanish Envenenamiento NEOM, Intoxicación, envenenamiento, intoxicación (trastorno), intoxicación, toxicosis, Envenenamiento
Japanese 中毒NOS, 中毒, チュウドク, チュウドクNOS
Swedish Förgiftningar
Czech otrava, Otrava NOS, Otrava
Finnish Myrkytys
Polish Zatrucie, Zatrucia
Hungarian Mérgezés k.m.n., Mérgezés
Norwegian Forgiftning

Ontology: Intentional drug overdose (C0520804)

Concepts Injury or Poisoning (T037)
SnomedCT 59274003
German absichtliche Ueberdosis, absichtliche Ueberdosierung, Absichtliche Ueberdosierung, Ueberdosierung absichtlich
Italian Sovradosaggio intenzionale, Sovradosaggio volontario, Sovradosaggio non accidentale
Dutch niet-accidentele overdosis, opzettelijke overdosis
French Surdosage délibéré, Surdosage non accidentel, Surdosage intentionnel, Overdose intentionnelle
Portuguese Sobredosagem não acidental, Sobredosagem deliberada, Sobredosagem intencional
Spanish Sobredosis deliberada, Sobredosis no accidental, sobredosis intencional de una droga, sobredosis intencional de drogas (trastorno), sobredosis intencional de drogas, sobredosis intencional de un medicamento, sobredosis intencional de una droga (trastorno), Sobredosis intencional
Japanese 企図的過量投与, 故意の過量投与, 非偶発的過量投与, キトテキカリョウトウヨ, コイノカリョウトウヨ, ヒグウハツテキカリョウトウヨ
Czech Úmyslné předávkování, Nenáhodné předávkování, Záměrné předávkování, Předávkování úmyslné
English Non-accidental overdose, Deliberate overdose, Overdose intentional, Intentional drug overdose, Intentional drug overdose (disorder), Intentional overdose
Hungarian Szándékos túladagolás, Nem véletlen túladagolás

Ontology: Accidental ingestion (C0857807)

Concepts Injury or Poisoning (T037)
SnomedCT 418757007
English accidental ingestion, accidental ingestion (history), accidental ingestions, Accidental ingestion
Czech Náhodné pozření
Dutch toevallige opname
French Ingestion accidentelle
German versehentliche Einnahme
Hungarian Véletlen lenyelés
Italian Ingestione accidentale
Japanese グウハツテキゴイン, 偶発的誤飲
Portuguese Ingestão acidental
Spanish Ingestión accidental

Ontology: Accidental ingestion of drug (C3544179)

Concepts Injury or Poisoning (T037)
English Accidental ingestion of drug
Czech Náhodné spolknutí léku
Dutch accidenteel inslikken van geneesmiddel
French Ingestion accidentelle de médicament
German Versehentliches Schlucken eines Arzneimittels
Hungarian Gyógyszer véletlen lenyelése
Italian Ingestione accidentale di farmaco
Japanese グウハツテキヤクザイゴイン, 偶発的薬剤誤飲
Portuguese Ingestão acidental de fármaco
Spanish Ingestión accidental de fármaco