Module 2 : Initial Evaluation and Stabilization

Learning Objectives:

1. Recognize vital sign patterns and common toxidromes in poisoned patients
2. Perform a focused physical exam to identify key findings suggestive of certain toxins 
3. Address the “ABCs” – airway, breathing, and circulation in the compromised patient
4. Utilize rapid bedside diagnostics to guide initial management 
5. Administer appropriate antidotes like naloxone and dextrose based on clinical presentation

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Initial Presentation and Vital Signs:

• The first priority is stabilizing any life-threatening conditions – assess mental status, airway, breathing, circulation.
• Obtain a full set of vital signs including blood pressure, pulse, respiratory rate, and temperature.
• Note any abnormalities that may indicate a particular toxidrome:
• Tachycardia suggests sympathomimetics (cocaine), anticholinergics (antihistamines), or antidysrhythmics (tricyclics)
• Bradycardia can be seen with cholinergics (organophosphates), beta-blockers, or cardiotoxins like digoxin
• Hypotension indicates possible sedative-hypnotics, calcium channel blockers, or shock states
• Hypertension may occur with stimulants, anticholinergics, or drug withdrawal syndromes
• Hypothermia or hyperthermia are common with various toxins and environmental exposures.

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Focused Physical Exam Findings:

• Assess mental status – agitation, stupor, confusion, or coma.
• Check pupillary size – pinpoint suggests opioids, dilated indicates anticholinergics.
• Note skin moisture and bowel sounds – dryness and hypoactive bowel sounds suggest anticholinergics.
• Examine for trauma that could indicate alternate etiology or related injury.
• Signs of injection drug use may suggest opioid or stimulant toxicity. 
• Localize any neurologic deficits.

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Addressing the ABCs:

• Ensure airway patency in unconscious or severely poisoned patients.
• Intubate early if airway compromise seems likely – do not wait for respiratory arrest.
• Assess adequacy of breathing – give supplemental O2, support ventilation if necessary.
• Monitor oxygenation with pulse oximetry and/or ABG analysis.
• Address dysrhythmias, hypo- or hypertension. Start with IV fluids, then consider pressors if hypotensive.
• Treat seizures rapidly with benzodiazepines. Avoid proconvulsant agents.

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Rapid Bedside Diagnostics:

• Check fingerstick glucose in all patients with depressed mental status.
• Give IV dextrose immediately if hypoglycemia cannot be excluded.
• Consider naloxone 0.4-2 mg IV if opioid toxicity is suspected – start with lower dose.
• Obtain ECG to diagnose conduction delays, dysrhythmias.
• Check carboxyhemoglobin and methemoglobin levels with co-oximetry when available.
• Measure serum electrolytes, renal function, hematology, and liver tests.

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Key Antidotes and Initial Support:

• Dextrose, thiamine, naloxone form the “coma cocktail” given empirically to undifferentiated coma.
• Specific antidotes like cyanide kit, physostigmine, or glucagon may be indicated urgently based on presentation.
• Administer benzodiazepines for agitation, stimulant toxicity, withdrawal syndromes.
• Correct electrolyte, glucose, and acid-base abnormalities.
• Avoid hypotonic fluids, proconvulsants, vasopressors that could worsen the clinical syndrome.
• Consult poison control or clinical toxicology service for guidance on diagnosis and management.

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This covers the essential steps in the initial evaluation and stabilization of the poisoned patient. Recognizing the toxidrome and providing appropriate early support is crucial. In the next module, we will discuss diagnostic testing for poisoning cases.

Here is a table with common toxidromes, their symptoms, and corresponding antidotes:

Toxidrome	Symptoms	Antidotes
Cholinergic	Bradycardia, miosis, bronchospasm, bronchorrhea, salivation, lacrimation, urinary incontinence, diarrhea, muscle fasciculations	Atropine, pralidoxime, benzodiazepines
Anticholinergic	Tachycardia, mydriasis, decreased bowel sounds, urinary retention, delirium, agitation	Physostigmine
Sympathomimetic	Tachycardia, hypertension, diaphoresis, hyperthermia, agitation, psychosis	Benzodiazepines, propranolol
Sedative-hypnotic	Respiratory depression, miosis, hypothermia, hypotension, decreased reflexes	Naloxone, flumazenil
Opioid	Respiratory depression, miosis, decreased bowel sounds, sedation	Naloxone
Serotonin syndrome	Hyperreflexia, clonus, tremor, rigidity, hyperthermia	Cyproheptadine, benzodiazepines