You are called to see a 16-year-old girl in the Emergency Department. She was brought in by ambulance after being found unconscious by her parents. She was last seen alive and well 12 hours ago. Several empty bottles of tablets were found beside her.
(a) What is your initial management?
(a) What is your initial management?
Initial management is to and assess vital signs (airway, breathing and circulation), institute appropriate monitoring (ECG, pulse oximeter) and institute whatever immediate supportive management is required. Early supportive management of the airway and breathing may require endotracheal intubation (eg. significant hypoxia, GCS < 9, not protecting airway, respiratory acidosis), and circulation will normally require intravenous fluids and/or vasopressors (ie. intravenous ± central venous access). History of presentation (including nature of tablets found and other medications she would have access to), past history of medical problems (including treatment and allergies) and time course of presentation are essential (from whoever can provide the most information). Examination allows search for toxidromes (pupils, sweating, heat rate etc), focal neurological signs (which may suggest an alternate diagnosis) and any complications of unconsciousness including aspiration, pressure areas etc.) Early investigations would include blood gases (oxygenation, ventilation, acidosis), electrolytes (especially K), blood glucose and paracetamol levels (treatable problem). Other specific investigations may be indicated (eg CK, Creatinine, phosphate if concerned about rhabdomyolysis; osmolality for osmolar gap etc.). It would be reasonable to consider a head CT if there were concerns about the neurological state. Decontamination
and antidotes are considered in subsequent parts of this question.
a)
The website of the American Academ of Clinical Toxicology has several position statements which might be useful to the fellowship candidate: