Bacterial food poisoning is the most common cause of gas-trointestinal signs and symptom appearing in a group of indi-viduals within several hours of a common meal. Consumption of food contaminated with preformed bacterial toxins such as Staphylococcus or Bacillus cereus toxins can result in vomiting after an incubation interval as short as 1–2 hours. However, the onset of vomiting in some individuals within 15 minutes and the progression to hypotension and metabolic acidosis in several individuals are not typical for bacterial food poisoning and are more suggestive of intoxication by certain toxic chemi-cals or drugs, including inorganic arsenic and mercury salts (eg, sodium arsenite or mercuric chloride). The absence of hematemesis, bloody diarrhea, or renal insufficiency lowered the likelihood that inorganic mercury was responsible. An epidemiologic investigation subsequently revealed that all affected individuals had consumed the deliberately adulter-ated coffee, which contained 6300 ppm of inorganic arsenic. Analysis of urine for arsenic and mercury and stool and emesis for bacterial pathogens would be reasonable initial diagnostic tests. Pending test results, prompt empiric treat-ment of this constellation of findings with the chelating agents unithiol, succimer, or dimercaprol would be appropriate. [Based on an actual incident, see: Gensheimer KF et al: Arse-nic poisoning caused by intentional contamination of coffee at a church gathering: An epidemiological approach to a forensic investigation. J Forensic Sci 2010;55:1116].
Management of the Poisoned Patient
Kent R. Olson, MD
A 62-year-old woman with a history of depression is found in her apartment in a lethargic state. An empty bottle of bupro-pion is on the bedside table. In the emergency department, she is unresponsive to verbal and painful stimuli. She has a brief generalized seizure, followed by a respiratory arrest. The emergency physician performs endotracheal intubation and administers a drug intravenously, followed by another sub-stance via a nasogastric tube. The patient is admitted to the intensive care unit for continued supportive care and recovers the next morning. What drug might be used intravenously to prevent further seizures? What substance is commonly used to adsorb drugs still present in the gastrointestinal tract?
Over 1 million cases of acute poisoning occur in the USA each year, although only a small number are fatal. Most deaths are due to intentional suicidal overdose by an adolescent or adult. Childhood deaths due to accidental ingestion of a drug or toxic household product have been markedly reduced in the last 50 years as a result of safety packaging and effective poisoning prevention education.
Even with a serious exposure, poisoning is rarely fatal if the victim receives prompt medical attention and good supportive care. Careful management of respiratory failure, hypotension, seizures, and thermoregulatory disturbances has resulted in improved survival of patients who reach the hospital alive.
This chapter reviews the basic principles of poisoning, initial management, and specialized treatment of poisoning, including methods of increasing the elimination of drugs and toxins.
The term toxicokinetics denotes the absorption, distribution, excretion, and metabolism of toxins, toxic doses of therapeutic agents, and their metabolites. The term toxicodynamics is used to denote the injurious effects of these substances on body functions. Although many similarities exist between the pharmacokinetics and toxicokinetics of most substances, there are also important differences. The same caution applies to pharmacodynamics and toxicodynamics.
Volume of Distribution