5. Some other more general issues relating to ICU admission for poisoning
Referral to an ICU in the context of poisoning is sometimes due to the fact that as a result of the poisoning itself, the patient has rendered themselves unmanageable, rather than the need for continuous invasive monitoring or specific organ support.
The patient may be combative and as a result at direct risk of harm to themselves and those around them. Indirectly, they may be at risk of further harm to themselves if their condition means that simple non-invasive monitoring or investigations such as intravenous access, blood tests including toxicology levels and ECGs cannot be performed.
It is frequently the case that in this situation the patient has also rendered him- or herself incapacitated. In such circumstances treatment may be initiated using reasonable force under common law, as long as it is in the patients best interests. The ICU team is often involved in a patients care when the above treatment has mandated the suppression of consciousness to the extent that a definitive airway is required, and when there is a risk of aspiration (vomiting often accompanies poisoning).
Due to the uncertainty of fasting status, and the need for a minimal duration of paralysis without a secure airway, intubation and ventilation in this situation would probably follow a classical Rapid Sequence Induction. Depending on the hospital, this may be performed by either the anaesthetic or the ICU team.
This may seem drastic, however history may be unreliable or non-existent in acute poisoning. You may not even know that poisoning has even occurred. Pyrexia can accompany toxicity with many agents, and confronted with a pyrexial, acutely disturbed patient with a depressed conscious level and often a concurrent head injury, one may be obliged to perform a CT head scan with or without subsequent lumbar puncture. Both of these require patient cooperation.
As further information arises, initial investigation results are known, and the patient’s clinical condition changes, it may quickly become apparent that the patient may not require ICU admission. In these circumstances, the Emergency Department or Medical Teams will have certainly appreciated your assistance. On the other hand, if the patient does require ICU admission, it will be you who will be glad that you’ve been involved from an early stage.
Even if the ICU intervention goes no further than a brief period of observation and monitoring, it still allows the best possible opportunity to minimise morbidity and mortality.
Risk to others
It should go without saying that during the initial management of such patients you should under no circumstances expose yourself or any of your colleagues to unacceptable risk.