6. General Approach to the Toxicological Patient

Objectives

  • Review the assessment and initial treatment of children with toxic exposures.
  • Discuss the importance of decontamination in toxicological disasters.
  • Describe the decontamination process.

Whether a patient should be stabilized prior to decontamination depends on the nature of the toxic exposure, the needs of the patient, and the risks of possible exposure to personnel. Prioritization for treatment of any victim of toxic injury, especially children, begins with the ABCs of Airway, Breathing and Circulation.

A key concept is: treat the patient first, not the poison. Supportive and symptomatic care is sufficient for the majority of poisonings.

The assessment and establishment of a patent Airway always is the first step. Adequate Breathing and ventilation must be assured (place patient in fresh air, give supplemental oxygen and/or administer positive pressure ventilatory support as indicated). Adequacy of Circulation can be assessed by noting the color, capillary refill, pulse and blood pressure (see Module 4, Pediatric Trauma). Once the airway, breathing, and circulation are established, the patient can undergo decontamination procedures. Perform a complete physical examination with close attention to any breath or skin odors that may aid in the patient’s diagnosis. In the hospital setting, obtain basic laboratory studies, such as an arterial or venous blood gas, electrolytes, blood urea nitrogen, and creatinine, as indicated. Clinical manifestations from toxic exposures may vary considerably. Whether the child presents as a “classic case” or as a partial toxic syndrome, the severity of the exposure and resultant disease cannot be dismissed or downplayed. Acknowledge possible delayed symptomatology and plan a suitable follow-up.

Whether the child presents as a “classic case” or as a partial toxic syndrome, the severity of the exposure and resultant disease cannot be dismissed or downplayed.

With ingested chemicals, avoid inducing emesis as this can aggravate the injury. Instead, encourage conscious patients to drink 4 to 8 ounces of water. Send patients with toxic ingestions immediately to a medical facility. Vomitus potentially containing chemicals is considered toxic. When vomiting has occurred, quickly wipe up the vomitus with towels and then double bag the towels. Provide nauseated patients with ingestions disposable bags to collect possible vomitus.