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Poisoning Key Feature 2: In intentional poisonings (overdose) think about multi-toxin ingestion. Skill: Clinical Reasoning Phase: Hypothesis generation Key Feature 3: When assessing a patient with a potentially toxic ingestion, take a careful history about the timing and nature of the ingestion. Skill: Clinical Reasoning Phase: History Key Feature 4: When assessing a patient with a potential poisoning, do a focused physical examination to look for the signs of toxidromes. Skill: Clinical Reasoning Phase: Physical Key Feature 5: When assessing a patient exposed (contact or ingestion) to a substance, clarify the consequences of the exposure (ex: don’t assume it is non-toxic, call poison control). Skill: Clinical Reasoning Phase: Hypothesis generation, Treatment Key Feature 6: When managing a toxic ingestion, utilize poison control protocols that are current. Skill: Clinical Reasoning, Professionalism Phase: Treatment Key Feature 7a: When managing a patient with a poisoning: Assess ABCs. Skill: Clinical Reasoning Phase: Hypothesis generation, Diagnosis Key Feature 7b: When managing a patient with a poisoning: Manage ABC's Skill: Clinical Reasoning Phase: Treatment Key Feature 7c: When managing a patient with a poisoning: Regularly reassess the patient’s ABC’s (i.e., do not focus on antidotes and decontamination while ignoring the effect of the poisoning on the patient). Skill: Clinical Reasoning Phase: Hypothesis generation, Treatment Substance Abuse Key Feature 3: In patients with signs and symptoms of withdrawal or acute intoxication, diagnose and manage it appropriately. Skill: Clinical Reasoning Phase: Diagnosis, Treatment Suicide Key Feature 4: In suicidal patients presenting at the emergency department with a suspected drug overdose, always screen for acetylsalicylic acid and acetaminophen overdoses, as these are common, dangerous, and frequently overlooked. Skill: Clinical Reasoning Phase: Investigation Working in a subacute nursery, as I am currently, I am helping to provide care for neonates with the neonatal abstinence syndrome, a consequence of maternal opioid use during pregnancy. I am not used to thinking about poisoning in this way. My experience is usually more in the domain of opioid overdose and other illicit substance intoxication in the adult population. When it comes to pediatrics, the first thing that comes to mind when I think about poisoning is accidental ingestion of household chemicals and medications by young children. In adolescents and adult patients with suicidal behaviour, I think about this in terms of any types of pills, sometimes with alcohol. In any of these cases, it is important to understand that if poisoning from one substance is possible, it is certainly possible that poisoning from more than one substance is the reality. The neonate whose mom recently injected street drugs may have been exposed to more than opioids via a contaminated substance mom had injected. If a child managed to get their hands on and ingest one non-food substance, whose to say they didn't ingest multiple poisons. And in the acutely suicidal patient, it would not be uncommon to try to mix various drugs in order to make the ingestion more lethal. In intentional but arguably unintentional poisonings as well, it is always important to thing about multi-toxin ingestion. Part of the reason it's important to keep an open mind regarding what was ingested is because of the uncertainty when relying on obtaining an accurate history in these circumstances. The patient using illicit substances may wish to avoid having health care workers find out what they took to prevent judgement or persecution (although disclosing specific substance use to police authorities would generally go against the physician's code of ethics). The patient with the suicide attempt may not want to say what they ingested so that access to those pills for a future attempt is not taken from them, or because they took someone else's medications and don't want them to know, etc. And of course, a child may not be able to communicate what they took. So, even if a patient is coherent enough to provide information after a toxic ingestion, it is always important to obtain as much collateral as possible to best piece together the story. One important point to try to nail down is the timing of contact with the substance, be it by ingestion, intravenous injection, inhaled, absorption through the skin, etc., as this directly affects the choice of interventions in managing the overdose. If the substance was ingested by mouth within the preceding hour or so, activated charcoal may be administered to bind to a substance still sitting in the stomach. Gastric lavage, or "stomach pumping" as it is colloquially known, can be done as another way to get rid of an acute ingestion, although its effectiveness is debatable and so it is done less frequently than in the past. Skin or mucous membrane contact may warrant thorough flushing of the exposed site with water or saline. Other than for the possible use of decontamination procedures, it is also important to try to estimate when a substance was ingested to predict where in the course of the ingestion the patient is with respect to the impact the substance has on their body. For example, one of the few highly effective antidotes is N-acetylcysteine, given in the setting of acetaminophen overdose. Being able to look at the level of acetaminophen in the blood based on a nomogram is how one knows whether or not N-acetylcysteine is helpful if administered. Another substance to think about the setting of suspected suicide attempt is acetylsalicylic acid (aka Aspirin), another easy to access over the counter medication that can be life-threatening and for which we can intervene to improve morbidity and mortality. In a setting of suspected poisoning, it is always important to check the serum salicylate along with the serum acetaminophen.  Being unable to rely big-time on the history in the setting of an overdose, the physical examination becomes key in terms of figuring out what sorts of ingestions took place, although there is a lot of overlap between the effects of different substances and the possibility of mixed ingestions certainly can confuse the matter. UpToDate provides a helpful table of the signs to look for with the ingestion of various classes of substances, and it is important for the physician responding to possible ingestions to have a sense of the signs on examination that suggest certain substances were ingested rather than others. Apart from considering co-ingestions, it is also important to think about the presentation as a possible withdrawal rather than acute ingestion from a substance, with withdrawal symptoms occurring because of longstanding use of the substance, and with effects that are generally the opposite of the effects of the substance. (For example, in the patient who has been using opioids regularly, which tends to cause constipation among many other effects, if they are in withdrawal, they commonly will have diarrhea.) There are often institutional protocols for the acute management of substance withdrawal (ex: CIWA protocol for alcohol withdrawal), and patients should be referred to a setting in which they will have the necessary supportive care depending on the severity of their presentation. These patients can derive significant benefit from community supports beyond the acute withdrawal phase, and consideration should be given to long-term therapy (ex: opioid agonist therapy for opioid use disorder). The above list is something I found when reading up on substance intoxication. But there are far more substances that can poison, particularly when you consider the number of day to day household chemicals a young child could potentially ingest. If you aren't at all sure that the substance is safe, in general but also at high doses if a large exposure was possible, call your local poison control centre for confirmation and/or guidance. The World Health Organization has a list online of all of the poison control centres worldwide here. As well, at least for the provincial poison control centre where I am located in Vancouver, they have a part of their webpage devoted to the suggested management of some more toxic ingestions. I looked up the ingestion of crayons, which although are supposed to be "non-toxic" can actually have some heavy metal contamination, more so if you've gotten them outside of Canada and the US. And even if they don't, they can have an apparent laxative effect from the wax. The poison control centre advises to rinse out the mouth and then drink a small glass of water or milk. Whether using their website or calling their centre, which I think is more advisable for ingestions you have not managed before, especially if they are out of the ordinary, like, say, crayons from Cambodia, it is important to approach poisonings with the most up to date protocol, as approaches here can change with time. It is also always only a phone call away, 24 hours a day. As part of my well child visits with young children, I advise parents to keep this number handy in the case of accidental ingestions, per the Rourke Baby Record.
Of course, if a patient presents with a possible life-threatening ingestion, it is always important for physicians to prioritize the assessment, immediate management, and ongoing reassessment of the ABCs of life-sustaining emergency medical care over looking for an antidote to the suspected poisons(s). Antidotes can still be a very important part of the care provided to the patient, and as I mentioned previously, some ingestions do have antidotes that, if given early, can potentially save a life. The patient just needs to be able to breathe and circulate blood to their brain and body while you get on the phone with your nearest poison control centre.
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Crisis Key Feature 11b: When dealing with an unanticipated medical crisis (ex: seizure, shoulder dystocia): Be calm and methodical. Skill: Professionalism Phase: Treatment Key Feature 11c: When dealing with an unanticipated medical crisis (ex: seizure, shoulder dystocia): Ask for the help you need. Skill: Professionalism Phase: Treatment Suicide Key Feature 5: In trauma patients, consider attempted suicide as the precipitating cause. Skill: Clinical Reasoning Phase: Hypothesis generation Trauma Key Feature 1: Assess and stabilize trauma patients with an organized approach, anticipating complications in a timely fashion, using the primary and secondary surveys. Skill: Clinical Reasoning Phase: Treatment, Physical Key Feature 2: Suspect, identify, and immediately begin treating life-threatening complications (ex: tension pneumothorax, tamponade). Skill: Selectivity Phase: Treatment, Diagnosis Key Feature 5c: In a patient with signs and symptoms of shock: Treat the shock. Skill: Clinical Reasoning, Selectivity Phase: Treatment Key Feature 6: In trauma patients, rule out hypothermia on arrival and subsequently (as it may develop during treatment). Skill: Clinical Reasoning Phase: Hypothesis generation, Physical Key Feature 7: Suspect certain medical problems (ex: seizure, drug intoxication, hypoglycemia, attempted suicide) as the precipitant of the trauma. Skill: Clinical Reasoning Phase: Hypothesis generation Key Feature 8: Do not move potentially unstable patients from treatment areas for investigations (ex: computed tomography, X-ray examination). Skill: Clinical Reasoning Phase: Treatment, Investigation Key Feature 9: Determine when patient transfer is necessary (ex: central nervous system bleeds, when no specialty support is available). Skill: Selectivity, Clinical Reasoning Phase: Treatment, Referral Key Feature 10: Transfer patients in an appropriate manner (i.e., stabilize them before transfer and choose the method, such as ambulance or flight). Skill: Clinical Reasoning Phase: Treatment, Referral I have not yet encountered a patient presenting with life-threatening trauma during my residency so far, but during my clerkship, I did see a handful of these, and I mostly watched and stayed out of the way as my preceptors proceeded to inspect and initiate life-saving measures. Fascinating. Ironically, although I was getting more exposure to trauma in clerkship, in residency is when I may actually be called upon to direct the resuscitation of a patient with life-threatening trauma. Although it is extremely unlikely that a family medicine resident would be expected to do this in a tertiary hospital like St Paul's Hospital where I work in Vancouver, when I am posted rurally for 2 months next year, on the remote archipelago of Haida Gwaii, it is not unlikely that I may be the one needed to take charge. Advanced Trauma Life Support (ATLS) is an emergency response course to trauma (the equivalent of ACLS for cardiac arrest). While I have not taken ATLS, the design is infused into all educational teaching about how to respond to trauma, namely, by calmly and methodically first performing a rapid primary survey to assess and intervene immediately for signs of life-threatening compromise, and then by performing a history and complete secondary survey to not overlook any injuries not noticed on the rapid first-over. My take on the rapid primary survey is as follows: (ABCDEF)
After performing the rapid primary survey, perform a history and secondary survey. The brief initial trauma history is best known as obtaining a SAMPLE history. S = Symptoms at present A = Allergies M = Medications P = Past medical and surgical history L = Last eaten when (important if considering need for surgery) E = Events leading up to and surrounding trauma (This includes gathering information to determine precipitating factors such as substance use, mental illness, seizure, or domestic violence, the latter of which requires a high index of suspicion. In particular, it is important to think of this possibility with patients who may be vulnerable to repeat trauma if it is not picked up and they return to an abusive living situation. Consider intimate partner violence, consider child abuse, and consider elder abuse in terms of who may be a victim. Consider self-harm/attempted suicide. Does the mechanism of injury make sense? If your gut is twitching, pay attention.) If the patient is not getting expedited to surgery and is stable enough to answer more questions, consider obtaining a more complete history as indicated. The detailed secondary survey is essentially a complete head to toe examination that assesses as much as can be examined. Then you can consider if any additional investigations not yet ordered would be helpful (ex: CT scans may be quite helpful but are generally contraindicated if a patient is unstable; first-line imaging in the unstable patient includes portable xray and FAST scan).  Note that in the approach above, I reviewed general resuscitation measures, but I didn't review the approach to addressing any rapidly reversible specific life-threatening etiologies that may be suspected during the assessment per se. If there was a life-threatening etiology of distress that was suspected on the primary or secondary survey, immediate correction of this is warranted. Two important complications of trauma to be on the lookout for when performing the rapid primary survey are tension pneumothorax and cardiac tamponade. These seriously life-threatening etiologies are as fatal as they are correctable, so the assessing physician needs to be on the lookout for them and correct them swiftly if detected.
Tension pneumothorax A tension pneumothorax can be a complication of trauma, and should be suspected in the patient who has dyspnea, hypotension, and ipsilateral decreased breath sounds. It is basically the creation of a one-way valve, or a sucking chest wound, which causes air to fill up the thorax, compressing the lung and major blood vessels in the thorax. Confirmatory imaging in the setting of high suspicion for this should not be done, and the physician should proceed to decompression of the lung immediately with a large angiocatheter (ex: 14 gauge) or else by immediate tube thoracostomy. Needles may need to be as long as 7-8 cm to penetrate far enough into the chest wall of a large patient. Insert the needle into the second or third intercostal space in the midclavicular line, or alternatively into the 5th intercostal space in the anterior or midaxillary line (success is reportedly better at this latter site). If needle decompression is done, then tube thoracostomy will simply need to follow immediately after. This is because there is expected to be blood and fluid that will fill this space afterward and so is necessary to allow it to drain. The chest tube should be at least a size 36 French. Cardiac tamponade Otherwise known as pericardial tamponade, this can occur as a complication of trauma and basically involves the sac around the heart filling with blood, constricting the heart and impairing it's ability to function as a pump. Unsurprisingly, this can lead to a triad of signs (known as Beck's triad) that are as follows: hypotension (from decreased cardiac output), jugular-venous distention (from impaired venous return to the heart), and muffled heart sounds (from decreased transmission of heart sounds as they are muffled by the surrounding fluid-filled sac). Nowadays, if and when rapid bedside FAST ultrasound scans are done in trauma, this is another way this can be picked up. However, it is unlikely I will have someone around to do a FAST scan when I am practicing rural medicine. The treatment for cardiac tamponade is drainage or pericardiocentesis and may need to be done at the beside if the patient's life is truly and emergently threatened. Yikes! By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Crisis Key Feature 2: Identify your patient’s personal resources for support (ex: family, friends) as part of your management of patients facing crisis. Skill: Patient Centered, Clinical Reasoning Phase: History, Treatment Key Feature 3: Offer appropriate community resources (ex: counselor) as part of your ongoing management of patients with a crisis. Skill: Patient Centered, Professionalism Phase: Treatment Key Feature 4: Assess suicidality in patients facing crisis. Skill: Clinical Reasoning Phase: Hypothesis generation, Diagnosis Key Feature 8: Negotiate a follow-up plan with patients facing crisis. Skill: Clinical Reasoning, Communication Phase: Treatment, Follow-up Depression Key Feature 1a: In a patient with a diagnosis of depression: Assess the patient for the risk of suicide. Skill: Clinical Reasoning, Selectivity Phase: History Key Feature 1b: Decide on appropriate management (i.e., hospitalisation or close follow-up, which will depend, for example, on severity of symptoms, psychotic features, and suicide risk). Skill: Clinical Reasoning, Selectivity Phase: Treatment Suicide Key Feature 1: In any patient with mental illness (i.e., not only in depressed patients), actively inquire about suicidal ideation (ex: ideas, thoughts, a specific plan). Skill: Clinical Reasoning Phase: History Key Feature 2: Given a suicidal patient, assess the degree of risk (ex: thoughts, specific plans, access to means) in order to determine an appropriate intervention and follow-up plan (ex: immediate hospitalization, including involuntary admission; outpatient follow-up; referral for counselling). Skill: Clinical Reasoning, Selectivity Phase: Diagnosis, Treatment Key Feature 3: Manage low-risk patients as outpatients, but provide specific instructions for follow-up if suicidal ideation progresses/worsens (ex: return to the emergency department [ED], call a crisis hotline, re-book an appointment). Skill: Clinical Reasoning Phase: Treatment, Follow-up A 19 year old female presented to clinic for a yearly refill of her antidepressant. When I asked her what she takes it for, she said it was for depression and anxiety. She didn't elaborate. I probed further by asking how her mood has been lately. She said it had been worsening over the past month or so but again was brief in her answer. By around this point I started to clue in to the fact that not only were her answers minimally detailed, she was also slow to speak them (psychomotor retardation). I asked her if she was having thoughts about self-harming or suicide. She responded to say she was having suicidal thoughts. She denied any homicidal ideation. I asked her if she had thought of a plan for committing suicide, and without time to think she answered very matter-of-factly, "Yeah I think about hanging myself. When I was younger I used to think I'd want to drown, but now I think hanging makes the most sense." I asked if she's been thinking about going through with it, and she said, "There are all these deaths that seem to be happening around me, even like celebrities and whatnot, and I think to myself how those people have the courage to do what I haven't been able to. But then I think to myself how that's just a temporary solution to a bigger problem sort of thing." I didn't quite understand what she meant by her last sentence, but I was a little relieved to hear she had a protective thought. Just how at risk was this patient of completing suicide? In patients who endorse having suicidal thoughts, it's important to clarify
SADPERSONS mnemonic for risk-stratifying patients with suicidal ideation (1 pt for each if present)
According to the SADPERSONS suicidal ideation risk stratification mnemonic, this patient was low risk. Note that depression gives one point on the SADPERSONS scale, which is something important to note as it raises the point that suicidal ideation is not a phenomenon that is unique to patients with depression. According to the UpToDate article, "Suicidal ideation and behaviour in adults," "The psychiatric disorders most commonly associated with suicide include depression, bipolar disorder, alcoholism or other substance abuse, schizophrenia, personality disorders, anxiety disorders including panic disorder, posttraumatic stress disorders, and delirium." This article also notes, "Anxiety disorders more than double the risk of suicide attempts (odds ratio 2.2), and a combination of depression and anxiety greatly increases the risk (odds ratio 17). Symptoms of psychosis (delusions, command auditory hallucinations, paranoia) may increase the risk regardless of the specific diagnosis." Once you've got a patient in front of you who endorses suicidal ideation, what are your next steps? My approach to a patient that is risk-stratified for suicidal ideation (SI) as either low, medium, or high risk is as follows:
The 19 year old patient in the office agreed to follow-up in clinic in one week, agreed to avoiding triggers (aka precipitants) for her SI, and agreed to present to the ED or call a suicide crisis line before taking any action if she was having thoughts about completing suicide. The Canadian Association for Suicide Prevention website has a list of local crisis centres organized by province on their home page. I provide both the CSAP website address and the province-wide crisis line (1-800-SUICIDE) to patients at risk of SI. |
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