5. 1) Immediate and Supportive measures
Remove patient from contact with poison, for example gases.
Preserve any evidence, for example bottles, thrown tablets,
written notes….
Assess vital signs (Pulse, body temperature, B.P, respiratory rate
& pupil size).
Ensure clear
6. 1) Immediate and Supportive measures
Remove patient from contact with poison, for example gases.
Preserve any evidence, for example bottles, thrown tablets, written notes….
Assess vital signs (Pulse, body temperature, B.P, respiratory rate & pupil size).
Ensure clear
= Airway
= Breathing
= Circulation
7. 1) Immediate and Supportive measures
Causes of air way obstruction:
Drug-induced mucosal swelling.
Increased salivation.
Posterior displacement of
the tongue.
Swallowing of foreign bodies.
A=Air way
8. 1) Immediate and Supportive measures
Symptoms of airway obstruction:
Dyspnea.
Tachypnea
Air hunger.
Cyanosis.
Hoarseness(stridor).
Diaphoresis.
Drooling.
.
A=Air way
9. 1) Immediate and Supportive measures
Management of airway obstruction:
Suction of excessive secretions.
Chin lift maneuver.
A=Air way
10. 1) Immediate and Supportive measures
Management of airway obstruction:
Suction of excessive secretions.
Chin lift maneuver.
Nasopharyngeal intubation Alert patients.
Oropharyngeal intubation Comatosed patients.
A=Air way
11. 1) Immediate and Supportive measures
Management of airway obstruction:
Suction of excessive secretions.
Chin lift maneuver.
Nasopharyngeal intubation Alert patients.
Oropharyngeal intubation Comatose patients.
A=Air way
12. 1) Immediate and Supportive measures
Management of airway obstruction:
Suction of excessive secretions.
Chin lift maneuver.
Nasopharyngeal intubation Alert patients.
Oropharyngeal intubation Comatose patients.
A= Air way
13. 1) Immediate and Supportive measures
Management of airway obstruction:
• Suction of excessive secretions.
• Chin lift maneuver.
• Nasopharyngeal intubation Alert patients.
• Oropharyngeal intubation Comatose patients.
• Finally Emergency Cricothyrotomy.
A=Air way
14.
15. 1) Immediate and Supportive measures
Causes of respiratory depression:
• Drug-induced respiratory depression (Sedatives & hypnotic
such as barbiturates & BDZs).
• Pulmonary edema & pneumonitis.
• Bronchospasm.
B = Breathing
16. 1) Immediate and Supportive measures
Management of respiratory depression:
Nasotracheal intubation Alert patients.
Orotracheal intubation Comatosed patients.
B = Breathing
17. 1) Immediate and Supportive measures
The shock is the clinical picture in which the patient shows signs
of inadequate tissue perfusion.
Symptoms of shock:
C =Circulation
SHOCK
Coma
18. 1) Immediate and Supportive measures
Management of shock:
Initially:
• Trendlenburg position.
• Saline Infusion.
C =Circulation
19. 1) Immediate and Supportive measures
Management of shock:
If the patient doesn't respond to 2L infusion & the signs of shock
persist, the vasopressors should be used:
C =Circulation
vasopressors
Dopamine
Norepinephrine
N.B.
1) Dopamine at low dose stimulates
dopamine receptors renal & mesenteric
vasodilatation.
2) Dopamine at medium dose stimulates
cardiac β1 receptors ↑cardiac contractility
& C.O.P.
3) Dopamine at high dose stimulates α1
receptors systemic vasoconstriction.
2-5 µg/kg/minute
up to 20 µg/kg/
minute
0.1-0.2 µg/kg/minute.
20. 2) Preventing absorption (Gut Decontamination)
It is usually not effective if more than 4-6 hrs passed
after poison ingestion.
It is used only for orally ingested poisons.
Methods of gut decontamination:
Emesis Gastric
Lavage
Activated
Charcoal
Cathertics
Whole
Bowel
Irrigation
21. 2) Preventing absorption (Gut Decontamination)
Method:
By the use of syrup of ipeca.
The active ingredients are two alkaloids, emetine
&cephaeline.
Dose:
In children 6-9 months 5 ml ipeca syrup + 120 ml water.
9-12 months 10 ml ipeca + 120 ml water
1- 12 years 15 ml ipeca + 120 ml water.
> 12 year 30 ml ipeca + 250-350 ml water.
The dose can be repeated if emesis has not occurred in 30 minutes.
Emesis
22. 2) Preventing absorption (Gut Decontamination)
Don’t use for emesis
• Water alone: hyponatremia
• Finger down throat: incomplete, dangerous, unsuccessful
• Cu & Zn SO4: not reliable & if absorbed may cause poisoning.
• Apomorphine: may cause lethargy, depress resp. center,
hypotension
Complications:
Emesis
Lethargy Drowsiness
Prolonged
vomiting
Diarrhea
23. 2) Preventing absorption
(Gut Decontamination)
Contraindication:
1- Children up to 6 months of age.
2- Comatose patient because of increased risk of aspiration.
3- Seizures (due to compromised gag reflex).
4- Certain toxins:
- Hydrocarbons& volatile substances.
- Corrosives (Caustics).
5- Ingestion of sharp objects.
Emesis
24. 2) Preventing absorption (Gut Decontamination)
Method:
• performed by introducing warm water alternating
with saline
• use nasogastric (alert patients & children) or an
orogastric (comatose patient) tube into the stomach
• & the removal of stomach contents
by suction.
• For comatosed patients (with absent gag
reflex) or hydrocarbons use cuffed
endotracheal tube to prevent
aspiration.
Gastric Lavage
25.
26.
27. 2) Preventing absorption (Gut Decontamination)
Precautions:
Warm solution should be used.
Warm water alternating with saline
The patient should be placed on his left side.
G.L can be used in comatosed patients with concurrent insertion
of cuffed endotracheal intubation.
Gastric Lavage
To avoid hypothermic shock
To avoid hyponatremia
liver blocks the junction between stomach & small intestine, and therefore
the toxin is kept in the stomach available for lavage.
30. 2) Preventing absorption (Gut Decontamination)
Contraindications:
Varicoses.
Gastric ulcers.
Corrosives (Caustics) intoxication.
Ingestion of sharp objects.
Cardiac dysrhythmias (must be controlled before initiating G.L
because insertion of the tube may create a vagal response
leading to life-threatening dysrhythmia or cardiac arrest.
Gastric Lavage
31. 2) Preventing absorption (Gut Decontamination)
Other washing solutions for specific toxins:
Gastric Lavage
Poison Solution
Formaldehyde
Oxalic acid, fluoride
Silver nitrate
Alkaloids, mushroom
Ferrous sulfate
Alkaloids
Iodine
Ammonium Acetate
Ca gluconate
Normal saline
K permenganate
NaHCO3
Tannic acid
Starch solution
32. • Formaldehyde + ammonia Hexa/penta-methylene
tetramine (inert)
• Ferrous iron + NaHCO3 FeCO3 (poorly absorbed)
• alkaloids + K permanganate OR tannic acid ppt
• Iodine + starch blue colour as indicator
• HF + Ca gluconate ppt
33. 2) Preventing absorption (Gut Decontamination)
Method:
Activated charcoal effectively adsorbs a variety of drugs &
chemicals.
Dose:
1-2 g/kg or 50 gm (10 table spoonful)
It is mixed with 70% sorbitol to avoid constipation & resorption.
Activated Charcoal
35. 2) Preventing absorption (Gut Decontamination)
Contraindications:
In comatosed patient unless the cuffed intubation is used.
Activated charcoal doesn't bind well to:
Boric acid.
Pesticides.
Ferrous salts (as ferrous sulphate).
Cyanide.
Caustics.
Alcohols.
Petroleum distillates.
Activated Charcoal
36. 2) Preventing absorption (Gut Decontamination)
Cathertics
(Purgation)
Saline/salt Oil basedSaccharide
Magnesium Citrate
Sodium Phosphate Sorbitol
N.B. although safe,
but not given to
children < 1 y, &
with caution in 3 y
age
Not used now
because of
increased risk of
lipoid pneumonia
37. 2) Preventing absorption (Gut Decontamination)
Complications:
Cathertics
Abdominal
distention &
cramps.
Prolonged
diarrhea.
Electrolyte
disturbances
(when given by
the gastric lavage
technique).
38. 2) Preventing absorption (Gut Decontamination)
Contraindications:
• Magnesium cathartics should be avoided in patients with renal
failure &/or C.N.S problems. WHY??
(Renal failure ↓ Magnesium excretion Magnesium accumulation
Electrolyte disturbance and C.N.S depression)
• Sodium salts should be avoided in patients with renal failure,
heart failure, &/or hypertension.
• Absence of bowel sounds.
• Intestinal obstruction
• Pre-existing electrolyte disturbance,
• GI bleeding, perforation, peritonitis.
• Poisoning with corrosives
• Severe diarrhea
Cathertics
39. 2) Preventing absorption (Gut Decontamination)
It is the complete irrigation of the bowel by PEG (Colyte®).
The patient receives PEG until clear effluent is attained.
Whole Bowel Irrigation
(WBI)
41. 3) Elimination Enhancement
Requirements:
When large amounts of drug are retained in plasma.
The drug molecular weight should be less than 500 Dalton so can
pass easily across the dialysis membrane.
The drug should be water soluble.
The drug should be of low protein binding.
Heparin should be administrated before dialysis to avoid blood
coagulation.
Hemodialysis
43. 3) Elimination Enhancement
Indications:
Severely intoxicated patients who don't respond to early
supportive management.
Renal failure (where forced diuresis can't be applied).
Prolonged coma.
If lethal amounts of drug was absorbed despite gut
decontamination.
Presence of significant quantity of a toxin that is metabolized to a
toxic metabolite.
Hemodialysis
46. 3) Elimination Enhancement
It is a method for removing toxic material by pumping blood
through a cartridge of adsorbent material such as activated
charcoal or resin.
Hemoperfusion
Advantages:
Hemoperfusion can be used with:
-Drugs of high molecular weight.
-Protein bound drug (Phenytoin).
- Poorly water soluble drugs.
- N.B. Heparin is used here.
48. 3) Elimination Enhancement
It is infrequently used.
It is the removal of the patient's blood & replacement with
fresh whole blood.
Exchange transfusion
49. 3) Elimination Enhancement
Indications:
Iron toxicity.
Chloramphenicol toxicity.
Patients who are refractory to other enhanced elimination
methods or antidotes.
Exchange transfusion
51. 3) Elimination Enhancement
The toxins diffuse from mesenteric capillaries across the
peritoneal membrane into a washing solution in the peritoneal
cavity.
Peritoneal Dialysis
52. 3) Elimination Enhancement
The toxins diffuse from mesenteric capillaries across the
peritoneal membrane into a washing solution in the peritoneal
cavity.
Peritoneal Dialysis
Advantages:
It is well tolerated.
It doesn’t require heparinization.
53. 3) Elimination Enhancement
Indications:
when hemodialysis or hemoperfusion is unavailable or
contraindicated, such as patients with bleeding disorders or
receiving anticoagulant therapy.
Can be used in patients with acute renal failure.
Peritoneal Dialysis
55. 3) Elimination Enhancement
Principle:
Many drugs are weak acids or weak bases.
At physiological pH, most drugs are partially ionized (polar).
It is known that the ionized form is increased when the drug is placed in a
medium opposite to its nature (i.e. the acidic drug is significantly ionized in
alkaline medium & the basic drug is ionized in acidic medium).
The ionized form is unable to cross through cell membranes.
The goal of forced diuresis is to enhance renal excretion by increasing the
amount of the ionized form in the urine the drug is trapped in renal
tubules & not reabsorbed Increased excretion
Forced Diuresis
57. 3) Elimination Enhancement
Forced Diuresis
Forced Alkaline Diuresis Forced acidic Diuresis
Used for acidic toxins such as
salicylates, phenobarbital.
The urine is alkalinized by I.V infusion of
sodium bicarbonate.
Complications pulmonary or cerebral
edema – electrolyte disturabances.
Used for basic drugs, but its use is now
limited because the adverse effects are
common and the process is technically
difficult.
The method is carried out using
ammonium chloride (oral or I.V).
Complications ammonia
encephalopathy.
58. 4) Antidotes
When the antidote competes with the toxin at its
site of action (same receptor).
Examples:
• Atropine acts at muscarinic receptors to block the toxic effects
of Acetylcholine.
• Naloxone acts at opioid receptors to reverse the effects of
narcotic analgesic.
• Flumazenil competes with BZDs at its binding site near the
GABA receptors.
1) Competitive Antidote
59. 4) Antidotes
When the antidote reverses the effect of the toxin
at a different site
Example:
• Organophosphorous pesticides act by inhibiting the
enzyme “acetylcholinestrase”.
• Atropine acts to dampen the binding of excessive
acetylcholine to muscarinic recetors.
2) Non-Competitive Antidote
60. 4) Antidotes
When the antidote forms a non toxic water soluble
complex with the toxin, to be excreted out of the
body
Example:
BAL: for most metals such as gold, lead, mercury & arsenic.
EDTA: for lead.
Penicillamine: for lead & copper.
Deferrioxamine: for iron.
Dicobalt EDTA: for cyanide.
3) Chelating Antidote
61. 4) Antidotes
When the antidote acts at a particular site in the metabolic
pathway of the toxin to prevent its toxicity &/or accelerates
its metabolism to a non toxic metabolite.
Example:
Methanol
(Toxin)
4) Antidote affecting toxin metabolism
Alcohol dehydrogenase
Formaldehyde + Formic acid
Cause optic nerve toxicity (Blindness)
62. 4) Antidotes
When the antidote act at particular site in the metabolic
pathway of the toxin to prevent its toxicity &/or accelerate
its metabolism to a non toxic metabolite.
Example:
Methanol
(Toxin)
4) Antidote affecting toxin metabolism
Alcohol dehydrogenase
Formaldehyde + Formic acid
Cause optic nerve toxicity (Blindness)
Ethanol
(Antidote)
Acetaldehyde + acetic a’
Non Toxic Metabolite
63. 4) Antidotes
When the antidote act at particular site in the metabolic
pathway of the toxin to prevent its toxicity &/or accelerate
its metabolism to a non toxic metabolite.
Example:
Cyanide
+ Nitrites cyanoMetHb
4) Antidote affecting toxin metabolism
Toxicity
Sodium Thiocyanate
(More water soluble
& less toxic).
Sodium Thiosulphate
(Antidote)
++++++++++++++++++++++
64. 4) Antidotes
When the antidote act at particular site in the metabolic
pathway of the toxin to prevent its toxicity &/or accelerate
its metabolism to a non toxic metabolite.
Example:
N-Acetylcysteine: provides substrate for conjugation of
the toxic metabolite (NAPQI) of paracetamol.
4) Antidote affecting toxin metabolism
65. 4) Antidotes
When the antidote neutralizes the toxin by binding to it.
Example:
Specific antibody fragment (Fab) for digoxin:
It is prepared by injecting sheep or horse with the toxic substance
formation of antibodies for the toxicant Ag-Ab Complex
fractionation to remove the antigenic fragment & retain the
specific Antigen Binding Fragment (Fab).
5) Antibody Antidote
66. 4) Antidotes
Example:
Oximes (ex: pralidoxime, PAM):
it is used in the treatment of
OPCs toxicity. It acts by
reactivating acetylcholine
esterase.
6) Antibody affecting enzyme-poison complex
