Disposition and observation (toxicology)
Related FACEM curriculum (2022) learning objectives:
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Disposition Planning
- Deliberate self-poisoning requires psychiatric and social review.
- Risk assessment allows early planning for medical and psychosocial care.
- Admission must ensure adequate monitoring, supportive care, and resources for decontamination, enhanced elimination, or antidote use.
- Patients may be discharged after observation if no toxicity develops.
Emergency Observation Units (EOUs)
- Established in many emergency departments in Australasia.
- Located adjacent to EDs, staffed by emergency doctors, and provide short-term goal-oriented care.
- Benefits include streamlined treatment, reduced bed days, higher patient satisfaction, fewer inappropriate discharges, and reduced litigation.
Toxicology Patients in EOUs
- EOUs ideal for management of acute poisoning post-assessment.
- Advantages include trained staff, 24-hour availability, open-plan observation, and rapid assessment ethos.
- Requires adequate medical, nursing, psychiatric, and social service resources.
- Design features:
- Central nursing stations with full visibility.
- Self-harm protection measures.
- Secure entrances.
- Dedicated interview areas.
- Social work and liaison services.
- Monitoring equipment ± telemetry.
- Resuscitation equipment and duress alarms.
- Staff with appropriate skills and 24/7 senior coverage.
- Psychiatric services and appropriate nurse–patient ratios.
Admission Criteria for EOUs
- Cardiac monitoring not required (optional in some EOUs).
- Adequate sedation for delirium.
- No anticipated deterioration based on risk assessment and ED observation.
Challenges Addressed by EOUs
- Avoids scattered admissions across the hospital.
- Prevents issues with inexperienced nursing staff and limited medical availability.
- Reduces security incidents and absconding.
- Limits prolonged admissions managed by junior clinicians without toxicology training.
Retrieval of the Poisoned Patient
- Transfer required if the initial hospital lacks adequate resources.
- Risk assessment ensures early planning and smooth retrieval.
- Poisoning transfers often occur during severe illness phases.
Resuscitation During Retrieval
- Resuscitation and supportive care remain the priority.
- Stabilisation tasks (e.g., intubation, ventilation, hypotension management, seizure control) must be completed before transfer.
- Retrieval teams must be informed if stabilisation resources are unavailable.
Transport Considerations
- Patient must not experience lower care levels during transfer.
- Mode and staffing ensure care continuity.
Planning and Communication
- Anticipate complications (e.g., early intubation for coma or hypotension resources for calcium channel blocker poisoning).
- Transport to centres equipped for identified complications (e.g., haemodialysis for salicylate poisoning).
- Engage receiving clinicians and specialists for continuity of care and reduced errors.
Antidote Administration
- If an antidote stabilises the patient (e.g., N-acetylcysteine, Digoxin immune Fab), it should be administered before transfer.
Psychosocial Assessment
- Poisoning often linked to underlying psychosocial disorders.
- All deliberate self-poisoning cases require psychosocial assessment before discharge.
- Assessment ideally initiated before completing medical treatment.