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Chapter 56:
Drug Overdose and Poisoning
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Statistics on Overdoses
• 2.4 million exposures in 2004, 1,183 fatalities
• Largest group was children but more fatalities in adults
• Types of exposures include herbal products, snake or
insect bites, alcohol or drugs, plants, hazmats, etc.
• Local poison control center # is 1-800-222-1222
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Exposures
HOME
• Poisons
– Improper storage
– Inability to read labels
– Ingesting the wrong
medication/wrong
amount of medication
• Toxic fumes
– Carbon monoxide
– Cleaning fluids
SUBSTANCE ABUSE
• Most ICU admissions
are from
intentional/suicidal
attempts
• Substance most
commonly abused are
alcohol, heroin,
narcotic analgesics,
amphetamines,
benzodiazepines,
cocaine.
• Toxidrome
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Assessment of the Overdose Patient
• Information at the scene of the incident
– Time and duration of exposure
– Care given by medical providers at the scene
– Information from family, friends, significant others
• Triage decisions
– ABCDEs
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Toxidromes
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
A patient is admitted to the ICU for suspected suicidal
overdose. Temp is 96, HR 60 and regular, respirations 12
and shallow. The patient doesn’t follow commands and
his pupils are constricted. The agent most likely
responsible for this is:
A. Anticholinergic
B. Cholinergic
C. Sympathomimetic
D. Opioid
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
D. Opioid
Rationale: All of this patient’s vital signs and symptoms
indicate some type of CNS depressant. The only one that
fits the scenario is an opioid. Most of the other
toxidromes include an increase in vital signs.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Assessment of Laboratory Data
• Electrolytes
• Hepatic function
• Urinary function
• Electrocardiogram
and EEG monitoring
• Drug toxicology
levels
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Patient Management and Nursing Care:
The ABCs
PRIORITIES
OF CARE
NURSING INTERVENTIONS
Airway
Nasotracheal or endotracheal intubation; suctioning
Breathing
Bag-mask ventilation until placed on mechanical
ventilator, especially if opioid ingestion or respiratory
depression
Circulation
Cardiac monitor and ECG; treat cardiac
dysrhythmias. Monitor BP for hyper- or hypotension;
manage BP. May need PA catheter and urimeter.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Secondary Survey
• Acid-base balance
– Monitor and treat metabolic/respiratory acidosis
– Serial arterial blood gases
• Mental status
– Glasgow Coma Scale
– Monitor for hypoglycemia
– Assess for hypoxemia
– Use of Narcan (naloxone) and the “coma cocktail”
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Secondary Survey (cont.)
• Associated injuries
• Past medical history
• Vital signs/temperature monitoring
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
A small child is admitted to the Emergency Care Unit after
swallowing bleach. The child is awake and oriented but
very scared and crying. Which of the following is true
regarding initial decontamination of this substance?
A. Have the child drink 2 to 8 ounces of milk.
B. Give the child 2 ounces of syrup of ipecac.
C. Induce emesis by stimulating the gag reflex.
D. Insert a small-bore nasogastric tube and initiate
gastric lavage.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
A. Have the child drink 2 to 8 ounces of milk.
Rationale: Try the least invasive measure first. Once the
child is settled, give the child 2 to 8 ounces of milk to
drink to help neutralize the bleach. Syrup of ipecac or
inducing vomiting is no longer recommended. A tube is
the most invasive measure and isn’t indicated at this
time.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Decontamination Methods by Type of
Exposure
Ocular
Continuous eye irrigation for 15 minutes;
blink frequently; check pH. Ophthalmologic
consult.
Dermal
Continuous skin irrigation for 15 to 30 minutes.
Remove clothes if contaminated. Wash with soap
and water.
Inhalation
Move to fresh air immediately. Consider rescuer
status too. Oxygen prn.
Ingestion
If awake and alert with positive gag reflex, give
water or milk.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Gastric Lavage
• Insert large-bore stomach tube
– Confirm placement per hospital protocol
• Instill 150 to 200 mL of warmed saline into stomach
• Allow to drain by gravity
• Irrigate until return of effluent is clear or 2,000 mL NSS
• Collect contents and send to toxicology
• Complications include esophageal perforation, aspiration,
electrolyte imbalance, hypothermia, tension pneumothorax
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Other Gastrointestinal Decontaminants
• Adsorbents
– Activated charcoal
• Cathartics
– Magnesium citrate
• Whole-bowel irrigation
– Used for bowel absorption, especially of hidden,
smuggled narcotics
– GoLYTELY is commonly used
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Enhancing Drug Elimination
• Multiple-dose activated
charcoal
– Every 2 to 6 hours
• Hemodialysis (HD)
– Requires access site
– Nephrology consult
– Equipment and nurse
• Hemoperfusion
– Larger surface area and
faster than HD
• Chelation
– Binds to the chemical to
remove it
• Hyperbaric oxygenation
(HBO)
– Treatment of choice for
CO poisoning
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
Which of the following medications CANNOT be removed
from the blood by dialysis?
A. Theophylline
B. Opioids
C. Lithium
D. Salicylates
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
B. Opioids
Rationale: Levels of all drugs listed can be decreased by
dialysis, except for opioids.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Ongoing Monitoring and Care
• Needs observation
for hours/days
• ECG
• X-rays, CT for
damage
• ABGs
• Anion gap
• Osmolal gap
• Patient education
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins