Letter to the Editor

American Heart Association Guidelines for Resuscitation of the Poisoned Patient

Kennon Heard MD
Colorado Emergency Medicine Research Center
University of Colorado Health Sciences Center
Rocky Mountain Poison and Drug Center
Kennon.Heard@uchsc.edu

Int J Med Toxicol 2001; 4(3): 24


For the first time, the 2000 version of the American Heart Association guidelines included a special section on resuscitation of the poisoned patient.1 While the recognition of the special problems encountered during resuscitation of the toxicology patient is notable, the information presented in this section has many limitations. Primarily the toxicology data to make guidelines is very limited. Eight of thirty studies cited in this report were single case reports, seven were animal studies, four were volunteer studies and six reported general information regarding poisoning and treatment. Only five systematic studies of poisoned patients were included.1

 

An expanded systematic review of the literature of therapies for several poisonings was also recently published. This publication was as an expansion of the work done by the Emergency Cardiac Care (ECC) Toxicology Panel.2 While more systematic human studies are included in this report, the total number of patients included in this analysis is less than 500, if studies on naloxone are excluded. Furthermore, several of these studies included patients who were not truly in need of "life support," but, in actuality, were only mildly poisoned. While this systematic review provides an accurate review of the available data, it is clear that the available data are less than adequate.

The 2000 guidelines for toxicology in the ECC are reminiscent of resuscitation guidelines from ten to fifteen years ago: there are many expert opinions but few quality data. For example, the most recent Advanced Ccardiac Life Support (ACLS) guidelines included amiodarone and vasopressin for use in cardiac arrest, while lidocaine has fallen out of favor.3,4 The new guidelines represent a change from utilization of the "expert opinion" recommendations to recommendations based on prospective, systematically collected human data. It is crucial that medical toxicologists begin to systematically collect data on critically poisoned patients, and that these results form the basis for clinical trials of therapies for critically poisoned patients.

The ACLS recommendations note that no single center treats enough seriously poisoned patients to perform a meaningful resuscitation study.1 This fact may lead to the conclusion that large studies are not practical. A similar claim was often made regarding the exclusion of cervical spine injuries without radiographs. However, the recent National Emergency X-Radiography Utilization Study (NEXUS) has demonstrated that a large multi-center study of an uncommon problem can result in clinically useful information.5 The Crotalid antivenom Ovine Fab (CroFab) and the Methylpyrazole for Toxic Alcohols (META) trials demonstrate that a core of medical toxicologists can be successfully assembled and demonstrate the efficacy of a promising therapy for uncommon conditions.6,7 As the experts in treatment of poisoned patients, we need to develop a multi-center system for systematically recording the treatment and course of critically ill poisoned patients. These data can provide the basis for future clinical trials, or at least allow future recommendations to be based on experience with a larger number of patients. Toxicology must keep up with the emerging standard in resuscitation science.

References:

  1. Emergency Cardiac Care Committee and Subcommittee, American Heart Association. Part 8- Advanced challenges in the ECC: Section 2-Toxicology in the ECC. Circulation 2000; 108 (suppl):I223-I229.
  2. Albertson, T. E.; Dawson, A.; de Latorre, F.; Hoffman, R. S.; Hollander, J. E.; Jaeger, A.; Kerns, W. R. 2nd; Martin, T. G., and Ross, M. P. TOX-ACLS: toxicologic-oriented advanced cardiac life support. Ann Emerg Med. 2001 Apr; 37(4 Suppl):S78-90.
  3. Emergency Cardiac Care Committee and Subcommittee, American Heart Association. Part 6- Advanced Cardiac Life Support- Section 5 : Pharmacology I: Agents for arrhythymias. Circulation 2000; 108 (suppl) :I112-I129.
  4. Emergency Cardiac Care Committee and Subcommittee, American Heart Association. Part 6- Advanced Cardiac Life Support- Section 6 : Pharmacology II: Agents to optimize cardiac output and blood pressure. Circulation 2000; 108 (suppl):I129-I136.
  5. Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. N Engl J Med 2000 Jul 13;343(2):94-9
  6. Brent J, McMartin KE, Phillips S et al. Fomepizole for the treatment of ethylene glycol poisoning. N Engl J Med 1999; 340:832-838.
  7. Dart RC, Siefert SA, Carroll L et al. Mixed monospecific Crotalid antivenom Ovine Fab for the treatment of Crotalid venom poisoning. Ann Emerg Med 1997; 30: 33-39.



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