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ACUTE POISONING GUIDELINES FOR INITIAL MANAGEMENT Prof. Dr. Saad S Al Ani Senior Pediatric Consultant Head of Pediatric Department Khorfakkan Hospital Sharjah ,UAE [email protected]

Acute poisoning guidelines for initial management

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What are the initial steps in management of acute poisoning ,presentation ,types ,Salicylates ,paracetamol ,Iron ,and others,

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Page 1: Acute poisoning   guidelines for initial management

ACUTE POISONING GUIDELINES FOR INITIAL MANAGEMENT

Prof. Dr. Saad S Al Ani

Senior Pediatric Consultant

Head of Pediatric Department

Khorfakkan Hospital

Sharjah ,UAE

[email protected]

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INTRODUCTION

• The majority of poisonings are accidental, especially in the under-5 age group

• Intentional overdoses and substance abuse are seen in older children

http://emedicine.medscape.com/pediatrics_general/

04/12/2023 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

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CONT.

• Deaths in children from poisoning are becoming increasingly rare

• Factors responsible for this decline include: 1. Introduction of child-resistant containers 2. Reducing the pack sizes of aspirin and acetaminophen 3. More effective management

http://emedicine.medscape.com/pediatrics_general/

04/12/2023 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

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HOW CHILDREN DIFFER FROM ADULTS

• Pediatric patients may be particularly vulnerable to certain toxins at specific stages of childhood.

• Breast fed infants may be exposed to drugs or toxins excreted in breast milk; neonates have immature metabolic capabilities

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04/12/2023 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

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CONT.

• Toddlers, as they develop exploratory hand-to-mouth activity, may be exposed to a wide range of potential hazards

http://emedicine.medscape.com/pediatrics_general/

04/12/2023 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

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GENERAL PRINCIPLES

Assess:Type of ingestion (drug, preparation)Time of incidentAmount of ingestion (include all medication

that was potentially in the bottle or packet when calculating)

Weight of child

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

04/12/2023 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

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GENERAL PRINCIPLES

Cont.Is the ingestion potentially harmful?Beware of the possibility of mixed overdoseBeware of the possibility of inaccurate dose

reporting on history takingIf mixed or undetermined ingestion

Paracetamol level should be done

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

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GENERAL PRINCIPLES

ManagementAirwayBreathingCirculationRemoval of poison (if necessary)Emesis

No role in the hospital setting

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

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GENERAL PRINCIPLES

Cont.

Activated Charcoal  The treatment of choice for most ingestions. Most effective when given within first hour.

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

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GENERAL PRINCIPLES

Cont.

 

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

Activated Charcoal Contraindications: •Patients with altered conscious state

•The following agents:

6.Potassium and other metallic ions 1.Ethanol/glycols

7.Fluoride 2.Alkalis

8.Cyanide 3.Boric acid

9.Hydrocarbons 4.Lithium

10.Mineral acids 5.Iron compounds

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GENERAL PRINCIPLES

Cont. Whole Bowel Irrigation has a limited role in

treatment of some slow release preparations

Gastric Lavage has a very limited role in treatment and should not be used without consultation.

Specific antidotes may be available and serum drug levels may help in treatment decisions

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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GENERAL PRINCIPLES

Cont. All acts of deliberate self harm

must be taken extremely seriously.All intentional self poisonings in

adolescents require admission If unexplained symptoms exist a

urinary drug screen may be indicated

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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INITIAL ASSESSMENT AND MANAGEMENT

The initial priority in treating poisoned children is the standard ABC (airway, breathing, and circulation) resuscitation approach

http://emedicine.medscape.com/pediatrics_general/

04/12/2023 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

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A: ASSESS AIRWAY PATENCYBy looking, listening, and feeling for

air movement. If there is no air movement, try to open

the airway with simple maneuvers such as the jaw thrust or the use of airway adjuncts.

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04/12/2023 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

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CONT.Certain ingested agents may predispose

to airway edema and obstruction, including caustic agents, angiotensin-converting enzyme inhibitors, and plants containing calcium oxalate crystals (e.g. Dieffenbachia  and Philodendron  house plants)

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04/12/2023 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

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B: ASSESS THE ADEQUACY OF BREATHING

It is important to remember that succinylcholine may cause prolonged block in children who have a reduced cholinesterase concentration due to exposure to cocaine or organophosphate compounds: prolonged apneas of up to 7 h have been described.

http://emedicine.medscape.com/pediatrics_general/

04/12/2023 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

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CONT.

Observing ventilatory frequency, use of accessory muscles, breath sounds, and oxygen saturations.

Reduced respiratory effort may require bag-valve-mask ventilation until a definitive airway can be secured

http://emedicine.medscape.com/pediatrics_general/

04/12/2023 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

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C: ASSESS THE CIRCULATION

In terms of cardiovascular status (heart rate, arterial pressure, and capillary refill) and the effect of circulatory inadequacy on other organs (mental state, urine output, skin temperature, and colour).

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04/12/2023 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

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CONT.Hypotension should initially be treated

with a 20 ml/ kg crystalloid bolus, remembering that if it is caused by specific toxins such as β-blockers, the specific antidote should also be given, for example, glucagon

http://emedicine.medscape.com/pediatrics_general/

04/12/2023 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

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CONT.Arrhythmias associated with poisoning

are best treated by: i. Correcting precipitating factors (e.g.

hyperkalaemia and acidosis) ii. Administering the appropriate

antidote;

http://emedicine.medscape.com/pediatrics_general/

04/12/2023 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

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CONT.Children in cardiac arrest should be

treated according to standard guidelines (e.g. The Advanced Cardiac Life Support protocol), although it is important to address the need for a specific antidote, for example, sodium bicarbonate for tricyclic antidepressant (TCA) poisoning

http://emedicine.medscape.com/pediatrics_general/

04/12/2023 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

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SALICYLATES POISONING

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SALICYLATES POISONING

Assessment

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

Symptoms

Seizures Tinnitus

Hyperthermia Vomiting

Dehydration Hyperventilation

Hypoglycemia Lethargy

Non cardiogenic pulmonary edema Coma

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SALICYLATES POISONING

Cont.• Initial respiratory alkalosis (may

be transient), followed by paradoxical aciduria (pH <6), then metabolic acidosis & Hypokalemia (± ongoing respiratory alkalosis). 

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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SALICYLATES POISONING

Patients Requiring TreatmentAcute ingestion ≥ 150mg/kgAll symptomatic patientsIngestion of unknown quantity

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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SALICYLATES POISONING

Investigations Serum salicylate level at presentation (on

patients requiring treatment), and 2 hrly if symptomatic or enteric coated preparation. (Need to call the RCH lab to get test run urgently as it is sent to RMH for analysis)

Urea & electrolytes, creatinine, acid-base, glucose

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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SALICYLATES POISONING Management Asymptomatic

Charcoal 1g/kg (if <1 hour since ingestion unless enteric coated preparation)

Observe 6 hours & discharge if still asymptomaticIf enteric coated preparations, serial salicylate levels (2

hourly)Admit if levels have not plateaued at 6 hours post

ingestionI.V. bicarbonate infusion 1mmol/kg/hr to correct any

acidosis (pH <7.3)http://www.rch.org.au/clinicalguide/guideline_index/

Acute_Poisoning_Guidelines_For_Initial_Management/

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SALICYLATES POISONING

Cont. Symptomatic

All symptomatic patients require urgent medical assessment and investigations as above.

Charcoal 1g/kg unless altered conscious state (protect airway first)

I.V. fluid resuscitation to correct dehydration (use N. Saline)

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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SALICYLATES POISONING

Symptomatic (Cont.) I.V. bicarbonate infusion 1mmol/kg/hr, after initial

slow bolus of 2mmol/kg, (keep urine pH >7.5)Potassium replacement as requiredWorsening symptoms, convulsion, coma, contact

I.C.U. for respiratory support ± hemodialysisSalicylate level >7mmol/l following an acute

poisoning contact I.C.U. for consideration of hemodialysis.

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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PARACETAMOL POISONING

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PARACETAMOL POISONING

Patients Requiring Management1. Acute ingestion of > 200 mg/kg2. Ingestion of unknown quantity3. Repeated supratherapeutic ingestion of > 100mg/kg/day

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

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PARACETAMOL POISONING

AssessmentConsider the possibility of co ingestions,

either accidental or deliberate

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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PARACETAMOL POISONING

ManagementActivated charcoal is not useful in liquid ingestions

due to rapid absorptionActivated charcoal 1 g/kg may be considered in a

cooperative patient seen within 1 hour of tablet or capsule ingestion.

Serum paracetamol level at (or as soon as possible after) 4 hours post ingestion determines the need for N-acetyl cysteine (NAC) administration.  (see nomogram)

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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PARACETAMOL POISONING

There is no benefit in measuring paracetamol level earlier than 4 hours

It is safe to wait for the paracetamol level to decide on the need for NAC in all cases that present within 8 hours of ingestion.

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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PARACETAMOL POISONING

Cont. Patients who present > 8 hours after a toxic ingestion /

symptoms of toxicity (RUQ pain or tenderness, nausea, vomiting) should be commenced on NAC immediately. 

The decision to continue or cease NAC is then based on the paracetamol level. 

Delaying NAC administration beyond 8 hours is associated with a progressive increased risk of liver injury.

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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PARACETAMOL POISONING

There is little evidence to guide management in repeated supratherapeutic doses.  Potential toxicity should be assessed when: > 200 mg/kg (or 10g) ingested over a 24

hour period> 150 mg/kg/day (or 6 g) ingested over a 48

hour period> 100 mg/kg/day ingested over a 72 hour period

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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PARACETAMOL POISONING

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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PARACETAMOL POISONING

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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PARACETAMOL POISONING

N- Acetyl cysteine (NAC) Infusion Instructions

The standard administration of NAC is a 3 stage infusion giving a total dose of 300 mg/kg:

1. 150 mg/kg over the first hour

2. 50 mg/kg over the next 4 hours

3. 100mg/kg over the next 16 hourshttp://www.rch.org.au/clinicalguide/guideline_index/

Acute_Poisoning_Guidelines_For_Initial_Management/

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PARACETAMOL POISONING

Cont.For patients > 110 kg, calculate the dose based on

110 kg body weight.NAC may be diluted in 5% dextrose or 0.9%

saline (normal saline).  It can also be diluted in combination dextrose-

saline solutions not exceeding these concentrations including 0.45% saline in 5% dextrose, and 0.9% saline in 5% dextrose.

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

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PARACETAMOL POISONING

For adolescent / adult:1. 150 mg/kg in 250 or 500 ml over 1

hour2. 50 mg/kg in 500 ml over 4 hours3. 100 mg/kg in 1000 ml over 16 hours

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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IRON POISONING

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IRON POISONING

Background

Iron is found in several different forms in different medicines.

The important ingestion is the amount of elemental iron not the iron salt.

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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IRON POISONING

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

Table: Iron Medications

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IRON POISONING

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

Percentage elemental iron:• Ferrous fumarate 33%• Ferrous chloride 28%• Ferrous sulfate 20%• Ferrous chloride 28%• Ferrous gluconate 12%Iron is also found in plant fertilizers  (e.g. sulphate of iron -20% elemental iron).

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ASSESSMENT

Patients Requiring Assessment

1. Ingestion of > 40 mg/kg elemental iron. (approximately  > ½ tablet/kg or 6.5 ml syrup/kg)

2. Ingestion of an unknown quantity.

3. Any symptomatic patients

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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HISTORY AND EXAMINATION

Initial symptoms: Usually occur within 20 minutes Nausea, vomiting, diarrhea, abdominal pain,

hypotension, Hematemesis, fever Gastrointestinal symptoms related to the corrosive

nature of iron may occur without systemic toxicity, however any symptoms require iron levels.

Lack of symptoms within the first 6 hours makes significant toxicity unlikely.

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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HISTORY AND EXAMINATION

Latent period:There is often 6-24 hour latent period  when

initial symptoms resolve, before overt systemic toxicity

Thus improvement over this time may be a result of improvement or deterioration

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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HISTORY AND EXAMINATION

Other symptoms:Usually appear at 6-24 hours and last 12-24Tachycardia, vasoconstriction, hypotension

and shockMetabolic acidosis can occur.These are related to fluid shifts from

intravascular to extravascular compartments and cellular hypoxia

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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HISTORY AND EXAMINATION

Multiple organ failure:Occurs 12-48 hours after ingestionParticularly hepatic failure 

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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Management

ABCSupportive therapy to maintain adequate

blood pressure and electrolyte balance is essential

I.V. fluid resuscitation 20 ml/kgPotassium and glucose administration as

necessary.http://www.rch.org.au/clinicalguide/guideline_index/

Acute_Poisoning_Guidelines_For_Initial_Management/

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IRON POISONING

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Investigations

Asymptomatic patients:If tablet ingestion do AXR and if negative -

does not need further investigation or observation

If unknown amount or >60mg/kg ingested need serum iron levels 4 hourly until falling

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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IRON POISONING

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All symptomatic patients should have the following investigations:

AXR if tablet ingestion ABG/CBG (acidosis) Glucose (hyperglycaemia)

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

IRON POISONING

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Cont. Serum iron

Peak levels are usually seen at 4 hours.Levels taken after four hours may underestimate toxicity

because the subject iron may have either been distributed into tissues or be bound to ferritin.

In the case of slow release or enteric coated tablets, levels should be repeated at six to eight hours as absorption may be erratic.

Once desferroxamine is commenced,  iron levels are not accurate at most labs using automated methods (including RCH)

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

IRON POISONING

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Cont. FBE (leukocytosis) U&E & Cr X-match Clotting (reversible early coagulopathy and late

coagulopathy secondary to hepatic injury) LFTs AXR may be helpful in evaluating gastrointestinal

decontamination after treatment if tablets have been ingested.

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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IRON POISONING

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Cont. Decontamination Charcoal is of no benefit. Decontamination of choice is whole bowel irrigation

(WBI) with naso-gastric colonic lavage solution 30ml/kg/hr until rectal effluent clear (contraindicated if there are signs of bowel obstruction or haemorrhage).

WBI is indicated:If AXR reveals tablets, or capsules ingestedIn symptomatic patients

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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IRON POISONING

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Antidote:Desferroxamine is a chelating agent which

forms a water soluble desferroxamine-iron complex.

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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IRON POISONING

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Consider desferroxamine in:Serum iron  levels > 90 micromol/lLevel 60 - 90 micromol/l and tablets visible on XRay or

symptomatic (nausea, vomiting, diarrhea, abdominal pain, haematemesis, fever)

Any patient with significant symptoms of altered conscious state, hypotension, tachycardia, tachypnea, or worsening symptoms irrespective of ingested dose or serum iron level.

Do not wait for iron level if altered conscious state, shock, severe acidosis (pH <7.1), or worsening symptoms but commence Desferroxamine without delay.

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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IRON POISONING

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Dose: Desferroxamine 15 mg/kg/hr I.V. The rate is reduced after four to six hours so that the total intravenous dose in general does not exceed 80 mg/kg/24 hours.

Desferroxamine -iron complex is renally excreted. If oliguria or anuria develop, peritoneal dialysis

or hemodialysis may become necessary to remove ferrioxamine.

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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IRON POISONING

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It is difficult to determine the endpoint for chelation therapy.

Significant poisoning usually requires 12 - 16 hours,

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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IRON POISONING

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Cont.

It is recommended to continue desferroxamine until:Patient is asymptomatic.decontamination completeanion-gap acidosis resolvedIron level (if measurable) is <54 micromol/L Desferroxamine has been associated with

pulmonary toxicity and should be used with caution if indications persist  >24 hours.

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

IRON POISONING

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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

HYDROCARBON POISONING

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Hydrocarbons Include: Petrol Kerosene Lighter Fluid Mineral Turpentine Paraffin Oil Lubricating Oil Furniture Polishes 2 Stroke Fuel Diesel Fuel White Spirit

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

HYDROCARBON POISONING

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Assessment Main complication is Aspiration

Pneumonitis C.N.S. toxicity can be evident (either

depression or excitement)

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

HYDROCARBON POISONING

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Symptoms: Coughing, choking, respiratory distress

ataxia, drowsiness, coma, convulsions

persistent burping (particularly seen after petrol ingestion

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

HYDROCARBON POISONING

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Keep nil orally charcoal is contraindicated.Asymptomatic

Observe 6hoursDischarge if remains asymptomaticArrange review by LMO the following day

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

MANAGEMENT

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Symptomatic If develops respiratory symptoms (aspiration),

do CXR & O2 saturationGive O2 to maintain saturation > 94%If stable, admit to general medical wardIf increasing O2 requirements or increased

respiratory distress contact I.C.U. If altered conscious state at any time contact

I.C.U. http://www.rch.org.au/clinicalguide/guideline_index/

Acute_Poisoning_Guidelines_For_Initial_Management/

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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

MANAGEMENT (CONT.)

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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

ALKALIS POISONING

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Alkalis include: Drain cleaners, Oven cleanersAutomatic dish washing liquids & powdersLaundry detergents, AmmoniaPortland cement

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

ALKALIS POISONING

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pH of >11.5 is likely to cause significant GI ulceration

Attempt to obtain container to check contents and strength of substance.

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

ALKALIS POISONING

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Corrosive potential varies with concentration of specific ingredients and preparations, ie liquid preparations are more likely to cause esophageal burns than powders.

Check preparations with Poisons Information Centre to determine whether ingested substance is weak, strong, irritant or corrosive in nature.

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

ALKALIS POISONING(CONT.)

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ToxicityExposure may lead to severe burns of GIT, especially esophagusAbsence of mouth or pharyngeal ulcers does not preclude gastro- oesophageal lesions

Symptoms: May be minimalPainNausea & vomiting, drooling or refusing to eat and

drinkStridor, respiratory distress

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

ASSESSMENT

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Activated charcoal is contraindicatedIf asymptomatic treat with fluid dilution:

10ml/kg of water (max 250ml)If asymptomatic after 4 hours and able to

eat and drink the patient can be safely discharged

If any symptoms, contact surgical registrar, & admit for oesophagoscopy

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

MANAGEMENT

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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

ANTICONVULSANT POISONING

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CARBAMAZEPINE, PHENYTOIN, SODIUM VALPROATE, PHENOBARBITONE

Assessment CNS

Ataxia, drowsiness, coma, convulsions GIT

Nausea & Vomiting CVS

Hypotension, Arrhythmias Drug levels are available for some anticonvulsants e.g.

carbamazepine, phenytoin, phenobarbitonehttp://www.rch.org.au/clinicalguide/guideline_index/

Acute_Poisoning_Guidelines_For_Initial_Management/

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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

ANTICONVULSANT POISONING

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All symptomatic patientsAcute ingestion of unknown quantityCarbamazepine ingestion of >20mg/kg (for

patients not on maintenance treatment) or the greater of more than twice the daily dose or 20mg/kg for patients on maintenance treatment

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

PATIENTS REQUIRING TREATMENT

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Charcoal 1g/kg unless altered conscious state (protect airway first)

Mild symptoms (e.g. ataxia, blurred vision) observe 4 hours, discharge if symptom free

Moderate or persistent symptoms (after 4 hours of observation) Admit for observation

Severe symptoms Depressed conscious state or cardiac arrhythmias contact

I.C.U. .

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

MANAGEMENT

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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

TRICYCLIC OVERDOSE

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AssessmentSymptoms Anticholinergic

vomiting, blurred vision, ataxia, tachycardia, urinary retention Antiadrenergic

vasodilatation Sodium Channel blockade

widened QRS (>0.12 ms) QT prolongation reduced cardiac contractility & hypotension

CNS Depression drowsiness, coma, convulsions

Symptomatic patients require urgent medical assessmenthttp://www.rch.org.au/clinicalguide/guideline_index/

Acute_Poisoning_Guidelines_For_Initial_Management/

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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

TRICYCLIC OVERDOSE

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Charcoal 1g/kg unless altered conscious state (protect airway first)

Require ECG, cardiac monitoring Asymptomatic: observe for 6 hours post ingestion and

discharge if have a normal ECG just prior to discharge All symptomatic patients should be admitted If widened QRS on ECG commence Sodium Bicarbonate

infusion 1mmol/kg/hr, after initial slow bolus of 2mmol/kg If altered conscious state, widened QRS or arrhythmia

contact I.C.U. & protect airwayhttp://www.rch.org.au/clinicalguide/guideline_index/

Acute_Poisoning_Guidelines_For_Initial_Management/

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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

MANAGEMENT

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Assessment

Symptoms CNS depression, drowsiness, comaRespiratory depressionHypotensionBeware additive toxicity with other CNS &

Respiratory depressants

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

BENZODIAZEPINE POISONING

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Ingestion of ≥3 times recommended dose for age

All symptomatic patientsIngestion of unknown quantity

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

PATIENTS REQUIRING OBSERVATION

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Charcoal is not usually of benefit (due to low order of toxicity)

If depressed state of consciousness, protect airway and contact ICU

Antidote available - Flumazenil, not indicated for ingestions and should only be used after discussion with consultant staff.

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

MANAGEMENT

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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

THEOPHYLLINE POISONING

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AssessmentCNS

Agitation, hyperventilation, headache, convulsions

Cardiovascular Arrhythmias

GIT nausea & vomiting (may be intractable), thirst,

diarrheahttp://www.rch.org.au/clinicalguide/guideline_index/

Acute_Poisoning_Guidelines_For_Initial_Management/

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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

THEOPHYLLINE POISONING

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Acute ingestion of ≥ 10mg/kgAny ingestion while on maintenance

theophyllineIngestion of unknown quantityAll symptomatic patients

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

PATIENTS REQUIRING TREATMENT

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Theophylline levels should be determined on all patients requiring charcoal

Serial levels are required at 2 hours then every 2 hours until peak reached or decline demonstrated.

If slow release preparation has been taken:admit, continue levels at 4 hourly intervals after decline or plateau to ensure detection of secondary peak

Seizures are common at levels >330 micromol/L Haemoperfusion commonly needed at levels > 550

micromol/L. U&E, Cr and Glucose on all patients.

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

INVESTIGATIONS

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Asymptomatic Charcoal 1g/kgObserve 4 hours. If no symptoms,

discharge if not slow release medication.If ingestion of slow release preparation,

admit for observation and serial drug levels

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

MANAGEMENT

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Symptomatic Charcoal 1g/kg initially unless altered conscious state (protect

airway first) then 0.5g/kg 4 hourly, and whole bowel irrigation with colonic lavage solution 30ml/kg/hr.

Cardiac monitoring I.V. fluid resuscitation & maintenance of adequate hydration is

vital If depressed conscious state, arrhythmias or intractable vomiting

contact I.C.U. as likely to need intubation Severe intoxication may require haemoperfusion If agitated, may need sedation with a benzodiazepine or

phenobarbitone.

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

MANAGEMENT(CONT.)

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http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

ETHANOL POISONING

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Ethanol Containing Preparations Light beer 2% Beer 5% Cider 5% Wine 10% Wine coolers 5% Fortified wine 20% Spirits 45% Liqueurs 30% Perfumes& colognes >60% Aftershaves 80% Mouth washes (some) 25% Methylated spirit 95% (does not contain methanol)

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

ETHANOL POISONING

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Fatalities generally occur with blood levels > 86.8mmol/L (breath alcohol >0.4)

Assessment

Symptoms Nausea, vomiting, abdominal pain Hypoglycemia Ataxia, lethargy, coma, convulsions Respiratory depression

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

ETHANOL POISONING

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Hypothermia Hypokalemia, metabolic acidosis Unexplained drowsiness, hypothermia or hypoglycemia in

adolescents may be ethanol induced. In adolescents ethanol ingestion often accompanies ingestion of other drugs.

Patients Requiring Treatment symptomatic patients

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

ETHANOL POISONING(CONT.)

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Charcoal is of no benefit Check blood glucose in younger children Asymptomatic or Mild Symptoms (decreased

inhibition, slight incoordination) Observe for 2 hoursGive frequent carbohydrate containing drinksBreath alcohol if possibleIf remains symptomatic or symptoms worsen

admithttp://www.rch.org.au/clinicalguide/guideline_index/

Acute_Poisoning_Guidelines_For_Initial_Management/

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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

MANAGEMENT

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Symptomatic (more than just mild symptoms or continued symptoms after 2 hours) Blood ethanol measurement, U& E, GlucoseI.V. fluidTemperature regulationAdmit.If unconscious or convulsions contact I.C.U.

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

MANAGEMENT(CONT.)

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American Association of Poison Control Centers: http://www.aapcc.org/dnn/Home.aspx

American Academy of Clinical Toxicology: http://www.clintox.org/index.cfm

Centers for Disease Control and Prevention, Section on Environmental health: http://www.cdc.gov/Environmental

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/

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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

REFERENCES

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THANK YOU