01. Toxicology Basics

Always call Poison Control at 1-800-222-1222 or Medical Toxicology Consult Service at 415-443-0122 for assistance.

Emergency Stabilization

  • Airway: can the patient protect their airway? Hoarseness or stridor may indicate airway edema. Consider intubation with these signs.
  • Breathing: bag/mask ventilation, ABG.
  • Circulation: BP, HR, IV access (start 1-2 lines, preferably large bore), ECG (special attention to QRS and QTc), normalize body temperature.
  • Decontamination
    • Cutaneous: to protect yourself from secondary contamination (e.g. with pesticides), wear gloves, gown, goggles. Remove contaminated clothing and double bag. Wash skin with soap and water.
    • Eyes: irrigate with at least 1L water or saline (easier if proparacaine given first).
    • Inhalation: a paper mask will not protect you against fumes or vapors; cartridge respirator or self-contained breathing apparatus may be required (ask for assistance from Environmental Health & Safety department or Fire Department HazMat team. For exposure to irritant gases or vapors, humidified O2 may provide some symptomatic relief.
    • Gastrointestinal: decision to use gastrointestinal contamination should be based on potential severity of ingestion and time since ingestion.
      • Contraindications: inability to protect airway (unless patient is already intubated with an inflated endotracheal cuff), bowel obstruction, bowel perforation, need for endoscopy.
      • Relative contraindications: decreased peristalsis, late presentation (>1-2 hours).
  • Elimination: hemodialysis (useful for ethylene glycol, lithium, methanol, carbamazepine, metformin, salicylates, theophylline, valproic acid, phenobarbital), enhance urinary elimination via alkalinization (salicylates, phenobarbital), give antidotes if available.

GI Decontamination

  • Activated charcoal (25-100g): highly absorbent powder in aqueous suspension. Preferred treatment for ingestions occurring within the last hour, but possibly also effective for patients presenting later.
    • Single dose (goal 10:1 ratio charcoal to poison). Some preparations contain sorbitol (not recommended), which causes fluid loss and electrolyte shifts. Avoid in corrosive ingestions.
    • Multi-dose charcoal can be used with ingestions with prolonged absorptive phase such as sustained-release preparation, anticholinergic, opiate/opioid, and massive salicylate ingestion. Charcoal won’t bind highly ionic salts such as iron, lithium or potassium. 
  • Whole bowel irrigation: preferred treatment for ingestions of illicit drug packets, foreign bodies, sustained release or enteric coated pills, potassium or iron tabs, lithium, massive aspirin ingestions. GoLytely 2L/hr via NG tube until clear stool. Ok to give with charcoal (stool will be black).
  • Restricted GI decontamination methods: ipecac and cathartics (magnesium citrate, mannitol) not recommended as monotherapy for decontamination. Can be used in combination with other methods under guidance of Poison Control. Gastric lavage may be appropriate in potentially lethal ingestions for which there is no other treatment, such as colchicine. Contact Poison Control prior to initiation of these therapies.

Secondary Survey

  • History: special attention to amount, time of ingestion, history of vomiting/hematemesis, empty bottles, drugs in household (access, co-ingestions), herbal meds/vitamins. Attempt to find others who can provide collateral history (family, EMS or coworkers). Think about sexual assault.
  • Physical exam: look for toxidromes (See section Toxidromes), with special attention to vital signs (HR, BP), pupil size, bowel sounds, axillary sweat or lack of sweat/skin dryness, signs of assault.
  • Labs: CBC, CHEM 10, PT/INR/PTT, serum osmolality and osmol gap, POC BG, LFTs, UA, Utox, APAP, ASA, ABG, UPreg. Consider CK, serum ethanol, therapeutic drug levels. Request lab to hold an additional serum tube for future analysis of unknowns.
  • Imaging: some substances can be radiopaque.
  • Psychosocial: call psych, place 5150 for suspected intentional ingestions.
  • Empiric treatment: for profound altered mental status/coma, give thiamine 100mg, dextrose (25g), naloxone (often start 0.4 mg IV, though if known opioid dependence can start with very small dose of 0.04 mg).