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• Mam Dr. Rabea Khan Su

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• 12• 60• 74• 83• 91

Poisoning Management

• Introduction to poisoning

• Causes and Cases of poisoning

• Types of poisoning

• Treatment considerations

• Prevention

• “Poison is a substance ( solid/ liquid or gaseous ), which if introduced in the living body, or brought into contact with any part there of, will produce ill health or death, by its constitutional or local effects or both.”

• “Any substance that can harm the body by altering cell structure or functions.”

What is a Poison ?

What is Poisoning..?• “The development of dose related adverse effects following

exposure to chemicals, drugs or other xenobiotics.”

• Poisoning occurs when any substance interferes with normal body functions after it is swallowed, inhaled, injected, or absorbed.

• The branch of medicine that deals with the detection and treatment of poisons is known as toxicology.

Poisoning Management

• It includes procedures designed to prevent the absorption, minimize the toxicity, and hasten the elimination of the suspected toxin.

• The prompt employment of appropriate emergency management procedures often can prevent unnecessary morbidity and mortality.

• It includes all those attempts that are made to accurately

a) identify the toxin,

b) estimate the quantity involved,

c) determine the time that has passed since the exposure and finally

d) controlling or minimizing the effects of poison.

Nature of PoisoningHomicidal – killing of a human being by another human being by administering poisonous substance deliberately.

Suicidal – when a person administer poison himself to end his/ her life.

Accidental – E.g. Household poisons- nail polish remover , acetone .

Occupational – in professional workers. E.g. insecticides, noxious fumes.

Nature of Poisoning

Homicidal

Suicidal

Accidental

Occupational

Routes of Poisoning

Routes of Poisoning

Inhalational

Poisons that are breathed in: Gases: ammonia, chlorine

Vapors: carbon monoxide

Sprays: insecticides

Volatile liquid chemicals: change easily from liquid to gas

Ingestion

Poisons that are swallowed:

Household and industrial chemicals

Medications

Improperly prepared food

Plant materials

Petroleum products

Routes of PoisoningInjection

o Intra venous – Benzodiazepines, barbiturates, tricyclic antidepressants etc.

o Intramuscular – Benzodiazepines, opioids etc.

o Subcutaneous – Botulinum toxin

o Intra- dermal – Local anesthetics, organophosphates

Absorption

Poisons taken in through unbroken skin:

o Corrosives or irritantso Through bloodstreamo Insecticides and chemicals

Checking the Scene

Often, the scene itself is the best clue that a poisoning may have occurred. Factors to notice include—

o Unusual odors.o Flames or smoke.o An open medicine cabinet.o Open or spilled containers.o Overturned or damaged plants.o Drug paraphernalia or empty containers.

Check for severity of scene that depends upon:o The type and amount of poison.o How and where the poison entered the body.o The time elapsed since the poisoning.o The victim’s size, weight, medical condition and age.

Scene Assessment

What substance was involved and how much?

• Get exact spelling. • Bring container to hospital with patient.• If unknown—estimate the maximum

possible amount.

When did the exposure occur?• ED personnel need to know as closely as

possible the time of ingestion.

Period of exposure• First time use or chronic user• If unknown—estimate the shortest and

longest possible time.

Scene Assessment

What interventions have been done?– Traditional home remedies may be harmful.

Patient’s weight?– Critical in determining appropriate

treatment

What effect is patient experiencing?– Nausea and vomiting are the two most

common signs and symptoms.

Signals of poisoning• Nature of Signals

Sudden appearance of symptoms after food or drink in an otherwise healthy person

Symptoms – uniform in character, rapidity Sudden onset delirium, paralysis, cyanosis, collapse etc.

• Neurological Status

- conscious, - confused, - comatose

• Convulsions

Ethylene glycol, Lithium, SSRI

Signals of poisoning

• Pupillary Examination

Normal – Celphos (Al phosphide) poisoning Miosis – Opioids, OP poisoning Mydriasis – TCA, Theophylline, Datura, Methanol

• Hyperthermia

Amphetamines, Alcohol withdrawal, MAO inhibitors, Anticholinergic agents, Salicylates

• Hypothermia

Barbiturates, Benzodiazepines, Ethanol, Opiates, Cyclic antidepressants

Signals of poisoning• Skin Color & Lesions

Colour Toxin/ Poison

Pink Cyanide

Yellow (Jaundice) Phosphorous, hepatotoxins ( Acetaminophen)

Red Rifampicin

Blue (Cyanosis) Aniline, Nitrites,

• Diaphoresis

Salicylate, OP poisoning Sympathomimetic, serotonin syndrome Phencyclidine, alcohol or sedative withdrawal

Fundamentals of poisoning management

1. Initial resuscitation and stabilization

2. Removal of toxin from the body3. Prevention of further poison

absorption4. Enhancement of poison

elimination5. Administration of antidote6. Supportive treatment7. Prevention of re - exposure

Management

1. Initial resuscitation & stabilization:

First priorities are ABC’s I/V access – I/V fluids Endo tracheal intubation - to prevent aspiration

Unconscious patientsRespiratory depression/ failure

Convulsions- give anticonvulsants

2.Removal of Toxin :

Copious flushing with water or saline of the body including skin folds, hair Inhalational exposure

Fresh air or oxygen inhalation

1).Gastric Lavage:

Done with water ,1:5000 potassium permanganate , 4% Tannic acid, saturated lime water or starch solution with orogastric or Ewald’s tube.

Performed until clear fluid is obtained or a maximum of 3 L . Lavage decreases ingestant absorption by an average of :-

52 % - if performed within 5 min. of ingestion 26 % - if performed at 30 min. 16 % - if performed at 60 min.

Contraindications:o Corrosive poisoningo Recent esophageal / gastric surgeryo Unconscious patient

3.Prevention of poison absorption

Ewald’s tube

3.Prevention of poison absorption

2). Ipecac Syrup induced emesis

Administered orallyDose :-

30 ml – adults 15 ml – children 10 ml – small infants

Contraindications: Corrosives CNS depression or seizures Rapidly acting CNS poisons ( cyanide, strychnine, camphor )

3.Prevention of poison absorption

3). Activated Charcoal:

o Charcoal adsorbs ingested poisons within gut lumen allowing charcoal- toxin complex to be evacuated with stool or removed by induced emesis / lavage

o Dose – 1 g/kg body wt.o Given orally as a suspension ( in water ) or through NG tube

Contraindications:o Mineral acids, alkalis, cyanide, fluoride ,iron

3.Prevention of poison absorption

4).Whole bowel irrigation

Administration of bowel cleansing solution containing electrolytes & polyethylene glycol

Orally or through gastric tube Rate – 2 L/hr. ( 0.5 L /hr. in children) End point- rectal fluid is clear Position – sitting

Contraindications :

a. Bowel obstruction

b. Ileus

c. Unprotected airway

Infusion of large amount of NS+NAHCO3 Used to eliminate acidic drug that mainly excreted by the kidney eg salicylates Serious fluid and electrolytes disturbance may occur Need expert monitoring

4.Enhancement of Elimination of Poison

Forced alkaline diuresis

Acidification of urine:

o Enhance elimination of weak bases such as Phencyclidine & Amphetamine

4.Enhancement of Elimination of Poison

Extracorporeal Removal:

Dialysis

Acetone, Barbiturates, Bromide, Ethanol, Ethylene glycol, Salicylates, Lithium Less effective when toxin has large volume of distribution (>1 L/kg), has large molecular

weight, or highly protein bound.

Peritoneal Dialysis Alcohols , long acting salicylates, Lithium

Chelation:

Heavy metal poisoning Complex of agent & metal is water soluble & excreted by kidneys Eg. BAL, EDTA,

BAL – Arsenic, Lead, Copper, Mercury EDTA- Cobalt, Iron, Cadmium

Administration of Antidote:

• Not all poisons have antidotes• Typical Examples are mentioned only

Prevention:

By following these guidelines you will be able to prevent most poisoning emergencies: Keep the household products and medications out of the reach of children. Use childproof safety caps on containers of medications and other potentially

dangerous substances. Keep products in their original containers. Use poison symbols to identify dangerous substances. Dispose of outdated medications and household products. Use chemicals only in well-ventilated areas. Wear proper clothing.

Some poisoning cases:Food Poisoning:

A young boy visited Pharmacy department. Unfortunately he drank a glass of water from water cooler and on his way back to home , ate a more than enough amount of eatables from canteen. After some time, he developed following signs and symptoms:

Nausea, vomiting, abdominal cramps, chills, diarrhea, and fever

Home Remedies: Take enough amount of fluids Drink oral rehydration mixtures to replace fluids and minerals lost through vomiting and diarrhea Get plenty of restIn case of severity; Call 1122 In the hospital, the treatment is designed to rehydrate the pt. This is usually done with intravenous (IV)

fluids. The doctor may prescribe antibiotics if your food poisoning is bacterial.Prevention:-Wash your hands, utensils and food surfaces often -Keep raw foods separate from ready-to-eat foods.-Cook foods to a safe temperature -Never visit department again.

Inhaled Poisoning:A laboratory worker while on his work inhaled Chlorine gas . He claimed of : Eye tearing, nose and throat irritation , Sneezing, Excess salivation, Vomiting.TREATMENT: Nebulized lidocaine analgesia & cough.

Nebulized sodium bicarbonate

Saline irrigation for skin or eye exposures

Perform on-going assessment.

Consult medical control.

Transport.

Do focused history and physical exam (SAMPLE & vital signs).

Expose chest for auscultation.

Establish airway and provide high-concentration oxygen

Remove from source of poison.

Poisoning understudy:Facebook Poisoning: