What should we examine in poison patient
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I now have rich content from Goldman-Cecil Medicine on the examination of a poisoned patient. Let me compile a thorough, well-organized answer.
Examination of a Poisoned Patient
1. History
The history is the starting point. Key elements to obtain (from patient, relatives, bystanders, or EMS personnel):
- What substance(s)? - drugs, medications (patient's own + those of spouse/relatives/friends), herbals, supplements, industrial chemicals, pesticides, venoms
- How much? - estimated or known dose
- When? - time of exposure (helps assess chronicity: acute vs. chronic vs. acute-on-chronic)
- Route of exposure - ingestion, inhalation, injection, dermal, ocular
- Symptoms already present - from the time of exposure onward
- Treatment already given - including any antidotes or home remedies
- Occupational/hobbies history - past and current jobs; exposure to metals, gases, chemicals
- Past medical history - known conditions suggest available medications (e.g., heart disease -> cardiac drugs)
- Intent - suicidal, accidental, homicidal, occupational
Note: The patient's account may be incomplete or inaccurate if they are confused or suicidal. Always corroborate with family, EMS scene reports, and pill bottles brought from home. - Goldman-Cecil Medicine
2. Physical Examination
The exam should cover:
A. Vital Signs (Most Diagnostically Valuable)
| Finding | Toxidrome / Causes |
|---|---|
| Tachycardia | Anticholinergic, sympathomimetic (cocaine, amphetamines) |
| Bradycardia | Beta-blockers, calcium-channel blockers (diltiazem, verapamil), digoxin/cardioactive steroids, clonidine, opioids, organophosphates, cholinesterase inhibitors, antiarrhythmics (procainamide, amiodarone), cyanide (preterminal) |
| Hypertension | Sympathomimetics, anticholinergics |
| Hypotension | Sedative-hypnotics, opioids, tricyclic antidepressants, antihypertensives |
| Hyperthermia | Anticholinergics, sympathomimetics, serotonin syndrome, salicylates, NMS |
| Hypothermia | Opioids, sedative-hypnotics, ethanol, hypoglycemics |
| Tachypnea / Hyperventilation | Salicylates (metabolic acidosis), stimulants |
| Bradypnea / Hypoventilation | Opioids, sedative-hypnotics |
B. Eyes (HEENT Exam)
| Finding | Significance |
|---|---|
| Mydriasis (dilated pupils) | Anticholinergic, sympathomimetic, serotonin syndrome |
| Miosis (pinpoint pupils) | Opioids, organophosphates (cholinergic), pontine lesion |
| Nystagmus | Ethanol, phencyclidine (PCP), phenytoin, lithium, sedative-hypnotics |
| Lacrimation | Cholinergic toxidrome (organophosphates) |
C. Skin (Dermatologic Exam)
| Finding | Significance |
|---|---|
| Dry, flushed, hot skin | Anticholinergic ("dry as a bone, red as a beet") |
| Diaphoresis (sweating) | Sympathomimetic, cholinergic, serotonin syndrome, salicylates |
| Cyanosis | Methemoglobinemia, hypoxia |
| Track marks / needle sites | IV drug use (opioids, stimulants) |
| Burns / erythema | Caustic ingestion, chemical skin exposure |
| Jaundice | Hepatotoxins (acetaminophen, mushrooms, carbon tetrachloride) |
| Pallor | Cyanide, carbon monoxide, shock states |
D. Neurologic Exam
| Finding | Significance |
|---|---|
| Level of consciousness / GCS | Depressed with sedative-hypnotics, opioids; agitated with stimulants, anticholinergics |
| Agitation / delirium | Anticholinergic, sympathomimetic, serotonin syndrome, alcohol withdrawal |
| Seizures | Cocaine, tricyclics, isoniazid, organophosphates, theophylline, lithium |
| Coma | Opioids, sedative-hypnotics, ethanol, cyanide, CO |
| Tremor / rigidity | Serotonin syndrome, NMS, lithium, strychnine |
| Hyperreflexia / clonus | Serotonin syndrome |
| Muscle fasciculations | Organophosphates, carbamate pesticides |
| Focal deficits | Consider structural cause (intracranial bleed in cocaine use) |
E. Cardiovascular Exam
- Auscultate for arrhythmias, heart rate regularity
- ECG (part of workup) - look for QRS widening (tricyclics), QTc prolongation (antipsychotics, antiarrhythmics), Brugada pattern (sodium-channel blockers)
- Capillary refill / peripheral perfusion - shock assessment
F. Respiratory / Pulmonary Exam
- Respiratory rate and depth - hypoventilation (opioids) vs. Kussmaul breathing (acidosis)
- Breath sounds - aspiration pneumonitis, pulmonary edema (opioids, salicylates)
- Odors on breath: Alcohol (ethanol), bitter almond/almonds (cyanide), garlic (arsenic/organophosphates), pear (chloral hydrate), acetone (ketoacidosis, isopropanol)
G. Gastrointestinal Exam
| Finding | Significance |
|---|---|
| Bowel sounds absent | Anticholinergic, ileus |
| Hyperactive bowel sounds | Cholinergic (organophosphates, carbamates) |
| Abdominal pain / tenderness | Caustics, iron, heavy metals, colchicine |
| Nausea / vomiting / diarrhea | Cholinergic toxidrome; also GI irritants, heavy metals |
| Urinary retention | Anticholinergic |
3. Toxidrome Recognition (Key Summary)
The 5 major toxidromes to recognize on physical exam:
| Toxidrome | Pupils | HR | BP | Temp | Skin | Bowel Sounds | Mental Status |
|---|---|---|---|---|---|---|---|
| Anticholinergic | Dilated | Fast | High | High | Dry, flushed | Absent | Agitated/delirium |
| Cholinergic (SLUDGE) | Pinpoint | Slow | Low | Low | Wet | Hyperactive | Confusion |
| Sympathomimetic | Dilated | Fast | High | High | Wet | Normal | Agitated |
| Opioid | Pinpoint | Slow | Low | Low | Dry | Decreased | Depressed/coma |
| Sedative-Hypnotic | Normal/small | Slow | Low | Low | Normal | Decreased | Depressed/coma |
SLUDGE = Salivation, Lacrimation, Urination, Defecation, GI cramping, Emesis
4. Laboratory & Diagnostic Studies
These are part of the standard workup alongside the exam:
- Basic metabolic panel - glucose, electrolytes, renal function (anion gap)
- ABG - acidosis type (anion gap vs. non-gap), oxygenation, ventilation
- Serum acetaminophen and salicylate levels - universal in any unknown overdose
- Urine toxicology screen - qualitative (many false positives/negatives; guides, not rules)
- ECG - QRS, QTc, arrhythmias
- Serum ethanol, specific drug levels (digoxin, lithium, valproate, phenytoin, carbamazepine, iron, methanol, ethylene glycol) as indicated
- CBC, coagulation studies, LFTs - for specific toxins (e.g., acetaminophen, anticoagulants, snake envenomation)
- Serum osmolality - osmol gap elevated with methanol, ethylene glycol, isopropanol
- Lactate - elevated with cyanide, CO, severe hypoperfusion
- Urinalysis - calcium oxalate crystals (ethylene glycol); myoglobinuria (rhabdomyolysis)
- Chest X-ray - aspiration, pulmonary edema
- CT head - if altered mental status without a clear toxicologic explanation
The key principle from Goldman-Cecil is: "In most cases, it is less important to predict exactly which toxin is responsible than to create a differential diagnosis based on careful history, physical examination, and basic laboratory assays." Recognizing the toxidrome guides initial stabilization, decontamination decisions, and empirical antidote administration while confirmatory results are pending.
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