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
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
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
Susrutha (350 BC) Described as how poisons were
mixed with food and drink ,medicine , snuff etc.
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
Others who worked are Marsh, Magendie, Ambrose,
Scheelle, Robert Christison and Rudolf Kobert.
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.
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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
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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.
It was a methyl isocynate (MIC) which leaked in
Bhopal considered the world ‘s worst industrial
It exposed more than 5,00,000 people to toxic
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
Principles of management consist of;
ii. Gut Decontamination.
iii. Antidote administration
v. Symptomatic treatment.
None (0) – no symptoms or signs judged not
to be related to poisoning.
Minor (1)- Mild, transient and spontaneously
Moderates (2)- pronounced or prolonged
Severe (3)- severe or life threatening
Antidotes are available for very few
commonly encountered poisons, and
treatment is usually non-specific and
In such cases management and stabilization
measures, appropriate treatment to reduce
absorption, measures to enhance life support
followed by psychiatric counselling.
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.
Scandinavian Regime is a term used for anti shock
measures when the patient is going into shock.
It includes ABCD of resuscitation.
D. Depression of CNS
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.
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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
If necessary positive pressure ventilation with
monitoring and respiratory stimulants for severe
depression should be applied.
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.
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.
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Agent & Amount
Time & Location of Exposure
Intake of Other Substances
Circumstances of Exposure
Past Medical History
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Examine General Status
See the Skin (color change)
Smell the breath
Listen the Lungs
Hear the Heart
Asses the Abdomen
Perform Neurological Exam
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May need to remove clothing for thorough exam
Check clothing for objects or substances
Assess general appearance of patient – Orientation,
Agitation, confusion, or obtundation
Reactivity to light
Oropharynx for increase salivation or excessive
Extremities: fasciculation's, tremor
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Heart: rhythm, rate, regularity
Lungs: bronchorrhea or wheezing
Abdomen: bowel sounds,
tenderness or rigidity
Neuro: CNS, reflexes, muscle tone
coordination, cognition, ability to
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Rash – Allergic Reaction
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Mees line – Arsenic Poisoning
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Cyanosis – Cyanide poisoning
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Coma & Hypothermia
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Ingestion of large doses of:
Opioids (Drug Abuse-Morphine)
Airway – Not needed if naloxone/
Breathing – Pulse Oximetry
Not Reliable in meth-HB/ CO poisoning
Circulation – Continuous BP/ECG
Drug – Naloxone/ Flumazenil/
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disulfiram (ethanol Interaction)
Trazodone, quetiapine, and other
Aluminum or zinc phosphide
Mushrooms (contain pilocarpine)
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Nature of poisoning Treatment
TCAs/Sod. channel blockers NaHCO3 50–100 mEq
NE 4–8 mcg/min
(more effective than dopamine)
β-blockers Glucagon 5–10 mg
CCBs calcium chloride 1–2 g i.v.
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Hypertension with…. Treatment
agitation and anxiety Lorazepam 2–3 mg
persistent nature Phentolamine 2–5 mg
excessive tachycardia Propranolol 1–5 mg
Esmolol 25–100 mcg/kg/min
Labetalol 0.2–0.3 mg/kg
Caution: Do not give β-blockers alone, since doing so may paradoxically
worsen hypertension as a result of unopposed alpha-adrenergic
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Ventricular arrhythmias Lidocaine/ Amiodarone
at usual antiarrhythmic doses
NaHCO3 50–100 mEq
i.v. bolus infusion
Torsades de pointes Mg(2 g i.v. over 2 minutes) or
Digitalis-induced arrhythmias Digoxin specific antibodies
Propranolol 1–5 mg
Esmolol 25–100 mcg/kg/min
Caution: Avoid class Ia
antiarrhythmic agents (eg,
disopyramide), which may
caused by tricyclic
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Lorazepam, 2–3 mg,
or diazepam, 5–10
over 1–2 minutes
midazolam, 5–10 mg
is preferred over
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“Ecstasy”), atropine and other
Cocaine, salicylates, strychnine
paroxetine,sertraline) or their use
in a patient taking an MAO
inhibitor may cause serotonin
malignant syndrome [NMS])
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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
Use bedside EEG (paralysis - no convulsion but seizure
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With rigidity /
Dantrolene 2–5 mg/kg i.v.
Neuroleptic malignant syndrome Bromocriptine 2.5–7.5 mg
Serotonin syndrome Cyproheptadine 4 mg
orally every hour (3-4 doses)
Chlorpromazine 25 mg
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Serum osmolality & osmol gap
Electrolytes and anion gap
Oxalate crystals with ethylene glycol poisoning
Myoglobinuria with rhabdomyolysis
Serum acetaminophen and ethanol quantitative levels
should be determined in all patients with drug overdoses
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Laboratory test Observation
Osmol gap ↑s in presence of large
quantities of low-
Anion gap ↑s due to poisoning of
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Protect yourself and others
Irrigate copiously with water or normal
Don’t forget your ABC’s
Patient must be fully awake or
Most common complication is
Very little evidence for their use
Protect yourself and other workers
Flush with water or normal saline
Use soap and water if oily
Chemical neutralization can
Corrosive agents injure skin and can
have systemic effects
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
Give supplemental humidified oxygen
Observe for airway obstruction
Intubate as necessary
The actions of ipecac are mainly those of
major alkaloids(emetine and cephaeline).
Local : irritate the gastric mucosa
Central: by stimulating the medullary chemoreceptor
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
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 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
WITHIN 2 hrs
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 increase
the surface area available for adsorption or
SUPERACTIVATED CHARCOAL has double
adsorbing surface area as compared to
It is not effective for a number of poisonings
including strong acids or
alkali, cyanide, iron, lithium,
arsenic, methanol, ethanol or ethylene
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
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It is a combination of physical and
It is an absolute antidote and had only
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Magnesium oxide (1
part) neutralizes acid
without gas formation
Charcoal (2 parts)
Tannic acid (1 part)
4 October 2016 78General Management of Poisoning
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
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EDTA is prescription
medicine, given by
injection into the vein
(intravenously) or into the
more common in lead
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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.
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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
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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.
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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.
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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
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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.
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BAL is useful against metals that interfere
with sulfhydryl enzymes in the body such
as arsenic , mercury , bismuth , copper ,
antimony , and nickel.
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In liver damage
Iron and cadmium toxicity
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Serious side effects:
Fast heart rate, feeling anxious or restless;
Pain or tightness in your throat, chest, or
Burning sensation of your throat, mouth, or
Burning sensation in your penis.
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Less serious side effects include:
Nausea, vomiting, stomach pain
Numbness or tingling (especially around your
Eye redness, swelling, or watering;
Twitching of your eyelid
Mild fever or
Pain, redness, or swelling where the needle is
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Also known as a
Similar to BAL in chelating
Less toxic than BAL and
used against mercury , arsenic
and lead poisoning.
EDTA is contraindicated in
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Loss of appetite
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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
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Copper poisoning :- drug of choice
Mercury poisoning:- alternative to BAL
Chronic lead poisoning
Cystinuria and cystine stone
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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
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loss of appetite
mild stomach pain
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Ferrioxamine is long chain iron containing
complex obtained from an actinomycete.
Chemical removal of iron from it yields
desferrioxamine that has great affinity for
Administrated orally , less absorbed and
binds with iron and prevents iron
absorption in GIT.
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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
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Acute iron poisoning
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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.
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Mild stomach pain
NAME: Sagarika Upadhyay
ROLL NO. : 89
BATCH - 2014
Hemodialysis & Peritoneal dialysis
Multiple dose activated charcoal
General Management of Poisoning 1054 October 2016
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.
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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
IN ACIDIC URINE IN BASIC URINE
(after NaHCO3 infusion)
(pKa = 7.2)
not diffusible across
General Management of Poisoning 1084 October 2016
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
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.
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Diuretics are needed to maintain high
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
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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
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Solute diffusion across a semi-permeable membrane
down a concentration gradient from circulation into
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
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Semipermeable membrane is of 4 category:-
(e.g. cellulose acetate)
(e.g. polysulphone, poly
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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
size of molecule
Large size creatinine ( 113Da) cleared less
Small size urea(60Da) cleared more
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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
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Two geometric configurations of dialysers:
1) Hollow fiber
Composed of bundles of
capillary tubes through
which blood circulates
while dialysate travels on
the outside of the fiber
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2) Flat plate
Less frequently used
sandwiched sheets of
membrane in a parallel
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Hollow fiber Flat plate
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.
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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.
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Using a roller
moves blood at the
flow rate 250 to
4 October 2016 General Management of Poisoning 121
Extracorporeal circuit Dialysis access
Blood pump Dialysis solution delivery system Various safety monitors
It dilutes the
Through which the
blood is obtained for
haemodialysis is called
dialysis access. Monitors
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Clearance of urea =
Hypotension(most common particularly in diabetics)
Bleeding tendency (due to heparin)
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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.
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A. CAPD=Continues ambulatory peritoneal dialysis
(During day & 3 to 4 time)
(midnight dwell at bedtime and remains through
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)
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Perforation of abdominal organs
Dehydration or over hydration.
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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.
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Because the drug or toxin is in direct contact
with the adsorbent material, drug size, water
solubility and protein binding are less important
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
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Patients with coagulopathy
Patients with uncontrolled hypotension
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More than 2 doses of oral activated charcoal.
Free charcoal available in the intestines to bind any
free toxin in the blood tends to diffuse out of the
blood into the intestines binds the charcoal
It is simple, inexpensive, and safe and avoids the
need for invasive procedures, such as haemodialysis
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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
Carbamazepine, dapsone, phenobarbital,
theophylline, quinine, phenytoin .
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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
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.
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in the presence of ileus ( disruption of the
normal propulsive ability of the gastrointestinal
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.
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The need for ministration of cathartics such
as sorbitol remains unproven and is not
Should not be used in children because of
possible fluid and electrolyte disturbances.
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In summary, physicians should take the best
judgment according to the presence of
contraindications and the effectiveness and
availability of alternative treatment.
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