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KEY POINTS

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  • Clinical toxicology encompasses the expertise in the specialties of medical toxicology, applied toxicology, and clinical poison information.

  • Important components of the initial clinical encounter with a poisoned patient include stabilization of the patient, clinical evaluation (history, physical, laboratory, and radiology), prevention of further toxin absorption, enhancement of toxin elimination, administration of antidote, and supportive care with clinical follow-up.

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HISTORY OF CLINICAL TOXICOLOGY

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The history of poisoning and poisoners goes back to ancient times. Formulas for creating poisonous and noxious vapors have been found in Chinese writings dating back to 1000 BC. Documentation regarding the use of antidotes can be found in Homer’s Odyssey and Shastras from 600 BC. Additional history is found in Chapter 1.

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INTRODUCTION OF THE POISON CONTROL CENTER

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In the United States, poison control centers are staffed by a medical director (medical toxicologist), administrator, specialists in poison information, and educators for poison prevention programs. Personnel provide direct information to patients with expert recommendations for medical treatment, critical diagnostic and treatment information for health care professionals, education for health care professionals, and poison prevention activities through public education. Poison control centers serve as a potential early-warning system for a potential chemical or biologic terrorist attack.

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CLINICAL STRATEGY FOR TREATMENT OF THE POISONED PATIENT

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The following general steps represent important components of the initial clinical encounter with a poisoned patient:

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  1. Stabilization of the patient

  2. Clinical evaluation (history, physical, laboratory, and radiology)

  3. Prevention of further toxin absorption

  4. Enhancement of toxin elimination

  5. Administration of antidote (if available)

  6. Supportive care and clinical follow-up

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Clinical Stabilization

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The first priority in the treatment of the poisoned patient is stabilization. Initial assessment of airway, respiration, and circulation is crucial. Some toxins or drugs can cause seizures early in the course of presentation. The steps and clinical procedures incorporated to stabilize a critically ill, poisoned patient are numerous and include, if appropriate, support of ventilation, circulation, and oxygenation. In critically ill patients, sometimes treatment interventions must be initiated before a patient is truly stable.

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Clinical History in the Poisoned Patient

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The primary goal of taking a medical history in poisoned patients is to determine, if possible, the substance ingested or the substance to which the patient has been exposed as well as the extent and time of exposure. In the setting of a suicide attempt, patients may not provide any history or may give incorrect information so as to increase the possibility that they will successfully bring harm to themselves. Information sources commonly employed in this setting include family members, emergency medical technicians who were at the scene, a pharmacist who can sometimes provide a listing of prescriptions recently filled, or an employer who can disclose what chemicals are available in the work environment.

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