Número Actual

VOL. 1 / NO. 2

Toxicological Chain of Survival (TCS): An integral approach to the intoxicated patient. Narrative review

Samantha De La Vega González

Ramsés Dorado García

Leslie D. Ramírez Luna María V. Hernández Valencia María E. Vásquez Sánchez Arlette B. Cardona Barco

SDLVG, LRL, MHV, MVS, ACB: Emergency Department, Zone 1 IMSS General Hospital “Dr. Rodolfo Antonio de Mucha Macías”, Mexico City, Mexico.

RDG: Clinical Toxicology Department, Zone 1 IMSS General Hospital “Dr. Rodolfo Antonio de Mucha Macías”, Mexico City, Mexico.

Submitted: 2024-02-24

Accepted: 2024-04-08

Published: 2024-06-30

DOI: 10.62129/YCNP7473 Artículo PDF

Abstract

Intoxications are a frequent cause for consultation and admission in emergency medical services. Treating these patients is a challenge both diagnostically and therapeutically, where some critical circumstances may determine the prognosis. A structured search was conducted in the PubMed/Medline database, for articles discussing how intoxications were handled in emergency medical services published between March 2005 and December 2023. A combination of the following keywords was used to perform the search: “intoxication”, “poisoning”, “management”, “emergency”, and “patient”. All reviews, clinical trials, observational studies, and case reports related to handling intoxicated patients were considered. Lastly, articles in the authors’ databases were included, as well as reference books and gray literature. 42 articles that met the selection criteria were chosen. Upon review of the literature, a Toxicological Chain of Survival (TCS) was devised, a basic diagnostic and therapeutic algorithm that can be useful for the first responder.

Keywords

Intoxication Poisoning Management Antidotes Antagonists

References

1. Dorado García R, Soto Estrada 1 M, & Ontiveros Holguín A. (2022). 10 Errores Graves en el Manejo del Paciente Intoxicado. 10 Errores en el Manejo del Paciente Intoxicado, 1–7. Available from: https://doi.org/10.58281/ccme22191103.

2. Thompson TM, Theobald J, Lu J, Erickson TB. The general approach to the poisoned patient. Dis Mon. 2014;60(11):509–24. Available from: http://dx.doi.org/10.1016/j.disamonth.2014.10.002.

3. Erickson TB, Thompson TM, Lu JJ. The approach to the patient with an unknown overdose. Emerg Med Clin North Am. 2007;25(2):249–81; abstract vii. Available from: http://dx.doi.org/10.1016/j.emc.2007.02.004.

4. Holstege CP, Eldridge DL, Rowden AK. ECG manifestations: the poisoned patient. Emerg Med Clin North Am. 2006;24(1):159–77, vii. Available from: http://dx.doi.org/10.1016/j.emc.2005.08.012.

5. Gummin DD, Mowry JB, Beuhler MC, Spyker DA, Rivers LJ, Feldman R, et al. 2022 annual report of the national poison data system® (NPDS) from America’s poison centers®: 40th annual report. Clin Toxicol (Phila). 2023;61(10):717–939. Available from: http://dx.doi.org/10.1080/15563650.2023.2268981.

6. Holstege CP, Borek HA. Toxidromes. Crit Care Clin. 2012;28(4):479–98. Available from: http://dx.doi.org/10.1016/j.ccc.2012.07.008.

7. Almarales JR, Saavedra MÁ, Salcedo Ó, Romano DW, Morales JF, Quijano CA, et al. Inducción de secuencia rápida para intubación orotraqueal en Urgencias. Rev Repert Med Cir. 2016;25(4):210–8. Available from: http://dx.doi.org/10.1016/j.reper.2016.11.009.

8. Kapur N, Clements C, Bateman N, Foëx B, Mackway- Jones K, Hawton K, et al. Self-poisoning suicide deaths in England: could improved medical management contribute to suicide prevention? QJM. 2010;103(10):765–75. Available from: http://dx.doi.org/10.1093/qjmed/hcq128.

9. Burket GA, Horowitz BZ, Hendrickson RG, Beauchamp GA. Endotracheal intubation in the pharmaceutical poisoned patient: A narrative review of the literature. J Med Toxicol. 2021;17(1):61–9. Available from: https://doi.org/10.1007/s13181-020-00779-3.

10. Pellatt RA, Isoardi K, Keijzers G. Intubation for patients with overdose: Time to move on from the Glasgow Coma Scale. Emerg Med Australas. 2023;35(4):702–5. Available from: http://dx.doi.org/10.1111/1742-6723.14254.

11. Duncan R, Thakore S. Decreased Glasgow Coma Scale Score Does Not Mandate Endotracheal Intubation in the Emergency Department. J Emerg Med. 2009 Nov;37(4):451-5. Available from: https://doi.org/10.1016/j.jemermed.2008.11.026.

12. Turgut K, Yavuz E. Comparison of non-invasive CPAP with mask use in carbon monoxide poisoning. Am J Emerg Med. 2020;38(7):1454–7. Available from: http://dx.doi.org/10.1016/j.ajem.2020.04.050.

13. Yesiloglu O, Gulen M, Satar S, Avci A, Acehan S, Akoglu H. Treatment of carbon monoxide poisoning: high-flow nasal cannula versus non-rebreather face mask. Clin Toxicol (Phila). 2021;59(5):386–91. Available from: http://dx.doi.org/10.1080/15563650.2020.1817477.

14. Menke NB, Walsh SJ, King AM. Cardiotoxicodinámica: Toxicidad de los xenobióticos cardiovasculares. Emerg Med Clin North Am. 2015;33(3):563–95. Available from: http://dx.doi.org/10.1016/j.emc.2015.04.007.

15. Gunja N, Graudins A. Management of cardiac arrest following poisoning: Management of toxic cardiac arrest. Emerg Med Australas. 2011;23(1):16–22. Available from: https://doi.org/10.1111/j.1742-6723.2010.01369.x.

16. Raj SR, Stein CM, Saavedra PJ, Roden DM. Efectos cardiovasculares de los fármacos no cardiovasculares. Circulación. 2009;120(12):1123–32. Available from: http://dx.doi.org/10.1161/CIRCULATIONAHA.107.728576.

17. Bradberry SM, Thanacoody HKR, Watt BE, Thomas SHL, Vale JA. Management of the cardiovascular complications of tricyclic antidepressant poisoning : role of sodium bicarbonate. Toxicol Rev. 2005;24(3):195–204. Available from: http://dx.doi.org/10.2165/00139709-200524030-00012.

18. Thanacoody HKR, Thomas SHL. Intoxicación por antidepresivos tricíclicos: toxicidad cardiovascular. Toxicol Rev. 2005;24(3):205–14. Available from: http://dx.doi.org/10.2165/00139709-200524030-000134.

19. Tan HH, Hoppe J, Heard K. Una revisión sistemática de los efectos cardiovasculares después de una sobredosis de medicamentos antipsicóticos atípicos. Am J Emerg Med. 2009;27(5):607–16. Available from: http://dx.doi.org/10.1016/j.ajem.2008.04.020.

20. Parris MA, Calello DP. Found down: Approach to the patient with an unknown poisoning. Emerg Med Clin North Am. 2022;40(2):193–222. Available from: http://dx.doi.org/10.1016/j.emc.2022.01.011.

21. Ornillo C, Harbord N. Fundaments of toxicology approach to the poisoned patient. Adv Chronic Kidney Dis. 2020;27(1):5–10. Available from: http://dx.doi.org/10.1053/j.ackd.2019.12.001

22. Chiang C, Kashetsky N, Feschuk A, Burli A, Law RM, Maibach HI. Efficacy of water-only or soap and water skin decontamination of chemical warfare agents or simulants using in vitro human models: A systematic review. J Appl Toxicol. 2022;42(6):930-941. Available from: https://doi.org/10.1002/jat.4251.

23. Zhu H, Jung EC, Phuong C, Hui X, Maibach H. Effects of soap-water wash on human epidermal penetration [published correction appears in J Appl Toxicol. 2016 Nov;36(11):1526]. J Appl Toxicol. 2016;36(8):997-1002. Available from: https://doi.org/10.1002/jat.3258.

24. Procopio GL, Patel R, Gupta A. Clinical Pearls in Medical Toxicology: Updates Ranging From Decontamination to Elimination. J Pharm Pract. 2019;32(3):339-346. Available from: https://doi.org/10.1177/0897190019854565.

25. Benson BE, Hoppu K, Troutman WG, Bedry R, Erdman A, Höjer J, et al. Position paper update: gastric lavage for gastrointestinal decontamination. Clin Toxicol (Phila). 2013;51(3):140–6. Available from: http://dx.doi.org/10.3109/15563650.2013.770154.

26. Zellner T, Prasa D, Färber E, Hoffmann-Walbeck P, Genser D, Eyer F. The use of activated charcoal to treat intoxications. Dtsch Arztebl Int. 2019;116(18):311–7. Available from: http://dx.doi.org/10.3238/arztebl.2019.0311.

27. Hoegberg LCG, Shepherd G, Wood DM, Johnson J, Hoffman RS, Caravati EM, et al. Systematic review on the use of activated charcoal for gastrointestinal decontamination following acute oral overdose. Clin Toxicol (Phila). 2021;59(12):1196–227. Available from: http://dx.doi.org/10.1080/15563650.2021.1961144.

28. File:Activated carbon A.jpg [Internet]. Wikimedia.org. Available from: https://commons.wikimedia.org/wiki/File:Activated_carbon_A.jpg.

29. Wikipedia contributors. Archivo:Activated Charcoal.jpg [Internet]. Wikipedia, The Free Encyclopedia. Available from: https://es.m.wikipedia.org/wiki/Archivo:Activated_Charcoal.jpg.

30. Juurlink DN. Activated charcoal for acute overdose: a reappraisal. Br J Clin Pharmacol. 2015 Nov 9;81(3):482-7. Available from: https://doi.org/10.1111/bcp.12793.

31. American Academy of Clinical Toxico, European Association of Poisons Cen. Position paper: Singledose activated charcoal. Clin Toxicol (Phila). 2005;43(2):61–87. Available from: http://dx.doi.org/10.1081/clt-51867.

32. American Academy of Clinical Toxicology, European Association of Poisons Centres and Clinical Toxicologists. Position statement and practice guidelines on the use of multi-dose activated charcoal in the treatment of acute poisoning. J Toxicol Clin Toxicol. 1999;37(6):731-51. Available from: http://dx.doi.org/10.1081/clt-100102451.

33. Position statement: Cathartics: American academy of clinical toxicology; European association of poisons centres and clinical toxicologists. J Toxicol Clin Toxicol. 1997;35(7):743–52. Available from: http://dx.doi.org/10.3109/15563659709162570.

34. Thanacoody R, Caravati EM, Troutman B, Höjer J, Benson B, Hoppu K, et al. Position paper update: Whole bowel irrigation for gastrointestinal decontamination of overdose patients. Clin Toxicol (Phila). 2015;53(1):5–12. Available from: http://dx.doi.org/10.3109/15563650.2014.989326.

35. Mégarbane B, Oberlin M, Alvarez J-C, Balen F, Beaune S, Bédry R, et al. Management of pharmaceutical and recreational drug poisoning. Ann Intensive Care. 2020;10(1):157. Available from: http://dx.doi.org/10.1186/s13613-020-00762-9.

36. Boyer EW, Weibrecht KW. Salicylate (aspirin) poisoning in adults. In: Traub SJ, editor. UpToDate. Waltham: UpToDate; 2017.

37. King JD, Kern MH, Jaar BG. Eliminación extracorpórea de venenos y toxinas. Clin J Am Soc Nephrol. 2019;14(9):1408–15. Available from: http://dx.doi.org/10.2215/CJN.02560319.

38. Ghannoum M, Hoffman RS, Gosselin S, Nolin TD, Lavergne V, Roberts DM. Uso de tratamientos extracorpóreos en el manejo de las intoxicaciones. Riñón Int. 2018;94(4):682–8. Available from: http://dx.doi.org/10.1016/j.kint.2018.03.026.

39. Jha VK, Padmaprakash KV. Extracorporeal treatment in the management of acute poisoning: What an intensivist should know? Indian J Crit Care Med. 2018;22(12):862–9. Available from: http://dx.doi.org/10.4103/ijccm.IJCCM_425_18.

40. RECOMMENDATIONS [Internet]. extrip-workgroup. [cited 2024-03-25]. Available from: https://www.extripworkgroup.org/recommendations.

41. de Farmacia S. Guía de administración de Antídotos y Antagonistas [Internet]. [cited 2024-10-2023]. Available from: www.chospab.es.

42. Kaiser SK, Dart RC. The roles of antidotes in emergency situations. Emerg Med Clin North Am. 2022;40(2):381–94. Available from: http://dx.doi.org/10.1016/j.emc.2022.01.008.

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Número Actual

Toxicological Chain of Survival (TCS): An integral approach to the intoxicated patient. Narrative review

Abstract

Keywords

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