Abstract
Drug and alcohol abuse are often associated with trauma and significantly confound the initial evaluation of such patients. Adult intoxications are usually polysubstance in nature, and the resultant toxidromes, combined with sequelae of the traumatic injury pattern, make stabilizing these patients less than straightforward. Clinicians must maintain a high index of suspicion for possible toxic exposure when evaluating any trauma patient, especially when mental status changes are present. An overview of both the current indications and the techniques for evidence-based detoxification methods will be reviewed to provide a basic foundation for clinicians caring for this population. Early consultation with either a toxicologist or the local poison control center is always encouraged with complicated ingestions.
Keywords
activated charcoal, antidotes, diagnosis, management, overdose, poisoning, toxic ingestions, toxidromes, trauma, whole bowel irrigation
Case Synopsis
A 25-year-old restrained male driver involved in a rollover motor vehicle accident presents acutely for repair of bilateral open tibia fractures. Loss of consciousness was reported at the scene. The patient is currently alert but disoriented, with a Glasgow Coma Scale score on examination of 14. He also exhibits slurred speech and injected conjunctivae. He admits to ingestion of alcohol and amphetamines just before the accident. He is stable hemodynamically, and a thorough trauma evaluation is undertaken after completion of the primary and secondary surveys (including a negative computed tomography [CT] scan of the head, cervical spine, chest, abdomen, and pelvis), making other significant injuries much less likely. Other findings are as follows: blood pressure 110/50 mm Hg, pulse 124 beats per minute, respiratory rate 24 breaths per minute, temperature 37.1°C, and pulse oximetry 100% on room air. Significant laboratory findings include hematocrit 24%, pH 7.27, base deficit of −10 mEq/L, and blood alcohol content 279 mg/dL.
Problem Analysis
Definition and Recognition
Exposure to toxic substances occurs commonly, as evidenced by the 3.1 million calls received by poison control centers in 2013. Such calls typically involved an acute (88%), unintentional (80%), oral (79%) exposure to a single toxin (89%) by a child (57%) at a private residence (91%). Although almost 70% of such cases in 2013 were managed outside the health care system, toxic ingestions still resulted in 601,642 physician visits, 228,230 hospital admissions, 99,117 critical care admissions, and 2113 deaths. These data are even more impressive given that poison control center information likely underestimates the true incidence of both toxic exposure and adverse poisoning outcomes due to underreporting. Drug classes associated with the largest number of deaths in 2013 (in descending order of frequency) were analgesics, stimulant/street drugs (heroin, methamphetamine, and cocaine), cardiovascular drugs, antidepressants, and sedatives/hypnotics/antipsychotics.
Risk Assessment
Most poisoning ingestions tend to follow one of two general patterns. Children (<12 years of age) usually take small quantities of a single toxin unintentionally and seldom manifest significant morbidity or mortality. In contrast, adolescents and adults typically ingest larger amounts of multiple toxins intentionally and suffer higher rates of morbidity and mortality.
Large series of mixed adult overdoses suggest that the coingestion of ethanol occurs in approximately 50% of cases, and alcohol significantly confounds the initial clinical assessment in a similar percentage of trauma patients. Ethanol-related motor vehicle accidents in the United States during 2013 caused nearly one-third (31%) of all traffic-related deaths and resulted in an associated cost of over $59 billion. To complicate things, drugs other than alcohol are reportedly involved in approximately 18% of motor vehicle driver deaths.
The clinician should therefore maintain a high index of suspicion that adolescent and adult trauma victims have some form of acute intoxication and should evaluate the patient for evidence of substance abuse during the initial history, physical examination, and diagnostic workup. Important historical data include the specific toxin or toxins, quantity taken, ingestion time, signs and symptoms since ingestion, past medical and psychiatric history (including suicidal intent), current medications, allergies, and trauma (accidental, incidental, or self-inflicted). Because the history can often be unreliable or incomplete in acute poisoning situations, supplemental data from other sources (e.g., public safety personnel, family, medical records, area pharmacies, local poison control centers, state narcotic databases) may be helpful in diagnosing toxic exposures. A rapid, systematic, and thorough physical examination is mandatory, given the vague history that often surrounds poisoning and trauma scenarios. Barrier precautions should be exercised where appropriate to prevent self-intoxication (such as cutaneous exposure to organophosphate insecticides). The assessment should initially focus on the ABCs (airway, breathing, and circulation), with aggressive intervention to stabilize any abnormalities discovered. Additional assessment considerations are as follows:
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Gag reflex. This has implications for airway protection and possible aspiration in overdose patients, but contributes little to clinician assessment and the Glasgow Coma Scale regarding the possible need for intubation.
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Core temperature disturbances. Multiple etiologies may be involved, including toxic (salicylates, stimulants), environmental, and/or infectious causes.
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Neurologic examination abnormalities. Detection of central nervous system dysfunction (such as confusion, coma, or delirium) should prompt the clinician to pursue additional diagnostic imaging such as CT or magnetic resonance imaging to evaluate for other potential causes such as cervical spinal cord injury, ischemic stroke, or intracranial hemorrhage.
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Incidental trauma and stigmata of substance abuse. The patient should be examined for puncture wounds, needle tracks, and nasal septal perforation.
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Constellation of signs and symptoms (“toxidromes”). The ingestion of certain toxins may present as characteristic toxidromes typically involving abnormal vital signs, altered mental status, pupillary changes, and a variety of miscellaneous effects that can be attributed to the known pharmacologic properties of the particular drug class. Examples of specific toxidromes are provided in Table 80.1 .
TABLE 80.1
Common Toxidromes
Syndrome
Common Clinical Signs
Potential Toxic Agents
Anticholinergic
Tachycardia, fever, dry skin, urinary retention, ileus, mydriasis, delirium, seizures
Antihistamines, phenothiazines, tricyclic antidepressants, antipsychotics, atropine, scopolamine, jimsonweed, amantadine, antiparkinson drugs, Amanita mushrooms, baclofen
Cholinergic
Bradycardia, diaphoresis, urinary or fecal incontinence, emesis, miosis, central nervous system depression, weakness, fasciculations, wheezing
Organophosphate and carbamate insecticides, physostigmine, pyridostigmine, edrophonium, certain mushrooms
Sympathomimetic (stimulants)
Tachycardia (bradycardia with pure α-agonist), hypertension, mydriasis, diaphoresis, piloerection, fever, delusions, paranoid ideation, restlessness, agitation
Cocaine, amphetamines, over-the-counter decongestants (pseudoephedrine, phenylpropanolamine, phenylephrine)
Narcotic
Mental status depression, hypoventilation, miosis, ileus, hypotension, bradycardia
Opioids
Sedative-hypnotic
Confusion, slurred speech, mental status depression, respiratory depression, ataxia, hypothermia
Benzodiazepines, barbiturates, ethanol, antipsychotics, anticonvulsants
Serotonin
Fever, diaphoresis, flushing, diarrhea, hyperreflexia, tremor, myoclonus, trismus
Selective serotonin reuptake inhibitors, trazodone, clomipramine, meperidine, methadone, dextromethorphan, linezolid, tramadol, others.
Hallucinogenic
Hallucinations, psychosis, paranoid ideation, panic, fever, mydriasis
Cocaine, amphetamines, cannabinoids, phencyclidine (PCP), lysergic acid diethylamide (LSD), antihistamines
Extrapyramidal
Tremor, rigidity, opisthotonos, torticollis, choreoathetosis, trismus, hyperreflexia
Typical and atypical antipsychotics
Data from Hoffman RS, Howland MA, Lewin NA, et al., editors: Goldfrank’s toxicologic emergencies, 10th ed. New York, McGraw-Hill, 2015; and Levine M, Brooks DE, Truitt CA, et al.: Toxicology in the ICU: part 1: general overview and approach to treatment. Chest 140:795-806, 2011.Related posts:
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