166 Tox icolog y
Most cases of acute poisoning are acts of deliberate self-harm in the adult, but
they are usually accidental in children. All cases are initially managed as medical
emergencies and require substance identification, risk assessment, resuscitation,
specific and non-specific treatment, and a period of observation. Thereafter,
cases will require psychiatric assessment. Remember that an apparently trivial
act of self-harm may still indicate serious suicidal intent (see p. 438).DIAGNOSIS1 Consider acute poisoning in any unconscious patient or one exhibiting
bizarre behaviour, or in unexplained metabolic, respiratory or cardio-
vascular problems.
2 Obtain specific information from the patient, witnesses, and ambulance
personnel regarding:
(i) Pharmaceutical agent or toxin ingested:
(a) remember that two or more drugs are taken in 30% of cases
(b) alcohol is a common adjunct.
(ii) Quantity of agent ingested (look for empty blister packets or
bottles).
(iii) Time since ingestion.
(iv) History of any toxic effects experienced from the poisoning.
(v) Specific events prior to arrival in the emergency department
(ED), such as:
(a) rapid deterioration in conscious level
(b) seizures.
(vi) Clinical features on presentation.
3 Corroborate the history in the cooperative patient, but do not be misled, as
information supplied may be incomplete or deliberately fa lse.
4 Focus the examination on immediate life threats, identification of clinical
signs specific to certain drugs, and obtaining baseline vital signs.
(i) Rapidly assess airway patency, respiratory function and conscious
level.
(ii) Record the pulse, blood pressure, respiratory rate, temperature
and blood sugar level, and attach a cardiac monitor and pulse
oximeter to the patient
(a) hypoglycaemia and hyperthermia are common findings in
the collapsed patient with a drug overdose, and are often
overlooked.
(iii) Look for signs of seizure activity, assess upper and lower limbs
for signs of hypertonicity and clonus, and examine the pupils.