Question

You are visiting a friend who is just home from the hospital after major surgery. You notice that your friend is having a difficult time concentrating, is sweating, looks pale and reports feeling nauseous. Your friend tells you that he thinks he might have taken too many of the pain pills prescribed by the physician. What is wrong with your friend and how will you care for him? Include common signals for this type of illness.  Discuss the questions that you should ask for victims of suspected poisonings and why they can be helpful. What concerns or special treatment does the text discuss for various types of poisonings?

Answer 1

• An overdose occurs when a person uses more of a substance than their body can handle. No one can tell exactly how much of a drug it will take to push someone to the point of an overdose. Different people have different thresholds, but risk factors for an overdose include poor physical health, mental illness, using alone, or having a history of a previous overdose. Whether it occurs accidentally or intentionally, an overdose can often be fatal.

Users of prescription painkillers report a sensation of euphoria when the drug first hits their brains. This is why people become addicted: to continually chase the feeling of being high. Eventually, though, your brain will develop a tolerance to painkillers, and you’ll need to take larger doses of the drug to achieve the same high – and that puts you at risk of an overdose.

• During an overdose, the drug overwhelms the parts of your brain that control your respiratory and circulatory functions. Neurological signals are suppressed, leading to slowed breathing and heart rate. Sometimes, people who overdose may experience abnormal heart rhythms; sometimes they will enter full cardiac arrest.

  As heart and lung function ceases, your organs become deprived of oxygen. At this point, kidney and liver damage can occur, and the longer your brain goes without oxygen-rich blood, the higher your chances are of developing severe seizures and irreversible brain damage.

• Signs of a painkiller overdose

  People in the midst of an overdose may experience disorientation, hallucinations, severe headaches, or overheating. However, in the moment, they usually don’t have the self-awareness to realize what’s happening. It’s often up to outside observers to identify the signs of an overdose, which include:

• Cold, clammy skin
• Blue or grey lips and nails
• Slow or absent breathing
• Gurgling sounds or snoring
• Vomiting
• Shaking
• Tiny pupils
• Unresponsiveness

• What to do during an overdose

  If you suspect someone is experiencing a painkiller overdose, it’s crucial to call 911 immediately. Timely medical attention can mean the difference between life and death. Emergency first responders are equipped with naloxone, a drug that can reverse the effects of an opioid overdose and potentially save lives. Administered via nasal spray or injectable syringe, naloxone works by blocking the opioid receptors in the brain, enabling lung and heart function to resume almost instantaneously.

• Treatments

Assessment and Stabilization

EMERGENCY ASSESSMENT

• A brief physical assessment should be performed immediately in all patients to determine the effects of toxin(s) and other conditions that might be present. Particular attention should be directed to adequacy of the airway and ventilation, level of mental status and cardiac function. Unstable patients should be placed on a cardiac monitor, with measurement of vital signs every five to 15 minutes until the patient is stabilized to the point that monitoring is no longer necessary.

• Initial Stabilization Procedures

  Stabilization of the patient is the first priority in managing toxic ingestions and is performed simultaneously with the initial physical assessment. Treatment should address the “ABCs” (airway, breathing, circulation) without delay. Also, the potential for rapid changes in the patient's condition should be considered in making decisions about airway and ventilatory support. Treatment with naloxone (Narcan), dextrose and thiamine should be considered in patients with altered mental status.2–4 Naloxone is a competitive antagonist at opiate receptors and can reverse narcotic-induced symptoms when given intravenously, intramuscularly, endotracheally, subcutaneously or intralingually. Successful submental administration of naloxone has also been reported

• DETERMINATION OF INGESTED SUBSTANCE

  Physical findings may suggest the type of toxin(s) ingested but, more often, a detailed history, examination of medication containers or toxicologic analysis reveals the answer. Physical findings, however, often enable the clinician to determine if the toxin is a physiologic stimulant or a depressant, and which common poisons should be considered in the initial management of the patient.

  Physical signs following ingestion of stimulants often include mydriasis (dilated pupils), tremor, tachycardia, irritability, diaphoresis, mania, convulsions and tachyarrhythmias. Commonly ingested stimulants include cocaine, amphetamines, caffeine, theophylline, tricyclic antidepressants (early symptoms after overdose), antihistamines and hallucinogens.

• Laboratory Evaluation

  Laboratory evaluation is indicated in most symptomatic patients, when ingested substances are unknown, if the poison has the potential to produce moderate to severe toxicity and if the ingestion was intentional. Routine studies should include a complete blood cell count, determination of serum electrolyte and glucose levels, a chemical screen with hepatic and renal function studies (e.g., calcium, aspartate aminotransferase, alanine aminotransferase, bilirubin, alkaline phosphatase, lactate dehydrogenase, prothrombin time, blood urea nitrogen, creatinine) and urinalysis. Measurement of serum osmolarity may be helpful if poisoning with methanol, ethylene glycol or isopropanol is suspected.

• ANCILLARY TESTS

  An electrocardiogram should be performed in patients with arrhythmias and/or suspected ingestion of cardiotoxic drugs. Chest radiographs should be obtained in patients with suspected aspiration, coma or ingestion of medications (salicylates, narcotics, paraquat, sedative-hypnotics) that can produce noncardiogenic pulmonary edema.11 Abdominal radiographs may detect abnormal densities in patients who have ingested drug packets, salicylates, calcium salts, heavy metals (e.g., iron tablets) or radiopaque foreign bodies. Ingested hydrocarbons may be visualized as a “layer” between gastric fluid and the gastric air bubble.

  Ancillary tests such as electrocardiograms, chest radiographs and plain abdominal films need not be routinely ordered but, when appropriate, can provide the clinician with additional useful information.

  Decontamination

  Following evaluation and stabilization of the poisoned patient, attention is directed toward decontamination, i.e., decreasing absorption of the ingested poison from the gastrointestinal tract. This can be accomplished by emptying the stomach via gastric lavage, administration of activated charcoal within the gut lumen and use of methods for increasing transit of the toxic substances through the gastrointestinal tract.

• GASTRIC LAVAGE

  In most situations, gastric lavage is preferable to administration of ipecac, particularly in emergency departments where prolonged ipecac-induced vomiting may delay treatment with activated charcoal. Indications for lavage include ingestions of highly toxic substances (large ingestions or substances associated with high morbidity and/or mortality); substances not well adsorbed by activated charcoal (i.e., lithium, iron, lead, methanol) and in patients with the potential for a jeopardized airway (e.g., altered alertness

• IPECAC

  Ipecac continues to be useful in the telephone management of alert patients unable to travel to a health care facility within one hour of the ingestion. It has been shown that ipecac used at home by experienced hospital staff treating pediatric poisonings following ingestions identified as not being “high-risk” decreases pediatric emergency department visits without jeopardizing safety.14

  Syrup of ipecac is administered in the following dosages: in infants six months to one year of age, 10 mL; in children one to 12 years of age, 15 mL; in adolescents over 12 years of age, 30 mL. Water is given immediately after the ipecac to enhance the efficacy of gastric emptying with emesis; adults should receive 8 to 16 oz; children should receive 4 to 8 oz; children less than one year of age should receive 5 to 15 mL per kg body weight.

• ACTIVATED CHARCOAL

  Activated charcoal forms the mainstay of gastric decontamination and is effective for most oral poisonings when given alone or following gastric emptying. Exceptions include ingestions of caustic acids and alkalis, alcohols, lithium and heavy metals (e.g., iron, arsenic). Activated charcoal is inert and remains within the gastrointestinal tract, offering a large surface area for adsorption of ingested toxins. In addition, activated charcoal may decrease the absorption of drugs that undergo enterogastric or enterohepatic circulation.

• WHOLE BOWEL IRRIGATION

  Whole bowel irrigation uses isosmotic cathartic solutions to flush and cleanse the bowel. It is potentially beneficial in patients who have ingested substances that are not well-absorbed by activated charcoal and/or are not amenable to lavage. Examples of such substances include iron, lithium and slow-release potassium, and packets or vials containing cocaine and other drugs. Commonly used irrigants (Golytely, Colyte) contain a polyethylene glycol electrolyte solution that is not absorbed from the gastrointestinal tract and does not cause significant fluid or electrolyte imbalances

• Antidotes

  Table 4 lists antidotes to several of the common and dangerous poisons. Antidotes are typically given once the patient has been stabilized, usually within a few hours of the ingestion. Unless clinicians are familiar with the use of an antidote, it is probably wise to contact a certified poison control center regarding the specifics of its use. In addition, many antidotes have a short duration of action relative to the effects of the ingested poison, and observation in a specialized hospital unit following administration of the antidote is advisable.