What to do?It is much more important step to think, than to provide an agent to reduce absorption of poison or to counteract its effects. The fact is Patient must be treated first and then the Poison.

1. “Principles Of
Management In A
Poisoned Patient”
1

2. The most important step in the
management of a poisoned patient
is,
what to do?
In what order to do?
2

3. What to do?
It is much more
important step to think, than to
provide an agent to reduce
absorption of poison or to
counteract its effects. The fact is
Patient must be treated first and
then the Poison.
3

4. In other words most important first
step is to save the life of the
patient. It will be of no value to
remove the chemical from the
patient’s stomach if he has stopped
breathing or his heart is fibrillating.
So always asses the patient first,
then what must be done and in
what order.
4

5. Once the victim is stabilised, only
then try to identify the poison, its
quantity involved and how much
time has passed.
SO THE FLOW CHART OF
MANAGEMENT WILL BE,
5

6. Victim
Removal of
unabsorbed
poison
Elimination
of absorbed
Poison
Symptomatic
Treatment
Universal
Antidoting

7. Steps of Management :
Clinical
evaluation
Symptomatic
treatment
• To relief
the pain
Removal of
unabsorbed
poison
• With skin
• In side
stomach

8. Removal of unabsorbedDilution of poison
Emesis
G Lavage
Cathartics
• Demulcents
• Adsorbents
Forced Diuresis
• Dialysis & Haemo-perfusion

9. Antidoting
Antidote
Non - Specific
Specific Anti doting

10. After clinical evaluation of the
patient and after saving the life of
the patient, the next aim should be,
1) Removal of unabsorbed
poison
2) Elimination of absorbed
poison from the body
3) Treatment of general
condition and symptoms
4) Universal Antidoting. 10

11. Steps of management will be,
1) Clinical evaluation
2) Non- Specific Anti-doting
3) Dilution of poison
4) Emesis
5) Adsorbents 11

12. 6) Cathartics
7) Lavage
8) Forced Diuresis
9) Demulcents
10) Dialysis &
Haemo-perfusion
11) Specific Anti-doting 12

13. 1.CLINICAL EVALUATION
It should be done
regarding specific signs and
symptoms of various poisons.
13

14. 2. Non-Specific Anti-doting:
Generalised procedures
exists for anti-doting symptoms of
most of the poisons. Most ingested
poisons are removed by emesis,
Inhaled poisons are treated with
oxygen and skin contaminations
are managed by washing with soap
& water. So anti-doting is by and
large always non-specific and is not
an unapproachable activity. 14

15. Specific anti-dotes are only used
when these are appropriate. When
a poison ingestion is suspected,
whether the victim is actually a
candidate for anti-dote therapy?
This question has no absolute
answer.
15

16. When poisoning is suspected and
the suspected poison is extremely
toxic, then anti-dote therapy should
be initiated without any delay.
Because many poisons do not
cause symptoms until many hours
after exposure. Also when the
ingested quantity of a poison is
unknown, it should be assumed
that it is sufficient to cause serious
problems. 16

17. Sometimes people are reluctant to
administer an emetic, hours after
poison is swallowed, thinking it is
too late. But it has been seen
effective even after 8-12 hours after
ingestion and victim vomit large of
clumps of poison. All patients of
poisoning event, confirmed or
suspected, should not be brushed
aside as unimportant. 17

18. 3. Dilution of the Poison:
The initial procedure
recommended, whenever ingestion
of poison is suspected, is to dilute
it. Water is the best fluid that
should be used. The quantity which
can be comfortably swallowed,
should be given.
18

19. Excessive fluid may distend the
stomach, which may cause
premature relaxation of pyloric
sphincter. And once this occurs it
becomes much more difficult to
remove the poison before it is
absorbed. Water causes two
functions, First it reduces gastric
irritation, Second it adds bulk to the
stomach which may be needed for
later emesis. 19

20. Carbonated beverages on one
hand causes distension of
stomach, and if the ingested poison
is corrosive, the gas may potentiate
perforation.
Milk contains fat, and if substance
is fat soluble, it may lead to serious
toxicity. Milk also delays emesis.
20

21. Whether ingested poison should be
diluted or not, is still a debateable
issue.
1) The chemicals are more readily
absorbed into blood when they are
diluted.
21

22. 2) Dilution of strong acids or bases
may cause serious problems than
benefits.
3) Dilution followed by emesis
when appropriate offer certain
advantages.
22

23. 4.Emesis:
It means to induce
vomiting. For many years emesis
has been mainstay for the
treatment of ingested poisons.
Emetics have been used for this
purpose and some of them are still
in use, eg; Syp. Of Ipecac
23

24. Chemically induced vomiting is
accepted as first line procedure for
anti-doting poisons. However many
common techniques and drugs
used for emesis have been shown
ineffective and even dangerous.
But they still occupy important
position in anti-doting many
poisons.
24

25. Certain precautions are to be
observed for all emetics,
25

26. 1. If the victim is
unconscious, the danger of vomitus
of being aspirated into the lungs
still exists, and cause chemical
pneumonia.
26

27. 2. If the poison is
convulsant, forced emesis may
precipitate convulsions.
27

28. 3. For petroleum distillates
special care is needed, because of
low surface tension & viscosity they
may aspirated into lungs during
emesis.
28

29. 4. If poison is a corrosive
acid or alkali, emesis should be
avoided because it may cause
further damage to the oesophagus.
Tissue damage in corrosives is
related to the contact time between
poison and tissue.
29

30. 5. If children under 6
months of age, then emetics should
not be given, because gag reflex is
poorly developed, may cause
choking with aspiration.
30

31. 6. In persons with severe
cardio-vascular problems, emetics
should not be given.
31

32. 5. Adsorbents: The absorption of
ingested poisons can be reduced
by use of adsorbents. Several
substances, Kaolin, Pectin,
Attapulgite are used.
Activated charcoal is very
useful and should be used for
adsorption of ingested poisons.
32

33. Another preparation known as
“Universal Antidote” is used. It
contains,
Tannic acid ________ 1 part
Magnesium Oxide___ 1 part
Activated Charcoal ___ 2 parts
33

34. The activated charcoal for many
years remained first choice
antidote. But experimentally it is
proved that charcoal component of
“Universal Antidote” adsorbs part of
MgO and Tannic acid. This results
in reducing the adsorptive
capability and hence reducing anti-
dotal capacity.
34

35. Tannic acid may be absorbed into
circulation and is hepatotoxic. Thus
“Universal Anti-dote” is no longer
recommended as an emergency
anti-dote.
35

36. Only Activated Charcoal is
regarded today as one of the most
important for removing ingested
chemicals from GIT.
In the stomach and intestine poison
diffuse onto the charcoal surface
and form tight Charcoal-Chemical
complex and passes out of body.
36

37. Activated charcoal is not contra-
indicated in any poison even when
it is not regarded as useful. Its only
restriction is in the absence of
bowel sounds.
37

38. Time interval:
It should be administered within
30 minutes, but even later
administration is beneficial.
Multiple small doses in 6 hours
is more beneficial.
Burnt toasts or crushed coal
are not accepted as substitutes.
38

39. Dose:
50-60 Grams in adults
15-30 Grams in children
Usually a ratio of 10 : 1, Charcoal
to Drug is given, But on one hand it
will become too large amount to be
swallow and secondly at multiple
occasions we do not know the
nature and amount of poison taken.
39

40. In the presence of food the
adsorptive property of charcoal is
reduced, so it is recommended that
higher dose should used in the
presence of food.
It should not be given within 30
minutes of syp of ipecac and
emesis will not occur.
40

41. 6.Cathartics:
These are the substances
which induce diarrhoea and toxic
substances are removed from GIT.
It reduces the contact time between
poison and the absorption site,
reduces potential for toxicity,
however requires several hours.
41

42. Cathartics can be recommended
for most of the poisons but it should
not be attempted,
1) When poison is strongly
corrosive, as it may increase
chemical injury.
2) In patients with
electrolyte disturbances or in
absence of bowel movements.
42

43. 7. Lavage:
Lavor ; To wash
Lavage is a process of washing
out the stomach with water, saline,
etc;
It is indicated when the poison
must be quickly removed from
stomach before emesis or where
emesis is contra-indicated.
43

44. Significance:
It may be life saving if it is
done early i.e. within 4-6 hours
after ingestion of poison.
If excessive vomiting has occurred,
then the benefit from stomach
wash are less, but even then it
should be done because poison
might be adherent to stomach wall.
44

45. Precautions & Contra-indications
It is absolutely contra-
indicated in corrosive poisoning,
coma, and strychnine poisoning but
can be performed with precaution
in petroleum distillates poisoning.
45

46. Procedure:
1) The patient should
lie prone or semi-prone on the side
preferably left lateral position. With
this position the pyloric end of the
stomach is upside and contents do
not enter intestine. And if the
patient vomits, this position
prevents the regurgitated material
from entering respiratory passages.
46

47. 2) Dentures if any should be
removed.
3) Airways should be cleared.
A wooden mouth gag with
central hole is used which prevents
the rubber tube from being bitten
off by the teeth.
47

48. 4) The stomach wash tube is
made up of flexible rubber about
1.5 meter long and external
diameter of 12.7 mm, sufficiently
stiff to avoid kinking.
5) A funnel is provided at the
top of the upper end.
48

49. 6) A suction bulb is provided in
the middle of the tube, which
sucks out fluids when siphon
action fails or to push air into
the tube to force out any
obstruction.
7) The lower end is blunt and
rounded to avoid any injury and
is perforated with many holes.
49

50. 8) The distance between lips
and cardiac end the stomach is
about 45 cms in adults. It is marked
at distance of 50 cms which means
that at this mark at lips the lower
end is into the stomach.
50

51. Technique:
The lower end of the
tube is lubricated with liquid
paraffin or glycerine, pass it
through the hole in the wooden
mouth gag, over the tongue down
the oesophagus. When the mark
reaches the lips, then the lower end
is in the stomach.
51

52. To confirm that, the tube is
in the stomach, a little air is forced
down the tube simultaneously
placing the stethoscope at the
epigastrium. You will hear a
bubbling sound if it is in the
stomach, or a hissing sound if in
the trachea. If the patient is
conscious, reflex coughing will
start. 52

53. After confirming tube is in the
stomach, half a litter plain water is
run into the funnel, which is held
above the level of head. The fluid
enters the stomach by gravity. The
funnel is then lowered, below the
level of stomach over a receptacle
and gastric contents will start
coming out by siphon action.
53

54. Too much fluid may force the
contents into the duodenum. The
first washing should be preserved
for analysis. Keep repeating this
process, each time using half a
litre, till the returning fluid is clear. A
total of 10 litres is generally
necessary for complete lavage.
54

55. Sometimes an appropriate
anti-dote can be used for washing.
If KMnO4 is used & the returning
fluid is pink, it indicates poison has
been neutralised. Some anti-dote
may be left in the stomach.
Magnesium sulphate or Sodium
sulphate to ensure purgation,
Activated charcoal to adsorb and
liquid paraffin as demulcent. 55

56. Before the with-drawl of tube, it
should be pinched to prevent
aspiration of material into air
passages.
In children stomach wash should
be done with soft Ryle’s tube, 8-12
French size. About 25 cms length
is sufficient to reach stomach.
56