Clinical Protocols

Red zone Scorpion Envenomation Systemic envenomation should be considered in patients with autonomic findings such as sweating, hypersalivation, tachy/bradycardia, hypertension after a scorpion sting (especially with a low threshold in children under 6 years of age). Variable Acute Ethanol (Alcohol) Intoxication Acute ethanol intoxication should be considered in patients with altered consciousness, ataxia, vomiting, or respiratory depression after alcohol intake; if impaired consciousness is disproportionate to clinical effects, look for another cause. Variable Acute Radiation Syndrome (ARS) Acute radiation syndrome should be considered in a patient with early-onset nausea and vomiting and rapid lymphocyte decline after nuclear/radiological exposure. Red zone Aluminum / Zinc Phosphide Poisoning (Grain Fumigant — "Rice Tablet") Phosphide poisoning should be considered in a patient with garlic breath, refractory hypotension, and severe metabolic acidosis after ingestion of agricultural fumigant (rice/wheat tablet). Red zone Acute Arsenic / Heavy Metal Poisoning Acute arsenic poisoning should be considered in patients developing cholera-like rice-water diarrhea, hypovolemic shock, and QT prolongation following intentional ingestion or occupational exposure. Variable Baclofen Toxicity and Intrathecal Baclofen Withdrawal Consider in patients on baclofen/with a pump presenting with altered consciousness-respiratory depression (overdose) or fever + severe rigidity + pruritus (pump/catheter withdrawal). Variable Benzodiazepine Overdose Should be considered in patients showing sedation-ataxia-confusion after benzodiazepine ingestion, particularly when co-ingestion must be excluded. Red zone Beta-blocker / Calcium Channel Blocker Poisoning Consider this in a patient developing bradycardia and hypotension after beta-blocker or calcium channel blocker intake. Red zone Herbal Cardiac Glycoside Poisoning (Oleander / Foxglove) Consider this poisoning in patients who have ingested plants like oleander or foxglove, or been exposed to their boiling water, and develop nausea-vomiting, arrhythmia, or hyperkalemia. Variable Insect Bite and Bee Sting (Local Reaction) Should be considered in patients with local pain-swelling-itching after insect bite or bee/wasp sting, who also need assessment for systemic/anaphylactic reaction. Variable Boric Acid / Borate Poisoning Should be considered in patients exposed to boric acid/borate-containing products such as insect/ant traps, especially if rash-vomiting-kidney injury develops after massive ingestion. Variable Mercury (Hg) Poisoning Mercury poisoning should be considered in patients with a history of exposure to mercury vapor, mercury salts, or methyl mercury-containing food and presenting with tremor, GIT corrosion, or delayed neurotoxicity findings. Red zone Digoxin (Digitalis) Toxicity Consider digoxin toxicity in a patient on digoxin presenting with nausea and vomiting, yellow-green visual disturbances, confusion, and arrhythmia showing increased automaticity + AV block combination. Variable Phencyclidine (PCP) Poisoning Consider PCP toxicity in a patient presenting with agitation, nystagmus or psychosis after PCP use. Red zone GHB / GBL Poisoning GHB/GBL poisoning should be considered in a patient with a pattern of sudden deep coma, respiratory depression, and bradycardia followed by spontaneous sudden awakening within hours. Variable Glyphosate-Surfactant Herbicide (Roundup etc.) Poisoning Glyphosate-based herbicide (Roundup etc.) poisoning should be considered in a patient with a history of ingestion, especially in large volume/concentrated exposures, presenting with GI irritation and circulatory collapse. Red zone Hydrofluoric Acid (HF) Burn and Systemic Toxicity Hydrofluoric acid burn and systemic toxicity should be considered in patients with a history of chemical contact/burn with pain disproportionate to appearance. Red zone Hydrogen Sulfide (H2S) Poisoning Hydrogen sulfide poisoning should be considered in patients with sudden loss of consciousness, apnea, or collapse in sewage/septic/closed spaces; inability to detect the odor does not exclude it. Variable Inhalant (Volatile Substance) Toxicity (Thinner / Bali / Glue) In a patient presenting with euphoria, ataxia, confusion, or sudden cardiac arrhythmia after volatile substance use such as thinner/bali/glue (especially adolescents), inhalant toxicity should be considered. Red zone Isoniazid (INH) Toxicity INH toxicity should be considered in a patient with refractory seizure/status epilepticus + high anion gap metabolic acidosis + coma after isoniazid ingestion. Variable Camphor and Naphthalene Poisoning After ingestion of mothballs/mentholated products, these poisonings should be considered in a child with sudden seizure (camphor) or signs of hemolysis including pallor-jaundice-dark urine (naphthalene, especially in G6PD deficiency). Red zone Carbamazepine Toxicity CBZ toxicity should be considered in patients presenting after carbamazepine ingestion with ataxia, nystagmus, dysarthria, altered consciousness, or seizures. Red zone Carbon Monoxide (CO) Poisoning CO poisoning should be considered in patients presenting with headache, nausea, dizziness or syncope (especially more than one person in the same environment) in a closed environment caused by stove/geyser/barbecue/generator. Red zone Cocaine Poisoning (Sympathomimetic + Na-Channel Toxicity) In a patient with agitation, hypertension, tachycardia, chest pain, or wide-QRS arrhythmia after cocaine use, cocaine poisoning should be considered. Red zone Colchicine Toxicity Colchicine toxicity should be considered in patients who have taken colchicine in overdose and present with nausea, vomiting, and diarrhea, carrying a risk of multi-organ failure. Variable Ingestion of Caustic / Corrosive Substance In a patient with ingestion of bleach, drain opener, or acidic substance who presents with voice changes, drooling, or abdominal pain, caustic/corrosive burn should be considered. Red zone Hepatotoxic Mushroom Poisoning (Amanita / Amatoxin) Amatoxin (Amanita) poisoning should be considered in patients with severe GI symptoms (delayed onset) occurring 6-24 hours after mushroom ingestion. Variable Metformin-Associated Lactic Acidosis (MALA) In a patient on chronic metformin who develops wide anion gap lactic acidosis after a trigger (AKI, sepsis, dehydration), MALA should be considered. Red zone Methemoglobinemia Methemoglobinemia should be considered in a patient with oxygen-unresponsive cyanosis, chocolate-brown blood, and pulse oximeter stuck at ~85% saturation. Red zone Neuroleptic Malignant Syndrome (NMS) NMS should be considered in a patient with hyperthermia, lead-pipe rigidity, altered consciousness, and autonomic instability after antipsychotic initiation/dose increase. Red zone Opioid Overdose In a patient with the triad of depressed consciousness + respiratory depression (RR<12/apnea) + miosis, opioid overdose should be considered, and airway support should start together with naloxone. Red zone Paraquat Poisoning Paraquat poisoning should be considered in patients with a history of herbicide (paraquat) ingestion who develop oropharyngeal/GI corrosive injury or progressive renal-hepatic failure. Variable Paracetamol (Acetaminophen) Poisoning Paracetamol poisoning should be considered in patients with a history of paracetamol ingestion, who may be asymptomatic in the early period but later develop nausea-vomiting or elevated liver enzymes. Variable Synthetic Cannabinoid (Bonzai/Spice) Poisoning Synthetic cannabinoid poisoning should be considered in a patient who develops agitation, psychosis, seizures, hyperthermia, or rhabdomyolysis after bonzai/spice use. Red zone Serotonin Syndrome Serotonin syndrome should be considered in a patient using serotonergic drugs who presents with agitation, clonus, hyperreflexia, and hyperthermia. Red zone Cyanide Poisoning Cyanide poisoning should be considered in patients with altered consciousness, hypotension, and high anion gap lactic acidosis after enclosed-space fire/smoke inhalation. Red zone Strychnine Poisoning Strychnine poisoning should be considered in patients with stimulus-triggered generalized muscle contractions but PRESERVED consciousness and no postictal period. Red zone Sulfonylurea / Glinide-Associated Hypoglycemia (Antidote: Octreotide) Consider this diagnosis in patients with recurrent or resistant hypoglycemia after sulfonylurea/glinide intake (recurrence despite dextrose). Red zone Thallium Poisoning Thallium poisoning should be considered in patients who develop painful ascending peripheral neuropathy following gastrointestinal symptoms and delayed alopecia. Red zone Theophylline (Theophylline/Aminophylline) Toxicity In a patient using theophylline, the presence of persistent vomiting, tachycardia/arrhythmia, tremor, and seizures resistant to benzodiazepines should raise suspicion for theophylline toxicity. Red zone Toxic Alcohol Poisoning (Methanol / Ethylene Glycol) Toxic alcohol poisoning should be considered in a patient with unexplained high anion gap metabolic acidosis + elevated osmolar gap who has suspected illicit alcohol or antifreeze ingestion. Red zone Tricyclic Antidepressant (TCA) Poisoning In patients after TCA ingestion with QRS widening on ECG, hypotension, anticholinergic findings, or seizures, tricyclic antidepressant poisoning should be considered. Red zone Valproate (Valproic Acid) Toxicity Valproate toxicity should be considered in patients who develop altered consciousness/coma after valproate intake, even if levels are normal, if hyperammonemic encephalopathy is suspected. Variable Snake Bite (Viper Envenomation) — Bedside Protocol In a patient who develops progressive local edema, coagulopathy, bleeding, or hypotension after a snake bite, systemic envenomation should be considered and early antivenom should be evaluated. Red zone Snake Bite (Envenomation) In patients with snakebite who have coagulopathy, bleeding, progressing swelling, or hemodynamic/neuro findings, systemic envenomation should be considered and IV antivenom evaluated.