Inadequate assessment of the airway and ventilation in acute poisoning. a need for improved education?
Introduction
Self-poisoning, the most common cause of non-traumatic coma in patients under 35, accounts for up to 10% of acute medical admissions [1]. Respiratory depression due to a reduced level of consciousness may occur from either the direct central effects of the drugs taken, drug metabolite actions or from cardiovascular side-effects, notably arrhythmias and hypotension. This may be compounded by the fact that the drugs may have been taken in conjunction with alcohol. A reduction in conscious level puts the patient at an increased risk of not only aspiration but also respiratory arrest.
If significant morbidity and mortality is to be avoided a high index of suspicion for such complications is necessary. Several studies [1], [2], [3], [4], [5], [6] have identified sub-optimal management of airway, breathing and circulation in a ward setting as major contributing factors to morbidity and prolonged admission to the Intensive Care Unit. Two of these studies have identified a lack of understanding of the predictable respiratory consequences of worsening coma, namely respiratory depression and ultimately respiratory arrest [3], [7]. Patients at risk are being under diagnosed by those who may be unfamiliar with the assessment of the unconscious patient, early recognition of respiratory embarrassment may not occur as adequate oxygen saturation on pulse oximetry is often confused with adequate ventilation [8].
Section snippets
Subjects and methods
The initial management of a group of patients subsequently admitted to either Coronary Care or Intensive Care for observation following episodes of acute poisoning was reviewed. Forty one patient episodes were identified between 12 January 1997 and 21 January 1998 (16 male and 18 female) age range 15–75. One male was admitted on six separate occasions and two females on four and two occasions, respectively.
The study was a retrospective review of clinical record keeping in terms of initial
Results
Of the 41 patient episodes in our study, one was an accidental poisoning occurring at work. Twenty five had also consumed alcohol at the time of poisoning and therefore in addition to the sedative effects of alcohol, there was the potential for alterations in both gastric volume and pH affecting the prognosis if aspiration occurred [11].
Four patients had no documentation of Glasgow Coma Scales on admission. None required intubation and ventilation. Their clinical courses ran as follows; two
Discussion
The study analysed the upper airway management of patients admitted to hospital following episodes of acute poisoning that required respiratory and cardiovascular monitoring. The standards used were criteria for resuscitation and intubation that have been incorporated into guidelines for the management of other comatose or semi-conscious patients. According to such criteria on ten occasions patients received sub-optimal care; on six of these occasions, patients suffered symptoms suggestive of
Conclusions
Although the number of patient episodes (41) in the study was small, problems were identified which can be modified to improve patient care, therefore concluding that:
- 1.
Respiratory morbidity is increased in acute poisoning by poor understanding of airway and ventilation. Is this an educational problem?
- 2.
Medical training for acute medicine at undergraduate and postgraduate level should continue to increase its emphasis on ‘airway, breathing and circulation’ [4], [5], [9]. An increased role in
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