Drug Intoxication: Emergency Assessment, Management and Nursing Care
Drug intoxication is a reversible syndrome caused by recent exposure to a psychoactive medicine or substance, producing clinically significant changes in consciousness, perception, behaviour, cognition, coordination or vital functions. Severe intoxication is a medical emergency; psychiatric assessment follows stabilization.
Never assume “just intoxicated.” Perform ABCDE, capillary glucose, temperature, pupils, ECG and trauma assessment. Consider mixed overdose, hypoxia, infection, head injury, stroke and self-harm.
Routes, circumstances and risk factors
- Ingestion, inhalation, injection, smoking, transdermal or mucosal absorption.
- Accidental dosing error, recreational use, intentional self-poisoning, drug interaction, impaired renal/hepatic clearance or contaminated substances.
- Higher risk with children, older adults, pregnancy, multiple medicines, opioid/benzodiazepine combination, alcohol use and previous self-harm.
Recognizing major toxidromes
| Pattern | Typical findings | Examples/priority |
|---|---|---|
| Opioid | Reduced consciousness, slow/shallow breathing, pinpoint pupils, cyanosis | Ventilate; naloxone per protocol. |
| Sedative-hypnotic/alcohol | Drowsiness, slurred speech, ataxia, respiratory depression | Airway protection; check glucose and co-ingestion. |
| Sympathomimetic | Agitation, dilated pupils, sweating, tachycardia, hypertension, hyperthermia, chest pain/seizures | Cooling, cardiac monitoring, benzodiazepine per protocol. |
| Anticholinergic | Hot dry skin, dilated pupils, urinary retention, delirium, tachycardia | Supportive care, temperature control, specialist advice. |
| Cholinergic | Salivation, tears, diarrhoea, vomiting, sweating, pinpoint pupils, wheeze/secretions, weakness | Decontaminate safely; airway/suction; atropine-based protocol. |
| Serotonin toxicity | Agitation, sweating, fever, diarrhoea, hyperreflexia and clonus | Stop serotonergic agents; cool and refer urgently. |
Immediate ABCDE management
- Protect staff: PPE; avoid direct contact with powders, vomit or pesticide-contaminated clothing.
- Airway: recovery position if breathing adequately; suction; airway adjunct/intubation by trained team when reflexes are lost.
- Breathing: oxygen when indicated, respiratory rate and SpO₂; bag-mask ventilation is the immediate lifesaving treatment for opioid apnoea while naloxone is prepared.
- Circulation: pulse, BP, perfusion, IV access, ECG; isotonic fluids for shock while identifying cause.
- Disability: GCS/AVPU, pupils, glucose; treat hypoglycaemia promptly and seizures according to protocol.
- Exposure: temperature, injuries, needle marks, patches, odour, skin contamination and pregnancy.
Focused history and investigations
Ask what substance, strength, amount, route, time, co-ingestants, prescribed medicines, intent, symptoms and pre-hospital treatment. Bring containers without delaying care. Obtain collateral history respectfully. Investigations are guided by severity: glucose, ECG, electrolytes, renal/liver function, blood gas, pregnancy test, paracetamol level where relevant, CK for severe agitation/hyperthermia and imaging for trauma/focal signs. A negative toxicology screen does not exclude poisoning.
Decontamination and enhanced elimination
- Remove contaminated clothing and wash exposed skin; protect staff and bag clothing safely.
- Do not induce vomiting. Gastric lavage is not routine and is dangerous without a protected airway; consider only under expert/local guideline direction.
- Activated charcoal may reduce absorption of selected poisons when given early to an appropriate, cooperative patient with a protected airway. It does not bind alcohols, corrosives, hydrocarbons or metals effectively and is contraindicated with unprotected airway or obstruction.
- Repeated charcoal, urinary manipulation or dialysis is toxin-specific and requires specialist guidance.
Selected antidotes and medicine safety
| Antidote | Indication/action | Cautions, interactions and monitoring |
|---|---|---|
| Naloxone | Competitive opioid antagonist for respiratory depression. Titrate per Uganda/local protocol to adequate ventilation, not necessarily full wakefulness. | Shorter action than many opioids: recurrent toxicity requires observation/re-dosing/infusion. May precipitate vomiting, agitation and withdrawal; protect airway. |
| Atropine | Reverses muscarinic effects of organophosphate/carbamate poisoning; repeat per protocol to dry bronchial secretions and improve ventilation. | Endpoint is respiratory secretion control, not pupil size alone; monitor pulse, chest and temperature. |
| N-acetylcysteine | Prevents/treats paracetamol liver injury; most effective early but may help later. | Use weight- and time-based protocol; monitor LFT/INR and infusion reaction. |
| Activated charcoal | Adsorbent, not a universal antidote; Uganda guideline adult dose commonly 50 g when indicated. | Aspiration, vomiting, constipation/obstruction; avoid when airway unprotected. |
Management of agitation
- Quiet, well-ventilated, low-stimulation area; one speaker; respectful verbal de-escalation.
- Check hypoxia, hypoglycaemia, hyperthermia, pain, urinary retention and head injury before labeling behaviour psychiatric.
- If imminent danger persists, trained team uses least restrictive measures and prescribed sedation appropriate to the suspected toxidrome, with continuous airway, respiratory, cardiac and temperature monitoring.
- Avoid physical struggle in severe stimulant intoxication because hyperthermia, acidosis and rhabdomyolysis may worsen.
Nursing care plan
| Diagnosis | Interventions and rationale |
|---|---|
| Ineffective breathing pattern | Continuous RR/SpO₂/GCS, airway positioning, oxygen/ventilation, naloxone when prescribed; detects and reverses hypoxia. |
| Risk for aspiration | Nothing orally while consciousness impaired, lateral position, suction ready, protect airway before charcoal. |
| Hyperthermia/risk for injury | Temperature monitoring, remove excess clothing, external cooling, IV fluids as ordered, seizure/falls precautions. |
| Risk for self-directed violence | After medical stabilization conduct private suicide assessment, remove means, observation matched to risk and urgent mental-health review. |
| Deficient knowledge | Non-judgmental brief intervention, safer storage, overdose recognition, naloxone education where available and referral for substance-use care. |
Observation, referral and discharge
Observe according to agent, dose, formulation, symptoms and antidote duration. Admit/transfer patients with respiratory depression, persistent altered consciousness, abnormal vital signs/ECG, seizures, hyperthermia, significant self-harm intent, pregnancy, long-acting agent, mixed/unknown ingestion or unreliable follow-up. Before discharge, document capacity and risk assessment, create a safety plan, address access to medicines/substances and arrange mental-health/substance-use follow-up.
Revision questions
- Describe six toxidromes and their priorities.
- State contraindications to activated charcoal.
- Explain why naloxone-treated patients need continued observation.
- Outline nursing care following intentional overdose.
References
- Uganda Ministry of Health. Uganda Clinical Guidelines, 2023: acute poisoning and opioid poisoning.
- WHO. mhGAP Guideline, 2023.