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Toxic Ingestions and Overdoses

Critical care physicians often care for patients who have either a toxic ingestion or an overdose of a prescription medication or illicit substance, either intentional or accidental. The most important aspect of treating these disorders is to remove the offending substance from the patient if at all possible. This may involve placing a nasogastric tube and evacuating the stomach of any contents. Occasionally pill fragments are removed, thus preventing further absorption of the substance into the patient's system. These specimens are often sent to the laboratory for identification. Following the insertion of the nasogastric tube, we often place activated charcoal through the tubes directly into the stomach to absorb the offending substance from the patient's gastrointestinal tract. The charcoal will bind the substance and keep it inside the gastrointestinal tract until it is excreted in the feces, thus preventing absorption into the blood stream.

Many substances that are taken in an overdose situation have specific antidotes. The most common overdose seen is Acetaminophen (Tylenol). This medication is readily available and in most households. Many people are not aware of the potentially serious liver injury that can occur from an Acetaminophen overdose. Fortunately, there is a specific antidote (n-acetylcysteine or Mucomyst) which is used to protect the liver from the damage of a very high acetaminophen level. All overdoses are screened for concomitant acetaminophen toxicity as this is a potentially serious, though very treatable overdose.

Many overdoses result in an altered state of consciousness for the patient and occasionally the respiratory status is so compromised that they need to be placed on a mechanical ventilator. This provides for proper gas exchange and to prevent the patient from vomiting and later aspirating into the lung. If gastric contents are vomited and aspirated into the lung, this can potentially injure the patient's lungs and compromise his/her ability to get oxygen into the blood stream.

As part of our evaluation and treatment of patients with intentional toxic ingestions and overdoses, they may undergo a psychiatric evaluation to look for underlying depression or other factors that led to potential self-harm. These patients are also placed on close monitoring with a bedside attendant until we are confident that they are not at risk to injure themselves. Fortunately, with the above techniques of removing the offending substance, using specific antidotes, aggressive supportive care, and full psychiatric evaluation, the vast majority of patients requiring hospitalization for toxic ingestions and overdoses have no significant or long-lasting injury.

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