Clinically oriented discussion of important notes in the management of common poisoning problems and their management.

2. Management of the
Poisoned Patient
By:
M. H. Farjoo M.D, Ph.D.
Shahid Beheshti University of Medical Sciences

3. Management of the Poisoned Patient
 Introduction
 Initial Management
 History & Physical Examination
 Decontamination
 Laboratory & Imaging Procedures
 Common Toxic Syndromes

6. Common Toxidromes

7. Initial Management
 Almost all patients who reach the hospital alive survive
with appropriate care, inpatient mortality rates are 0.2 to
0.5%.
 A specific toxicologic diagnosis only delays the CAB of
poisoning treatment.
 hypoglycemia may mimic ANY disease.
 Every adult with altered mental status should receive 50
ml of 50% dextrose (children 1 ml/kg of 50% dextrose).
 For benzodiazepine overdose: flumazenil, ≥1 mg.

8. Initial Management
 For opioid overdose: naloxone 0.4 - 2 mg IV.
 It is useful to remember that opioid drugs cause death
primarily by respiratory depression.
 If airway and breathing assistance have already been
instituted, naloxone may not be necessary.

9. Dextrose Vial 50% & 20%

10. Dextrose 50%

11. NALOXONE 0.4 mg/1mL

12. Flumazenil Ampule 0.1 mg / 1mL, 5 ml

13. History & Physical Examination
 Other causes of coma or seizures
should be looked for and treated.
Such as:
 Head trauma
 Meningitis
 Metabolic abnormalities

14. History & Physical Examination
 Hypertension and tachycardia are typical with
amphetamines, cocaine, and anticholinergic drugs.
 Hypotension and bradycardia denote CCBs, β
blockers, and sedative hypnotics.
 Hypotension with tachycardia is common with TCAs,
vasodilators, and β agonists.
 Hyperthermia is seen with sympathomimetics,
anticholinergics, and salicylates.
 Hypothermia is caused by any CNS-depressant

15. History & Physical Examination
 Miosis is typical of opioids, phenothiazines,
cholinesterase inhibitors, and deep coma.
 Mydriasis is common with amphetamines, cocaine,
LSD, and anticholinergic drugs.
 Typical odors of alcohol, and hydrocarbon solvents,
may be noted.
 Poisoning due to cyanide has an odor like bitter
almonds.

16. Note that atypical toxidromes are common because of mixed toxicant
exposures, so the examiner can be misled if relying only on this sign.

17. History & Physical Examination
 Horizontal nystagmus is characteristic of intoxication
with phenytoin, alcohol, barbiturates, and other
sedative drugs.
 The presence of both vertical and horizontal
nystagmus is strongly suggestive of phencyclidine
poisoning.
 Ptosis and ophthalmoplegia are characteristic features
of botulism.

18. spontaneous upbeat nystagmus (Video 1)
gaze-evoked nystagmus (Video 2)

19. History & Physical Examination
 The skin often appears flushed, hot, and dry in
poisoning with antimuscarinics.
 Excessive sweating occurs with organophosphates,
nicotine, and sympathomimetic drugs.
 Icterus may suggest hepatic necrosis due to
acetaminophen or Amanita phalloides poisoning.

20. Amanita phalloides

21. Amanita phalloides

22. History & Physical Examination
 Ileus is typical of poisoning with antimuscarinic,
opioid, and sedative drugs.
 Hyperactive bowel sounds, and diarrhea are common
with iron, arsenic, organophosphates, a phalloides,
and a muscaria.

23. Amanita muscaria

24. Amanita muscaria

25. Amanita muscaria

26. Amanita muscaria

27. History & Physical Examination
 Focal neurologic defects suggest a structural lesion
(intracranial hemorrhage) rather than toxic
encephalopathy.
 Seizures are caused by antidepressants (TCAs),
cocaine, amphetamines, and theophylline.
 Flaccid coma with absent reflexes and even an
isoelectric EEG may be seen with CNS depressant
intoxication
 This may be mistaken for brain
death.

28. Decontamination
 Decontamination involves removing toxins from the
skin or GI tract.
 Contaminated clothing should be completely removed
and double-bagged to prevent illness in health care
providers.
 Wash contaminated skin with soap and water.
 Use of emetics or gastric lavage, is controversial
especially more than 1 hour after ingestion.

29. Decontamination
 For most ingestions, activated charcoal can bind
poisons in the gut.
 Activated charcoal is most effective if given in a ratio
of at least 10:1 of charcoal to estimated dose of toxin
by weight.
 It is not useful for iron, lithium, potassium, alcohols,
cyanide, corrosive acids and alkali.
 it is contraindicated for hydrocarbons ingestion
(kerosene & gasoline).

30. Activated Charcoal

31. Activated carbon, as viewed by an electron microscope

32. Activated Charcoal Tab
price of each pack: 39,000 Toman

33. ‫فعال‬ ‫ذغال‬

34. Activated Charcoal

35. Decontamination
 Emetics should NOT be used if the intoxicant is a
corrosive agent, or a petroleum distillate.
 Inducing emesis by provoking gag reflex, salt water,
and apomorphine should not be used.
 As large a tube as possible should be used for gastric
lavage, solutions should be at body temperature.
 Laxatives may hasten removal of toxins from the GI
tract and reduce absorption.

36. Apomorphine 5 mg/ ml
Price of each vial: 265,000 Toman

37. Apomorphine 10 mg/ ml
Price of each vial: 265,000 Toman

38. Decontamination
 Forced diuresis may cause volume overload and
electrolyte abnormalities and is not recommended.
 Urinary alkalinization is useful in cases of salicylate
overdose.
 Peritoneal dialysis is inefficient in removing most
drugs.
 Hemodialysis is useful in methanol poisoning, and
ethylene glycol poisoning.
 Hemodialysis is especially useful when the drug can
be removed and electrolyte imbalances are present
(salicylate intoxication).

39. Laboratory & Imaging Procedures
 The Po2 measures only oxygen dissolved in the
plasma.
 It does not reflect total blood oxygen content or
oxyhemoglobin saturation.
 Po2 may appear normal in patients with severe carbon
monoxide poisoning.
 Pulse oximetry may also give falsely normal results
in carbon monoxide intoxication.

40. Common Toxic Syndromes

41. Common Toxic Syndromes

42. Common Toxic Syndromes
 Acetaminophen
 Aspirin
 Cholinesterase Inhibitors
 Antidepressants
 Amphetamines & Other Stimulants
 Ethanol and Methanol
 Arsenic ‫موش‬ ‫مرگ‬ / ‫واجبی‬
 Aluminium phosphide ‫برنج‬ ‫قرص‬
 Cyanide
 Hydrocarbons

43. Acetaminophen
 Ingestion of >150 mg/kg in children or 10 g (~30 tablets)
in adults is toxic and >20 g (~60 tablets) are fatal.
 After 2-4 days, liver injury and even death may happen.
 Hypoglycemia results from liver failure, and plasma
glucose should be monitored closely.
 Activated charcoal, if given within 4 h of poisoning,
decreases absorption by 50%–90%.
 The antidote is acetylcysteine, which binds the toxic
metabolite.
 It should be started within 8-10 hours.

44. Aspirin
 Acute ingestion of more than 200 mg/kg produces
intoxication.
 At first hyperventilation and respiratory alkalosis
happens.
 Then, Metabolic acidosis follows, and anion gap
increases from accumulation of lactate.
 Signs of toxicity may be delayed after overdoses of
enteric-coated tablets.
 Treatment is supportive.

45. Cholinesterase Inhibitors
 Care providers may be poisoned by
contaminated clothing, and Antidote is
atropine.

46. Antidepressants
 Ingestion of more than 1 g of a tricyclic (or about
15-20 mg/kg) is lethal.
 Treatment of TCA overdose is supportive.

47. Amphetamines & Other Stimulants
 Stimulant drugs include:
 Methamphetamine ("crank," "crystal")
 Methylenedioxymethamphetamine (MDMA, "ecstasy")
 Cocaine ("crack")
 Pseudoephedrine (sudafed)
 Ephedrine.

48. Ephedra distachya
(Ephedrin Plant)

49. Ephedra sinica
(Ephedrin plant)

50. Ephedrin plant

51. Ephedra sinica
(Ephedrin)

52. Amphetamines & Other Stimulants Cont’d
 At high doses, agitation, and psychosis may occur.
 For body temperatures > 40°C, neuromuscular
paralysis is used to abolish muscle activity.
 Hyperthermia may result from sustained muscular
hyperactivity
 This can lead to muscle breakdown and
myoglobinuria, renal failure, lactic acidosis, and
hyperkalemia.
 There is no specific antidote.
 Seizures and hyperthermia must be treated
aggressively with IV lorazepam.

53. Ethanol and Methanol
 There is no antidote for ethanol.
 Methanol poisoning causes blurred vision and
blindness.
 Methanol is metabolized by alcohol dehydrogenase to
formic acid (severe metabolic acidosis).
 Alcohol dehydrogenase prefers ethanol to methanol.
 For methanol poisoning, ethanol is given orally or IV
(5% pharmaceutical grade) as 42 g/70 kg.

54. fl oz = US fluid ounce
1 fl oz = 29.5 ml

56. Alcoholic Beverage Source
Alcohol Content
(%ABV)
Standard Drink
Beer (standard) Cereals 3-4 300-400ml
Beer (Strong) Cereals 8-11 100-150ml
Wine
Grapes (and
other fruits)
5-13 100-250ml
Fortified Wine
Grapes (and
other fruits)
14-20 60-90ml
Distilled Spirits
Fruits, cereals,
sugarcane
40 30ml
Arrack
Coconut flowers,
sugarcane, grain
33 40ml
Toddy
Palm sap,
coconut flowers
5-10 200ml
Indian Made Foreign
Liquor (IMFL)
Molasses, grain 42.8 30ml

57. ‫عرق‬‫سگی‬‫الکل‬‫بیشتری‬‫از‬
‫انواع‬‫دیگر‬‫عرق‬‫داشته‬‫و‬
‫سنگینتر‬‫است‬.‫میزان‬‫الکل‬
‫موجود‬‫در‬‫این‬‫نوع‬‫مشروب‬
‫تا‬۹۰٪‫نیز‬‫گزارش‬‫است‬‫شده‬
(‫معادل‬‫قویترین‬‫ودکای‬
‫روسی‬)‫ولی‬‫به‬‫طور‬‫معمول‬
‫بین‬۴۵‫تا‬۵۵‫درصد‬‫است‬.
‫تولید‬‫عرق‬‫سگی‬‫بصورت‬‫سنتی‬
‫و‬‫پنهانی‬‫و‬‫بدون‬،‫نظارت‬
‫بارها‬‫جان‬‫ای‬‫عده‬‫از‬
‫ایرانیان‬‫را‬‫به‬‫خطر‬
‫انداخته‬‫است‬.

58. Alcohol intoxicated person

59. Arsenic (‫موش‬ ‫)مرگ‬
 The lethal dose ranges from 100 to 300 mg which is
present in 10 g of the poison.
 Intoxication causes: Excessive salivation, nausea,
vomiting, colicky abdominal pain, and profuse
watery, bloody diarrhea.
 Acute psychosis, and seizures may occur.
 Death occurs within 1 to 4 days.
 Treatment involves bowel irrigation and chelation
therapy (Dimercaprol).

60. Dimercaprol
Price of each ampule: 240,000 Toman

61. Arsenic (‫نظافت‬ ‫)داروی‬
‫که‬ ‫نظافت‬ ‫داروی‬‫آن‬ ‫به‬‫واجبی‬‫یا‬‫نوره‬
،‫شود‬‫می‬ ‫گفته‬ ‫هم‬‫به‬‫و‬ ‫است‬ ‫سفید‬ ‫رنگ‬‫از‬
‫و‬ ‫آهک‬ ‫شدن‬ ‫آمیخته‬‫زرنیخ‬‫درست‬‫شود‬‫می‬.
‫همان‬ ‫زرنیخ‬‫سولفید‬‫آرسنیک‬‫است‬.
‫آرسنیک‬ ‫های‬‫نمک‬،‫اسیدی‬‫و‬‫بازی‬ ‫آهک‬
‫و‬ ‫خورنده‬ ‫بسیار‬ ‫آنها‬ ‫مخلوط‬ ‫لذا‬ ‫و‬ ‫بوده‬
‫است‬ ‫مخاطی‬ ‫بافتهای‬ ‫به‬ ‫رسان‬ ‫آسیب‬.
‫هم‬ ‫خودکشی‬ ‫به‬ ‫اقدام‬ ‫در‬ ‫واجبی‬ ‫از‬
‫است‬ ‫شده‬ ‫استفاده‬.
‫در‬‫تولیدات‬‫جدید‬‫از‬ ،‫باریوم‬‫سولفات‬‫به‬

62. ‫زرنیخ‬

63. ‫برنج‬ ‫قرص‬

64. ‫برنج‬ ‫قرص‬

65. ‫برنج‬ ‫قرص‬

66. Aluminium Phosphide (‫برنج‬ ‫)قرص‬
 This agent liberates free radicals and cellular hypoxia
due to inhibition of cytochrome C oxidase.
 The signs and symptoms are nonspecific and
instantaneous.
 The toxicity particularly causes profound and
refractory hypotension, and congestive heart failure.
 The diagnosis is by clinical suspicion or history.
 The mortality rates vary from 40% to 80%.
 Management remains primarily supportive.

67. Cyanide Poisoning
 Cyanide poisoning results in tissue anoxia by
chelating the ferric part of cytochrome oxidase.
 It uncouples oxidative phosphorylation and inhibits
cellular respiration.
 Poisoning may results from:
 Inhaling smoke from burning foams in furniture
 Ingesting amygdalin (in the kernels of pear, apricot,
bitter almond, plum, apple, cherry and peach)
 Excessive use of sodium nitroprusside for severe
hypertension.

68. Sources of cyanide
Drugs
Sodium Nitroprusside
Cigarette smoking
Combustion
Wool
Silk
Polyurethanes
Polyacrylonitriles
Nylon
Melamine resins
Plastics

69. Cyanide Poisoning
 The symptoms are due to tissue anoxia (dizziness,
palpitations, a feeling of chest constriction and
anxiety).
 The breath smells of bitter almonds.
 In more severe cases there is acidosis and coma.
 Inhaled cyanide kills within minutes, but ingested salt
require several hours.
 Inhalation of 2,000 parts per million hydrogen
cyanide causes death within one minute, the LD50 for
ingestion is 50-200 milligrams.

70. Cyanide Poisoning
 hydroxocobalamin (5 g for an adult) which combines
cyanide to form cyanocobalamin and is excreted by
the kidney.
 Alternatively, IV sodium nitrite (10 mg/kg) produces
methaemoglobin, and its ferric ion takes up cyanide
as cyanmethaemoglobin.
 After sodium nitrite, IV sodium thiosulphate 25% (50
mL), which forms thiocyanate.

71. Cyanide poisoning

72. Hydrocarbons
 Activated charcoal is contraindicated poisoning.
 Inhalation injury may manifest up to 6 hrs after
exposure.
 Hydrocarbons can cause rapid onset CNS depression
and seizures.
 Volatile hydrocarbons can be aspirated and cause
chemical pneumonitis.
 Induction of vomiting is controversial and is not
prudent with light weight substances (danger of
aspiration).

73. Specific
Antidotes

74. Specific
Antidotes

76. Thank you
Any question?