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Toxicology
Toxicology
Preface To xi co lo gy
James A. Kruse, MD Guest Editor
Patients with serious toxic ingestions, drug overdoses, envenomations, and other forms of poisoning are frequently admitted to intensive care units (ICUs), either because they are critically ill at the time of hospital admission or because they have the potential for rapid deterioration in their condition. As such, known or suspected intoxications constitute a common reason for admission to medical and mixed medical–surgical ICUs, and occasionally as initially unsuspected or otherwise comorbid factors in critically ill or injured patients admitted to ICUs caring exclusively for patients with surgical problems. This issue of Critical Care Clinics includes 10 reviews pertaining to toxicologic topics relevant to the ICU setting. The first title, by Drs Holstege and Borek, reviews the general approach to the poisoned patient, specifically focusing on the recognition of particular constellations of clinical findings and simple screening laboratory tests, which have been named toxic syndromes or “toxidromes.” As the authors point out, early recognition of occult intoxication can be key to a favorable outcome. The second article, by Drs Hodgman and Garrard, reviews one of the most common and potentially very serious drug overdoses, namely, acetaminophen poisoning. Ingestion of an otherwise lethal dose of acetaminophen is potentially survivable with no sequelae if the patient presents to the hospital soon after the ingestion, but only if the diagnosis is recognized and appropriate antidotal treatment is properly administered in a timely manner. The next topic, by Dr Zimmerman, covers one of the most commonly abused illicit drugs, cocaine, which can be associated with diverse life-threatening complications. Drs Kanji and MacLean next review the topic of cardiac glycoside intoxication. This form of poisoning can occur from intentional or accidental overdose, including occasional iatrogenic overdoses and less commonly in association with ingestion of various species of plants. While less common than acetaminophen or cocaine intoxication, cardiac glycoside poisoning can be life-threatening and there is specific effective antidotal therapy. Dr Guzman covers the pathophysiology, clinical recognition, and treatment of carbon monoxide poisoning, the leading cause of death due to unintentional poisoning in the United States. Dr Carlson and colleagues provide an extensive review
Crit Care Clin 28 (2012) xi–xii http://dx.doi.org/10.1016/j.ccc.2012.08.001 criticalcare.theclinics.com 0749-0704/12/$ – see front matter Ó 2012 Elsevier Inc. All rights reserved.
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of alcohol withdrawal. The resulting syndrome, in contrast to the other topics herein, generally occurs after a period of abstinence rather than at the time of intoxication. However, the topic is of immense relevance because of its prevalence and potential seriousness, both within and outside the ICU. Dr Hedge’s article covers a number of specific central nervous system intoxicants. The huge number of toxic agents that could be included in this category necessitated limiting the included substances to some of the newer antidepressants, which are now commonly involved in intentional drug overdoses seen in the ICU setting, as well as the atypical neuroleptic agents and selected anticonvulsant drugs. Dr Cartwright and colleagues provide a unique review of both toxigenic and metabolic causes of ketosis and ketoacidotic syndromes, including recommendations for their identification and management. Envenomations requiring ICU admission are uncommon in the United States, but do occur and can threaten life and limb. Dr Quan reviews the most serious envenomations by arthropods and snakes indigenous to North America. The final topic details the clinical recognition and management of methanol and ethylene glycol poisoning. James A. Kruse, MD Clinical Professor College of Physicians and Surgeons Columbia University New York, NY 10027, USA Chief, Critical Care Services Bassett Medical Center One Atwell Road Cooperstown, NY 13326, USA E-mail address: [email protected]
Preface To xi co lo gy
James A. Kruse, MD Guest Editor
Patients with serious toxic ingestions, drug overdoses, envenomations, and other forms of poisoning are frequently admitted to intensive care units (ICUs), either because they are critically ill at the time of hospital admission or because they have the potential for rapid deterioration in their condition. As such, known or suspected intoxications constitute a common reason for admission to medical and mixed medical–surgical ICUs, and occasionally as initially unsuspected or otherwise comorbid factors in critically ill or injured patients admitted to ICUs caring exclusively for patients with surgical problems. This issue of Critical Care Clinics includes 10 reviews pertaining to toxicologic topics relevant to the ICU setting. The first title, by Drs Holstege and Borek, reviews the general approach to the poisoned patient, specifically focusing on the recognition of particular constellations of clinical findings and simple screening laboratory tests, which have been named toxic syndromes or “toxidromes.” As the authors point out, early recognition of occult intoxication can be key to a favorable outcome. The second article, by Drs Hodgman and Garrard, reviews one of the most common and potentially very serious drug overdoses, namely, acetaminophen poisoning. Ingestion of an otherwise lethal dose of acetaminophen is potentially survivable with no sequelae if the patient presents to the hospital soon after the ingestion, but only if the diagnosis is recognized and appropriate antidotal treatment is properly administered in a timely manner. The next topic, by Dr Zimmerman, covers one of the most commonly abused illicit drugs, cocaine, which can be associated with diverse life-threatening complications. Drs Kanji and MacLean next review the topic of cardiac glycoside intoxication. This form of poisoning can occur from intentional or accidental overdose, including occasional iatrogenic overdoses and less commonly in association with ingestion of various species of plants. While less common than acetaminophen or cocaine intoxication, cardiac glycoside poisoning can be life-threatening and there is specific effective antidotal therapy. Dr Guzman covers the pathophysiology, clinical recognition, and treatment of carbon monoxide poisoning, the leading cause of death due to unintentional poisoning in the United States. Dr Carlson and colleagues provide an extensive review
Crit Care Clin 28 (2012) xi–xii http://dx.doi.org/10.1016/j.ccc.2012.08.001 criticalcare.theclinics.com 0749-0704/12/$ – see front matter Ó 2012 Elsevier Inc. All rights reserved.
xii
Preface
of alcohol withdrawal. The resulting syndrome, in contrast to the other topics herein, generally occurs after a period of abstinence rather than at the time of intoxication. However, the topic is of immense relevance because of its prevalence and potential seriousness, both within and outside the ICU. Dr Hedge’s article covers a number of specific central nervous system intoxicants. The huge number of toxic agents that could be included in this category necessitated limiting the included substances to some of the newer antidepressants, which are now commonly involved in intentional drug overdoses seen in the ICU setting, as well as the atypical neuroleptic agents and selected anticonvulsant drugs. Dr Cartwright and colleagues provide a unique review of both toxigenic and metabolic causes of ketosis and ketoacidotic syndromes, including recommendations for their identification and management. Envenomations requiring ICU admission are uncommon in the United States, but do occur and can threaten life and limb. Dr Quan reviews the most serious envenomations by arthropods and snakes indigenous to North America. The final topic details the clinical recognition and management of methanol and ethylene glycol poisoning. James A. Kruse, MD Clinical Professor College of Physicians and Surgeons Columbia University New York, NY 10027, USA Chief, Critical Care Services Bassett Medical Center One Atwell Road Cooperstown, NY 13326, USA E-mail address: [email protected]