toxicology: what not to do

TOXICOLOGY…WHAT NOT TO DO

Chris Nickson FACEM FCICM Intensivist, The Alfred ICU

Financial Conflicts of Interest NO !

http://litfl.org/CONCEPTOS

ResusRSI DEAD

ResuscitationRisk AssessmentSupportive care & monitoringInvestigationsDecontaminationEnhanced eliminationAntidotesDisposition

RESUSCITATION

(WHAT NOT TO DO)

Do not get distracted… resuscitation comes first!

RES

USC

ITIA

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N

Do not intubate based on !risk assessment alone when!there are no signs of toxicity!

RES

USC

ITIA

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Do not rush to intubate a salicylate overdose patient lightly or allow respiratory

acidosis to develop!

RES

USC

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Do not use phenytoin for toxin-induced seizures!

RES

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Do not give up too early! in cardiac arrest !

RES

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RISK ASSESSMENT

(WHAT NOT TO DO)

Do not be lazy…! seek more information

RIS

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SSES

SMEN

T

Do not be reassured by!the apparently well patient

RIS

K A

SSES

SMEN

T

Do not expect toxidromes !to “fit” in a mixed overdose

RIS

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SSES

SMEN

T

Do not get your !calculations wrong

RIS

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SSES

SMEN

T

Do not ignore phone advice, but do not forget you are !

the one at the bedside!

RIS

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SSES

SMEN

T

SUPPORTIVE CARE & MONITORING

(WHAT NOT TO DO)

Do not forget to !observe and monitor !

in an appropriately !staffed and equipped

environmentSUPP

OR

TIVE

CA

RE

INVESTIGATIONS

(WHAT NOT TO DO)

Do not ever forget glucose

INVE

STIG

ATIO

NS

Do not rely on “gaps”! to diagnose !

toxic alcohol poisoning

INVE

STIG

ATIO

NS

Osmolar gap Anion gap

Do not order! drug levels unless you !

can interpret them and they will change management

INVE

STIG

ATIO

NS

Do not perform !urine drug screens

INVE

STIG

ATIO

NS

DECONTAMINATION

(WHAT NOT TO DO)

Do not perform !gastric lavage

DEC

ON

TAM

INAT

ION

Eddleston et al (2007), PMCID: PMC1941903!

Do not administer!activated charcoal

‘within 1 hour’ as a routine

DEC

ON

TAM

INAT

ION

Do not ‘freak out’ about organophosphate poisoning!

DEC

ON

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ION

ENHANCED ELIMINATION

(WHAT NOT TO DO)

Do not hesitate to call in the renal team when

hemodialysis is indicated!

ENH

AN

CED

ELI

MIN

ATIO

N

ANTIDOTES

(WHAT NOT TO DO)

Do not overdose your !patients with naloxone

unless they are !apneic or peri-arrest!

RES

USC

ITIA

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N

Do not forget octreotide for sulfonylurea-induced

hypoglycemia

AN

TID

OTE

S

Do not give flumazenil

AN

TID

OTE

S

Do not give glucagon

AN

TID

OTE

S

Do not be afraid of physostigmine for

anticholinergic delirium

AN

TID

OTE

S

Do not stop !N-acetylcysteine for

anaphylactoid reactions

AN

TID

OTE

S

Do not forget transporting!the antidote to the patient !

is an option

AN

TID

OTE

S

DISPOSITION

(WHAT NOT TO DO)

Do not forget!self-poisoning is a “snapshot” of a psychosocial disorder

DIS

POSI

TIO

N

ResuscitationRisk AssessmentSupportive care & monitoringInvestigationsDecontaminationEnhanced eliminationAntidotesDisposition

http://litfl.org/CONCEPTOS