第一部分中毒的一般处理原则.docVIP

Chapter 280 General Considerations: Recognition, Initial Approach, and Early Management of the Poisoned Patient Joshua G. Schier Robert S. Hoffman Poisoning is a clinical or physiologic state induced by exposure to a xenobiotic (a foreign chemical). The presence and severity of poisoning after exposure to a particular agent is dependent on a number of unalterable factors, including the agent itself, dose of agent, route and duration of exposure, age, weight, and health status (e.g., presence of comorbid conditions) of the patient. However, factors that occur after exposure can be optimized for the best outcome. These include time to emergency department (ED) presentation, whether the history is adequate to diagnose a possible poisoning, and finally, the timely delivery of potentially beneficial therapies. Emergency physicians see acutely poisoned patients first and have the best opportunity to limit the severity of poisoning. This chapter focuses on the most common type of poisonings, which are ingestions and respiratory exposures, and does not discuss dermal or eye exposures. Differential Diagnosis The first challenge in a poisoned patient is to recognize that a chemical exposure has occurred. Frequently, patients or witnesses may suggest an accidental poisoning, a potential suicide, or recreational drug use. At other times, the history is not available. Clinical manifestations of poisoning can often mimic other diseases. For instance, an elderly patient with chronic salicylate toxicity may present solely with altered mental status, and the diagnosis may be delayed while the patient is evaluated and treated for infection. Patients may not be aware that a chemical exposure is the cause of their symptoms, may choose not to share information about it (e.g., intentional drug overdose in a suicidal patient), or may be unable to communicate because of altered mental status. Therefore, it is critical to (a) consider poisoning in the undifferentiated patient presenting to