Problems Encountered in the Patient with Poisoning
| Problem | Comment and management |
|---|---|
| Coma | If associated with focal neurological signs or evidence of head injury, CT must be done to exclude intracranial haematoma. |
| Cerebral oedema | May occur after cardiac arrest, in severe carbon monoxide poisoning, in acute liver failure from paracetamol (Chapter 77), and in MDMA poisoning, due to hyponatraemia. Results in hypertension and dilated pupils. Give mannitol 20% 100–200 mL (0.5g/kg) IV over 10 min, provided urine output is >30 mL/h. Check plasma osmolality: further mannitol may be given until plasma osmolality is 320mOsmol/kg Hyperventilate to a PaCO2 of 4kPa (30 mmHg) |
| Seizures | Due to toxin or metabolic complications. Check blood glucose, arterial gases and pH, plasma sodium, potassium, calcium and magnesium. Treat prolonged or recurrent major fits with diazepam IV up to 20 mg. See Chapter 16 for further management. |
| Respiratory depression | Half-life of most opioids is longer than that of naloxone and repeated doses or an infusion may be required. Elective ventilation may be preferable. |
| Inhalation pneumonia | Treatment includes tracheobronchial suction, consideration of bronchoscopy to remove particulate matter from the airways, physiotherapy and antibiotic therapy (Chapter 63). |
| Hypotension | Usually reflects vasodilatation, but always consider other causes (e.g. gastrointestinal bleeding). Obtain an ECG if the patient has taken a cardiotoxic poison, has known cardiac disease, if hypotension does not respond to IV fluids. |
| Arrhythmias | Due to toxin or metabolic complications. Check arterial gases and pH, and plasma potassium, calcium and magnesium. See Chapter 39 for further management. |
| Acute kidney injury | May be due to prolonged hypotension, nephrotoxic poison, haemolysis or rhabdomyolysis. See p. 160 for further management. |
| Gastric stasis | Place a nasogastric tube in comatose patients to reduce the risk of regurgitation and inhalation. |
| Hypothermia | Usually managed by passive rewarming. See Chapter 107. |
MDMA, 3,4-methylenedioxy-methamphetamine (‘ecstasy’).