Toxicology

an emphasis on airway, breathing, and circulation (ABC). The most common factor contributing to death

from a poisoning or drug overdose is the loss of the protective reflexes of the airway secondary to flaccid

tongue, aspiration of gastric contents into the lungs, or respiratory compromise including arrest. Emergent

endotracheal intubation should be performed when necessary. Vital signs (HR, RR, BP, temperature, and

oxygen saturation) and changes in mental status should be closely monitored. After stabilization, the DEFG

approach can be considered:

D: Decontamination

E: Enhanced elimination

F: Focused antidote therapy

G: Get help from a poison control center or toxicologist

intravenous fluids, supplemental oxygen, and advanced airway management. Other potential complications

should be assessed, such as presence of rhabdomyolysis, rigidity, or dystonia. Additional tests, such as a

12-lead ECG, chest radiograph, or electroencephalogram may be required. In addition, essential laboratory

tests should be conducted and assessed for the presence of an osmolar gap, anion gap acidosis, hyper/

hypoglycemia, hyper/hyponatremia, hyper/hypokalemia, renal failure, and liver failure.

Use of “coma cocktail” preparations is controversial and therefore not routinely recommended because

they should not replace or substitute for a thorough analysis of the patient (JEMS 2002;27:54-60).

Formulations vary, but they typically contain one or more of the following: dextrose, thiamine, and

naloxone. The following text presents an overview of the common additives, a rationale for use, and

potential controversies.

Dextrose 50%, 12.5–25 g (25–50 mL) intravenously is administered to treat hypoglycemia; it is

recommended to perform point-of-care blood glucose testing to confirm before administration.

Thiamine 100 mg is administered intravenously to prevent Wernicke encephalopathy; often under-

recognized, several doses of high-dose parenteral thiamine (e.g., 500 mg) concurrent with or

immediately following intravenous dextrose before intravenous dextrose are typically required to

effectively treat (J Emerg Med 2012;42:488-94).

Naloxone 0.04–2 mg IV is administered in a stepwise titration to reverse respiratory depression

secondary to opiate overdose.

A thorough physical examination should be performed.

the-counter agents, illicit substance use, and herbal products.

The history of the ingestion should be determined, if possible, including the following elements (Ann

Emerg Med 1999;33:735-56):

Timing and route of the exposure, the possible agents involved and their strengths and amounts,

and the potential intent of the patient

History from the prehospital care providers, family members, or other patient advocates

Onset and progression of any symptoms

Some providers advocate for the use of toxidromes, which are a collection of symptoms that occur

with particular classes of toxic agents. Toxidromes may help identify the toxic agent and assist in care

by helping providers anticipate additional symptoms. Although they may be very useful in the care of

an acute poisoning, they should be used with caution because some symptoms may overlap with other

classes of toxins, may be impacted by comorbid conditions, or may be absent altogether.