Chapter 46
Principles of toxicology
Christine M. Murphy,
Christine M. Murphy
Search for more papers by this authorChristine M. Murphy,
Christine M. Murphy
Search for more papers by this authorBook Editor(s):David C. Cone MD,
Jane H. Brice MD, MPH,
Theodore R. Delbridge MD, MPH,
J. Brent Myers MD, MPH,
David C. Cone MD
Professor of Emergency Medicine
Yale University School of Medicine, New Haven, Connecticut
Search for more papers by this authorJane H. Brice MD, MPH
Professor of Emergency Medicine
University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
Search for more papers by this authorTheodore R. Delbridge MD, MPH
Executive Director
Maryland Institute for Emergency Medical Services Systems, Baltimore, Maryland
Search for more papers by this authorJ. Brent Myers MD, MPH
Chief Medical Officer ESO Associate Medical Director
Wake County EMS, Raleigh, North Carolina
Search for more papers by this authorFirst published: 18 August 2021
Summary
Exposure to any substance can cause illness or injury depending on the substance, method of exposure, or amount of exposure. Basic principles of toxicology, including the importance of history and physical exam findings, and the decontamination and treatment of exposed patients, are reviewed. Use of antidotes readily available to EMS clinicians is discussed. Application of the principles reviewed in this chapter will improve clinician preparedness for most exposure and poisoning emergencies.
References
- Gummin D , Mowry J , Spyker D , et al. 2018 Annual report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 36th annual report . Clin Toxicol (Phila) . 2019 ; 57 : 1220 – 1413 .
- Eddleston M , Haggalla S , Reginald K , et al. The hazards of gastric lavage for intentional self-poisoning in a resource poor location . Clin Toxicol (Phila) . 2007 ; 45 : 136 – 143 .
- Lawrence DT , Bechtel L , Walsh JP , Holstege CD . The evaluation and management of acute poisoning emergencies . Minerva Med . 2007 ; 98 : 543 – 68 .
- Taylor RL , Cohan SL , White JD . Comprehensive toxicology screening in the emergency department: an aid to clinical diagnosis . Am J Emerg Med . 1985 ; 3 : 507 – 11 .
- Erickson TB , Thompson TM , Lu JJ . The approach to the patient with an unknown overdose . Emerg Med Clin North Am . 2007 ; 25 : 249 – 81 .
- Merigian KS , Hedges JR , Roberts JR , et al. Use of abbreviated mental status examination in the initial assessment of overdose patients . Arch Emerg Med . 1988 ; 5 : 139 – 145 .
- Delk C , Holstege CP , Brady WJ . Electrocardiographic abnormalities associated with poisoning . Am J Emerg Med . 2007 ; 25 : 672 – 87 .
- Holstege C , Baer A , Brady WJ . The electrocardiographic toxidrome: the ECG presentation of hydrofluoric acid ingestion . Am J Emerg Med . 2005 ; 23 : 171 – 6 .
- Kolecki PF , Curry SC . Poisoning by sodium channel blocking agents . Crit Care Clin . 1997 ; 13 : 829 – 48 .
- Harrigan RA , Brady WJ . ECG abnormalities in tricyclic antidepressant ingestion . Am J Emerg Med . 1999 ; 17 : 387 – 93 .
- Heaney RM . Left bundle branch block associated with propoxyphene hydrochloride poisoning . Ann Emerg Med . 1983 ; 12 : 780 – 82 .
- Fernandez-Quero L , Riesgo MJ , Agusti S , Cidoncha B. Left anterior hemiblock, complete right bundle branch block and sinus tachycardia in maprotiline poisoning . Intensive Care Med . 1985 ; 11 : 220 – 2 .
- Wolfe TR , Caravati EM , Rollins DE . Terminal 40-ms frontal plane QRS axis as a marker for tricyclic antidepressant overdose . Ann Emerg Med . 1989 ; 18 : 348 – 51 .
- Berkovitch M , Matsui D , Fogelman R , et al. Assessment of the terminal 40-millisecond QRS vector in children with a history of tricyclic antidepressant ingestion . Pediatr Emerg Care . 1995 ; 11 : 75 – 7 .
- Brady WJ , Skiles J . Wide QRS complex tachycardia: ECG differential diagnosis . Am J Emerg Med . 1999 ; 17 : 376 – 81 .
- Clark RF , Vance MV . Massive diphenhydramine poisoning resulting in a wide-complex tachycardia: successful treatment with sodium bicarbonate . Ann Emerg Med . 1992 ; 21 : 318 – 21 .
- Joshi AK , Sljapic T , Borghei H , Kowey PR . Case of polymorphic ventricular tachycardia in diphenhydramine poisoning . J Cardiovasc Electrophysiol . 2004 ; 15 : 591 – 593 .
- Zareba W , Moss AJ , Rosero SZ , et al. Electrocardiographic findings in patients with diphenhydramine overdose . Am J Cardiol . 1997 ; 80 : 1168 – 73 .
- Stork CM , Redd JT , Fine K , Hoffman RS . Propoxyphene-induced wide QRS complex dysrhythmia responsive to sodium bicarbonate—a case report . J Toxicol Clin Toxicol . 1995 ; 33 : 179 – 83 .
- Kerns W 2nd , Garvey L , Owens J . Cocaine-induced wide complex dysrhythmia . J Emerg Med . 1997 ; 15 : 321 – 9 .
- Bania TC , Blaufeux B , Hughes S , et al. Calcium and digoxin vs. calcium alone for severe verapamil toxicity . Acad Emerg Med . 2000 ; 7 : 1089 – 96 .
- Dorsey ST , Biblo LA . Prolonged QT interval and torsades de pointes caused by the combination of fluconazole and amitriptyline . Am J Emerg Med . 2000 ; 18 : 227 – 9 .
- De Ponti F , Poluzzi E , Montanaro N . QT-interval prolongation by non-cardiac drugs: lessons to be learned from recent experience . Eur J Clin Pharmacol . 2000 ; 56 : 1 – 18 .
- Yap YG , Camm AJ . Drug induced QT prolongation and Torsades de pointes . Heart . 2003 ; 89 : 1363 – 72 .
- Anderson ME , Al-Khatib SM , Roden DM , Califf RM . Cardiac repolarization: current knowledge, critical gaps, and new approaches to drug development and patient management . Am Heart J . 2002 ; 144 : 769 – 81 .
- Sides GD . QT interval prolongation as a biomarker for torsades de pointes and sudden death in drug development . Dis Markers . 2002 ; 18 : 57 – 62 .
- Nelson LS . Toxicologic myocardial sensitization . J Toxicol Clin Toxicol . 2002 ; 40 : 867 – 79 .
- De Ponti F , Poluzzi E , Cavalli A , et al. Safety of non-antiarrhythmic drugs that prolong the QT interval or induce torsade de pointes: an overview . Drug Saf . 2002 ; 25 : 263 – 86 .
- Houston M , Hendrickson RG . Decontamination . Crit Care Clin . 2005 ; 21 : 653 – 72 .
- Kuckelkorn R , Schrage N , Keller G , Redbrake C . Emergency treatment of chemical and thermal eye burns . Acta Ophthalmol Scand . 2002 ; 80 : 4 – 10 .
- Wagoner MD . Chemical injuries of the eye: current concepts in pathophysiology and therapy . Surv Ophthalmol . 1997 ; 41 : 275 – 313 .
- Saidinejad M , Burns M . Ocular irrigant alternatives in pediatric emergency medicine . Pediatr Emerg Care . 2005 ; 21 : 23 – 26 .
- Ernst A , Thompson T , Haynes M , Weiss S . Warmed versus room temperature saline solution for ocular irrigation: a randomized clinical trial . Ann Emerg Med . 1998 ; 32 : 676 – 9 .
- Hoffman L. Solutions for difficult problems: eye irrigation–Morgan lens no more! Part 2 . Emergency Medicine News . Available at: https://journals.lww.com/em-news/blog/theproceduralpause/pages/post.aspx?PostID=61 .
- Krenzelok EP , McGuigan M , Lheur P . Position statement: ipecac syrup. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists . J Toxicol Clin Toxicol . 1997 ; 35 : 699 – 709 .
- Poison treatment in the home . American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention . Pediatrics . 2003 ; 112 : 1182 – 5 .
- Bond GR . Home syrup of ipecac use does not reduce emergency department use or improve outcome . Pediatrics . 2003 ; 112 : 1061 – 4 .
- Chyka PA , Seger D . Position statement: single-dose activated charcoal. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists . J Toxicol Clin Toxicol . 1997 ; 35 : 721 – 41 .
- Moll J , Kerns W 2nd , Tomaszewski C , Rose R . Incidence of aspiration pneumonia in intubated patients receiving activated charcoal . J Emerg Med . 1999 ; 17 : 279 – 83 .
- Eddleston M , Dawson A , Karalliedde L , et al. Early management after self-poisoning with an organophosphorus or carbamate pesticide–a treatment protocol for junior doctors . Crit Care . 2004 ; 8 : R391 – 7 .
- Howland M . Atropine . In: RS Hoffman , M Howland , NA Lewin , LS Nelson , LR Goldfrank , Editors. Goldfrank's Toxicological Emergencies , 11th ed. New York, NY : McGraw-Hill , 2019 .
- Newmark J . Nerve agents . Neurologist . 2007 ; 13 : 20 – 32 .
- Shih T-M , Rowland TC , McDonough JH . Anticonvulsants for nerve agent-induced seizures: the influence of the therapeutic dose of atropine . J Pharmacol Exp Ther . 2007 ; 320 : 154 – 161 .
- Seger DL . Flumazenil—treatment or toxin . J Toxicol Clin Toxicol . 2004 ; 42 : 209 – 16 .
- Bledsoe BE . No more coma cocktails. Using science to dispel myths and improve patient care . JEMS . 2002 ; 27 : 54 – 60 .
- Flumazenil injection [package insert]. Basel, Switzerland : Roche . Available at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2007/020073s016lbl.pdf . Accessed July 5, 2020.
- Chamberlain JM , Klein BL . A comprehensive review of naloxone for the emergency physician . Am J Emerg Med . 1994 ; 12 : 650 – 60 .
- Clarke SFJ , Dargan PI , Jones AL . Naloxone in opioid poisoning: walking the tightrope . Emerg Med J . 2005 ; 22 : 612 – 616 .
- Kim H , Nelson L . Reversal of opioid-induced ventilatory depression using low-dose naloxone (0.04 mg): a case series . J Med Toxicol . 2016 ; 12 : 107 – 110 .
- Moss R , Carlo D . Higher doses of naloxone are needed in the synthetic opioid era . Subst Abuse Treat Prev Policy . 2019 ; 14 : 1 – 6 .
- Williams K , Lang E , Panchal A , et al. Evidence-based guidelines for EMS administration of naloxone . Prehosp Emerg Care . 2019 ; 23 : 749 – 63 .
- Ryan S . Pharmacokinetic properties of intranasal and injectable formulations of naloxone for community use: a systematic review . Pain Manag . 2018 ; 8 : 231 – 45 .
- Chen KK , Rose C , Clowes G . Methylene blue, nitrites, and sodium thiosulfate against cyanide poisoning . Proc Soc Exp Biol Med . 1933 ; 31 : 250 – 252 .
- Chen KK , Rose C . Nitrite and thiosulfate therapy in cyanide poisoning . JAMA . 1952 ; 149 : 11319 .
- Bebarta VS , Tanen DA , Lairet J , et al. Hydroxocobalamin and sodium thiosulfate versus sodium nitrite and sodium thiosulfate in the treatment of acute cyanide toxicity in swine (Sus scrofa) model . Ann Emerg Med . 2010 ; 55 : 345 – 51 .
- Sodium nitrite [package insert]. Manufactured by Cangene BioPharma, Inc., Baltimore, MD, for Hope Pharmaceuticals, Scottsdale, AZ ; 2011 . Available at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/203922s000lbl.pdf . Accessed April 26, 2020.
- Hall AH , Dart R , Bogdan G . Sodium thiosulfate or hydroxocobalamin for the empiric treatment of cyanide poisoning? Ann Emerg Med . 2007 ; 49 : 806 – 13 .
- Borron SW , Baud FJ , Barriot P , et al. Prospective study of hydroxocobalamin for acute cyanide poisoning in smoke inhalation . Ann Emerg Med . 2007 ; 49 : 794 – 801 .
- Megarbane B , Delahaye A , Goldgran-Toledano D , Baud FJ . Antidotal treatment of cyanide poisoning . J Chin Med Assoc . 2003 ; 66 : 193 – 203 .
- Geller RJ , Barthold C , Saiers JA , Hall AH . Pediatric cyanide poisoning: causes, manifestations, management, and unmet needs . Pediatrics . 2006 ; 118 : 2146 – 58 .
- DesLauriers CA , Burda AM , Wahl M . Hydroxocobalamin as a cyanide antidote . Am J Ther . 2006 ; 13 : 161 – 5 .
- Uhl W , Nolting A , Golor G , Rost K , Kovar A . Safety of hydroxocobalamin in healthy volunteers in a randomized, placebo-controlled study . Clin Toxicol (Phila) . 2006 ; 44 : 17 – 18 .
- Hydroxocobalamin [package insert]. Manufactured by McKesson. a.s., Semoy, France and distributed by Meridian Medical Technologies, Inc., Columbia, MD ; March 2017 . Available at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/022041s019,%20020lbl.pdf . Accessed May 4, 2020.
- Borron SW , Baud FJ , Barriot P , Imbert M , Bismuth C . Prospective study of hydroxocobalamin for acute cyanide poisoning in smoke inhalation . Ann Emerg Med . 2007 ; 49 : 794 – 801 .
- Mettler FA , Gus'kova AK , Gusev I . Health effects in those with acute radiation sickness from the Chernobyl accident . Health Phys . 2007 ; 93 : 462 – 469 .
- Johnson M . Human effects following exposure to ionizing radiation: the accident at Chernobyl–the data from Hiroshima and Nagasaki . Arch Dermatol . 1986 ; 122 : 1380 – 2 .
- Gonzalez A . Radiological protection issues arising during and after the Fukushima nuclear reactor accident . J Radiol Prot . 2013 ; 33 : 497 – 571 .
-
Weigert A
.
Caustic ingestion in children
.
Contin Educ Anaesth Crit Care Pain
.
2005
;
5
:
5
–
8
.
10.1093/bjaceaccp/mki007 Google Scholar
- Schaffer SB , Hebert AF . Caustic ingestion . J La State Med Soc . 2000 ; 152 : 590 – 6 .
- Boink AB , Wemer J , Meulenbelt J , et al. The mechanism of fluoride-induced hypocalcemia . Hum Exp Toxicol . 1994 ; 13 : 149 – 55 .
- Lepke S , Paasow H . Effects of fluoride on potassium and sodium permeability of the erythrocyte membrane . J Gen Physiol . 1968 ; 51 : 365S – 72S .
- Kao WF , Deng JF , Chiang SC , et al. A simple, safe and efficient way to treat severe fluoride poisoning–oral calcium or magnesium . J Toxicol Clin Toxicol . 2004 ; 42 : 33 – 40 .
- Crain EF , Gershel JC , Mezey AP . Caustic ingestions: symptoms as predictors of esophageal injury . Am J Dis Child . 1984 ; 138 : 863 – 5 .
- Rumack BH , Burrington JD . Caustic ingestions: a rational look at diluents . Clin Toxicol . 1977 ; 11 : 27 – 34 .
- Homan CS , Maitra SR , Lane BP , et al. Histopathologic evaluation of the therapeutic efficacy of water and milk dilution for esophageal acid injury . Acad Emerg Med . 1995 ; 2 : 587 – 591 .
- Homan CS , Maitra SR , Lane BP , et al. Therapeutic effects of water and milk for acute alkali injury of the esophagus . Ann Emerg Med . 1994 ; 24 : 14 – 19 .
- Homan CS , Maitra SR , Lane BP , Geller ER . Effective treatment of acute alkali injury of the rat esophagus with early saline dilution therapy . Ann Emerg Med . 1993 ; 22 : 178 – 82 .
- Homan CS , Singer AJ , Henry MC , Thode HC . Thermal effects of neutralization therapy and water dilution for acute alkali exposure in canines . Acad Emerg Med . 1997 ; 4 : 27 – 32 .
