Specific environmental toxidromes seen in the ED
Environmental chemical exposures are frequent, unpredictable and potentially rapidly life‑threatening.
The emergency clinician’s priorities are rapid recognition of characteristic toxidromes, immediate resuscitation (airway, breathing, circulation), early decontamination and prompt liaison with specialist toxicology/poison‑information services.
UK practice expects early contact with the National Poisons Information Service (NPIS/TOXBASE) and adherence to RCEM antidote guidance for local stocking and access to Category C antidotes (for example pralidoxime).
Below are practical, exam‑relevant summaries of the high‑risk environmental toxidromes commonly seen in ED practice: organophosphate/nerve‑agent cholinergic crisis, carbon monoxide (carboxyhaemoglobinaemia), hydrogen sulphide, methaemoglobinaemia, hydrofluoric acid (hydrogen fluoride) injury and paraquat poisoning.
Common initial principles
- Scene safety and PPE: confirm the scene is safe for staff. Vapours and contaminated clothing/hair can cause secondary exposures-treat unknown situations as hazardous‑materials incidents and involve local chemical‑incident teams if required.
- Remove contaminated clothing and start irrigation of skin/eyes promptly while protecting staff and the environment from contamination.
- ABCs: secure the airway and oxygenate as needed. Anticipate difficult airway management with inhalational irritants or copious secretions.
- Decontaminate topical exposures quickly (HF, paraquat): dry removal of gross contaminants followed by copious water irrigation.
- Early specialist contact: for antidote supply, dosing and complex decisions (oxime therapy, hyperbaric oxygen, nitrite therapy, extracorporeal support) contact NPIS/TOXBASE or a clinical toxicologist without delay.