Risk assessment (toxicology)
Related FACEM curriculum (2022) learning objectives:
- Learning Outcomes Principles of assessment of toxicological presentations in the ED, including: Triage and initial assessment
- ME 3.8.1.4(b) General approach to assessment
- ME 3.8.1.4(c) Risk assessment
- ME 3.8.1.4(d) History (dose, drug, timing, symptoms, patient factors)
- ME 3.8.1.4(g) Role of toxicologists
Risk Assessment in Poisoned Patients
- Priority: Second only to resuscitation in managing poisoned patients.
- Purpose: Predict clinical course and complications at presentation.
- Key Components
- Agent(s) involved.
- Dose(s) ingested.
- Time since ingestion.
- Clinical features and progress.
- Patient factors (e.g., weight, comorbidities).
- Importance
- Guides decisions on supportive care, monitoring, tests, decontamination, enhanced elimination, antidotes, and disposition.
- Enables identification of potential complications and avoids unnecessary interventions.
Gathering Information
- Patients with normal mental status: Usually provide reliable histories.
- Patients with altered mental status: Use alternative strategies:
- Ask ambulance officers or family members.
- Count missing tablets.
- Check medical records for prescriptions.
- Question relatives about accessible agents.
- In children or unknown ingestions, rely on worst-case scenario estimates and refine with clinical progress.
- Correlate agent, dose, and timing with clinical status.
- Review and revise risk assessment if discrepancies arise.
Clinical Course and Timing
- Acute poisoning is dynamic; timing influences risk assessment:
- Tricyclic antidepressants: Life-threatening events within 2–6 hours post-ingestion.
- Sustained-release calcium channel blockers: Delayed severe cardiovascular effects possible.
Benefits of Risk Assessment
- For trivial poisonings:
- Reassures staff, patient, and family.
- Minimizes unnecessary investigations/interventions.
- Facilitates early psychosocial assessment and discharge planning.
- For serious poisonings:
- Enables tailored proactive management.
- Supports decisions on decontamination, investigations, and planning for antidotes or procedures.
Role of the Poisons Information Centre
- Primary Role: Provide rapid, accurate, individualized risk assessment and management advice.
- via databases, product information, and staff toxicological expertise.
- Australian Network:
- Centres in Sydney, Perth, Brisbane, Melbourne (131126).
- New Zealand Centre:
- Located in Dunedin (0800-POISON).
- Staffed by pharmacy or medical science-trained specialists.
- Refer to on-call clinical toxicologists (consultants / registrars) for detailed advice in complex cases.