- Email: [email protected]
Poison Control in the Emergency Department
CLINICAL NOTEBOOK
POISON CONTROL IN THE EMERGENCY DEPARTMENT Author: Andrew D. Harding, RN, MS, CEN, NEA-BC, Taunton, MA Section Editors: Reneé Semonin-Holleran, RN, PhD, CEN, CCRN, CFRN, CTRN, FAEN, and Andrew D. Harding, RN, MS, CEN, NEA-BC
Earn Up to 9.0 CE Hours. See page 291. here were 61 participating poison control centers in 2007 for the American Association of Poison Control Centers 2007 Annual Report of the National Poison Data System, with 2,482,041 human exposures reported. The health care setting calls to poison control throughout the United States accounted for over 15% of total call volume.1 Many of these calls were generated from the nation’s emergency departments. Being prepared for toxic exposure should include understanding the resources available to the emergency department. Factors to consider are related to the preparedness of the medical and nursing teams to recognize toxic exposure, antidotes and treatments available within your emergency department and within your health care organization, and contingency plans on transferring patients as necessary, just to name a few. Poison control is an invaluable tool for the ED team. Poison control is mainly a publicly funded program throughout the nation, with regional poison centers. These regional centers typically have excellent resources. Many of these resources are free, but donations are accepted. These resources include online professional information and publicity items such as stickers, magnets, and flyers along with their service to the regional community.2 At the national level, the US Department of Health and Human Services funds the Centers for Disease Control and Prevention, which has a subsection that includes the Agency for Toxic Substances and Disease Registry (ATSDR).
T
ATSDR’s stated mission is as follows: “ATSDR serves the public by using the best science, taking responsive public health actions, and providing trusted health information to prevent harmful exposures and diseases related to toxic substances.”3 ATSDR also provides education specific for hospitals and emergency departments in 3 volumes titled “Managing Hazardous Materials Incidents.” There are other free nursing continuing educational courses available at the ATSDR Web site.3 I believe another resource that every emergency department should have posted is an antidote chart. There are many antidote charts available currently (Figure). My recommendation is to indicate on the chart whether the actual antidote is available in your emergency department or your pharmacy (Table). When an antidote is not available within your health care organization, your team should contact poison control to tell you where to locate the available antidote. This will determine how to best care for the patient. Calling poison control is recommended for documenting the exposure and is a typical policy in many emergency departments in a patient whom a toxic exposure is suspected. By calling poison control, the case is recorded and tracked in the United States’ only poison information and surveillance database. Patients presenting to the emergency department with suspected toxic exposure can be a harrowing experience for the department. The keys to obtaining a quick and accurate
Andrew D. Harding, Member, Mayflower Chapter, is Director of Patient Care Services, Morton Hospital and Medical Center, Taunton, MA.
FIGURE
For correspondence, write: Andrew D. Harding, MS, RN, CEN, NEA-BC, Morton Hospital and Medical Center, 88 Washington St, Taunton, MA 02780; E-mail: [email protected]. J Emerg Nurs 2010;36:242-5. Available online 30 December 2009. 0099-1767/$36.00 Copyright © 2010 Published by Elsevier Inc. on behalf of the Emergency Nurses Association. doi: 10.1016/j.jen.2009.08.014
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Antidote chart. ADR, adverse drug reactions; amps, ampules; BID, twice a day; Ca Gluc, calcium gluconate; CaCl, calcium chloride; dl, deciliter; EDTA, ethylenediaminetetraacetic acid; IM, intramuscular; INH, isoniazid; IV, intravenous; MAOI, monoamine oxidase inhibitors; Max, maximum; mEq, miliequivalents; Min, minimum or minutes; NAC, N-Acetylcysteine; OPCC, Oklahoma Poison Control Center; PO, by mouth; prn, as needed; pts, patients; Q, every; QID, four times a day; SSRI, selective serotonin reuptake inhibitors; tabs, tablets; TCA, tricyclic antidepressants; TID, three times a day; X, multiply. Reprinted with permission from the Oklahoma Poison Control Center and the University of Oklahoma College of Pharmacy. This figure can be viewed in color and as a full-page document at www.jenonline.org.
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CLINICAL NOTEBOOK/Harding
TABLE
ED antidote chart Toxic exposure
Acetaminophen Acetaminophen Crotaline snake envenomation Black widow spider envenomation Eastern and Texan coral snake envenomation Organophosphate and carbamate pesticides, muscarine-containing mushrooms, and acetylcholinesterase inhibitors Lead GI decontamination GI decontamination Cyanide Iron Digoxin and digitoxin Arsenic, gold, mercury, and lead Ethylene glycol and methanol Benzodiazepines Ethylene glycol and methanol β-Blockers and possibly calcium channel blockers GI decontamination Methemoglobin-producing drugs or poisons Opioids Oral sulfonylureas Extravasation of vasoconstrictive agents Anticholinergic agents Coumadin and indanedione derivatives GI decontamination Organophosphate pesticides Heparin Isoniazid and monomethylhydrazine Lead, arsenic, and mercury
Medication
Main RX ED stock
Acetylcysteine oral Acetylcysteine inj Antivenin (Crotalidae) Antivenin (Latrodectus) Antivenin (Micrurus) Atropine
X X X N/A N/A X
X X N/A N/A N/A X
Calcium EDTA Charcoal, activated; sorbitol Charcoal, activated; aqua Cyanide antidote kit Deferoxamine Digoxin immune Fab Dimercaprol (BAL in oil) Ethanol Flumazenil Fomepizole Glucagon Ipecac syrup Methylene blue Naloxone Octreotide Phentolamine Physostigmine Phytonadione (vitamin K) Polyethylene glycol (Golytely; Braintree Laboratories, Braintree, MA) Pralidoxime (2-PAM) Protamine Pyridoxine (vitamin B6) Succimer (DMSA)
N/A X X N/A X X N/A X X N/A X X X X X X X X X
N/A X X X X X N/A N/A X N/A X N/A X X X X X X N/A
X X N/A N/A
X X N/A N/A
Aqua, water; EDTA, ethylenediaminetetraacetic acid; GI, gastrointestinal; Ing, injection; Main RX, main pharmacy; N/A, not applicable. The phone number for the Poison Help hotline is 1-800-222-1222. The American Association of Poison Control Centers will have access to N/A medications.
diagnosis to determine the precise agent or agents include taking a thorough verbal history from the patient or person accompanying him or her, performing an extensive primary and secondary physical examination, and performing appropriate testing.4 Contacting poison control can also help to refine your assessment and narrow the choices for a diagnosis or potential toxicant. Having an antidote chart readily available that specifically displays the emergency
244
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department’s and organization’s antidote stock can decrease time to treatment. The phone number for the Poison Help hotline is 1-800-222-1222. REFERENCES 1. Bronstein AC, Spyker DA, Cantilena LR Jr, Green JL, Rumack BH. Heard SE. 2007 Annual Report of the American Association of Poison Control
VOLUME 36 • ISSUE 3
May 2010
Harding/CLINICAL NOTEBOOK
Centers’ National Poison Data System (NPDS): 25th Annual Report. Clin Toxicol (Phila). 2008;46(10):927-1057. 2. American Association of Poison Control Centers. http://www.aapcc.org/ DNN/. Accessed August 1, 2009. 3. Agency for Toxic Substances and Disease Registry. http://www.atsdr.cdc. gov/. Accessed August 1, 2009. 4. Sheehy SB. Toxicologic Emergencies. In: Sheehy’s Emergency Nursing: Principles and Practice, editor. 4th ed. St Louis, MO: Mosby; 1998. p. 647-63.
May 2010
VOLUME 36 • ISSUE 3
Submit descriptions of procedures in emergency care and/or quickreference charts suitable for placing in a reference file or notebook to Reneé Semonin-Holleran, RN, PhD, CEN, CCRN, CFRN, CTRN, FAEN or Andrew Harding, RN, MS, AIF, CEN, NEA-BC http://ees.elsevier.com/jen
WWW.JENONLINE.ORG
245
POISON CONTROL IN THE EMERGENCY DEPARTMENT Author: Andrew D. Harding, RN, MS, CEN, NEA-BC, Taunton, MA Section Editors: Reneé Semonin-Holleran, RN, PhD, CEN, CCRN, CFRN, CTRN, FAEN, and Andrew D. Harding, RN, MS, CEN, NEA-BC
Earn Up to 9.0 CE Hours. See page 291. here were 61 participating poison control centers in 2007 for the American Association of Poison Control Centers 2007 Annual Report of the National Poison Data System, with 2,482,041 human exposures reported. The health care setting calls to poison control throughout the United States accounted for over 15% of total call volume.1 Many of these calls were generated from the nation’s emergency departments. Being prepared for toxic exposure should include understanding the resources available to the emergency department. Factors to consider are related to the preparedness of the medical and nursing teams to recognize toxic exposure, antidotes and treatments available within your emergency department and within your health care organization, and contingency plans on transferring patients as necessary, just to name a few. Poison control is an invaluable tool for the ED team. Poison control is mainly a publicly funded program throughout the nation, with regional poison centers. These regional centers typically have excellent resources. Many of these resources are free, but donations are accepted. These resources include online professional information and publicity items such as stickers, magnets, and flyers along with their service to the regional community.2 At the national level, the US Department of Health and Human Services funds the Centers for Disease Control and Prevention, which has a subsection that includes the Agency for Toxic Substances and Disease Registry (ATSDR).
T
ATSDR’s stated mission is as follows: “ATSDR serves the public by using the best science, taking responsive public health actions, and providing trusted health information to prevent harmful exposures and diseases related to toxic substances.”3 ATSDR also provides education specific for hospitals and emergency departments in 3 volumes titled “Managing Hazardous Materials Incidents.” There are other free nursing continuing educational courses available at the ATSDR Web site.3 I believe another resource that every emergency department should have posted is an antidote chart. There are many antidote charts available currently (Figure). My recommendation is to indicate on the chart whether the actual antidote is available in your emergency department or your pharmacy (Table). When an antidote is not available within your health care organization, your team should contact poison control to tell you where to locate the available antidote. This will determine how to best care for the patient. Calling poison control is recommended for documenting the exposure and is a typical policy in many emergency departments in a patient whom a toxic exposure is suspected. By calling poison control, the case is recorded and tracked in the United States’ only poison information and surveillance database. Patients presenting to the emergency department with suspected toxic exposure can be a harrowing experience for the department. The keys to obtaining a quick and accurate
Andrew D. Harding, Member, Mayflower Chapter, is Director of Patient Care Services, Morton Hospital and Medical Center, Taunton, MA.
FIGURE
For correspondence, write: Andrew D. Harding, MS, RN, CEN, NEA-BC, Morton Hospital and Medical Center, 88 Washington St, Taunton, MA 02780; E-mail: [email protected]. J Emerg Nurs 2010;36:242-5. Available online 30 December 2009. 0099-1767/$36.00 Copyright © 2010 Published by Elsevier Inc. on behalf of the Emergency Nurses Association. doi: 10.1016/j.jen.2009.08.014
242
JOURNAL OF EMERGENCY NURSING
Antidote chart. ADR, adverse drug reactions; amps, ampules; BID, twice a day; Ca Gluc, calcium gluconate; CaCl, calcium chloride; dl, deciliter; EDTA, ethylenediaminetetraacetic acid; IM, intramuscular; INH, isoniazid; IV, intravenous; MAOI, monoamine oxidase inhibitors; Max, maximum; mEq, miliequivalents; Min, minimum or minutes; NAC, N-Acetylcysteine; OPCC, Oklahoma Poison Control Center; PO, by mouth; prn, as needed; pts, patients; Q, every; QID, four times a day; SSRI, selective serotonin reuptake inhibitors; tabs, tablets; TCA, tricyclic antidepressants; TID, three times a day; X, multiply. Reprinted with permission from the Oklahoma Poison Control Center and the University of Oklahoma College of Pharmacy. This figure can be viewed in color and as a full-page document at www.jenonline.org.
VOLUME 36 • ISSUE 3
May 2010
Harding/CLINICAL NOTEBOOK
May 2010
VOLUME 36 • ISSUE 3
WWW.JENONLINE.ORG
243
CLINICAL NOTEBOOK/Harding
TABLE
ED antidote chart Toxic exposure
Acetaminophen Acetaminophen Crotaline snake envenomation Black widow spider envenomation Eastern and Texan coral snake envenomation Organophosphate and carbamate pesticides, muscarine-containing mushrooms, and acetylcholinesterase inhibitors Lead GI decontamination GI decontamination Cyanide Iron Digoxin and digitoxin Arsenic, gold, mercury, and lead Ethylene glycol and methanol Benzodiazepines Ethylene glycol and methanol β-Blockers and possibly calcium channel blockers GI decontamination Methemoglobin-producing drugs or poisons Opioids Oral sulfonylureas Extravasation of vasoconstrictive agents Anticholinergic agents Coumadin and indanedione derivatives GI decontamination Organophosphate pesticides Heparin Isoniazid and monomethylhydrazine Lead, arsenic, and mercury
Medication
Main RX ED stock
Acetylcysteine oral Acetylcysteine inj Antivenin (Crotalidae) Antivenin (Latrodectus) Antivenin (Micrurus) Atropine
X X X N/A N/A X
X X N/A N/A N/A X
Calcium EDTA Charcoal, activated; sorbitol Charcoal, activated; aqua Cyanide antidote kit Deferoxamine Digoxin immune Fab Dimercaprol (BAL in oil) Ethanol Flumazenil Fomepizole Glucagon Ipecac syrup Methylene blue Naloxone Octreotide Phentolamine Physostigmine Phytonadione (vitamin K) Polyethylene glycol (Golytely; Braintree Laboratories, Braintree, MA) Pralidoxime (2-PAM) Protamine Pyridoxine (vitamin B6) Succimer (DMSA)
N/A X X N/A X X N/A X X N/A X X X X X X X X X
N/A X X X X X N/A N/A X N/A X N/A X X X X X X N/A
X X N/A N/A
X X N/A N/A
Aqua, water; EDTA, ethylenediaminetetraacetic acid; GI, gastrointestinal; Ing, injection; Main RX, main pharmacy; N/A, not applicable. The phone number for the Poison Help hotline is 1-800-222-1222. The American Association of Poison Control Centers will have access to N/A medications.
diagnosis to determine the precise agent or agents include taking a thorough verbal history from the patient or person accompanying him or her, performing an extensive primary and secondary physical examination, and performing appropriate testing.4 Contacting poison control can also help to refine your assessment and narrow the choices for a diagnosis or potential toxicant. Having an antidote chart readily available that specifically displays the emergency
244
JOURNAL OF EMERGENCY NURSING
department’s and organization’s antidote stock can decrease time to treatment. The phone number for the Poison Help hotline is 1-800-222-1222. REFERENCES 1. Bronstein AC, Spyker DA, Cantilena LR Jr, Green JL, Rumack BH. Heard SE. 2007 Annual Report of the American Association of Poison Control
VOLUME 36 • ISSUE 3
May 2010
Harding/CLINICAL NOTEBOOK
Centers’ National Poison Data System (NPDS): 25th Annual Report. Clin Toxicol (Phila). 2008;46(10):927-1057. 2. American Association of Poison Control Centers. http://www.aapcc.org/ DNN/. Accessed August 1, 2009. 3. Agency for Toxic Substances and Disease Registry. http://www.atsdr.cdc. gov/. Accessed August 1, 2009. 4. Sheehy SB. Toxicologic Emergencies. In: Sheehy’s Emergency Nursing: Principles and Practice, editor. 4th ed. St Louis, MO: Mosby; 1998. p. 647-63.
May 2010
VOLUME 36 • ISSUE 3
Submit descriptions of procedures in emergency care and/or quickreference charts suitable for placing in a reference file or notebook to Reneé Semonin-Holleran, RN, PhD, CEN, CCRN, CFRN, CTRN, FAEN or Andrew Harding, RN, MS, AIF, CEN, NEA-BC http://ees.elsevier.com/jen
WWW.JENONLINE.ORG
245