Clinical Policy for the Initial Approach to Patients Presenting With Acute Toxic Ingestion or Dermal or Inhalation Exposure

ACEP CLINICAL

POLICY

Clinical Policy for the Initial Approach to Patients Presenting With Acute Toxic Ingestion or Dermal or Inhalation Exposure Approved by the ACEP Board of Directors, June 26, 1994. Reprints of this clinical policy, the Quick Reference Form, product no. 04160A and Q~taIityAssurance Form, product no. 04160B, are available (onefree copy to ACEP members) by calling 1-800-798-1822, extension 6. This clinical policy was developed by the ACEP Clinical Policies Committee and the Clinical Policies Subcommittee on Acute Toxic Ingestion or Dermal or Inhalation Exposure.Members of the Clinical Policies Committee: Harris B Graves, MD (Chairman, 1989-1992)

Earl E Smith, III, MD, FACEP (Chairman, I992-1995) G Richard Braen, MD, FACEP Stephen V Cantrill, MD, FACEP William C Dalsey, MD, FACEP Dianne M Danis, RN, MS, CEN (ENA representative, I989-1991) Francis M Fesmire, MD, FACEP Constance S Greene, MD, FACEP Stephen Karas, Jr, MD, FACEP Marvin Leibovich, MD, FACEP Dineke Mackey, RN, MN, CEN (ENA representative, 1991-1995) George W Molzen, MD, FACEP Barbara A Murphy, MD, FACEP Dighton C Packard, MD, FACEP MichaeI P Pietrzak, MD, FACEP Daniel G Sayers, MD, FACEP David L Schriger, MD, FACEP Michael V Vance, MD, FACEP Members of the Clinical Policies Subcommittee: Michael V Vance, MD, FACEP (Chairman, 1990-1992) William C DaIsey, MD, FACEP (Chairman, 1992-1994) Cynthia K Aaron, MD, FACEP James V HilIman, MD, FACEP Dineke Mackey, RN, MN, CEN (ENA representative, 1991-1995) David L Schriger, MD, FACEP Copyright © by the American College of Emergency Physicians.

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[American College of Emergency Physicians: Clinical policy for the initial approach to patients presenting with acute toxic ingestion or dermal or inhalation exposure. Ann EmergMed April 1995;25:570-585.] PREFACE A clinical policy on the initial approach to patients with acute toxic ingestion or dermal or inhalation exposure was selected because of the frequency with which these patients present to the emergency department and the potential for serious adverse outcomes. Initial identification, evaluation, and management of these patients are recognized as an integral part of emergency medicine clinical practice. The complex clinical nature of these patients and the diverse toxic substances to which patients may be exposed required the development of a clinical policy that focuses on the basic clinical approach for most patients. This policy does not attempt to delineate the specific presentation of or treatments for specific toxic substances. The Clinical Policies Committee of the American College of Emergency Physicians recommends that clinicians use appropriate sources for this detailed information, when needed. This policy does not apply to all toxic substance exposures; excluded are envenomation, radiation exposure, food poisoning, parenteral exposure, and eye exposure. Frequently, the most challenging aspect of patient care is the recognition and identification of a toxic substance exposure that has caused the patient's symptoms. Emergency physicians must maintain a high level of clinical suspicion and consider toxicologic causes for many clinical presentations. This policy does not apply to patients who have not been recognized as having a toxic exposure. Because different institutions have different resources and capabilities in the management of these patients, the recommendation to admit a patient (or to obtain a specific consultation) may require transfer of the patient to an

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institution better able to deal with the patient's specific needs. The subcommittee preparing the initial draft of this policy was composed of emergency physicians and toxicologists. This policy is based on the existing literature; where literature was not available, consensus of emergency physicians and toxicologists was used. This policy went through the ACEP clinical policy development process, including expert review and field testing. The reasons for developing clinical policies and the approaches used in their development have been enumerated. ~ After this policy was drafted, it was reviewed by experts in toxicology and emergency medicine, and their responses were used for further refinement and enhancement of the policy Field testing was conducted in EDs differing in locales, sizes, and resources to deal with patients with acute toxic ingestion or dermal or inhalation exposure. The field testing experience resulted in further refinements to the policy. Clinical policies are scheduled for revision every 3 years; however, interim reviews are conducted when technology or the practice environment changes significantly. The value of this policy is in establishing a benchmark based on literature and a consensus of toxicologists and emergency physicians on a general approach to the care of patients with toxic substance exposures. The Clinical Policies Committee hopes the policy will help delineate areas for future research, which will further improve patient care. 1. Schriger Ok, Cantfill SV, Green CS: The origins, benefits, harms, and implications of emergency

medicineclinicalpolicies.Ann EmergMed19£3;22:5£7-602.

Inclusion Criteria: Patients with a presumptive diagnosis of toxic exposure. Exclusion Criteria: This policy is not intended for envenomation, radiation exposure, food poisoning, parenteral exposure, or eye exposure. Stabilization: This policy assumes that patients with life-threatening emergencies have been treated or stabilized and is not meant to apply to the unstable patient. If a patient presents in an unstable condition, initial resuscitation and stabilization must take precedence over any action in this policy. Rationale: Patients with toxicologic problems represent an important part of the practice of emergency medicine. This policy provides rational guidelines for the initial evaluation, stabilization, and treatment of patients once a presumptive diagnosis is considered. This policy does not address patients who present without suspicion of a toxicologic exposure; nor does it address all of the conditions that might result from exposure to a toxic

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substance, including occult or atypical presentations. Emergency physicians should be aware of the diverse presentations of toxic exposures and carefully consider toxic substances as a cause of many patients' complaints. Identification of the toxic substances will guide the> apy. When the patient is unable to or will not provide a reliable history of exposure, emergency physicians must use their best efforts to perform good detective work. A search to determine what substances were available to the patient will create a potential toxic substance list. This history-taking may include famil B friends, prehospital care providers, other witnesses, or a collection of physical evidence. The signs of toxicity of these agents then are searched for in the presentation and physical examination of the overdose patient. These steps will aid in the identification of the agent and thus guide treatment decisions. Initial stabilization and treatment focus on removal of the toxicologic agent to prevent further exposure and toxicity. Health care workers should protect their own safety and that of others by preventing exposure to toxic substances during the care of these patients. Initial treatment of dermal or inhalation exposure begins by separating the patient from the toxic substance to prevent further exposures and toxicity. Care must be exercised during the decontamination process to prevent exposures to toxic substances by health care providers. The health care worker may be protected by surface barriers, filters, masks, contained-breathing devices, ocular protection, equipment decontamination, and appropriate disposal of contaminated equipment and supplies. Gastrointestinal decontamination represents an area of tremendous controversy. Although some issues involving gastrointestinal decontamination are unresolved, the majority of the current literature supports the following conclusions: 1. Activated charcoal adsorbs almost all commonly ingested drugs and chemicals and usually should be administered to most overdose patients as quickly as possible. Commonly ingested substances n o t adsorbed include iron, lithium, ethanol, and potassium. 2. Syrup of ipecac generally is believed to be of little value in the ED. 3. Gastric lavage is of unproven benefit for routine use. In general, this procedure is best reserved for patients who may have recently ingested a life-threatening overdose. In these cases, administering a dose of activated charcoal before lavage is of theoretic benefit. 4. The use of cathartics is also of unproven benefit, but a single dose is commonly administered with activated charcoal to speed gastrointestinal transit and prevent char-

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coal inspissation. Multiple doses of any cathartics should not be used because dehydration and electrolyte imbalances may occur. 5. Whole-bowel irrigation has been shown to be effective under certain conditions, especially when activated charcoal lacks efficacy. No definitive recommendation can be made on the use of ipecac, gastric lavage, cathartics, and whole-bowel irrigation for all patients. If any of these modalities are used, the choice should be based on consideration of the offending toxic substance, time of exposure, and condition of the patient. The use of forced diuresis, hemodialysis, and charcoal hemoperfusion to eliminate toxic substances must be based on the suspected toxic substance and physiologic status of the patient. This policy does not advocate the routine use of toxicologic drug screens in the evaluation and treatment of most patients. The lack of proven clinical usefulness of qualitative screening tests--coupled with the scientific limitations and variability of the tests available at different institutions, their expense, and the time required for results--prevents recommendation of their use in most patients. Effective treatment may be provided without a toxicologic screen after obtaining a history and physical examination focused on identifying the toxic substance, or a clinical toxic syndrome, and establishing the physiologic status of the patient. Specific treatments must be based on the patient's physiologic condition and suspected or known toxic substances. Supportive care is successfully combined with removal or elimination of the toxic substance for most cases. For some toxic substances such as acetaminophen, methanol/ethylene glycol, lithium, and salicylates, specific quantitative tests may be useful in determining appropriate treatment and disposition. The value of quantitative and qualitative toxicologic tests in patients who have ingested unknown substances must be determined by the physician for individual patients. Some patients may be effectively treated with specific or nonspecific antidotes. The use of specific antidotes for individual toxic substances is beyond the scope of this policy. Generally, the use of antidotes should be individu-

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alized to the toxic substance and physiologic condition of the patient. The large number of potentially toxic agents and their diverse effects may require the emergency physician to access specific expertise, information, or both. Toxicologists, poison information centers° toxicology references, and computerized data bases may aid the emergency physician in the treatment of some patients. Emergency physicians should be familiar with resources through their poison information center. Many patients with a toxicologic problem have other injuries or illnesses. Altered mental status resulting from toxic substances may make identification of head injury or other pathologic conditions difficult. Emergency physicians should be aware of the need to consider other etiologies for their patients' signs and symptoms. In addition, these patients may be suicidal, have significant psychiatric illness, or be victims of abuse or neglect. After initial treatment of the toxicologic exposure, patients should be assessed for these underlying problems. Many exposures and pediatric ingestions are accidental. The ED encounter provides an opportunity for education and other preventive measures that may minimize the risk of future incidents. Implementing the Policy: The rules and guidelines for patient management emphasize findings with the potential for high risk to the patient. It is important that no single finding be considered independently. Some actions are separated by a slash mark (/), which means that either may be appropriate in a given clinical situation; the action is at the discretion of the clinician. The order in which items appear in the rules and guidelines is arbitrary and not meant to imply the order in which they should be performed. In using this clinical policy it may be helpful to think of Rules as broad categories that should be recorded as pertinent positives or negatives and of Guidelines as detailed or expanded lists that are meant to prompt the physician to consider many possibilities. Documentation should be sufficient to reflect the clinical decision-making process. It is unrealistic for a physician to perform or document every item in the guidelines.

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RULE*

GUIDELINE t

Solicit and record a history that includes: History of exposure

Consider these aspects of the history:

Past medical history

Conduct and record a physical exam that includes:

Vital signs: blood pressure, pulse, respirations, temperature General appearance Weight (if age <6 yr) Neurologic mental status

Cardiovascular Pulmonary

Route of exposure, what, how much, when, why (suicidal intent), other substances, chronicity Corroborative history and other physical evidence (eg, pill containers) from prehospital care providers Time course of symptoms Neurologic: seizure, alteration of consciousness, confusion, ataxia, slurred speech, tremor, headache, syncope Cardiopulmonary: syncope, palpitations, cough, chest pain, shortness of breath, burning or irritation in upper airway Gastrointestinal: abdominal pain, nausea, vomiting, diarrhea, pain or difficulty in swallowing Medications including nonprescription substances, alcohol/drug abuse, psychiatric history, allergies, occupational or hobby exposures, travel, prior ingestions, social history with potential for domestic violence/neglect, last normal menstrual period or pregnancy Consider these aspects of the physical exam:

Pulse: rate, regularity Respirations: rate, regularity, depth Temperature: rectal temperature preferable Agitation, color, signs of trauma, diaphoresis, odor Level of consciousness, orientation, affect, agitation, combativeness, hallucinations, cognition, speech Sensorimotor function: strength, tremor, fasciculation, myoclonus, pain in response to light touch General: cranial nerves, reflexes, coordination (cerebellar) HEENT: vision, sclerae, conjunctivae, nystagmus, dysconjugate gaze, fundi, pupils (size and reactivity), hearing, nasal mucosa, breath odor, oral mucosa (burns, moisture), gag reflex Rhythm, abnormal heart sounds, pulses Adequacy of respirations, breath sounds, rales, rhonchi, wheezes Gastrointestinal: abdomen: bowel sounds, tenderness, distention Genitourinary: bladder (distention), rectal (gross or occult blood, drugs), vaginal (drugs) Skin: moisture, color, temperature, signs of IV drug use, evidence of bleeding, lesions

*Rule: An action reflecting principles of good practice in most situations. There may be circumstances when a rule need not or cannot be followed; in these situations, it is advisable that deviation from the rule be justified in writing. Inability to comply with rules should be incorporatedin institutional policies. ~Guideline: An action that may be considered, depending on the patient, the circumstances, or other factors. Thus, guidelines are not always folrowed, and there is no implication that failure to follow a guideline is improper.

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Implement ACTIONS based on the FINDINGS for the following VARIABLES: VARIABLE

FINDING

History

ACTION

Rule Dermal exposure

Gastrointestinal exposure caustics

Guideline

Skin decontamination* Protection of health care worker

Complete disrobing of patient (proper disposal) Assess for systemic exposure/toxicity Copious eye irrigation with water Decontamination of skin folds/creases

Avoid emesis and gastric lavage

Dilute Endoscopy

hydrocarbons

Evaluate neurologic and pulmonary status

Most other toxic substances

Charcoal

Protection of health care worker GI decontamination Specific drug or toxic substance levels Radiopaque substances: KUB Drug bezoars, body packers: contrast study

Intentional ingestion

Evaluation for potential suicidal risk

Patient restraint Patient supervision Psychiatric consultation

Accidental ingestion

Evaluation for abuse or neglect

Protective service referral

Unknown potentially toxic substances

Charcoal

GI decontamination Acetaminophen level Salicylate level Toxicologic blood screen Toxicologic urine screen

Inhalation exposure

Protection of patient and health care worker Supplemental oxygen Humidification

ABGIommetrylcoo:dmetry/ methemoglobin level/ carboxyhemoglobin level Chest x-ray

*May be performedprehespital 574

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Implement ACTIONS based on the FINDINGS for the following VARIABLES: VARIABLE

FINDING

Physical Examination

ACTION Rule

Pulse <60

Supplemental oxygen/ ABG/oximetry ECG

>120 (>6yr) >140 (Peds <6 yr)

IV access Cardiac monitor

Supplemental oxygen/oximetry ABG/cooximetry/methemoglobin level/carboxyhemoglobin level ECG

Irregular

Cardiac monitor

IV access ECG

IV access Supplemental oxygen Cardiac monitor

Intubate Ventilate Rapid glucose determination ABG/cooximetry/ methemoglobin level/ carboxyhemoglobin level Pulse oximetry Opioid antagonist

IV access

Supplemental oxygen Cardiac monitor ABG/oximetry Salicylate level Chest x-ray

IV access Active cooling

Supplemental oxygen Cardiac monitor Assess for neuroleptic malignant syndrome ECG

Respirations <10 (Adult)
>24 (Adult) >xx (Peds) see Attachment A

Temperature >40 ° C

IV access Supplemental oxygen Cardiac monitor Rapid glucose determination ECG Treat hypothermia

<35 ° C

General appearance Cyanosis

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IV access Cardiac monitor

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IV access Supplemental oxygen Cardiac monitor ABG/oximetry

Intubate Methemoglobin level Measured oxygen saturation/cooximetry Chest x-ray ECG 575

ACEP CLINICAL POLICY

Implement ACTIONS based on the FINDINGS for the following VARIABLES: VARIABLE

FINDING

Physical Examination

Rule

Neurologic Decreased level of consciousness with no gag reflex

HEENT

Pulmonary

Abdomen

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ACTION Guideline

IV access Cardiac monitor Airway management

Rapid glucose determination

Unresponsive to painful stimuli

IV access Supplemental oxygen Cardiac monitor Glucose administration/ rapid glucose determination ABG/oximetry

ABG/cooximetry/carboxyhemoglobin level Toxicologic screen Urinalysis Abdominal x-ray for radiopaque toxic substances Opioid antagonist Thiamine

Altered level of consciousness

Frequent assessment

Rapid glucose determination Carboxyhemoglobin level Opioid antagonist Thiamine

Female with reproductive potential

Assess for pregnancy

Miotic pupils

IV access Opioid antagonist

Oral burns of mucous membranes

Endoscopy Avoid emesis and gastric lavage

Rales/rhonchi

Supplemental oxygen Cardiac monitor ABG/oximetry Chest x-ray

Wheezes

Supplemental oxygen Cardiac monitor ABG/oximetry Peak expiratory flow Chest x-ray Beta agonist

Rectal/vaginal drug packets

Remove

Abdominal series x-ray Cathartics

Distended abdomen

Rectal examination Abdominal series x-ray Orogastric tube

Distended bladder

Bladder decompression

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Implement ACTIONS based on the FINDINGS for the following VARIABLES: 'VARIABLE Physical Examination Skin

Diagnostic Testing ABG

Urinalysis

FINDING

ACTION

Rule

Guideline Assess for rhabdomyolysis/ compartment syndrome Carboxyhemoglobin level

Hypercapnia

Ventilate

Intubate Opioid antagonist

Hypoxemia

Supplemental oxygen

Intubate Chest x-ray ECG

Pressure sores (erythema/ vesicles) bullae

Dipstick positive for blood with few or no RBCs on microscopic analysis

Evaluate/treat for rhabdomyolysis/hemolysis

Implement ACTIONS for the following VARIABLES: Assessment The causes and clinical severity of toxic exposures in patients presenting to the ED are far too varied to be considered in detail in this clinical policy. However, the majority of toxic exposures are readily managed in the ED with the following: (1) General supportive care (2) Treatment of respiratory, cardiovascular, and neurologic complications (3) Attempt to identify toxic substance (4) Appropriate decontamination techniques (5) Specific therapy of treatable toxic exposures (6) Consultation/reporting with medical toxicologists or poison information centers when appropriate (7) Psychiatric evaluation/referral when appropriate VARIABLE Disposition Admission Transfer Discharge

ACTION

Rule Transfer care to accepting physician Follow ACEP and other applicable transfer principles 2 Provide referral for follow-up care Provide instructions regarding treatment and circumstances that require return to ED

Guideline

Social services/protective services consult

2. American Collegeof EmergencyPhysicians:Appropriate interhospitel patient transfer. Ann EmergMed 1993;22:766-767.

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Attachment A. Normal Resting Respiratory Rates3 Age Rate (breaths per minute) Newborn 30 to 60 Infant (1 to 6 mo) 30 to 50 Infant (6 to 12 mo) 24 to 46 1 to 4 y r 20 to 30 4 to 6 yr 20 to 25 6 to 12 yr 16 to 20 >12 yr 12 to 16 3. AmericanAcademyof Pediatricsand the American Collegeof EmergencyPhysicians: Respiratorydistress, in APLS: The Pediatric EmergencyMedicine Course,ed 2. Elk GroveVillage, Illinois, and Dallas,Texas,AAP and ACEP,1993, p 5.

BIBLIOGRAPHY The following citations are not intended to be a comprehensive review of the literature or a complete listing of all the works that were used in the development of this clinical policy. The purpose of this listing is to provide a sample of the kinds of documents that the Clinical Policies Committee reviewed during the development of this policy and to provide the reader with a general reading list. Albertson TE, Derlet RW, Foulke GE, et al: Superiority of activated charcoal alone compared with ipecac and activated charcoal in the treatment of acute toxic ingestions. Ann Emerg Med 1989;18:56-59. Amitai Y, Mitchell AA, McGuigan MA, et ah Ipecacinduced emesis and reduction of plasma concentrations of drugs following accidental overdose in children. Pediatrics 1987;80:364-367. Arnold M: Ipecac: When prevention fails. AJDC 1988;142:595. Askenasi R, Abramowicz M, Jeanmart J: Esophageal perforation: An unusual complication of gastric lavage. Ann Emerg Med 1984;13:146. Auerbach PS, Osterloh J, Braun O, et al: Efficacy of gastric emptying: Gastric lavage versus emesis induced with ipecac. Ann Emerg Med 1986;15:692-698. Banner W, Veltri JC: The case for ipecac syrup. ADJC 1988;142:596. Bennett HS, Spiro AJ, Pollack NA, et al: Ipecac-induced myopathy simulating dermatomyositis. Neurology 1982;32:91-94. Berlinger WG, Spector R, Goldberg MJ, et al: Enhancement of theophylline clearance by oral activated charcoal. Clin Pharmacol Ther 1983;33:351-354. Bessen HA, Rothstein RJ: Sorbitol--a safe and effective cathartic. Ann Emerg Med 1987;16:729.

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Blake DR, Bramble MG: Is there excessive use of gastric lavage in the treatment of self-poisoning? Lancet 1978;1362-1364. Boba A: Rapid whole-gut evacuation. Illinois Medical Journal 1979;155:156-157. Brotman MC, Forbath N, Garfinkel PE, et al: Myopathy due to ipecac syrup poisoning in a patient with anorexia nervosa. CMkJournal 1981;125:453-454. Burton BT, Bayer MJ: Gastric emptying: Initial management of the poisoned patient? Ann Emerg Med 1988;17:762-763. Burton BT, Bayer MJ, Barton L, et ah Comparison of activated charcoal and gastric lavage in the prevention of aspirin absorption. J Emerg Med 1984; 1:411-416. Caldwell JW, Nava AJ, DeHaas DD: Hypernatremia associated with cathartics in overdose management. West J Med 1987;147:593-596. Calvanese JC: Midesophageal kinking and lodgement of a 34-F gastric lavage tube. Ann Emerg Med 1985;14:11231125. Chafee-Bahamon C, Lacouture PG, Lovejoy FH: Risk assessment of ipecac in the home. Pediatrics 1985;75:11051109. Comstock EG, Boisaubin EV, Comstock BS, et al: Assessment of the efficacy of activated charcoal following gastric lavage in acute drug emergencies. J Toxicol Clin Toxicol 1982; 19:149-165. Cupit GC, Temple AR: Gastrointestinal decontamination in the management of the poisoned patient. Emerg Med Clin North Am 1984;2:15-28. Curd-Sneed CD, Parks KS, Bordelon JG, et ah In vitro adsorption of sodium pentobarbital by superchar, USP and Darco G-60 activated charcoals. Clin Tox 1987;25:111. Curtis RA, Barone J, Giacona N: Efficacy of ipecac and activated charcoal/cathartic. Prevention of salicylate absorption in a simulated overdose. Arch Intern Med 1984;144:48-52. Czajka PA, Konrad JD: Saline cathartics and the adsorptive capacity of activated charcoal for aspirin. Ann Emerg Med 1986;15:548-551. Czajka PA, Russell SL: Nonemetic effects of ipecac syrup. Pediatrics 1985;75:1101-1104. Danel V, HenryJA: Activated charcoal, emesis, and gastric lavage in aspirin overdose. BrJ Med 1988;296:1507. Decker WJ: Gastrointestinal decontamination, d Toxicol Clin Toxicol 1983;20:iii-vi. Freedman GE, Pasternak S, Krenzelok EP: A clinical trial using syrup of ipecac and activated charcoal concurrently. Ann Emerg Med 1987;16:164-166.

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Gaudreault P, McCormick MA, Lacouture PG, et al: Poisoning exposures and use of ipecac in children less than 1 year old. Ann Emerg Med 1986;15:808-810. Greenbaum DM: Clinical aspects of drug intoxication: The St. Vincent's hospital symposium-part I. J Crit Care 1983;12:109-114. Greensher J, Mofenson HC, Caraccio TR: Ascendency of the black bottle (activated charcoal). Pediatrics 1987;80:949-951. Jones J, Heiselman D, DoughertyJ, et ah Catharticinduced magnesium toxicity during overdose management. Ann Emerg Med 1986;15:1214-1218. Jorden RC: Initial evaluation of the patient with altered mental status. Topics in Emergency Medicine 1991; 13:1-9. Katona BG, Siegel EG, Cluxton RJ: The new black magic: Activated charcoal and new therapeutic uses. J Emerg Med 1987;5:9-18. Klein-Schwartz, Gorman RL, Oderda GM, et al: Ipecac use in the elderly: The unanswered question. Ann Emerg Med 1984;13:1152-1154. Krenzelok EE Dean BS: Syrup of ipecac in children less than one year of age. Clinical Toxicology 1985;23:171176. Krenzelok EP: The contemporary management of poisoning emergencies. Pharmacy Times 1990;56:132-139. Krenzelok EE Keller R, Stewart RD: Gastrointestinal transit times of cathartics combined with charcoal. Ann Emerg Med 1985; 14:1152-1155. Krenzelok EP: Misconceptions about gastric decontamination. Clin Toxicol Forum;3:1-6. Krenzelok EE Freedman GE, Pasternak S: Preserving the emetic effect of syrup of ipecac with concurrent activated charcoal administration: A preliminary study Clinical Toxicology 1986;24:159-166. Krenzelok EP, Lush RM: Container residue after the administration of aqueous activated charcoal products. AmJ Emerg Med 1991;9:144-146. Kulig K, Bar-Or D, Cantrill SV, et ah Management of acutely poisoned patients without gastric emptying. Ann Emerg Med 1985;14:562-567. Kulig K: Interpreting gastric emptying studies. J Emerg Med 1984; 1:447-448. Kulig K: Gastric lavage in acute drug overdose. JAMA 1989;262:1392. Lanphear WF: Gastric lavage. J Emerg Med 1986;4:4347. Litovitz T: In defense of retaining ipecac syrup as an over-the-counter drug. Pediatrics 1988;82:514-515.

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Margulis MS, Mordashev BK, Andreiman LA, et al: Prospects for the use of assisted circulation in cases of poisoning. Resuscitation 1982;10:121-127. Matthew H, Mackintosh TE Tompsett SL, et al: Gastric aspiration and lavage in acute poisoning. BMJ 1966; 1:13331337. Mattila MJ, Takki S, Jussila J: Effect of sodium sulphate and castor oil on drug absorption from the human intestine. Ann Clin Res 1974;6:19-24. McDougal C, Maclean MA: Modifications in the technique of gastric lavage. Ann Emerg Med 1981; 10:514-517. McNamara RM, Aaron CK: Sorbitol catharsis does not enhance efficacy of charcoal in a simulated acetaminophen overdose. Ann Emerg Med 1988;17:243-246. McNamara RM, Aaron CK, Gemborys M, et al: Efficacy of charcoal cathartic versus ipecac in reducing serum acetaminophen in a simulated overdose. Ann Emerg Med 1989;18:934-938. Meester W: Emesis and lavage. Presentation AACT/ AAPCC meeting, 1979. Merigian KS, Woodard M, Hedges JR, et ah Prospective evaluation of gastric emptying in the self-poisoned patient. Am J Emerg Med 1990;8:479-483. Millar AJW, Rode H, Buchler J, et ah Whole-gut lavage in children using an iso-osmolar solution containing polyethylene glycol (Golytely). J Pediatr Surg 1988;23:822-824. Minocha A, Krenzelok EE Spyker DA: Dosage recommendations for activated charcoal-sorbitol treatment. Clinical Toxicology 1985;23:579-587. Miser JS, Robertson WO: Ipecac poisoning. West J Med 1978; 128:440-443. Mofenson HC, Caraccio TR: Benefits/risks of syrup of ipecac. Pediatrics 1986;77:551-552. Mofenson HC, Caraccio TR, Greensher J, et al: Gastrointestinal dialysis with activated charcoal and cathartic in the treatment of adolescent intoxications. Clin Pediatr 1985;24:678-684. Moran DM, Crouch DJ, Finkle BS: Absorption of ipecac alkaloids in emergency patients. Ann Emerg Med 1984;13:1100-1102. Muhlendahl KE, Krienke EG, Bunjes R: Fatal overtreatment of accidental childhood intoxication, d Pediatr 1978;93:1003-1004. Nejman G, Hoekstra J, Kelley M: Gastric emptying in the poisoned patient. AmJ Emerg Med 1990;8:265-269. Neuvonen PJ, Vartiainen M, Tokola O: Comparison of activated charcoal and ipecac syrup in prevention of drug absorption. Eur d Clin Pharmacol 1983;24:557-562.

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Neuvonen PJ, Olkkola KT: Activated charcoal and syrup of ipecac in prevention of cimetidine and pindolol absorption in man after administration of metoclopramide as an antiemetic agent. Clinical Toxicology 1984;22:103114. Olkkola KT, Neuvonen PJ: Do gastric contents modify antidotal efficacy of oral activated charcoal? BrJ Clin Pharmacol 1984;18:663-669. Olson KR: Is gut emptying all washed up? Am J Emerg Med 1990;8:560-561. Park GD, Spector R, Goldberg MJ, et at: Expanded role of charcoal therapy in the poisoned and overdosed patient. Arch Intern Med 1986;146:969-973. Payment E Richardson L, Siemiatycki J, et al: A randomized trial to evaluate the risk of gastrointestinal disease due to consumption of drinking water meeting current microbiological standards. Am J Public Health 1991;81:703-708. Pond SM: A review of the pharmacokinetics and efficacy of emesis, gastric lavage and single and repeated doses of charcoal in overdose patients. Dev Toxicol Environ Sci 1986;12:315-328. Porter RS, Baker EB: Drug clearance by diarrhea induction. AmJ Emerg Med 1985;3:182-186. Rappolt RT, Gay GR, Decker WJ, et al: NAGD (naloxone, activated charcoal, glucagon, doxapram) regimen for the coma of drug-related overdose. Ann Emerg Meal 1980;9:357-363. Riegel JM, Becket CE: Use of cathartics in toxic ingestions. Ann Emerg Med 1981;10:254-258. Rodgers GC, Matyunas NJ: Gastrointestinal decontamination for acute poisoning. Pediatr Clin North Am 1986;33:261-285. Rosenberg PJ, Livingstone DJ, McLellan BA: Effect of whole-bowel irrigation on the antidotal efficacy of oral activated charcoal. Ann Emerg Med 1988; 17:681-683. Rudolph JP: Automated gastric lavage and a comparison of 0.9% normal saline solution and tap water irrigant. Ann Emelg Med 1985;14:1156-1159. Rumack BH: Emesis: Safe and effective? Ann Emerg Med 1981;10:551. Rumack BH: Ipecac use in the home. Pediatrics 1985;75:1148. Sarvesvaran R: Dilute the poison--a case of fatal water intoxication. Med Sci Law 1984:92-94. Sketris IS, Mowry JB, Czajka PA, et ah Saline catharsis: Effect on aspirin bioavailability in combination with activated charcoal. J Clin Pharmacol 1982;22:59-64.

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Sorensen PN, Lindkaer-Jensen St.: The effect of magnesium sulfate on the absorption of acetylsalicylic acid and lithium carbonate from the human intestine. Arch Toxicol 1975;34:121-127. Stewart JJ: Effects of emetic and cathartic agents on the gastrointestinal tract and the treatment of toxic ingestion. J Toxicol Clin Toxicol 1983;20:199-253. Tanberg D, Liechty EJ, Fishbein D: Mallory-Weiss syndrome: An unusual complication of ipecac-induced emesis. Ann Emerg Med 1981;10:521-523. Tandberg D, Diven BG, McLeod JW: Ipecac-induced emesis versus gastric lavage: A controlled study in normal adults. AmJ Emerg Med 1986;4:205-209. Tenebein M, Cohen S, Sitar DS: Efficacy of ipecacinduced emesis, orogastric lavage, and activated charcoal for acute drug overdose. Ann Emerg Med 1987;16:838841. Tenebein M: Whole bowel irrigation for toxic ingestions. Clinical Toxicology 1985;23:177-184. Tenenbein M: Inefficacy of gastric emptying procedures. J Emerg Med 1985;3:133-136. Tenenbein M, Cohen S, Sitar DS: Whole bowel irrigation as a decontamination procedure after acute drug overdose. Arch Intern Med 1987;147:905-907. Tenenbein M: Whole bowel irrigation in iron poisoning. J Pediatr 1987;111:142-145. Tenenbein M: Whole bowel irrigation as a gastrointestinal decontamination procedure after acute poisoning. Medical Toxicology 1988;3:77-84. Thompson AM, Robins JB, Prescott LF: Changes in cardiorespiratory function during gastric ]avage for drug overdose. Human Toxicol 1987;6:215-218. Todd JW: Do measures to enhance drug removal save lives? Lancet 1984:331. True RJ, Berman JM, Mahutte CK: Treatment of theophylline toxicity with oral activated charcoal. Crit Care Med 1984;12:113-114. Uden DL, Davison GJ, Kohen DP: The effect of carbonated beverages on ipecac-induced emesis. Ann Emerg Med 1981;10:79-81. Vale JA, Meredith TJ, Proudfoot AT: Syrup of ipecacuanha: Is it really useful? BMJ 1986;293:1321-1322. Vale A, Meredith T, Buckley B: Eliminating poisons. BMJ 1984;289:366-369. Wason S: Gastrointestinal decontamination of the poisoned patient--a critical review. Drugs of Today 1987;23:455-465. Watson WA, Leighton J, Guy J, et al: Recovery of cyclic antidepressants with gastric lavage. J gmerg Med 1989;7:373-377.

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Watson WA, Bradford DC, Vehri JC: The volume of a swallow: Correlation of deglutition with patient and container parameters. AmJ Emerg Med 1983;3:278-281. Wheeler-Usher DH, Wanke I_A, Bayer MJ: Gastric emptying: Risk versus benefit in the treatment of acute poisoning. Medical Toxicology 1986;1:142-153.

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Quality Assurance Form: Acute Toxic Ingestion or Dermal or Inhalation Exposure INSTRUCTIONS: Use this form to review medical records of patients presenting with the problem of acute toxic ingestion or dermal or inhalation exposure. D o c u m e n t a t i o n Review

Does the medical record contain a description of the following: Yes

No

Yes

No

1. History of exposure 2. Past medical history Is there documentation that the physical exam included the following: 3. Vital signs: blood pressure, pulse, respirations, temperature 4. General appearance 5. Weight (if age <6 yr) 6. Neurologic mental status 7. Cardiovascular 8. Pulmonary Comments

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Quality Assurance Form: Acute Toxic Ingestion or Dermal or Inhalation Instructions: Draw horizontal lines across QA Form for each positive finding. Draw vertical lines down QA Form for each action taken. Count the dets that are intersected by bath horizontal and vertical lines ( A : ) . Then count all the dots bisected by a horizontal line ( B : ) . Divide A by B to determine the QA ratio for this medical record. Rules Followed (A) Ratio = Rules Called for by Findings (B)

Findings: If positive, draw a horizontal line across the form

Actions: If done, draw a vertical line down the form ;iiid

iilIiii~

o

iiiil

£

..m +

-~

++++++ +++++

i

!+I +iii++

+

+

,~

m

~

~

-!Ni ~

Physical Examination Pulse <60? Pulse >120 (_>6yr), >140 (peds < 6 yr)? Irregular pulse? Respirations <10 (adults), 24 (adults), >xx (peds)? See Attachment A Temperature >40° C? Cyanosis? Decreased level of consciousness with no gag reflex?

5 82

ilili

:+

~.

Dermal exposure? Gastrointestinalexposure--caustics? Most othertoxic substances? Intentionalingestion? Accidentalingestion? Unknown potentially toxic substances?

iiiiii

ill}ill

.-o= +-'

History

Exposure-continued

++;+ • !+++i i!+

++++ +iiiii+ •

+if+ ii+i !ili • i~++i+ +++ . . .

+i+ +++i+ • +++++ +++++ +°+++ iiiiii • ++++++++++ ++++2+ ~++++ ++++++;~ +Ii+P += ++iii iliii ++++ ++ +~++ ................. i++ii • +++++ •

+i++++++i + i++++++++++++

I

++++++++ +++ ii++iii++ +++++

o

++iliiii

+!iii+ili

iii+i

+:ii++i+i

~

iiiii+ -

iliiii

i+i+i ++++ +i+++ 121111

~++++ii~

~i+f++ ++++, ii!i . ++i . .i !++. .

++! i+ +++:+ ++i++ +i+ ii+ii +iiiii +++++++++2++++++++ +++++++++++++++++++++ i;+Hi ++i+++++++ iiiii +i++++~+++ +++++++++ i+i+++ +++++++ ++++++++ + .++++++ ....... ++. . . ++++++ ++++ . . . . i+iiii+ +i+++++P++ ++~++++ ++++'............ ~ +++!i+ i+

+2 +~i ++i+++ +ii+ +++++++ +++++ ......ili ++ +++++~ ++. . .... ,+ +++++ ++ ......+++ +++++ iiiii +++++ +++ + • ++" ii+++ iii i++++i

+++ +++++,+ . . . ii!!I +++ ++++ ++++++ +ii++

+S+++

+++++~ i........ ii+++ +++i+I ii+++ .......... . . . +iii . . +iiii+ ++ .......... ++++++ 21i+i! !i+ +++ i++ i+++:

~+++ !iiii i+:ii+ +++++++

!i+i i++i!I ++ ;~'~++ +++ i?+++; iiiiiii +i+~ ++++ +++ ++++ iiPi!i ++ ........ +++ +++++ ++++++++' +!+ii+ ++++I

:ili+P

i

+~(l++t

+++++++++ +++++++ +i++,!+i +++~!i+ .......... ++++++++iii+. +ii+ +iii+ ii!+ +"++ ++++++ ii!i~++i :i!iiii!+ ++2++ i+++ii ++j++p i! +i * ++" i++i!, i+ii +++ +++++++++++++++++++++++ i+i+++ i++ ++++ ++++++ o+i+ + ++++ +,+ ++ ++++ ii ++~ii+ +++++ +++++ ii+ii +++++

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Exposure-continued

Quality Assurance Form: Acute Toxic Ingestion or Dermal or Inhalation

Actions: If done, draw a vertical line down the form

iN

Findings: If positive, draw a horizontal line across the form

N

Totals Physical Examination-cont'd

•

Unresponsiveto painful stimuli? Altered level of consciousness? Rectal/vagineldrug packets?

• ...........

Diagnostic Testing

'~

•

i

~I:i::

•

ill!

ABG-hypercapnia? ABG-hypoxemia?

A:

Disposition Admission? Transfer? Discharge?

25:4

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iiiiNiiii

iiiiiiiii i!i !i i i iiiiiiii !!!iiH.'i"i'i~ i i~!i,,ii

i!i!iiiii iiiiiiiiii i i !:ii i i !iiiii

APRIL 1995

Total dots with intersecting horizontal and vertical lines:

~,,,~

;i

tota, dotswith horizontal lines:

iiii~ii

B:

iiiiiii

QA Ratio =

5 83

ACEP CLINICAL POLICY

Quick Reference Form: Acute Toxic Ingestion or Dermal or Inhalation Exposure Solicit and record a history that includes: history of exposure, and past medical history. Conduct and record a physical exam that includes: vital signs (blood pressure, pulse, respirations, temperature), general appearance, weight (if age <6 years), neurologic mental status, cardiovascular, and pulmonary. Circle line number if yes. Bolded actions are rules. Actions not bolded are guidelines. 1. Dermal exposure...skin decontamination (may be performed prehospital), protection of health care worker, complete disrobing . . . . . . of patient (proper disposal), assess for systemic exposure/toxicity, perform copious eye irrigation with water, decontamination of skin ........................................................................................................ folds/creases 2. Gastrointestinal exposure-caustics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . avoid emesis and gastric lavage, dilute, endoscopy 3. Gastrointestinal exposure-hydrocarbons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . evaluate neurologic and pulmonary status 4. Most other toxic substances . . . . . charcoal, protection of health care worker, GI decontamination, specific drug or toxic substance levels, ......................................................... radiopaque substances: KUB, drug bezoars, body packers: contrast study 5. Intentional ingestion . . . . . . . . . . . . evaluation for potential suicidal risk, patient restraint, patient supervision, psychiatric consultation 6. Accidental ingestion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . evaluation for abuse or neglect, protective service referral 7. Unknown potentially toxic substances . . . . . charcoal, GI decontamination, acetaminephen level, salicylate level, toxicologic blood screen, ................................................................................................ toxicologic urine screen 8. Inhalation exposure . . . . . . . . . . . . . . protection of patient and health care worker, supplemental oxygen, humidification, ABG/oximetry/co.................................................................. oximetry/mothemoglobin level/carbexyhemoglobin level, CXR

Physical Examination 9. Pulse <60 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IV access, cardiac monitor, supplemental oxygen/ABG/oximetry, ECG 10. Pulse >120 (_>6years), >140 (pods <6 years) . . . . . . IV access, cardiac monitor, supplemental oxygen/oximetry, ABG/cooximetry/methe............................................................................... moglobin level/carboxyhemoglobin level, ECG 11. Pulse-irregular . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . cardiac monitor, IV access, ECG 12. Respirations <10 (adult), 24 (adult), >xx (peds) See Attachment A . . . . . . . . . . . . . . . IV access, supplemental oxygen, cardiac monitor, ABG/oximetry, ................................................................................................... salicylate level, CXR 14. Temperature >40°C . . . . . . . . . . . . . . IV access, active cooling, supplemental oxygen, cardiac monitor, assess for neuroleptic malignant ....................................................................................................... syndrome, ECG 15. Temperature <35% . . . . . . . . . . . . . . IV access, supplemental oxygen, cardiac monitor, rapid glucose determination, ECG, treat hypothermia 16. General appearance-Cyanosis . . . . . . . . IV access, supplemental oxygen, cardiac monitor, ABG/oximetry, intubate, methemoglebin ..................................................................... level, measured oxygen saturation/coeximetry, CXR, ECG 17. Neuro-Docreased level of consciousness with no gag reflex . . . . . . . . . . . . . . . IV access, cardiac monitor, airway management, rapid .................................................................................................. glucose determination 18. Neure-Unresponsive to painful stimuli . . . . . . . . . IV access, supplemental oxygen, cardiac monitor, glucose administration/rapid . . . . . . . . . . . glucose determination, ABG/oximetry, ABG/coeximetry/carboxyhemog]obin level, toxicologic screen, urinalysis, abd x-ray for ..................................................................... radiopaque toxic substances, opioid antagonist, thiamine 19. Neure-Altered level of consciousness . . . . . . . . . . . . frequent assessment, rapid glucose determination, carboxyhemoglobin level, opioid ................................................................................................... antagonist, thiamine 20. Female with reproductive potential . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . assess for pregnancy 21. HEENT-Miotic pupils . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IV access, opioid antagonist 22. HEENT-Oral burns of mucous membranes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . endoscopy, avoid emesis and gastric lavage 23. Pulmonary-Rales/rhonchi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . supplemental oxygen, cardiac monitor, ABG/oximetry, CXR 24. Pulmonary-Wheezes . . . . . . . . . . . . . . . . . . . . . . . . . supplemental oxygen, cardiac monitor, ABG/oximetry, peak exp flow, CXR, beta agonist 25. Abdomen-rectal/vaginal drug packets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . remove, abdominal series x-ray, cathartics 26. Abdomen-Distended abdomen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . rectal examination, abd series x-ray, orogastric tube 27. Abdomen-Distended bladder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . bladder decompression 28. Skin-Pressure sores (erythema/vesicles) bullae . . . . . . . . . . . . assess for rhabdomyolysis/compartment syndrome, carboxyhemoglobin level

Diagnostic Testing 29. ABG-hyporcapnia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

58 4

ventilate, intubate, opioid antagonist

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Quick Reference Form: Acute Toxic Ingestion or Dermal or Inhalation

Exposure-continued 30. ABG-hypoxemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31. Urinalysis-dipstick positive for blood with few or no RBCs on microscopic . . . . . . . . . . . . . . . . . .

supplemental oxygen, intubate, CXR, ECG evaluate/treat for rhabdomyolysis/hemolysis

Disposition 32. Admission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . transfer care to accepting physician 33. Transfer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . follow ACEP and other applicable transfer principles 34. Discharge . . . . . . . . provide referral for follow-up care, provide instructions regarding treatment and circumstances that require ....................................................................... return to ED, social services/protective services consult

Abbreviations Abd-abdominal ABG-arterial blood gas CXR-chest x-ray

ECG-electrocardiogram ED-Emergency Department GI-gastrointestinal IV-intravenous

KUB-kidney, ureter, and bladder Peak exp flow-Peak expiratory flow

Notes:

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