Emergency Medicine Book

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Unknown IngestionAka: Toxin Ingestion, Medication Overdose

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  1. History (Mnemonic: History MATtERS)
    1. Materials or Medications
    2. Amount or concentration
    3. Time taken
    4. Emesis
    5. Reason
    6. Signs and Symptoms
  2. Exam: Focus areas
    1. Toxin Induced Vital Sign Changes
    2. Toxin Induced Skin Changes
    3. Toxin Induced Neurologic Changes
    4. Toxin Induced Odors
    5. Pupil changes (Miosis, Mydriasis, and pupil reactivity)
      1. Also see Eye Examination Signs of Chemical Dependency
  3. 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
  4. Labs
    1. Complete Blood Count
    2. Chemistry Panel (Chem7)
    3. Arterial Blood Gas (ABG)
    4. Osmolality
    5. Urine Tox Screen (Urine superior to blood)
    6. Carboxyhemoglobin (Obtain immediately if suspected)
    7. Specific Drug Levels (when indicated)
      1. Aspirin Level (obtain 6-12 hours after ingestion)
      2. Acetaminophen Level (obtain 4 hours after ingestion; also consider at 2 hours)
      3. Theophylline Level
      4. Digoxin Level (obtain 2-4 hours after ingestion)
      5. Amitriptyline Level
      6. Alcohol level (obtain 0.5 to 1 hour after ingestion)
      7. Serum Iron level (obtain 2-4 hours after ingestion)
  5. Labs: Red Flags
    1. Metabolic Acidosis with elevated Anion Gap
    2. Elevated Osmolar Gap
  6. Diagnostics
    1. Electrocardiogram (esp. if Tricyclic Antidepressant or Antipsychotic overdose suspected)
      1. Prolonged QT interval
      2. Wide QRS
      3. Terminal R Wave in AVR
  7. Differential Diagnosis: Consider Toxidromes
    1. Cholinergic Toxicity
    2. Anticholinergic Toxicity
    3. Sympathomimetic Toxicity
    4. Salicylism
    5. Serotonin Syndrome
    6. Ilicit Drugs
      1. Narcotic Overdose
      2. Drug Withdrawal
      3. Club Drug or Date Rape Drug
      4. Chemical Dependency
        1. Opioids
        2. Hallucinogen
        3. Alcohol Abuse
        4. Amphetamine
        5. Benzodiazepine Abuse
        6. CNS Depressants
        7. Cocaine
        8. Volatile Inhalants
        9. Marijuana
        10. Phencyclidine
  8. Imaging
    1. Chest XRay
      1. Chemical pneumonitis
      2. Toxin Induced pulmonary edema
      3. Pneumothorax
    2. Abdominal XRay (KUB)
      1. See Radiopaque Toxins
  9. Management
    1. Consider Toxin Antidotes
    2. Consider Decontamination
      1. Protect medical personnel
        1. Liquid toxin
        2. Vapor off-gassing from patient
      2. Protect patient from further injury
    3. Consider Hemodialysis (for drugs cleared by dialysis)
    4. Supportive Care
      1. ABC Management
      2. Appropriate hydration

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