Page 622 - ACCCN's Critical Care Nursing

Emergency Presentations 599

TABLE 22.7 Summary of the management of poisoning victims

Aim Action
Prevent absorption of toxin l Ingested toxins: activated charcoal is the most effective method of reducing adsorption.
l Inhaled toxins: remove victim from source of contamination and administer oxygen or provide fresh air.
l Contact toxins: remove any substances from the body surface, preferably with copious amounts of
irrigating fluid. Remove clothing and place in a sealed bag to reduce vapour hazards. Use special
caution with corrosive materials and pesticides.
Enhance elimination of the toxin Ingested or injected toxins: administer an antidote or antagonist if available (e.g. naloxone for opiates;
from the blood flumazenil for benzodiazepines 2–4). Employ forced diuresis, for acidification or alkalinisation of the
urine; and haemodialysis.
Prevent complications by providing Carefully monitor all vital systems. Continually reassess patient for changes or response to therapy.
symptomatic or specific Administer antidotes as prescribed. Provide symptomatic care as needed for: cardiac arrhythmias, CNS
treatment depression or stimulation, fluid and electrolyte imbalances, acid–base disturbances, renal function,
effects of immobility.

CENTRAL NERVOUS SYSTEM DEPRESSANTS
TABLE 22.8 Common emergency antidotes A large number of common medications are capable of
depressing levels of consciousness, thought processes, or
Poison Antidote important regulatory centres in the central nervous
Benzodiazepines Flumazenil system (CNS). Clinical findings can vary from class to
class or within the same drug family, as physical effects
Carbon monoxide Oxygen
are dependent on the chemical structure of the drug,
Insulin Dextrose dose, route of exposure and rate of metabolism. The
Opioids Naloxone chemical structure and/or purity of illicit drugs may also
be affected by variations or deliberate aberrations in the
Paracetamol N-Acetylcysteine 112,117-119
manufacturing process. Drugs in this section
Organophosphates Atropine and pralidoxime include sedatives, hypnotics, tranquillisers and narcotics
Tricyclic antidepressants Sodium bicarbonate (see Table 22.9).
Assessment
The predominant observed effect is an altered level of
function enables identification of any deterioration. Elec- CNS function. 112,118,119 A spectrum of physical findings is
trolyte and acid–base balance are monitored closely if possible with the selective action of the specific drug on
large volumes of fluids or drugs that alter serum pH are inhibitory or excitatory centres of the brain; effects can
administered. vary from mild euphoria to convulsions, or mild sedation
to coma, dependence, addiction and tolerance. Narcotics
A poisoning may be the physical manifestation of an
emergency or crisis that requires emotional support. An produce miosis (constriction of the pupil), and some
underlying emotional conflict or mental health problem patients experience nausea and vomiting due to
may exist, regardless of whether the poisoning was inten- stimulation of the chemoreceptor trigger zone in the
112,118,119
tional or accidental. Psychological care is therefore an medulla.
important component for all patients presenting with A narcotic overdose is distinctive: a decreased respiratory
poisoning. 107,108,110 Many facilities offer the services of a rate and tidal volume, miosis, hypotension, and an
mental health worker while the patient is still in the ED. altered level of consciousness. 112,118,119 However, other
If the patient’s condition is stable and the poisoning has factors may affect these findings:
not altered their mental state, early psychological inter-
vention is appropriate. l a decreased respiratory effort may produce hyper-
carbia, causing pupil dilation
For adult patients, the desire for treatment is not as l chronic narcotic users tend to have multiple problems
important as the manner in which treatment is received. associated with their drug use or lifestyle, which may
Even though patients may initially refuse care, if modify findings
approached in a non-threatening way and provided some l a sufficiently high quantity of CNS depressant will
form of control they will usually comply. If threatened depress vital regulatory centres in the brain
with force or restraints, they are placed in a difficult posi- l altered respirations cause hypoventilation, stasis of
tion of either submitting to coercion or resisting therapy secretions, and atelectasis; resultant hypoxia aggra-
for self-protection. A paediatric patient may be too young vates the sensorium and cerebral functioning 119
either to fully understand or to effectively cooperate (see l narcotics may produce idiopathic pulmonary
Chapter 26). oedema 112,118,119