 NAME: RIYAVISAVADIYA
 ROLL NO. : 86
 MO. NO: 8153850989
 Email ID :
riyasvisavadiya@gmail.com
 BATCH - 2014
 Poison is a substance [ solid, liquid or gaseous]
which if introduced in the living body 0r brought
into contact with an...
 Poisoning occurs when any substance interferes
with normal body functions after if is swallowed,
inhaled or absorbed.
 ...
 The early history of poison is described in the
ancient Indian shastras , Egyptian papyri, Sumerian,
BabyIonian ,Hebrew ...
 The Italians brought the art of poisoning to its
zenith prior to 6th century A.D.
 Orfila (spanish chemist,1787-1853) w...
 Poisoning both accidental and intentional are a
significant contributor to mortality and morbidity
throughout the world....
 Acute poisoning forms one of the commonest
causes of emergency hospital admissions.
 It has been estimated that about 5...
 A Poison control center is a medical facility that is
able to provide immediate ,free and expert treatment
advice and as...
 It was a methyl isocynate (MIC) which leaked in
Bhopal considered the world ‘s worst industrial
disaster.
 It exposed m...
 Principles of management consist of;
i. Stabilization.
ii. Gut Decontamination.
iii. Antidote administration
iv. Elimina...
 None (0) – no symptoms or signs judged not
to be related to poisoning.
 Minor (1)- Mild, transient and spontaneously
re...
 Antidotes are available for very few
commonly encountered poisons, and
treatment is usually non-specific and
symptomatic...
 The unconscious patient should be transported in
the head down semiprone position to minimize the
risk of inhalation of ...
 Scandinavian Regime is a term used for anti shock
measures when the patient is going into shock.
 It includes ABCD of r...
 Opening up and cleaning up the airway (oral cavity ,
nostrils) of secretions, vomit or any other foreign
body might be l...
4 October 2016 General Management of Poisoning 18
 If the arterial blood gas cannot be maintained
inspite of establishing an effective airway, then
graduated supplement ox...
 I.V. Fluid administration may be life sustaining line.
 Maintenance of fluid and electrolyte balance and
administration...
 An unconscious patient should be turned to
lie on one side to stop the tongue blocking
the throat and to allow fluid to ...
4 October 2016 General Management of Poisoning 22
 NAME: Samarth Dubey
 ROLL NO. : 90
 MO. NO: 9153850989
 Email ID :
dubeysamarth@gmail.com
 BATCH - 2014
4 October 2016 General Management of Poisoning 24
4 October 2016 General Management of Poisoning 25
4 October 2016 General Management of Poisoning 26
 Agent & Amount
 Time & Location of Exposure
 Route
 Intake of Other Substances
 Circumstances of Exposure
 Current ...
 Examine General Status
(height/weight/built/TPR, etc.)
 See the Skin (color change)
 Smell the breath
(fruity/alcoholi...
 May need to remove clothing for thorough exam
 Check clothing for objects or substances
 Assess general appearance of ...
 Heart: rhythm, rate, regularity
 Lungs: bronchorrhea or wheezing
 Abdomen: bowel sounds,
tenderness or rigidity
 Neur...
Rash – Allergic Reaction
4 October 2016 General Management of Poisoning 31
Lead poisoning
Mees line – Arsenic Poisoning
4 October 2016 General Management of Poisoning 32
Cyanosis – Cyanide poisoning
Jaundice Hypercarotenemia
4 October 2016 General Management of Poisoning 33
 Coma & Hypothermia
 Hypotension
 Hypertension
 Arrhythmias
 Seizures
 Hyperthermia
4 October 2016 General Managemen...
 Go hand-in-hand
 Ingestion of large doses of:
 Antihistamines (diphenhydramine)
 Sedative/Hypnotic drug
(Benzodiazepi...
 Drugs-
 antihypertensive drugs
(α-blockers/CCB/β-blockers)
 disulfiram (ethanol Interaction)
 Iron
 Trazodone, queti...
Nature of poisoning Treatment
TCAs/Sod. channel blockers NaHCO3 50–100 mEq
i.v.bolus injection
NE 4–8 mcg/min
i.v. infusio...
 Amphetamines
 Anticholinergics
 Cocaine
 Performance-enhancing products
 Caffeine
 Phenylephrine
 Ephedrine
 Yohi...
Hypertension with…. Treatment
agitation and anxiety Lorazepam 2–3 mg
i.v.
persistent nature Phentolamine 2–5 mg
i.v.
OR
So...
4 October 2016 General Management of Poisoning 40
Cause Treatment
Electrolyte imbalance
↑K+
↓K+, Mg2+,Ca2+
Correct accordingly
Ventricular arrhythmias Lidocaine/ Amiodarone...
 Drugs-
 Amphetamines, cocaine
 Antidepressants (especiallyTCAs,
bupropion, and venlafaxine)
 Antihistamines (especial...
Lorazepam, 2–3 mg,
or diazepam, 5–10
mg, i.v.
over 1–2 minutes
OR
i.v. unavailable—
midazolam, 5–10 mg
i.m.
If convulsions...
 Amphetamines (MDMA;
“Ecstasy”), atropine and other
anticholinergics
 Cocaine, salicylates, strychnine
 TCA
 SSRI(eg, ...
 Removing the patient’s clothing
 Spray the skin with tepid water & fanning.
 Muscle rigidity/hyperactivity –
 NM para...
Hyperthermia… Treatment
With rigidity /
Malignant hyperthermia
Dantrolene 2–5 mg/kg i.v.
Neuroleptic malignant syndrome Br...
4 October 2016 General Management of Poisoning 47
 Serum osmolality & osmol gap
 Electrolytes and anion gap
 Blood glucose
 S. Creatinine
 BUN
 CK
 Urinalysis; e.g.-...
Laboratory test Observation
Osmol gap ↑s in presence of large
quantities of low-
molecular-weight
substances
Anion gap ↑s ...
4 October 2016 General Management of Poisoning 50
 NAME:Ruchit Patel
 ROLL NO. : 87
 MO. NO: 9824565789
 Email ID :
ruchitpatel@gmail.com
 BATCH - 2014
 External
 Protect yourself and others
 Remove exposure
 Irrigate copiously with water or normal
saline
 Don’t forget...
 Skin
 Protect yourself and other workers
 Remove clothing
 Flush with water or normal saline
 Use soap and water if ...
 Eyes
 Remove contact lens
 Flush copiously with water or normal saline
 Use local anesthetic drops
 Continue irrigat...
 Inhalation
 Give supplemental humidified oxygen
 Observe for airway obstruction
 Intubate as necessary
GAG REFLEX
 The actions of ipecac are mainly those of
major alkaloids(emetine and cephaeline).
 Action :
 Local : irritate the gas...
 Gastric lavage , also commonly called gastric
irrigation, is the process of cleaning out the
contents of the stomach.
 ...
Ewald’s
tube
Materials used
1:5000 kmno4,5%
sodium bicarbonate,4%
tannic acid,1% sodium
iodide and lime water
 Gastric lavage involves the passage of a tube (such as
an Ewald tube) via the mouth or nose down into the
stomach follow...
INDICATION
CONCIOUS
PATIENT
WITHIN 2 hrs
C/I
CORRROSIVE
POISON
COMATOSE
PATIENT
COMPLICATION
ASPIRATION
PNEUMONIA
PERFORAT...
 Sorbitol is cathartic of choice.
 Sodium sulphate may also be used.
 Activated carbon, also called activated
charcoal, is a form of carbon processed to
have small, low-volume pores that inc...
 It is not effective for a number of poisonings
including strong acids or
alkali, cyanide, iron, lithium,
arsenic, methan...
 Whole bowel irrigation (WBI) is a medical
process involving the rapid administration of
large volumes of an osmotically ...
 NAME: Sachin Patel
 ROLL NO. : 88
 MO. NO: 9159850809
 Email ID :
sachinpatel1243@gmail.com
 BATCH - 2014
4 October 2016 General Management of Poisoning 70
According toWHO -
“Antidote was defined as a
therapeutic substance used
...
 Paracetamol
 Methanol
 Benzodiazepines
 Opiates
4 October 2016 71General Management of Poisoning
:- Acetyl cysteine &...
 Organophosphates :- Atropine
 Dhatura :- Physostigmine
 Botulinum toxin :- Guanidine
 Methamoglobinemia :- Methelene ...
 Cyanide :- Amyl Nitrate + Na Thio
Sulphate
 CO :- Hyper Baric Oxygen
4 October 2016 73General Management of Poisoning
 Arsenic :- hydrated ferric oxide,
DMSA,BAL
 Copper :- Potassium ferrocyanide,
Penicillamine
 Ergot :- Sodium Nitroprus...
 Cadmium :- N-Acetyl Penicillamine
 Isoniazid :- pyridoxine
 Heparin :- Protamine Sulphate
 Warfarin :- Vit. K1
 TCA ...
 Common salt
 Silver Nitrate
 Mercury Chloride
 Copper Sulphate
 Phosphorus
 Arsenic
 Albumin
 Dialyzed iron
4 Oct...
It is a combination of physical and
chemical antidotes
 It is an absolute antidote and had only
historical importance
4 O...
Composition :-
 Magnesium oxide (1
part) neutralizes acid
without gas formation
 Charcoal (2 parts)
absorbs alkaloids
 ...
 It is combination of 3
medicines can be
given in unknown
poisoning with coma -
Dextrose (50%) 100 ml
Nalaxone 2 mg
B1(Th...
 EDTA
 BAL
 Succimer
 Penicillamine
 Desferrioxamine
4 October 2016 80General Management of Poisoning
 EDTA is prescription
medicine, given by
injection into the vein
(intravenously) or into the
muscle (intramuscularly).
 ...
 Intravenous EDTA is used to treat lead poisoning
and brain damage caused by lead poisoning; to
evaluate a patient's resp...
 EDTA is also used intravenously
for heart and blood vessel conditions including
irregular heartbeat due to exposure to c...
 Heart rhythm problems: EDTA might make
heart rhythm problems worse.
 Diabetes: EDTA might interfere with blood
sugar co...
 Liver problems and hepatitis: EDTA might
make liver disease worse. Avoid using EDTA if
you have a liver condition.
Kidne...
It is given by intramuscular route (5mg/kg
stat followed by 2 to 3mg/kg every 4 to 8
Hours for 2 days and then once a day ...
 BAL has two SH groups. The two SH groups binds to
those metals that produce toxicity by interacting with
sulfhydryl cont...
 BAL is useful against metals that interfere
with sulfhydryl enzymes in the body such
as arsenic , mercury , bismuth , co...
 In liver damage
 G6PD deficiency
 Iron and cadmium toxicity
4 October 2016 89General Management of Poisoning
Serious side effects:
 Fast heart rate, feeling anxious or restless;
 Pain or tightness in your throat, chest, or
hands;...
Less serious side effects include:
 Nausea, vomiting, stomach pain
 Numbness or tingling (especially around your
mouth)
...
Also known as a
“Dimercaptosuccinic acid”.
Similar to BAL in chelating
properties
Less toxic than BAL and
orally effective...
 Nausea
 Vomiting
 Loss of appetite
 Diarrhea
4 October 2016 General Management of Poisoning 93
 Also known as “D-penicillamine Cuprimine”
 It is dimethyl cysteine , obtained as a degradation product of
penicilline a...
 Copper poisoning :- drug of choice
 Mercury poisoning:- alternative to BAL
 Chronic lead poisoning
 Wilson’s disease
...
 For copper and mercury poisoning :-
1 to 1.5 gm/day in divided doses
 For wilson’s disease :- 0.5 to 1gm/day in
divided...
Diarrhea
loss of appetite
mild stomach pain
nausea
vomiting
4 October 2016 General Management of Poisoning 97
 Ferrioxamine is long chain iron containing
complex obtained from an actinomycete.
 Chemical removal of iron from it yie...
 Desferrioxamine molecule
turns round the ferric ion
and forms a stable non-
toxic complex that is
excreted in urine.
 1...
 Acute iron poisoning
 Transfusion siderosis
4 October 2016 100General Management of Poisoning
 Iron poisoning :- drug of choice
 Given intramuscularly-0.5 to 1gm repeatedly
4 to 12 hourly
 Patient with shock recei...
4 October 2016 General Management of Poisoning 102
 Diarrhea
 Dizziness
 Headache
 Mild stomach pain
 Nausea
 Stomac...
NAME: Sagarika Upadhyay
ROLL NO. : 89
MOBILE NO.:9099938328
Email.:-
upadhyaysagarika@gmail. Com
BATCH - 2014
 Forced diuresis
 Hemodialysis & Peritoneal dialysis
 Haemoperfusion
 Multiple dose activated charcoal
General Managem...
 Increased urine formation by diuretics or with
manipulation of urine pH .
 The renal tubular epithelium is relatively
i...
 Poison with following properties can be eliminated
by FORCED DIURESIS:-
1. Substance excreted mainly by kidneys.
2. Subs...
IN ACIDIC URINE IN BASIC URINE
(after NaHCO3 infusion)
uncharged form
(lipid-soluble,
diffusible across
lipid membranes)
R...
This method acts depending on the extent of ionization(pka)
1>forced alkaline diuresis
By achieving urinary pH of 7.5 to 9...
 Diuretics are needed to maintain high
urine flows.
 To prevent hypokalaemia potassium added.
 The vitals of the patien...
2> Acid diuresis
 Is uncommonly used method for certain poisons like
amphetamine.Vitamin C titrated to acidic urine pH .
...
 Solute diffusion across a semi-permeable membrane
down a concentration gradient from circulation into
dialysate.
 Haemo...
 Semipermeable membrane is of 4 category:-
 Cellulose
 Substituted cellulose
(e.g. cellulose acetate)
 Cellulosyntheti...
 Rate of diffusion depends on :-
 Magnitude of the concentration gradient
 Membrane surface area
 Porosity & thickness...
 Consist of a plastic device with the facility to
perfuse blood and dialysate compartments at
very high flow rates.
 The...
 Two geometric configurations of dialysers:
1) Hollow fiber
 Commonly used
 Composed of bundles of
capillary tubes thro...
4 October 2016 General Management of Poisoning 117
Hollow fiber Flat plate
 Dialyzers
 For the patient on chronic dialysis.
 To reduce the expense of individual dialyzer.
 Only the dialyzer unit is reproce...
 It consist of
1. Sequential rinsing of the blood and dialysate
compartments with water.
2. A chemical clearing step with...
SOLUTE BICARBONATE DIALYSATE
Sodium( meq/L) 137-143
Potassium( meq/L) 0-4.0
Chloride( meq/L) 100-111
Calcium( meq/L) 0-3.5...
 Using a roller
mechanism.
 moves blood at the
flow rate 250 to
500mL/min.
4 October 2016 General Management of Poisonin...
4 October 2016 General Management of Poisoning 122
4 October 2016 General Management of Poisoning 123
Clearance of urea =
200-350mL/min
 Hypotension(most common particularly in diabetics)
 Muscle cramps
 Electrolyte imbalance
 Cross infections
 Bleeding...
 peritoneum as semipermiable membrane.
 Infusing 1 to 3 L of a dextrose-containing
solution into the peritoneal cavity a...
A. CAPD=Continues ambulatory peritoneal dialysis
 (During day & 3 to 4 time)
 (midnight dwell at bedtime and remains thr...
COMPLICATIONS :
 Intra-abdominal bleeding
 Perforation of abdominal organs
 Peritonitis
 Dehydration or over hydratio...
4 October 2016 General Management of Poisoning 128
 Using equipment similar to that for haemodialysis,
the blood is pumped directly through a column
containing an adsorbent...
 Because the drug or toxin is in direct contact
with the adsorbent material, drug size, water
solubility and protein bind...
CONTRAINDICATIONS:
 Patients with coagulopathy
 Patients with uncontrolled hypotension
COMPLICATIONS:
 Thrombocytopen...
4 October 2016 General Management of Poisoning 132
 More than 2 doses of oral activated charcoal.
 Free charcoal available in the intestines to bind any
toxin
 free toxin...
 DOSE: Optimum dose is unknown.
Adult dose = from 50 to 100 grams per
dose, administered at the rate no less than 12.5
gr...
1. The toxin has long half life
2. Toxin has a significant enterohepatic circulation
(digoxin, phenobarbital, theophylline...
 Contraindicated:
 in the presence of ileus ( disruption of the
normal propulsive ability of the gastrointestinal
tract ...
 The need for ministration of cathartics such
as sorbitol remains unproven and is not
recommended.
 Should not be used i...
In summary, physicians should take the best
judgment according to the presence of
contraindications and the effectiveness...
THANK YOU
4 October 2016 General Management of Poisoning 139
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management of poisoning

  1. 1.  NAME: RIYAVISAVADIYA  ROLL NO. : 86  MO. NO: 8153850989  Email ID : riyasvisavadiya@gmail.com  BATCH - 2014
  2. 2.  Poison is a substance [ solid, liquid or gaseous] which if introduced in the living body 0r brought into contact with any part thereof will produce ill- health or death, by its constitutional or local effects or both.
  3. 3.  Poisoning occurs when any substance interferes with normal body functions after if is swallowed, inhaled or absorbed.  The branch of medicine that deals with the detection and treatment of poisons is known as Toxicology.
  4. 4.  The early history of poison is described in the ancient Indian shastras , Egyptian papyri, Sumerian, BabyIonian ,Hebrew and Greek records.  Among vedas- AtharvaVeda (1500 BC) describes poisons.  Susrutha (350 BC) Described as how poisons were mixed with food and drink ,medicine , snuff etc.
  5. 5.  The Italians brought the art of poisoning to its zenith prior to 6th century A.D.  Orfila (spanish chemist,1787-1853) was first to attempt a systemic correlation between the chemical and biologic information of the poisons known them.  Others who worked are Marsh, Magendie, Ambrose, Scheelle, Robert Christison and Rudolf Kobert.
  6. 6.  Poisoning both accidental and intentional are a significant contributor to mortality and morbidity throughout the world.  According toWHO three million acute poisoning cases with 2,20,000 deaths occur annually. Of these 90% of fatal poisoning occur in developing countries particularly among agricultural workers. 4 October 2016 General Management of Poisoning 7
  7. 7.  Acute poisoning forms one of the commonest causes of emergency hospital admissions.  It has been estimated that about 5 to 6 persons per lakh of populations die due to lake of proper immediate treatment of poisoning.  To prevent these deaths, poison centres were developed. 4 October 2016 General Management of Poisoning 8
  8. 8.  A Poison control center is a medical facility that is able to provide immediate ,free and expert treatment advice and assistance over the telephone is case of exposure to poisonous or hazardous substances.  It answer questions about potential poisons in addition to providing treatment management advice about household products ,plants ,bites ,pesticides , food poisoning and fumes.  It is useful to prevent sudden massive poisonous outbreaks like Bhopal gasTragedy.
  9. 9.  It was a methyl isocynate (MIC) which leaked in Bhopal considered the world ‘s worst industrial disaster.  It exposed more than 5,00,000 people to toxic gases.  A mixture of poisonous gases flooded the city, causing great panic as people woke with burning sensation in their lungs.  Thousands died immediately from the effects of the gas.
  10. 10.  Principles of management consist of; i. Stabilization. ii. Gut Decontamination. iii. Antidote administration iv. Elimination v. Symptomatic treatment.
  11. 11.  None (0) – no symptoms or signs judged not to be related to poisoning.  Minor (1)- Mild, transient and spontaneously resolving symptoms.  Moderates (2)- pronounced or prolonged symptoms.  Severe (3)- severe or life threatening symptoms.
  12. 12.  Antidotes are available for very few commonly encountered poisons, and treatment is usually non-specific and symptomatic.  In such cases management and stabilization measures, appropriate treatment to reduce absorption, measures to enhance life support followed by psychiatric counselling.
  13. 13.  The unconscious patient should be transported in the head down semiprone position to minimize the risk of inhalation of gastric contents.  A Clear Airway and ventilation.  Potentially serious abnormalities such as metabolic acidosis, hyper kalamia and hypo glycemia may require correction as a matter of urgency.
  14. 14.  Scandinavian Regime is a term used for anti shock measures when the patient is going into shock.  It includes ABCD of resuscitation. A. Airway B. Breathing C. Circulation D. Depression of CNS
  15. 15.  Opening up and cleaning up the airway (oral cavity , nostrils) of secretions, vomit or any other foreign body might be life saving.  Protecting and securing the airway by means of endo tracheal intubation may be necessary.  Proper positioning head tilt and chin lift and falling back of tongue is prevented by suitable airway tube must be present.
  16. 16. 4 October 2016 General Management of Poisoning 18
  17. 17.  If the arterial blood gas cannot be maintained inspite of establishing an effective airway, then graduated supplement oxygen therapy either by a ventimask or through endo tracheal tube should be administered.  If necessary positive pressure ventilation with monitoring and respiratory stimulants for severe depression should be applied.
  18. 18.  I.V. Fluid administration may be life sustaining line.  Maintenance of fluid and electrolyte balance and administration of I.V. Drugs for treatment is needed.
  19. 19.  An unconscious patient should be turned to lie on one side to stop the tongue blocking the throat and to allow fluid to come out of the mouth. (recovery position)  Most of the poisoning cases , whether they are conscious or unconscious recover with supportive care alone.
  20. 20. 4 October 2016 General Management of Poisoning 22
  21. 21.  NAME: Samarth Dubey  ROLL NO. : 90  MO. NO: 9153850989  Email ID : dubeysamarth@gmail.com  BATCH - 2014
  22. 22. 4 October 2016 General Management of Poisoning 24
  23. 23. 4 October 2016 General Management of Poisoning 25
  24. 24. 4 October 2016 General Management of Poisoning 26
  25. 25.  Agent & Amount  Time & Location of Exposure  Route  Intake of Other Substances  Circumstances of Exposure  Current Medications  Past Medical History  Pre-HospitalTreatment 4 October 2016 General Management of Poisoning 27
  26. 26.  Examine General Status (height/weight/built/TPR, etc.)  See the Skin (color change)  Smell the breath (fruity/alcoholic/garlic, etc.)  Listen the Lungs  Hear the Heart  Asses the Abdomen  Perform Neurological Exam 4 October 2016 General Management of Poisoning 28
  27. 27.  May need to remove clothing for thorough exam  Check clothing for objects or substances  Assess general appearance of patient – Orientation, Agitation, confusion, or obtundation  Ocular Examination  pupils size  Nystagmus  Reactivity to light  dysconjugate gaze  increased lacrimation  Oropharynx for increase salivation or excessive dryness  Extremities: fasciculation's, tremor 4 October 2016 General Management of Poisoning 29
  28. 28.  Heart: rhythm, rate, regularity  Lungs: bronchorrhea or wheezing  Abdomen: bowel sounds, tenderness or rigidity  Neuro: CNS, reflexes, muscle tone coordination, cognition, ability to ambulate 4 October 2016 General Management of Poisoning 30
  29. 29. Rash – Allergic Reaction 4 October 2016 General Management of Poisoning 31 Lead poisoning
  30. 30. Mees line – Arsenic Poisoning 4 October 2016 General Management of Poisoning 32 Cyanosis – Cyanide poisoning
  31. 31. Jaundice Hypercarotenemia 4 October 2016 General Management of Poisoning 33
  32. 32.  Coma & Hypothermia  Hypotension  Hypertension  Arrhythmias  Seizures  Hyperthermia 4 October 2016 General Management of Poisoning 34
  33. 33.  Go hand-in-hand  Ingestion of large doses of:  Antihistamines (diphenhydramine)  Sedative/Hypnotic drug (Benzodiazepines)  Ethanol  Opioids (Drug Abuse-Morphine)  Antipsychotic (Clozapine)  Antidepressants (TCAs)  Airway – Not needed if naloxone/ flumazenil works  Breathing – Pulse Oximetry  Not Reliable in meth-HB/ CO poisoning  Circulation – Continuous BP/ECG monitoring  Drug – Naloxone/ Flumazenil/ Dextrose+Thiamine 4 October 2016 General Management of Poisoning 35
  34. 34.  Drugs-  antihypertensive drugs (α-blockers/CCB/β-blockers)  disulfiram (ethanol Interaction)  Iron  Trazodone, quetiapine, and other antipsychotic agents  antidepressants  Poison-  Cyanide  Carbon monoxide  Hydrogen sulfide  Aluminum or zinc phosphide  Arsenic  Mushrooms (contain pilocarpine) 4 October 2016 General Management of Poisoning 36
  35. 35. Nature of poisoning Treatment TCAs/Sod. channel blockers NaHCO3 50–100 mEq i.v.bolus injection NE 4–8 mcg/min i.v. infusion (more effective than dopamine) β-blockers Glucagon 5–10 mg i.v. CCBs calcium chloride 1–2 g i.v. 4 October 2016 General Management of Poisoning 37
  36. 36.  Amphetamines  Anticholinergics  Cocaine  Performance-enhancing products  Caffeine  Phenylephrine  Ephedrine  Yohimbine  MAO inhibitors 4 October 2016 General Management of Poisoning 38
  37. 37. Hypertension with…. Treatment agitation and anxiety Lorazepam 2–3 mg i.v. persistent nature Phentolamine 2–5 mg i.v. OR Sod. nitroprusside 0.25–8 mcg/kg/min i.v. excessive tachycardia Propranolol 1–5 mg i.v. OR Esmolol 25–100 mcg/kg/min i.v. OR Labetalol 0.2–0.3 mg/kg i.v. Caution: Do not give β-blockers alone, since doing so may paradoxically worsen hypertension as a result of unopposed alpha-adrenergic stimulation 4 October 2016 General Management of Poisoning 39
  38. 38. 4 October 2016 General Management of Poisoning 40
  39. 39. Cause Treatment Electrolyte imbalance ↑K+ ↓K+, Mg2+,Ca2+ Correct accordingly Ventricular arrhythmias Lidocaine/ Amiodarone at usual antiarrhythmic doses TCAs/diphenhydramine/class Ia antiarrhythmic drugs NaHCO3 50–100 mEq i.v. bolus infusion Torsades de pointes Mg(2 g i.v. over 2 minutes) or Overdrive pacing Digitalis-induced arrhythmias Digoxin specific antibodies Chlorinated solvents/ Chloral hydrate/freons/ Sympathomimetic agents Propranolol 1–5 mg i.v. OR Esmolol 25–100 mcg/kg/min i.v. Caution: Avoid class Ia antiarrhythmic agents (eg, procainamide, disopyramide), which may aggravate arrhythmias caused by tricyclic antidepressants. 4 October 2016 General Management of Poisoning 41
  40. 40.  Drugs-  Amphetamines, cocaine  Antidepressants (especiallyTCAs, bupropion, and venlafaxine)  Antihistamines (especially diphenhydramine),  Antipsychotics  Camphor,  isoniazid (INH)  Chlorinated insecticides  Tramadol  Theophylline  Secondary causes-  Hypoxia/hypoglycemia/hypocalce mia/hyponatremia 4 October 2016 General Management of Poisoning 42
  41. 41. Lorazepam, 2–3 mg, or diazepam, 5–10 mg, i.v. over 1–2 minutes OR i.v. unavailable— midazolam, 5–10 mg i.m. If convulsions continue, administer phenobarbital (For drug-induced seizures, phenobarbital is preferred over phenytoin.) 4 October 2016 General Management of Poisoning 43
  42. 42.  Amphetamines (MDMA; “Ecstasy”), atropine and other anticholinergics  Cocaine, salicylates, strychnine  TCA  SSRI(eg, fluoxetine, paroxetine,sertraline) or their use in a patient taking an MAO inhibitor may cause serotonin syndrome  Antipsychotics (neuroleptic malignant syndrome [NMS]) 4 October 2016 General Management of Poisoning 44
  43. 43.  Removing the patient’s clothing  Spray the skin with tepid water & fanning.  Muscle rigidity/hyperactivity –  NM paralysis with a nondepolarizing neuromuscular blocker (eg, rocuronium, vecuronium)  Once paralyzed, patient must be  Intubated  Mechanically ventilated  Sedated  Use bedside EEG (paralysis - no convulsion but seizure may exist) 4 October 2016 General Management of Poisoning 45
  44. 44. Hyperthermia… Treatment With rigidity / Malignant hyperthermia Dantrolene 2–5 mg/kg i.v. Neuroleptic malignant syndrome Bromocriptine 2.5–7.5 mg orally daily Serotonin syndrome Cyproheptadine 4 mg orally every hour (3-4 doses) OR Chlorpromazine 25 mg i.v. OR 50 mg i.m. 4 October 2016 General Management of Poisoning 46
  45. 45. 4 October 2016 General Management of Poisoning 47
  46. 46.  Serum osmolality & osmol gap  Electrolytes and anion gap  Blood glucose  S. Creatinine  BUN  CK  Urinalysis; e.g.-  Oxalate crystals with ethylene glycol poisoning  Myoglobinuria with rhabdomyolysis  ECG  Serum acetaminophen and ethanol quantitative levels should be determined in all patients with drug overdoses 4 October 2016 General Management of Poisoning 48
  47. 47. Laboratory test Observation Osmol gap ↑s in presence of large quantities of low- molecular-weight substances Anion gap ↑s due to poisoning of - Carbon monoxide Cyanide Ethylene glycol Iron overload INH Methanol Metformin Ibuprofen Salicylates 4 October 2016 General Management of Poisoning 49
  48. 48. 4 October 2016 General Management of Poisoning 50
  49. 49.  NAME:Ruchit Patel  ROLL NO. : 87  MO. NO: 9824565789  Email ID : ruchitpatel@gmail.com  BATCH - 2014
  50. 50.  External  Protect yourself and others  Remove exposure  Irrigate copiously with water or normal saline  Don’t forget your ABC’s  Internal  Patient must be fully awake or intubated  Most common complication is aspiration  Very little evidence for their use
  51. 51.  Skin  Protect yourself and other workers  Remove clothing  Flush with water or normal saline  Use soap and water if oily substance  Chemical neutralization can potentiate injury  Corrosive agents injure skin and can have systemic effects
  52. 52.  Eyes  Remove contact lens  Flush copiously with water or normal saline  Use local anesthetic drops  Continue irrigation until ph is normal  Slit lamp and fluorescein exam
  53. 53.  Inhalation  Give supplemental humidified oxygen  Observe for airway obstruction  Intubate as necessary
  54. 54. GAG REFLEX
  55. 55.  The actions of ipecac are mainly those of major alkaloids(emetine and cephaeline).  Action :  Local : irritate the gastric mucosa  Central: by stimulating the medullary chemoreceptor trigger zone induce vomiting.
  56. 56.  Gastric lavage , also commonly called gastric irrigation, is the process of cleaning out the contents of the stomach.  Patient must be lying on left side or prone with head hanging over edge of bed,so that mouth is at lower layer than larynx.  Functioning of the technique is based on SYPHON ACTION.
  57. 57. Ewald’s tube Materials used 1:5000 kmno4,5% sodium bicarbonate,4% tannic acid,1% sodium iodide and lime water
  58. 58.  Gastric lavage involves the passage of a tube (such as an Ewald tube) via the mouth or nose down into the stomach followed by sequential administration and removal of small volumes of liquid.  The placement of the tube in the stomach must be confirmed either by air insufflations while listening to the stomach, by pH testing a small amount of aspirated stomach contents, or x-ray.  This is to ensure the tube is not in the lungs.  In adults, small amounts of warm water or saline are administered and, via a siphoning action, removed again.
  59. 59. INDICATION CONCIOUS PATIENT WITHIN 2 hrs C/I CORRROSIVE POISON COMATOSE PATIENT COMPLICATION ASPIRATION PNEUMONIA PERFORATION OF STOMACH
  60. 60.  Sorbitol is cathartic of choice.  Sodium sulphate may also be used.
  61. 61.  Activated carbon, also called activated charcoal, is a form of carbon processed to have small, low-volume pores that increase the surface area available for adsorption or chemical reactions.  DOSE-1gm/kg.  SUPERACTIVATED CHARCOAL has double adsorbing surface area as compared to activated charcoal.
  62. 62.  It is not effective for a number of poisonings including strong acids or alkali, cyanide, iron, lithium, arsenic, methanol, ethanol or ethylene glycol.
  63. 63.  Whole bowel irrigation (WBI) is a medical process involving the rapid administration of large volumes of an osmotically balanced POLYETHYLENEGLYCOL solution , either orally or via a nasogastric tube, to flush out the entire gastrointestinal tract.  Useful in lithium,iron,cocaine and heroine overdose.
  64. 64.  NAME: Sachin Patel  ROLL NO. : 88  MO. NO: 9159850809  Email ID : sachinpatel1243@gmail.com  BATCH - 2014
  65. 65. 4 October 2016 General Management of Poisoning 70 According toWHO - “Antidote was defined as a therapeutic substance used to counteract the toxic action(s) of a specified xenobiotic.”
  66. 66.  Paracetamol  Methanol  Benzodiazepines  Opiates 4 October 2016 71General Management of Poisoning :- Acetyl cysteine & Methionine :- fomepizole & Ethyl Alcohol :- Flumazenil :- Nalaxone
  67. 67.  Organophosphates :- Atropine  Dhatura :- Physostigmine  Botulinum toxin :- Guanidine  Methamoglobinemia :- Methelene blue (Nitrites) 4 October 2016 72General Management of Poisoning
  68. 68.  Cyanide :- Amyl Nitrate + Na Thio Sulphate  CO :- Hyper Baric Oxygen 4 October 2016 73General Management of Poisoning
  69. 69.  Arsenic :- hydrated ferric oxide, DMSA,BAL  Copper :- Potassium ferrocyanide, Penicillamine  Ergot :- Sodium Nitroprusside  Lead :- EDTA, DMSA, BAL  Iron :- Desferrioxamine  Mercury :- Penicillamine, BAL, Sodium formaldehyde 4 October 2016 General Management of Poisoning 74
  70. 70.  Cadmium :- N-Acetyl Penicillamine  Isoniazid :- pyridoxine  Heparin :- Protamine Sulphate  Warfarin :- Vit. K1  TCA :- NaHCo3  Beta-blockers :- Glucagon  Flourouracil,methotrexate :- Leucovorin  Cyclophospamide :- Mesna 4 October 2016 General Management of Poisoning 75
  71. 71.  Common salt  Silver Nitrate  Mercury Chloride  Copper Sulphate  Phosphorus  Arsenic  Albumin  Dialyzed iron 4 October 2016 76General Management of Poisoning
  72. 72. It is a combination of physical and chemical antidotes  It is an absolute antidote and had only historical importance 4 October 2016 77General Management of Poisoning
  73. 73. Composition :-  Magnesium oxide (1 part) neutralizes acid without gas formation  Charcoal (2 parts) absorbs alkaloids  Tannic acid (1 part) precipitates alkaloids 4 October 2016 78General Management of Poisoning
  74. 74.  It is combination of 3 medicines can be given in unknown poisoning with coma - Dextrose (50%) 100 ml Nalaxone 2 mg B1(Thiamine) 100 mg 4 October 2016 79General Management of Poisoning
  75. 75.  EDTA  BAL  Succimer  Penicillamine  Desferrioxamine 4 October 2016 80General Management of Poisoning
  76. 76.  EDTA is prescription medicine, given by injection into the vein (intravenously) or into the muscle (intramuscularly).  more common in lead poisoning. . 4 October 2016 General Management of Poisoning 81
  77. 77.  Intravenous EDTA is used to treat lead poisoning and brain damage caused by lead poisoning; to evaluate a patient's response to therapy for suspected lead poisoning; to treat poisonings by radioactive materials such as plutonium, thorium, uranium, and strontium; for removing copper in patients withWilson's disease; and for treating high levels of calcium. 4 October 2016 General Management of Poisoning 82
  78. 78.  EDTA is also used intravenously for heart and blood vessel conditions including irregular heartbeat due to exposure to chemicals called cardiac glycosides, “hardening of the arteries” (atherosclerosis), chest pain(angina), high blood pressure, high cholesterol, and blood circulation problems such as intermittent claudication and Raynaud's syndrome 4 October 2016 General Management of Poisoning 83
  79. 79.  Heart rhythm problems: EDTA might make heart rhythm problems worse.  Diabetes: EDTA might interfere with blood sugar control because it can interact with insulin. Low calcium levels in the blood (hypocalcemia): EDTA can decrease serum calcium levels, making hypocalcemia worse. 4 October 2016 General Management of Poisoning 84
  80. 80.  Liver problems and hepatitis: EDTA might make liver disease worse. Avoid using EDTA if you have a liver condition. Kidney problems: EDTA can harm the kidney and might make kidney disease worse. EDTA doses should be reduced in patients with kidney disease.Avoid using EDTA if you have severe kidney disease or kidney failure. 4 October 2016 General Management of Poisoning 85
  81. 81. It is given by intramuscular route (5mg/kg stat followed by 2 to 3mg/kg every 4 to 8 Hours for 2 days and then once a day for 10 days 4 October 2016 General Management of Poisoning 86
  82. 82.  BAL has two SH groups. The two SH groups binds to those metals that produce toxicity by interacting with sulfhydryl containing enzymes in the body.  BAL will combine with these metals forming BAL-metal complex thus dislodges the metal from acting site. 4 October 2016 87General Management of Poisoning
  83. 83.  BAL is useful against metals that interfere with sulfhydryl enzymes in the body such as arsenic , mercury , bismuth , copper , antimony , and nickel. 4 October 2016 88General Management of Poisoning
  84. 84.  In liver damage  G6PD deficiency  Iron and cadmium toxicity 4 October 2016 89General Management of Poisoning
  85. 85. Serious side effects:  Fast heart rate, feeling anxious or restless;  Pain or tightness in your throat, chest, or hands;  Burning sensation of your throat, mouth, or lips; or  Burning sensation in your penis. 4 October 2016 General Management of Poisoning 90
  86. 86. Less serious side effects include:  Nausea, vomiting, stomach pain  Numbness or tingling (especially around your mouth)  Headache  Eye redness, swelling, or watering;  Twitching of your eyelid  Runny nose  Increased sweating  Mild fever or  Pain, redness, or swelling where the needle is placed. 4 October 2016 General Management of Poisoning 91
  87. 87. Also known as a “Dimercaptosuccinic acid”. Similar to BAL in chelating properties Less toxic than BAL and orally effective used against mercury , arsenic and lead poisoning. EDTA is contraindicated in mercury 4 October 2016 92General Management of Poisoning
  88. 88.  Nausea  Vomiting  Loss of appetite  Diarrhea 4 October 2016 General Management of Poisoning 93
  89. 89.  Also known as “D-penicillamine Cuprimine”  It is dimethyl cysteine , obtained as a degradation product of penicilline and available in d-isomer and I-isomer form.  d-isomer is more used because I-isomer is more toxic and produce “optic neuritis”.  Metabolized in body,excreted in urine&feces 4 October 2016 94General Management of Poisoning
  90. 90.  Copper poisoning :- drug of choice  Mercury poisoning:- alternative to BAL  Chronic lead poisoning  Wilson’s disease  Cystinuria and cystine stone 4 October 2016 95General Management of Poisoning
  91. 91.  For copper and mercury poisoning :- 1 to 1.5 gm/day in divided doses  For wilson’s disease :- 0.5 to 1gm/day in divided doses , one hour before meals or two hour after the meals to avoid the chelation of diatery metals.  Contraindicated in arsenic 4 October 2016 96General Management of Poisoning
  92. 92. Diarrhea loss of appetite mild stomach pain nausea vomiting 4 October 2016 General Management of Poisoning 97
  93. 93.  Ferrioxamine is long chain iron containing complex obtained from an actinomycete.  Chemical removal of iron from it yields desferrioxamine that has great affinity for iron.  Administrated orally , less absorbed and binds with iron and prevents iron absorption in GIT. 4 October 2016 98General Management of Poisoning
  94. 94.  Desferrioxamine molecule turns round the ferric ion and forms a stable non- toxic complex that is excreted in urine.  1 gram of desferrioxamine is capable of removing 85 mg of elemental iron.  It removes loosely bound iron and iron from hemosiderin and ferritin but not remove iron from Hb or cytochrome 4 October 2016 99General Management of Poisoning
  95. 95.  Acute iron poisoning  Transfusion siderosis 4 October 2016 100General Management of Poisoning
  96. 96.  Iron poisoning :- drug of choice  Given intramuscularly-0.5 to 1gm repeatedly 4 to 12 hourly  Patient with shock receive intravenous desferrioxamine – 15 mg/kg/hour with a maximum daily dose upto 360 mg/kg or upto 6 gm total.  Also useful in treatment of toxicity with radioactive heavy metals. 4 October 2016 101General Management of Poisoning
  97. 97. 4 October 2016 General Management of Poisoning 102  Diarrhea  Dizziness  Headache  Mild stomach pain  Nausea  Stomach upset  Vomiting
  98. 98. NAME: Sagarika Upadhyay ROLL NO. : 89 MOBILE NO.:9099938328 Email.:- upadhyaysagarika@gmail. Com BATCH - 2014
  99. 99.  Forced diuresis  Hemodialysis & Peritoneal dialysis  Haemoperfusion  Multiple dose activated charcoal General Management of Poisoning 1054 October 2016
  100. 100.  Increased urine formation by diuretics or with manipulation of urine pH .  The renal tubular epithelium is relatively impermeable to the ionized molecules.  If the urinary pH is changed so as to produce more of ionized form of a chemical, it is trapped in the tubular fluid and is excreted in the urine. General Management of Poisoning 1064 October 2016
  101. 101.  Poison with following properties can be eliminated by FORCED DIURESIS:- 1. Substance excreted mainly by kidneys. 2. Substance with low volume of distribution. 3. Substance with low protein binding. General Management of Poisoning 1074 October 2016
  102. 102. IN ACIDIC URINE IN BASIC URINE (after NaHCO3 infusion) uncharged form (lipid-soluble, diffusible across lipid membranes) REABSORBED Phenobarbital (pKa = 7.2) anionic form (not lipid-soluble, not diffusible across lipid membranes) NOT REABSORBED O O O Phe H5C2 H N N H O O O Phe H5C2 H N N _ H+ H+ General Management of Poisoning 1084 October 2016
  103. 103. This method acts depending on the extent of ionization(pka) 1>forced alkaline diuresis By achieving urinary pH of 7.5 to 9 promotes excretion of drugs which are weak acids, such as:- Salicylates, phenobarbital, chlorpropamide, methotrexate Lithium.  A solution of sodium bicarbonate 50 to 100 meq added to 1 liter of 0.45% saline administered at the rate of 250 to 500 ml/hr for first 1 to 2 hours.  Alkaline solution and diuretics should be administered to maintain a urinary output of 2 to 3 ml/kg/hr. General Management of Poisoning 1094 October 2016
  104. 104.  Diuretics are needed to maintain high urine flows.  To prevent hypokalaemia potassium added.  The vitals of the patient along with input/output, electrolytes and acid base status should be closely monitored.  Contraindicated:- in patients with shock, hypotension, renal failure and congestive heart failure. General Management of Poisoning 1104 October 2016
  105. 105. 2> Acid diuresis  Is uncommonly used method for certain poisons like amphetamine.Vitamin C titrated to acidic urine pH .  It is dangerous method because of the risk of:  Myoglobin precipitation in the renal tubules (rhebdomyolysis)  Metabolic acidosis  Renal failure. General Management of Poisoning 1114 October 2016
  106. 106.  Solute diffusion across a semi-permeable membrane down a concentration gradient from circulation into dialysate.  Haemodialysis and Peritoneal are useful.  Dialysable substance for good results must have: Low volume of distribution. Low molecular weight. Low protein binding.  Dialysis is useful in ethanol, methanol, salicylates, phenobarbital, theophylline, ethylene glycol, and lithium intoxications. Peritoneal General Management of Poisoning 1124 October 2016
  107. 107.  Semipermeable membrane is of 4 category:-  Cellulose  Substituted cellulose (e.g. cellulose acetate)  Cellulosynthetic  Synthetic (e.g. polysulphone, poly methacrylate, polyacrylonitrile) General Management of Poisoning 1134 October 2016
  108. 108.  Rate of diffusion depends on :-  Magnitude of the concentration gradient  Membrane surface area  Porosity & thickness of membrane  conditions of flow on the two sides of membrane.  size of molecule  Large size creatinine ( 113Da) cleared less  Small size urea(60Da) cleared more 4 October 2016 General Management of Poisoning 114
  109. 109.  Consist of a plastic device with the facility to perfuse blood and dialysate compartments at very high flow rates.  The surface area of dialysis membrane in adult patient is usually in the range of 0.8 to 1.2 m2 4 October 2016 General Management of Poisoning 115  THE DIALYSER
  110. 110.  Two geometric configurations of dialysers: 1) Hollow fiber  Commonly used  Composed of bundles of capillary tubes through which blood circulates while dialysate travels on the outside of the fiber bundle. 4 October 2016 General Management of Poisoning 116 2) Flat plate  Less frequently used  Composed of sandwiched sheets of membrane in a parallel plate configuration.
  111. 111. 4 October 2016 General Management of Poisoning 117 Hollow fiber Flat plate  Dialyzers
  112. 112.  For the patient on chronic dialysis.  To reduce the expense of individual dialyzer.  Only the dialyzer unit is reprocessing or reused.  Either manual or automated. 4 October 2016 General Management of Poisoning 118
  113. 113.  It consist of 1. Sequential rinsing of the blood and dialysate compartments with water. 2. A chemical clearing step with reverse ultra – filtration from dialysate to blood compartment. 3. Tasting of the patency of the dialyzer. 4. Disinfection of dialyzer by Per acetic acid- Hydrogen peroxide or formaldehyde. 4 October 2016 General Management of Poisoning 119
  114. 114. SOLUTE BICARBONATE DIALYSATE Sodium( meq/L) 137-143 Potassium( meq/L) 0-4.0 Chloride( meq/L) 100-111 Calcium( meq/L) 0-3.5 Magnesium( meq/L) 0.75-1.5 Acetate( meq/L) 2.0-4.5 Bicarbonate( meq/L) 30-35 Glucose( meq/L) 0-0.25 4 October 2016 General Management of Poisoning 120
  115. 115.  Using a roller mechanism.  moves blood at the flow rate 250 to 500mL/min. 4 October 2016 General Management of Poisoning 121 Extracorporeal circuit Dialysis access Blood pump Dialysis solution delivery system Various safety monitors  It dilutes the dialysate concentrate with water.  Fistula  Graft  Catheter  Through which the blood is obtained for haemodialysis is called dialysis access. Monitors temperature, conductivity, flow of dialysate.
  116. 116. 4 October 2016 General Management of Poisoning 122
  117. 117. 4 October 2016 General Management of Poisoning 123 Clearance of urea = 200-350mL/min
  118. 118.  Hypotension(most common particularly in diabetics)  Muscle cramps  Electrolyte imbalance  Cross infections  Bleeding tendency (due to heparin)  Air embolism 4 October 2016 General Management of Poisoning 124
  119. 119.  peritoneum as semipermiable membrane.  Infusing 1 to 3 L of a dextrose-containing solution into the peritoneal cavity allowing the fluid to dwell for 2 to 4 hr.  USE: especially in children in barbiturates, and salicylate poisoning. 4 October 2016 General Management of Poisoning 125
  120. 120. A. CAPD=Continues ambulatory peritoneal dialysis  (During day & 3 to 4 time)  (midnight dwell at bedtime and remains through night) B. CCPD=Continues cyclic peritoneal dialysis  (by an automated cycler & at night)  (4 to 5 cycle while the patient sleeps)  (in morning – discontinuation and routine activities) C. NIPD=Nocturnal intermitant peritoneal dialysis  (10 hrs – each night) 4 October 2016 General Management of Poisoning 126
  121. 121. COMPLICATIONS :  Intra-abdominal bleeding  Perforation of abdominal organs  Peritonitis  Dehydration or over hydration. CONTRAINDICATIONS:  Pregnancy  Abdominal hernia  Respiratory distress. 4 October 2016 General Management of Poisoning 127
  122. 122. 4 October 2016 General Management of Poisoning 128
  123. 123.  Using equipment similar to that for haemodialysis, the blood is pumped directly through a column containing an adsorbent material ( either charcoal or Amberlite resin which is ion exchange resin).  Systemic anticoagulation is required. Often in higher doses than for haemodialysis  Thrombocytopenia is a common complication. 4 October 2016 General Management of Poisoning 129
  124. 124.  Because the drug or toxin is in direct contact with the adsorbent material, drug size, water solubility and protein binding are less important limiting factors.  For most drugs, hemoperfusion can achieve greater clearance than haemodialysis. for example, the for phenobarbital haemolysis clearance 60-80mL/min hemoperfusion clearance 200-300mL/min 4 October 2016 General Management of Poisoning 130
  125. 125. CONTRAINDICATIONS:  Patients with coagulopathy  Patients with uncontrolled hypotension COMPLICATIONS:  Thrombocytopenia  Hypocalcaemia  Hypoglycaemia  Hypotension 4 October 2016 General Management of Poisoning 131
  126. 126. 4 October 2016 General Management of Poisoning 132
  127. 127.  More than 2 doses of oral activated charcoal.  Free charcoal available in the intestines to bind any toxin  free toxin in the blood tends to diffuse out of the blood into the intestines binds the charcoal “gastrointestinal dialysis”.  It is simple, inexpensive, and safe and avoids the need for invasive procedures, such as haemodialysis and hemoperfusion. 4 October 2016 General Management of Poisoning 133
  128. 128.  DOSE: Optimum dose is unknown. Adult dose = from 50 to 100 grams per dose, administered at the rate no less than 12.5 grams/hr or its equivalent. Children =Lower doses of 10-25 grams are used.  Carbamazepine, dapsone, phenobarbital, theophylline, quinine, phenytoin . 4 October 2016 General Management of Poisoning 134
  129. 129. 1. The toxin has long half life 2. Toxin has a significant enterohepatic circulation (digoxin, phenobarbital, theophylline ) 3. Continuous release of toxin from sustained-release preparation 4. Toxin forms mass in the gut which is a source of continuous release of toxin. 5. The ingestion is very massive to be effectively adsorbed by a single dose of charcoal. 4 October 2016 General Management of Poisoning 135  INDICATIONS :-
  130. 130.  Contraindicated:  in the presence of ileus ( disruption of the normal propulsive ability of the gastrointestinal tract )  The use of multiple-dose charcoal for salicylate poisoning is controversial.  Not recommended for the elimination of astemizole, chlorpropamide, doxepin, imipramine, meprobamate, methotrexate, sodium valproate, tobramycin, and vancomycin. 4 October 2016 General Management of Poisoning 136
  131. 131.  The need for ministration of cathartics such as sorbitol remains unproven and is not recommended.  Should not be used in children because of possible fluid and electrolyte disturbances. 4 October 2016 General Management of Poisoning 137
  132. 132. In summary, physicians should take the best judgment according to the presence of contraindications and the effectiveness and availability of alternative treatment. 4 October 2016 General Management of Poisoning 138
  133. 133. THANK YOU 4 October 2016 General Management of Poisoning 139

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