Critical Care Toxicology Christopher P. Holstege, MD a,b,c, * , Stephen G. Dobmeier, BSN c , Laura K. Bechtel, PhD a a Division of Medical Toxicology, Department of Emergency Medicine, University of Virginia School of Medicine, PO Box 800774, 1222 Jefferson Park Avenue, 4th Floor, Charlottesville, VA 22908–0774, USA b Department of Pediatrics, University of Virginia School of Medicine, PO Box 800774, Charlottesville, VA 22908–0774, USA c Blue Ridge Poison Center, University of Virginia Health System, Room 4601, 1222 Jefferson Park Avenue, Charlottesville, VA 22903, USA Critically poisoned patients are commonly encountered in emergency medicine. Exposure to potential toxins can occur by either accident (ie, occupational incidents or medication interactions) or intentionally (ie, substance abuse or intentional overdose). The outcome following a poi- soning depends on numerous factors, such as the type of substance, the dose, the time from exposure to presentation to a health care facility, and the pre-existing health status of the patient. If a poisoning is recognized early and appropriate supportive care is initiated quickly, most patient out- comes are favorable. In modern hospitals with access to life support equip- ment the case fatality rate for self-poisonings is approximately 0.5%, but this can be as high as 10% to 20% in the developing world lacking critical care resources [1]. This article introduces the basic concepts for the initial approach to the critically poisoned patient and the steps required for stabilization. It intro- duces some key concepts in diagnosing the poisoning, using clinical clues and ancillary testing (ie, laboratory, ECG, and radiology). Finally, specific management issues are discussed. Clinical evaluation When evaluating a patient who has presented with a potential toxicologic emergency, the health care practitioner should not limit the differential diag- nosis. A comatose patient who smells of ethanol may be harboring an * Corresponding author. PO Box 800774, Charlottesville, VA 22908–0774. E-mail address: ch2xf@virginia.edu (C.P. Holstege). 0733-8627/08/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.emc.2008.04.003 emed.theclinics.com Emerg Med Clin N Am 25 (2008) 715–739