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Patients with multiple rib fractures and concern for sternal fractures often will need contrast
enhanced CT scan to make certain underlying
pulmonary or vascular injuries are not present.
6,7
Patients with nondisplaced sternal fractures can be
considered for trauma protocol placement, but in
most instances, retrosternal hematoma and more
significant sternal fractures are not amenable to
discharge within 24 hours. Age, medical comorbidities, functional status prior to injury, ability to
ambulate, ability to tolerate oral pain medications, and location and number of fractures are
all important considerations for disposition decisions in this patient population.
Head Injury
Clinical observation of the head injured patien ts is
one of the most frequently managed patients on a
trauma protocol in the OU. This approach has
been found to be safe and effective and can reduce
inappropriate inpatient admission in this patient
population.
9,10
Many such patients have concomitant intoxicants on board that render the observation period invaluable in clinically observing
patients to determine if their mental status is
appropriate for discharge (determination often
not feasible directly from the ED).
The challenge with this patient population is
defining (prior to OU placement) the patient’s
true GCS and making certain more significantly
head injured patients are not placed in this
care setting. Patients with mild head injuries can
also be observed with the benefit of not having
to perform a head CT (important for radiation
stewardship particularly in younger patients).
9
More advanced OUs with neurosurgical backup
have experience managing patients with isolated,
mild head trauma on coumadin and other blood
thinners. Such patients represent a high-risk
cohort of patients to discharge directly from the
ED. As long as these patients do not have evidence
of significant intra-cranial pathology on initial
imaging, monitoring the clinical status in the
OU is often appropriate.
Penetrating Trauma
Select patients with penetrating trauma can be
successfully managed in the OU. Patient selection
is very important with this patient population as
certain conditions are inappropriate for the level
of care offered in the ED OU and would be more
appropriately offered (due to the critical nature
and rapid deterioration) in the ICU setting.
Patients can have neurovascular checks and be
watched for compartment syndrome. Patients with
superficial wounds to the thorax and abdomen are
appropriate for OU placement and have a low
incidence of poor outcome even after brief observation.
11,12
At nontrauma hospitals, most penetrating injuries to the thorax and abdomen will require
transfer for initial evaluation by a trauma team
prior to OU placement. In general, patients with
penetrating neck trauma should not be placed in
the OU setting unless cleared by a trauma team at a
trauma facility with expertise in managing this
patient population in the OU setting.
Isolated extremity penetrating wounds are
well managed in most cases in the OU as a high
proportion of these patients can be safely monitored and then discharged. Extremity trauma with
signs of vascular compromise, compartment syndrome, or delayed presentations of injury with
infection should be excluded and require more
extensive resources in the inpatient setting.
Mechanical Falls
Patients with significant blunt trauma from
mechanical falls can be managed successfully in
the OU. Patients with extremity fractures can be
included in this patient cohort, but operative fractures like hip fractures and femur fractures should
not be placed in the OU. A mechanical fall protocol or accepting fall patients on a general observation protocol for trauma can be particularly
beneficial with elderly patients. If such patients
have gait instability and risk for further falls, then
resources such as physical therapy need to be
available for the clinician managing the patient
in the OU. Often such patients require additional
resources such as case management, social work,
and even pharmacists to aid in management and
safe disposition. Occult fractures and underlying
medical comorbidities can prevent discharge in
some cases as can the patient’s social situation,
living environment, and support system (or lack
thereof). (See also geriatric Chapter 55.)
Management/Intervention
Frequent vital signs are the mainstay of observation
for the injured trauma patient. Frequent neurologic
checks should take place for intoxicated or head
injured patients. Specific therapeutic interventions
Trauma
062
21:23:00
like pain and antiemetic medications, IV fluids,
and other needs will be patient and protocol specific. Frequency of vital signs should be consistent
with nursing resources and patient acuity. Vascular checks in higher risk patients looking for vascular compromise and compartment syndrome
should be delineated. Patients should be transitioned from IV therapies to oral therapies as one
data point to determine suitability for discharge
and to see if continued outpatient management is
appropriate. At trauma facilities it is important to
delineate who will be doing repeat examinations,
whether the OU providers or members of the
trauma team. Cervical spine clearance, if not
done initially prior to OU placement, should also
be protocolized and consistent with national
guidelines. Many trauma patients will need social
services support to facilitate follow-up, medication assistance, and even drug and alcohol counseling. As such, social worker coverage for the
OU is essential when managing trauma patients.
Resources such as physical therapy will depend on
the type of patient managed, but can be invaluable
in providing information about ongoing fall risk
for elderly patients.
Disposition after Observation
A significant majority of trauma patients can be
discharged from the OU after an appropriate
period of observation.
3,4
All such patients should
have stable vital signs, have normal GCS, be clinically sober, be able to ambulate, and be able to
tolerate oral intake. The ability to ambulate and
tolerate symptoms with oral medications is critical to ensure that such patients do not bounce
back to the ED in short order. Imaging studies
(which can be significant for this population)
should be finalized by radiology and available to
the clinician prior to disposition so radiographic
abnormalities can be addressed. The patient should
have a documented disposition examination; such
an examination should be comprehensive from
head to toe and include observation of the patient
ambulating. Follow-up should be time and action
specific related to reevaluation needs and specific
for the condition affecting the patient.
For more significantly injured patients,
prompt reevaluation is important. This can be a
challenge for patients without a primary care
physician. Unfortunately in this trauma patient
population (younger, more socioeconomically
troubled), many will not have access to health
care, will be uninsured or underinsured, and will
be poorly resourced. As such, bringing the patient
back to the ED for wound checks or injury checks
in 48–72 hours is a consideration if outpatient
follow-up can not be obtained in a timely fashion.
Patients are generally discharged with symptom
control medications for several days, particularly
for blunt trauma patients for whom musculoskeletal soft tissue injury can lead to prolonged pain
and symptoms.
Summary
Trauma patients are clearly a very viable patient
population to consider for the OU. As with all
clinical conditions managed in the OU, careful
patient selection is paramount to ensure successful discharge in the majority of managed patients.
Clear exclusion criteria should be set to ensure
that critically injured patients are not placed in
the OU setting. More so than most clinical patient
populations managed in the OU, local resources
need to be carefully considered to ensure adequate
backup is available, particularly at nontrauma
hospitals.
References
1. Conrad L, Markovchick V,
Mitchiner J, et al. The role of
an emergency department
observation unit in the
management of trauma
patients. J Emerg Med 1985;
2(5): 325–333.
2. Cowell VL, Ciraula D, Gabram
S, et al. Trauma 24-hour
observation critical path.
J Trauma 1998; 45(1): 147–150.
3. Madsen TE, Bledsoe JR,
Bossart PJ. Observation unit
admission as an alternative to
inpatient admission for
trauma activation patients.
Emerg Med J 2009; 26(6):
421–423.
4. Holly J, Bledsoe J, Black K,
et al. Prospective evaluation of
an ED observation unit
protocol for trauma activation
patients. Am J Emerg Med
2012; 30(8): 1402–1406.
5. Rivara FP, Jurkovich GJ,
Gurney JG, et al. The
magnitude of acute and
chronic alcohol abuse in
trauma patients. Arch
Surg 1993. Aug; 128(8):
907–912.
6. Kendall JL, Kestler AM,
Whitaker KT, et al. Blunt
abdominal trauma patients are
at very low risk for intraabdominal injury after
emergency department
Mark G. Moseley and Miles P. Hawley
062
21:23:00
observation. West J Emerg Med
2011. Nov; 12 (4): 496–504.
7. Menditto VG, Gabrielli B,
Marcosignori M, et al.
A management of blunt
thoracic trauma in an
emergency department
observation unit: pre-post
observation study. J Trauma
2012. Jan; 72(1): 222–228.
8. Ammons MA, Moore EE,
Rosen P. Role of the
observation unit in the
management of thoracic
trauma. J Emerg Med 1986; 4
(4): 279–282.
9. Holsti M, Kadish HA, Sill BL,
et al. Pediatric closed head
injuries treated in an
observation unit. Pediatr Emerg
Care 2005. Oct;21(10): 649–644.
10. MacLaren RE, Ghoorahoo HI,
Kirby NG. Use of an accident
and emergency department
observation ward in
management of head injury.
Br J Surg 1993. Feb; 80(2):
215–217.
11. Leppaniemi AK, Voutilainen
PE, Haapiainen RK.
Indications for early
mandatory laparotomy in
abdominal stab wounds. Br
J Surg 1999. Jan; 86(1): 76–80.
12. Ordog GJ, Wasserberger J,
Balasubramanium S, et al.
Asymptomatic stab wounds
of the chest. J Trauma 1994. 36
(5): 680–684.
Trauma
062
21:23:00
Subpart IVO
Chapter
59
Clinical – Toxicology
Toxicology
Steven J. Walsh, MD
Marsha Ford, MD, FACEP
Toxicologic disorders account for over 4 million
U.S. emergency department (ED) visits annually.
1
Many patients are discharged to home or to a
psychiatric facility after ED evaluation. However,
a significant number of poisoned individuals
require admission for further observation and
management. A large number of these patients
do not require an extended hospital stay, making
admission to the observation unit (OU) a reasonable disposition option.
The OU should be well-equipped to provide
care for the poisoned patient. Continuous cardiopulmonary monitoring, expeditious diagnostic
testing (electrocardiography, radiography, laboratory analysis, etc.), a variety of commonly used
medications/antidotes (including but not limited
to dextrose, antiemetics, analgesics, benzodiazepines, naloxone), a low nurse-to-patient ratio (most
OUs have a 1:5 or 1:4 nurse patient ratio), and oneto-one sitters for patient safety/psychiatric observation (if needed) should be available at all times.
Any items that could be used for self-harm by
suicidal individuals should be placed in a secure
location, and all patients should be searched for
such prior to admission to the OU. Providers
caring for these patients should be familiar with
common toxicities and toxidromes (such as opiate/
opioid, benzodiazepine, sympathomimetic, and
anticholinergic), as well as the dosing, administration, and adverse effects of the aforementioned
commonly used medications. All staff should be
aware of the Poison Help Hotline (800-222-1222
in the United States), which provides around-theclock,free, confidential,and expert advice regarding
poisoned patients.
A variety of poisonings are appropriate for
OU care. In general, toxicologic admissions to
the OU should include those patients whose
anticipated stay is less than 24 hours and who
have normal or near-normal vital signs. Somnolent but arousable patients are appropriate for
observation care, as are those with mild central
nervous system (CNS) hyperexcitation (hyperreflexia/clonus, mild altered mental status/agitation
controlled with benzodiazepines).
Not all poisoned patients are appropriate for
observation-type admissions, however. Individuals who will likely require more than 23 hours
of observation/management should be admitted
to an inpati ent service. Those with significant
tachycardia (heart rate [HR] > 110/minute) after
appropriate toxicologic treatment, severe delirium,
agitation and/or psychosis that cannot be controlled with benzodiazepines, significant laboratory
and/or EKG derangements (e.g., QRS duration
> 120 milliseconds [ms], QTc interval > 500
ms), a high likelihood of clinical deterioration,
and patients requiring ICU care should not be
admitted to the OU.
While impossible to discuss each and every
poisoning that is/is not appropriate for observation admission, some specific toxicities that lend
themselves to observation-type care are listed as
follows.
Substance: Acetaminophen (APAP)
Observation Admission Criteria:
– Single, acute APAP ingestion (defined as
ingestion of the entire amount of APAP
within 8 hours
2
) presenting within 24 hours
requiring treatment based upon RumackMatthew nomogram
3
– Patients receiving the oral (PO)/intravenous
(IV) bolus dose of N-acetylcysteine (NAC)
within 8 hours of acute ingestion
3,4
– Nausea/vomiting/abdominal pain controlled
with PO/IV antiemetics/non-APAP analgesics
– Lack of concomitant toxic ingestion that
would likely preclude disposition within
24 hours (i.e., sa licylate toxicity requiring
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21:22:48
bicarbonate infusion, long-acting opiate/
opioid toxicity requiring naloxone infusion)
Contraindications to Observation
Admission:
– Ingestions other than single acute
ingestions
3,5
– Individuals receiving the bolus dose of NAC
greater than 8 hours after acute ingestion
3
– Patients with baseline hepatic dysfunction
(elevated aspartate aminotransferase
[AST]/alanine amino transferase [ALT]/
international normalized ratio [INR]
secondary to alcoholic liver disease, infectious
hepatitis, or other underlying pathology)
– Elevated transaminases (AST and/or ALT
greater than the upper limit of laboratory
reference ranges)
– Coagulopathy (INR greater than the upper
limit of laboratory reference range)
– Renal insufficiency (creatinine greater than
the upper limit of laboratory reference range,
oliguria/anuria)
– Altered mental status
– Gravid patient
– Presence of concomitant toxicity that would
likely prevent disposition within 24 hours
(i.e., long-acting opiate/opioid toxicity
requiring naloxone infusion, salicylate toxicity
requiring bicarbonate infusion)
– Provider judgment
Observation Management:
– IV or PO (NAC) per individual facility’s
protocol
3,4
– Antiemetics as needed (PRN)
– Psychiatric consultation PRN
Discharge Criteria:
– Patient is cli nically w ell after NAC course
(resolution of abdominal pain, no nausea/
emesis, normal mentation)
3,4
– Undetectable [APAP] after NAC course
3,4
– Normal AST/ALT after NAC course
3,4
Comments:
– NAC protocols vary between facilities/
regions; consult your regional poison center
(800-222-1222 in the United States) for
treatment recommendations
– Patients may require extension of NAC course
if evidence of liver injury develops (elevated
AST/ALT, INR greater than 1.4, etc.; consult
your regional poison center for treatment
recommendations)
3
Substance: Benzodiazepines
Observation Admission Criteria:
– Confirmed/suspected symptomatic ingestion
(adult or child) after a 6-hour-or-less ED
observation period
Somnolence/stupor
Slurred speech
Ataxia
Contraindications to Observation
Admission:
– Hypoxia refractory to supplemental oxygen
delivered via nasal cannula
– Significant rhabdomyolysis (pressure ulcers/
blisters/bullae, creatine phosphokinase [CPK]
greater than eight times upper limit of
laboratory reference range, myoglobinuria) or
compartment syndrome (elevated
compartment pressures)
– Clinically significant aspiration pneumonitis
(fever, tachypnea, hypoxia, cough productive
of sputum, infiltrate on chest radiograph)
– Presence of concomitant toxic ingestion that
would likely prevent disposition within
24 hours
– Provider judgment
Observation Management:
– Continuous cardiopulmonary monitoring
– Prevention of respiratory compromise/
aspiration (head-of-bed elevation,
supplemental oxygen administration)
– Psychiatric consultation PRN
Discharge Criteria:
– Normal mentation
– Fluent (nonslurred) speech
– Ambulatory with a steady gait
– Normal pulse oximetry/respiratory rate
Toxicology
063
21:22:48
Comments:
– Use caution when considering pharmacologic
reversal with flumazenil (may precipitate
acute withdrawal, including seizures, in
patients with chronic use/abuse of gammaaminobutyric acid [GABA] agonists [e.g.,
benzodiazepines])
6
– Many benzodiazepines are not detected by
rapid bedside drugs of abuse screens (high
false negative rate)
7
– Consider aspiration pneumonitis and
rhabdomyolysis/compartment syndrome in
patients found unresponsive or with altered
mental status
Substance: Bupropion
Observation Admission Criteria:
– Any confirmed/suspected symptomatic
ingestion responsive to benzodiazepines
Mild CNS hyperexcitation (altered mental
status, mild agitation, hyperreflexia,
clonus)
Tachycardia/hypertension
– Confirmed/suspected asymptomatic
ingestion of:
10 mg/kg in children
900 mg in adults
Contraindications to Observation
Admission:
– Mild CNS hyperexcitation unresponsive to
benzodiazepines
– Seizure activity
– QRS interval > 120 ms
– Presence of concomitant toxic ingestion that
would likely prevent disposition within
24 hours
– Provider judgment
Observation Management:
– 18- to 24-hour period of observation
– Continuous cardiopulmonary monitoring
– Prevention of respiratory compromise/
aspiration
– Benzodiazepines PRN agitation
– Psychiatric consultation PRN
Discharge Criteria:
– Normal mentation/vital signs
– Absence of seizure activity during observation
period
– QRS < 120 ms
Comments:
– Many ingestions seize late (hours 15–18)
8,9,10
;
18-hour period of observation is adequate if
patient has remained asymptomatic to
that point
– All patients who seize should be admitted to
the hospital (rather than the OU)
– Consider aspiration pneumonitis in patients
found with altered mental status and those
who seize
Substance: Sulfonylureas
Observation Admission Criteria:
– Confirmed/suspected symptomatic ingestion
(adult or child)
11,12,13
Signs/symptoms of hypoglycemia
– Altered mental status/confusion/
somnolence, generalized weakness,
tremor, diaphoresis, piloerection,
nausea, etc.
– Documented hypoglycemia (blood
glucose less than lower limit of
laboratory reference range)
– Confirmed/suspected asymptomatic ingestion
(adult or child)
11,12,13
Contraindications to Observation
Admission:
– Multiple hypoglycemic episodes prehospital
and/or in ED
– Signs/symptoms of severe hypoglycemia
• Hypothermia, focal neurologic deficit,
seizure, coma
– Hypoglycemia refractory to dextrose 5% in
water (D5W) administration
– Presence of concomitant toxic ingestion that
would likely prevent disposition within
24 hours
– Provider judgment
Steven J. Walsh and Marsha Ford
063
21:22:48
Observation Management:
– Correct hypoglycemia with IV dextrose PRN
Empiric dextrose is not indicated in the
absence of suspected/documented
hypoglycemia (wait until patient becomes
symptomatic/hypoglycemic)
– Check blood glucose every 2 hours while
awake and every hour while asleep
– Meals/activity as tolerated
– Psychiatric consultation PRN
Discharge Criteria:
– Normal vital signs/blood glucose
– No clinical evidence of hypoglycemia
Normal mentation, steady gait, lack of
piloerection/diaphoresis, etc.
– No hypoglycemic episodes during a 24-hour
observation period
Each time the patient requires dextrose,
the “clock is reset ” and an additional 24hour observation period is required from
time of dextrose administration
Comments:
– After second episode of hypoglycemia
requiring dextrose administration, admit for
further evaluation/treatment with dextrose/
octreotide
11–15
Substance: Carbon Monoxide (CO)
Observation Admission Criteria:
– Non-gravid patients exposed to CO who may
benefit from hyperbaric oxygen (HBO) therapy
Syncope/loss of consciousness
Altered mental status/confusion
Abnormal neurologic (particularly
cerebellar) examination
Initial carboxyhemoglobin > 25%
No evidence of significant end-organ damage
– Normal EKG
– Normal troponin
– No renal insufficiency
Contraindications to Observation
Admission:
– Evidence of end-organ damage
Persistently abnormal neurologic
(particularly cerebellar) examination
CT evidence of cerebral ischemia/
hemorrhage
Abnormal EKG
Elevated troponin
Renal insufficiency
– Significant rhabdomyolysis and/or
compartment syndrome
– Clinically significant aspiration
pneumonitis
– Gravid patient
– Presence of concomitant toxic ingestion that
would likely prevent disposition within
24 hours
– Provider judgment
Observation Management:
– Continuous cardiopulmonary monitoring
– 100% oxygen administration
– Hyperbaric oxygen (HBO) as indicated
– Symptomatic care (nasal decongestants, etc.)
between HBO treatments
– Psychiatric consultation PRN
Discharge Criteria:
– Completion of facility’s HBO regimen
– Normal neurologic/cerebellar examination
Comments:
– Consider aspiration pneumonitis and/or
rhabdomyolysis/compartment syndrome in
patients found unresponsive or with altered
mental status
– Indications for HBO are somewhat
controversial
16–18
; consult your regional
poison center (800-222-1222 in the United
States) for recommendations
– Hyperoxygenation therapy is not without risk
(fire in the HBO chamber, seizure, hollow
organ rupture, pulmonary/middle ear
barotrauma, etc.)
Substance: Opiates/opioids
Observation Admission Criteria:
– Confirmed/suspected symptomatic ingestion
(adult or child) after 6-hour-or-less ED
observation period
Somnolence/stupor
Slurred speech
Ataxia
Toxicology
063
21:22:48
Contraindications to Observation
Admission:
– Hypoxia refractory to supplemental oxygen
delivered via nasal cannula
– Significant rhabdomyolysis and/or
compartment syndrome
– Clinically significant aspiration
pneumonitis
– Signs/symptoms requiring continuous
naloxone infusion
– Patients with QTc interval > 500 ms
19
– Presence of concomitant toxic ingestion that
would likely prevent disposition within
24 hours
– Provider judgment
Observation Management:
– Continuous cardiopulmonary monitoring
– Prevention of respiratory compromise/
aspiration
– Psychiatric consultation PRN
Discharge Criteria:
– Normal mentation
– Fluent speech
– Ambulatory with a steady gait
– Normal pulse oximetry/respiratory rate
Comments:
– Consider aspiration pneumonitis and
rhabdomyolysis/compartment syndrome in
patients found unresponsive or with altered
mental status
– Use naloxone for bradypnea/hypopnea/
hypoxia, not for somnolence
Use naloxone with caution in patients with
suspected or confirmed tramadol and/or
propoxyphene toxicity (may precipitate
seizure)
– If patient requires more than two doses of
naloxone, begin continuous infusion/admit
for further evaluation/management
Substance: Neuroleptics
Observation Admission Criteria:
– Confirmed/suspected symptomatic ingestion
(adult or child) after 6-hour-or-less ED
observation period
Altered mental status (somnolence/stupor,
agitation/confusion)
Slurred speech
Ataxia
Hyperreflexia/clonus
Contraindications to Observation
Admission:
– Tachycardia (HR > 110/min) and/or agitation
unresponsive to benzodiazepine
administration
– Hypoxia refractory to supplemental oxygen
delivered via nasal cannula
– Seizure activity
– Significant rhabdomyolysis and/or
compartment syndrome
– Clinically significant aspiration
pneumonitis
– Evidence of serotonin syndrome (SS)
20
Fever (core temperature > 38° C)
Autonomic instability (tachycardia/
bradycardia, hypertension/hypotension)
Altered mental status (typically confusion
or somnolence/stupor)
Tremor/hyperreflexia/clonus and/or
hypertonicity (often greater in the lower
extremities)
– Evidence of neuroleptic malignant syndrome
(NMS)
21,22
Fever
Autonomic instability
Altered mental status (typically
somnolence, confusion, or agitation/
hyperactivity)
“Lead-pipe” hypertonicity/rigidity
– QRS duration > 120 ms
– QTc interval > 500 ms
– Presence of concomitant toxic ingestion that
would likely prevent disposition within
24 hours
– Provider judgment
Observation Management:
– Continuous cardiopulmonary monitoring
– Prevention of respiratory compromise/
aspiration
– IV crystalloid hydration
– Benzodiazepines PRN agitation
– Psychiatric consultation PRN
Steven J. Walsh and Marsha Ford
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21:22:48
Discharge Criteria:
– Normal mental status
– Fluent speech
– Ambulatory with a steady gait
– QRS duration < 120 ms
– QTc interval < 500 ms
– No signs/symptoms consistent with SS/NMS
Comments:
– Consider aspiration pneumonitis and
rhabdomyolysis/compartment syndrome in
patients found unresponsive or with altered
mental status
– Neuroleptics are a heterogenous group of
medications, each with specific toxicities.
Contact your regional poison center (800-2221222 in the United States) for specific
recommendations.
Substance: Latrodectus Mactans
(Black Widow Spider) Envenomation
Observation Admission Criteria:
– Confirmed/suspected symptomatic grade I/II
envenomation (defined below) after 6-houror-less ED observation/treatment period
controlled with PO/IV analgesics and/or
benzodiazepines
23
Normal VS
Pain at the bite site that may be migratory
to the trunk
Contraindications to Observation
Admission:
– Grade I/II envenomation requiring
continuous infusion of opiates/opioids and/or
benzodiazepines
– Grade III envenomation
23,24,25
Autonomic instability, respiratory distress,
cardiac ischemia, severe muscle spasm/
rigidity, generalized myalgias/diaphoresis,
nausea/emesis, headache
– Evidence of superinfection
– Gravid patient
Observation Management:
– PO/IV analgesics/benzodiazepines PRN
tachycardia/pain/muscle spasm
– Tetanus prophylaxis
Discharge Criteria:
– Pain/muscle spasm well-controlled with PO
analgesics
– No evidence of superinfection
Comments:
– Avoid administration of calcium, dantrolene,
and centrally acting “muscle relaxants”
(methocarbamol, cyclobenzaprine,
metaxalone, etc.)
24,25
– Consult your regional poison center before
administering Latrodectus antivenom, which
may cause anaphylaxis/anaphylactoid reaction
and serum sickness
Substance: Crotalid (Pit Viper)
Envenomation
Observation Admission Criteria:
– Progression of swelling halted with elevation
in conjunction with antivenom administration
(see “Comments” regarding antivenom) and
elevation of affected extremity
– Intact neurovascular status
– No evidence of coagulopathy (normal platelet
count/PT/INR/fibrinogen)
– Pain controlled with IV/PO analgesics
Observation Admission
Contraindications:
– Anaphylaxis to venom/antivenom
– Compartment syndrome (very rare)
– Clinically significant hemorrhage (very rare)
– Pain requiring continuous opiate/opioid
infusion
Observation Management:
– Local wound care
– Splinting/elevation/serial circumferential
measurements of affected extremity
– Debridement of hemorrhagic blebs PRN
– Tetanus prophylaxis
– IV/PO analgesics PRN
– Antivenom PRN
Discharge Criteria:
– Stable laboratory studies (no worsening
thrombocytopenia/hypofibrinogenemia/INR
elevation)
Toxicology
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21:22:48
– Intact neurovascular status
– Pain controlled with PO analgesics
Comments:
– Consult with your regional poison center
prior to antivenom administration; some
envenomations may not require antivenom
administration; additionally, antivenom can
cause anaphylactoid/anaphylactic reactions as
well as serum sickness
– Incision and suction of venom and/or ice
application to the bite site/affected extremity
is not recommended
26–28
(See also Snakebites Chapters 84 and 85 under
Specialized Clinical Protocols)
References
1. Substance Abuse and Mental
Health Services Administration,
Center for Behavioral Health
Statistics and Quality. (July 2,
2012). The DAWN Report:
Highlights of the 2010 Drug
Abuse Warning Network
(DAWN) Findings on DrugRelated Emergency Department
Visits. Rockville, MD.
2. Dart RC, Erdman AR, Olson
KR, et al. Acetaminophen
poisoning: an evidence-based
consensus guideline for out-ofhospital management. Clin
Toxicol. 2006;44:1–18.
3. Rumack BH. Acetaminophen
hepatotoxicity: the first 35
years. J Toxicol Clin Toxicol.
2002;40:3–20.
4. Buckley NA, Whyte IM,
O’Connell DL, et al. Oral or
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