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?

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College Answer

(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.

Discussion

a)

  • Attention to the ABCS, with management of life-threatening problems simultanous with a rapid focused examination and a brief history
  • Airway:
    • assess the need for immediate intubation
    • given that the patient is unconscious, intubation will likely be required
  • Breathing/ventilation
    • maintain oxygenation with a reservoir mask, or by chemanical ventilation as indicated
  • Circulatory support
    • assess the need for fluid resuscitation and vasopressor support;
    • gain multiple points of intravenous access and commence cardiovascular monitoring.
    • Invasive hemodynamic monitoring may be required
  • Supportive management
    • Check BSL and maintain normoglycaemia
    • Check ABG and assess the need to correct her acid-base status
  • Specific management
    • This will be dictated by the history, physical examination, and the findings of investigations.

References

References

The website of the American Academ of Clinical Toxicology has several position statements which might be useful to the fellowship candidate:

 

Ipecac Syrup

Single-Dose Activated Charcoal

Multi-Dose Activated Charcoal

Cathartics

Whole Bowel Irrigation

Gastric Lavage

Urine Alkalization