Correctly identify toxicology prior to treatment

Robert W. Gould, MD

Robert W. Gould, MD

Up to 40% of patients presenting to the emergency department may have an intoxication, but they’re not always easy to recognize.

It’s important for anesthesiologists to know that there are really very few intoxications that have classic toxidromes, said Robert W. Gould, MD, Chief of Critical Care Anesthesiology and Associate Professor of Anesthesiology at the University of Minnesota in Minneapolis. While it would be convenient if every patient with cyanide poisoning had cherry lips or smelled of almonds like they do in Hollywood recreations, in real life the percentage of patients who present with those symptoms is actually quite low.

The most common cause of death by poisoning in the United States is carbon monoxide, but CO intoxication may not be obvious to the medical personnel treating the patient unless they can get a comprehensive look at the bigger picture.

“It’s very important to get the history from the patient if you can,” said Dr. Gould. If the patient is not able to say, ask family members, EMTs, bystanders: What was found with the patient? If he or she was found in a garage, it’s helpful to know what was there. Was the car running? What if the car was a Tesla? Were there industrial cleaners, antifreeze, or drug paraphernalia on the scene? Having all the information can help anesthesiologists understand exactly the issue they’re dealing with.

Dr. Gould cited 436 cases of CO poisoning that were identified in New York after Hurricane Sandy – and it turned out that 26.2% of those had come from indoor grilling, while 17.5% were the byproduct of using generators. Knowing exactly what is on the scene is critical.

Dr. Gould also mentioned common associations for other intoxications. Cyanide poisoning may be associated with patients who have smoke inhalation, as hydrogen cyanide is produced when plastic containing high nitrates is burned. It may also be the result of specific cleaners. Organophosphates are used in insecticides or nerve gas agents and may be identified in farmers from the field or even, in one case Dr. Gould discussed, an avid golfer who kissed his golf balls for good luck without knowing the course had recently been treated.

Anesthesiologists should also be aware of toxicities associated with three alcohols: ethylene glycol, methanol, and isopropanol, as they all feature metabolic, cardiopulmonary, and neurologic derangements and will have significant morbidity if ingested. A patient experiencing methanol poisoning may have been making their own bathtub gin, or a small child presenting with isopropyl alcohol intoxication may have been covered in too much hand sanitizer by overzealous parents.

The details matter. Only when you’ve identified the problem can you work to properly address it.


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