GENERAL APPROACH TO POISIONING

1. GENERAL APPROACH TO
POISIONING
PRESENTATION BY :- DR.MAHESH YADAV

2. APPROACH TO PAEDIATRIC
TOXICOLOGY
1. RESUSCITATION
2. RISK ASSESSMENT
3. SUPPORTIVE CARE
4. DECONTAMINATION
5. ENHANCED ELIMINATION
6. ANTIDOTES

3. RESUSCITATION
• GIVE PRIORITY OVER DECONTAMINATION AND
ADMINISTRATION OF ANTIDOTE
• AIRWAY:
1. INDICATION OF INTUBATION
A) CARDIO RESPIRATORY ARREST
B) AIRWAY INJURY
C) CORROSIVE INJESTION
D) GCS < 8
E) PROLONGED SEIZURE
• BREATHING:
A) OXYGEN VENTILATION IS REQUIRED

4. • CIRCULATION:
A) SUPPORTIVE PERFUSION IF NEEDED.
B) TREATMENT OF HYPERTENSION. BETA BLOCKERS SHOULD BE
AVOIDED IN CASE OF SYMPATHOMIMETIC POISONING.
C) ARRHYTHMIA.
D) DISABILITY.
- SEDATION
- SEIZURE CONTROL
- TREATMENT OF HYPOGLYCEMIA
- MAINTAIN NORMOTHERMIA.

5. RISK ASSESSMENT
• HISTORY
-IT IS TO BE OBTAINED VIA MULTIPLE FAMILY
MEMBERS,ALWAYS ASSUME WORST CASE SCENARIO.
- ATTEMPT TO ELUCIDATE AND CLEARLY DOCUMENT:
A) WHAT SUBSTANCE HAVE BEEN INGESTED?
B) HOW MUCH OF EACH SUBSTANCE HAS BEEN INGESTED?
C) WHAT TIME THE INGESTED OCCURED?
D) WHAT CLINICAL FEATURES HAVE OCCURED SO FAR?
E) OTHER RELEVANT PATIENT FACTORS (WEIGHT,OTHER
MEDICAL PROBLEMS)
-IF THE SUBSTANCE IS UNKNOWN, CONSIDER ALL MEDICATION
IN THE HOME INCLUDING KNOWN PHARMACEUTICAL

6. • FOCUSED CLINICAL EXAMINATION ESPECIALLY IMPORTANT IF
INGESTION IS UNKNOWN.
• LOOK FOR TOXIDROMES
TOXIDROME
S
EFFECTS EXAMPLES
ANTICHOLIN
ERGICS
DELIRIUM + PERIPHERAL EFFECTS
MAD AS A HATTER-CONFUSIONS,
HALLUCINATIONS,SEIZURES,COMA
RED AS A BEET – FLUSHED SKIN
BLIND AS A BAT –MYDRIASIS
HOT AS A HARE – HYPERTHERMIA
DRY AS A BONE – DRY SKIN ,URINARY
RETENTION ,ILEUS
-1ST GENERATION
ANTIHISTAMINES
-TRICYCLIC ANTI-DEPRESSANTS
-ANTIPSYCHOTICS
-ANTICONVULSANTS
-ANTIMUSCULARIINICS :ATROPINE
,SCOPOLAMINE ,IPRATROPIUM
BROMIDE
-PLANTS : SOME MUSHROOMS
,DATURA

7. TOXIDROME EFFECTS EXAMPLES
CHOLINERGIC D
DIAPHORESIS,DIARRHOEA
U URINATION
M MIOSIS
B
BRONCHOSPASM,BRONCH
ORRHOEA, BRADYCARDIA
E EMESIS
L LACRIMATION
S SALIVATION
• INSECTISIDES
• CHEMICAL
WARFARE AGENTS
• ALZHEIMER’S
MEDICATION
•AGENTS USED FOR
MYASTHENIA
GRAVIS

8. TOXIDROME EFFECTS EXAMPLES
SYMPATHOMIME
TIC
• ALPHA
- HYPERTENSION
- BRADYCARDIA
-MYDRIASIS
• BETA
-HYPOTENSION
-TACHYCARDIA
- MIOSIS
•ALPHA – PHENYLEPRINE
,OTC COLD PREPS
•BETA – SALBUTAMOL ,
THEOPHYLLINE ,CAFFEINE
•ALPHA AND BETA –
AMPHETAMINE, COCAINE
,PSEUDO/EPHEDRINE
SEDATIVE • DECREASED LOC
• HYPOVENTILATION
• HYPOTENSION
• BRADYCARDIA
• OPIODS AND BARBITURATES
- MIOSIS
- HYPOTHERMIA
•BENZODIAZEPINES
•BARBITURATES
•ALCOHOLS
•OPIOIDS
•ANTICONVULSANTS
•ANTIPSYCHOTICS

9. TOXIDROMES EFFECTS EXAMPLES
SERATONERGIC CNS
•ANXIETY, AGITATION,
HALLUCINATION, SEIZURES,
COMA.
NEUROMUSCULAR
•TREMOR, HYPER
REFLEXIA, CLONUS,
MYOCLONUS, RIGIDITY
AUTONOMIC
•FLUSHING/SWEATING,
TACHYCARDIA,
HYPERTENISON,
HYPERTHERMIA
-ANTIDEPRESSANTS
•SSRI, SSNRI, MAOI, TCAD
ANALGESICS
•TRAADOL, PETHIDINE,
FENTANYL
DRUG OF ABUSE
•AMPHETAMINE, MDMA,
LSD
DIETARY SUPPLEMENTS
•ST.JOHN’S WORT,
GINSENG

10. TOXIDROME EFFECTS EXAMPLES
HALLUCINOGENIC HALLUCINATIONS
PSYCHOSIS
PANIC
FEVER
MYDRIASIS
HYPERTENSION
-AMPHETAMINE
-CANNABOIDS
-COCAINE
-MAGIC MUSHROOM
ODOR BITTER ALOMONDS-CYANIDE
ACETONE – ISOPROPYL ALCOHOL,
METHANOL,
. PARALDEHYDE
ALCOHOL- ETHANOL
WINTERGREENT– METHYL
SALICYLATE
GARLIC – ARSENIC ,THALIUM ,
O.P

11. SUPPORTIVE CARE
• MOST OF CHILDREN ONLY REQUIRES SUPPORTIVE CARE
1. OBSERVATION
2. HYDRATION
3. NUTRITION
4. SEDATION
5. TREATMENT OF – HYPO/HYPERTHERMIA,HYPO/HYPER
GLYCAEMIA,AGITATION,SEIZURES

12. DECONTAMINATION
• DECONTAMINATION SHOULD NOT BE DISTRACT FROM
RESUSCITATION AND SUPPORTIVE CARE .
a. SKIN – WASH OFF WITH SOAPY WATER
b. EYES – IRRIGATE WITH 0.9 % NACI UNTILL PH IS <8.0
c. GI TRACT
- DILUTION WITH MILK/ WATER IS NOT RECOMMENDED.
- EMESIS SHOULD NEVER BE INDUCED .
- GASTIRC LAVAGE IS NOT RECOMMENDED .

13. • ACTIVATED CHARCOAL –
i. RARELY INDICATED IN PAEDIATRIC POISION ING .
ii. THE USE OF AC CARRIES A RISK OF ASPIRATION ANG
SUBSEQUENT CHEMICAL
iii. INDICATED IF ALL OF THE FOLLOWING ARE TRUE :-
- PRESENTATION WITHIN 1 HOUR OF INGESTION
- TOXIN IS ABSORBED BY AC
- PATIENT MAINTAINING OWN AIRWAY AND RISK ASSESSMENT
DETERMINES
- OTHERWISE ONLY GIVE IF AIRWAY IS PROTECTED
- THE SUBSTANCE HAS SIGNIFICANT TOXIXITY AND IS NOT EASILY
TREATABLE : 1 G/KG
CONTARINDICATION - ACIDS/ALKALIS ,ALCOHOLS,METALS AND
IONIC COMPOUNDS ,HYDROCARBONS

14. • WHOLE BOWEL IRRIGATION (WBI)
a) RARELY PERFORMED
b) INDICATED IF :-
-INGESTION OF A SLOW RELEASE OR EXTENDED
RELEASE SUBSTANCE OR A SUBSTANCE NOT BOUND
TO AC
- PRESENTATION PRIOR TO SYMTOM ONSET
- INGESTION IS LIKELY TO RESULT IN SIGNIFICANT
TOXICITY DESPITE SUPPORTIVE CARE OR ANTIDOTE
THERAPY
- POLYETHYLENE GLYCOL -30ML/KG/H UNTILL
EFFLUENT RUNS CLEAR

15. ENCHANCED ELIMINATION
• MULTIDOSE ACTVATED CHARCOAL
• URINARY ALKALINISATION
• EXTRACORPOREAL ELIMINATION ( HAEMODIALYSIS )

16. ANTIDOTE
POISON ANTIDOTE
•PARACETAMOL
•OPIODS
•BENZODIAZEPINES
•SODIUM CHANNEL BLOCKERS
•IRON
•GLIPIZIDE
•DIGOXIN
•ORGANOPHOSPHATES
•BETA BLOCKERS ,CA CHANNEL
BLOCKERS
N ACETYLCYSTEINE
NALOXONE
FLUMAZENIL
NAHCO3
DESFERROXAMINE
OCTREOTIDE
DIGOXIN FAB FRAGMENTS
PRALIDOXIME ,ATROPINE
INSULIN /DEXTROSE
EUGLYCAEMIC THERAPY

17. • THANK U