Tuesday, October 11, 2011

The blog world is filled with reports talking about Terrell Owens, the unemployed NFL wide receiver, who may have been admitted to the hospital after taking an overdose. There aren’t many details but perhaps it’s important to note that overdose patients commonly present to the emergency department and the approach to their care has changed over the years.

Once upon a time, the care of the overdose patient concentrated on decontamination. The stomach needed to be emptied to get rid of the pills, potions or other poisons that may have been ingested. Syrup of ipecac was a standard part of every home pharmacy to be used to induce vomiting in the event a child accidentally ate something they shouldn’t have. In the hospital, ipecac could be supplemented by lavaging or washing out the stomach by plunging a large tube through the mouth into the stomach to “pump” out the bad stuff. Unfortunately, these maneuvers didn’t particularly work and the stomach pumping seemed more punitive than therapeutic.

As it turns out, overdose care is mostly supportive, making certain the patient is breathing adequately and has good pulse and blood pressure. It’s also important to protect the patient from further harm from the overdose. While emptying the stomach isn’t routine, using activated charcoal in the few minutes after an ingestion may help bind the drug in the stomach and prevent it from being absorbed. Charcoal looks bad and has a gritty texture but most patients willingly drink it. It’s often mixed with a cathartic that promotes diarrhea, the idea being that the transit time from the stomach to the toilet bowel is faster, allowing less time fro stuff to be absorbed into the blood stream.

While there are few poisonings that have antidotes, it is important to know what was taken because certain overdoses are sneaky lethal. It makes sense that the most common overdoses are those that are most readily available and they include alcohol, tylenol and aspirin.

• Alcohol is pretty straight forward acting like a sedative and depressing parts of the brain that deal with breathing and swallowing. Too much alcohol can wipe out the gag reflex that protects stuff like vomit from getting into the lungs…not a good combination since drunk patients tend to vomit.
• Tylenol or acetaminophen is a nasty overdose. It has no obvious symptoms until a couple of days later when liver inflammation causes abdominal pain and vomiting. By then it may be too late and the treatment for liver failure is transplantation. Treatment needs to be started within a few hours of ingestion using medications that protect liver cells from the harmful byproducts of acetaminophen metabolism.
• Aspirin is salicylic acid and an abundance of this acid can cause changes in the acid base balance in the body. Initial symptoms include ringing in the ears, abdominal pain and vomiting. Untreated, the overdose can lead to seizure, coma and death. Treatment aims to help excrete aspirin from the body and dialysis may be needed emergently to do this.

Ultimately, the key to caring for the poisoned patient starts with history to find out what might be the cause. There is no magic, all-in-one test to determine what might be in the body. Blood tests for a few drugs like acetaminophen, salicylate and alcohol exist and can be done routinely, but other fly under the radar and tests confirming their existence in the body may take days or weeks to come back, certainly not helpful in making treatment decisions.

And it’s important to remember that in the intentional overdose patient, caring for the physical problems is only step one. Once the dust settles, psychological support and treatment is required to find out why the patient wanted to cause self-harm. Celebrities like Mr. Owens deserve to have their care provided outside the spotlight. Losing the dignity of privacy limits the ability of a patient to open up and delve into the intimacy of their personal situation and that limits their access to appropriate care. The same issue is true for the regular patient who can be considered a celebrity in their own life. Shielding them from the prying eyes of family and friends allows the opportunity to seek the help needed.

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