Medical treatment of Poisoning

1. POISONING
By,
Dr Natalia Noon

2. INTRODUCTION
• A poison is any substance that when ingested, inhaled,
absorbed into the body and produce harmful effects
by its chemical action.
• The branch of medicine that deals with the deduction
and treatment of poison is known as toxicology.

3. ROUTES OF POISONING
Ingestion
Inhalation
Injection
Absorption

4. THE EFFECT OF POISOINING MAY
BE:
LOCAL
SYSTEMIC
BOTH
It may occur immediately ,after several
hour or even days after the exposure.

5. TYPES OF POISONIONG
 Chemical
House hold e.g. Bleach, kerosene
Industrial e.g. Methanol Cyanide, Arsenic
Pesticides e.g. Organophosphate, Organochlorine (DDT), Rat poison
 Therapeutic drug overdose e.g. Paracetamol, Aspirin, Iron tablets,
Nifedipine
 Toxic plants e.g. Poisonous mushrooms and Herbal preparations
 Bites and stings of venomous animals e.g. Snakes, Scorpions, Spider
and aquatic animals .

6. SIGNS ANS SYMPTOMS
 FEVER
 VOMITING
 DIARRHEA
 ABDOMENAL PAIN
 DIFFICULTY IN BREATHING
 JAUNDICE
 SKIN RASHES
 SCANTY URINE
 PALPITATIONS
 SKIN LESIONS
 SEIZURES
 TONGUE DISCOLOURATION

7. DANGER SIGN
UNCONSIOUS
NOISY BREATHING
PULSE BELOW 50 OR ABOVE 110 BPM IRREGULAR
OR WEAK
NON REACTIVE PUPILS
SEIZURES
SEVERE ABDOMINAL TENDERNES
ANURIA

8. MANAGMENT
OBJECTIVE
 MAINTAIN THE NORMAL VITALS SIGNS
 TO DECONTIMINATE THE SITE OF EXPOSURE
 TO PREVENT AND REDUCE ABSORPTION
 TO ENHANCE ELIMINATION
 TO RELIEF SYMPTOMS
 TO PREVENT FURTHER ORGAN DAMAGE OR IMPAIRMENT WITHOUT
DELAY
 PSYCHIATIC ASSESSMENT
(INTENTIONS AT TIME ,PRESENT INTENSIONS,WHAT PROBLEM LED TO THE
ACT, ANY PSYCHIATRIC DISORDER,RESOURCES ,REFER TO PSYCHIATRIST )

9. NON-PHARMACOLOGICAL
TREATMENT
ENSURE AIRWAYS ARE PATENT.
REMOVE CONTAMINATED CLOTHING, IF NECESSARY
WASH CHEMICAL AWAY FROM THE SKIN WITH SOAP AND A
LOT OF WATER.
IF NECESSARY PERFORM NASOGASTRIC ASPIRATION IF
AIRWAY IS PROTECTED.

10. • CARRY OUT GASTRIC LAVAGE OR ASPIRATION
WITHIN THE FIRST 1 HOUR AFTER THE EVENT OR
LATER IF IT INVOLVES SLOW RELEASE OR HIGHLY
TOXIC SUBSTANCES
• DETAIN THE PATIENT IN THE CLINIC OR HOSPITAL
FOR CLOSE AND CONTINUOUS OBSERVATION, RE-
EVALUATION, AND SUPPORTIVE AND SYMPTOMATIC
TREATMENT
• MAINTAIN AND CONTINUOUSLY MONITOR VITAL
SIGNS

11. PHARMACOLOGICAL
TREATMENT
INITIAL MANAGEMENT
 FOR HYPOGLYCEMIA
GLUCOSE, IV,25-50 ml OF 50% OVER 1-3 MINUTES
 THIAMINE
IN ALCOHALIC OR MALNOURISHED GIVE THIAMINE 100 mg IM OR IN IV FLUIDS
 FOR OPIOID OVERDOSE NALOXONE, IV,
ADULT= 0.4-2mg , REPEAT EVERY 2-3 MINUTES (MAXIMUM OF 10 mg)
CHILDREN= 10 MICROGRAMS/KG STAT, SUBSEQUENT DOSE OF 100 MICROGRAM/KG IF
NO RESPONSE TO INITIAL DOSE
THEN,
 NALOXONE, SC OR IM, ONLY IF IV ROUTE IS NOT FEASIBLE

12.  FLUMAZENIL 0.2 -0.5mg IV (MAXIMIUM DOSE 3mg )may reserve
benzodiazepine induced coma
 Hypothermia :gradual rewarming is preferred unless the patient is in cardiac
arrest
 Hypotension :0.9% saline or crystalloid upto 1-2 L (MONITORING OF CVP SO
THAT FLUID THERAPY IS NEEDED OR NOT).
IF HYPOTENSION PERSIST INSPITE OF FLUID THERAPY THAN NOREPINEPHRINE
OR DOPAMINE CAN BE GIVEN
 TCA AND CA CHANNEL BLOCKERS:SODIUM BICARBONATE 50-100meq IV
BOLUS INJECTION .NOREPINEPHRINE 4-8mcg/MIN IV INFUSION MORE
EFFECTIVE THAN DOPAMINE
 BETA BLOCKER :GLUCAGON 5-10mg IV
 SEIZURES:LORAZEPAM 2-3mg OR DIAZEPAM 5-10mgIV (MIDAZOLAM 5-10mg
IM )
IF CONVULSIONS CONTINUES THAN PHENOBARBITOL 15-20mg/KG IV SLOWLY
OVER NO LESS THAN 30 MINUTES

13. MEDICATION REVERSAL
AGENTS
MEDICATION REVERSAL AGENT
ACETAMINOPHEN N-ACETYLCYSTEINE (MUCOMYST)
ANTICHOLINESTERASES ATROPINE
ANTICHOLINERGIC AGENTS PHYSOSTIGMINE
ANTICOAGULANTS VITAMIN K/PROTAMINE
BENZODIAZEPINES FLUMAZENIL (ROMAZICON)
BETA-BLOCKERS GLUCAGON
CALCIUM CHANNEL BLOCKERS GLUCAGON
HEAVY METALS SPECIFIC CHELATING AGENTS
DIGOXIN, DIGITOXIN DIGOXIN IMMUNE FAB (DIGIBIND)
DOXORUBICIN DEXRAZOXANE
FLUOROURACIL LEUCOVORIN CALCIUM
CYANIDE SODIUM NITRITE
IRON DEFEROXAMINE (DESFERAL)
ISONIAZID PYRIDOXINE
METHOTREXATE LEUCOVORIN CALCIUM
OPIATES NALOXONE (NARCAN)

14. GASTRIC EMPTYING
PROCEDURE
 SYRUP OF IPECAC TO INDUCE VOMITING IN THE ALERT PATIENT
(NEVER USE WITH CORROSIVE POISON)
 GASTRIC LAVAGE FOR THE OBTUNDED PATIENT, GASTRIC ASPIRATE
IS SAVED AND SEND TO LABORATORY FOR TESTING
 ACTIVATED CHARCOAL ADMINISTRATION (1G/KG)
 CATHARTIC WHEN APPROPRIATE
1. SORBITOL 1-2G/KG
2. SODIUM SUPLHATE
3. MAGNESIUM CITRATE

15. IF THERE IS SPECIFIC ANTIDOTE THEN ADMINISTER IT
AS EARLY AS POSSIBLE
IF ANTIDOTE IS NOT AVAILABLE THEN REMOVE THE
INGESTED MATERIAL BY ADMINITRATION OF
CHARCOAL, DIUREIS, DIALYSIS OR HEMOPERFUSION.
HEMPOPERFUSION INVOLVES DITOXIFICATION OF
THE BLOOD BY PROCESSING IT THROUGH AN EXTRA
CORPOREAL CIRCUIT AND AN ADSORBANT
CONTAINIG CHAROCOAL AFTER WHICH CLEAN
BLOOD IS RETURNED TO THE PATIENT.

16. INGESTED POISONS
ACIDS AND ALKALIS
PETROLEUM DISTILLATES/HYDROCARBONS
KEROSENE ,TURPENTINE
DRUG OVERDOSE
FOOD POISIONING

17. 1. ALKALINE PRODUCTS:
 DRAIN CLEANERS, TOILET, BOWL, CLEANERS, BLEACH, NON PHOSPHATE DETEGENTS, OVEN
CLEANERS, AND BUTTON BATTERIES
2. ACID PRODUCTS:
 TOILET BOWL CLEANERS, POOL CLEANERS, METAL CLEANERS, RUST REMOVERS AND BATTERIES
ACID.

18. MANAGEMENT
CHECK AND MAINTAIN ABC.
TAKE ECG
ASSESS NEUROLOGIC STATUS
GIVE WATER AND MILK TO DRINK FOR
DILUTION OF STRONG ACID AND
ALKALIES

19. PARAPHENYLENEDIAMINE
POISONING (KALA PATHAR)

20. INTRODUCTION
PPD IS A COAL-TAR DERIVATIVE, USED AS A
HAIR DYE IN SOUTH ASIA WHICH ON
OXIDATION PRODUCES BONDROWSKI’S BASE
HAVING ALLERGENIC, MUTAGENIC AND
HIGHLY TOXIC PROPERTIES
LETHAL DOSE = 6-10 GRAMS

21. PATHOGENESIS &
MANIFESTATIONS
 ANGIONEUROTIC EDEMA =
LARYNGOSPASM=DYSPNEA=HYPOXIA=ACUTE
RESPIROTORY FAILURE
 RHABDOMOYOLYSIS = MYCOCARDITIS = ARRHYTMIAS
 MYOGLOBINEMIA = MYOGLOBINURIA = RENAL TUBULAR
NECROSIS = ARF = COLA COLORED URINE
 INTRAVUSCULAR HEMOLYSIS = ANEMIA, HYPERKALEMIA,
HYPOTENSION;SHOCK
 HEPATIC NECROSIS

22. CLINICAL FEATURES
PAIN IN THROAT
ORAL ERYTHEMA
CERVICOFACIAL EDEMA
DYSPHAGIA
MUSCLE ACHE /RIGIDITY
OLIGURIA/ANURIA
HEPATITIS
SINUS BRADYCARDIA

23. MANAGEMENT
 AIRWAY MANAGEMENT
 SECURE BREATHING
 CIRCULATION
 GASTRIC LAVAGE :2 GRAMS OF ACTIVATED CHARCOAL EVERY 6 HOURS
 IF LAYRNGEAL EDEMA OR ARDS DEVELOPS :GIVE INJ SOLOCORTIF 500MG
FIVE A TIMES A DAY +INJ PHENIRAMINE MALEATE (AVIL)4MG EVERY 8 HOURS
 FORCED DIURETIC :GIVE 5-6 LITERS OF IV FLUIDS +
INJECTION SODIUM BICARBONATE 75MMOL+INJ FUROSEMIDE 20MG EVERY
8 HOURS.GIVE INJ MANNITOL 250 ML (IF PATIENT IS STILL OLIGOURIC)

24. CONT.
IF DEVELOPED HYPERKALEMIA:GIVE INJ CA
GLUCONATE 8 HOURLY AND SALBUTAMOL
(VENTOLIN)NEBULIZATION EVERY 3 HOURS.
CARDIAC SUPPORT:IF HYPOTENSION PERSIST
ADEQUEATE FLUID RESUSCITATION ,GIVE
INJECTION DOPAMINE INFUSION.
CONSULT NEPHROLOGIST :IF PATIENT DEVELOP
ARF
COUNSELLING OF THE PATIENTS FAMILY.

25. INHALED POISONING
 CARBON MONOXIDE : IT MAY OCCUR AS A RESULT OF INDUSTRIAL OR
HOUSEHOLD INCIDENTS OR ATTEMPTED SUICIDE.
 IT BINDS WITH HEMOGLOBIN CALLED CARBOXYHEMOGLOBIN.
 REDUCING THE O2 CAPACITY OF THE BLOOD
 CO2 BINDS WITH HEMOGLOBIN 200 TIMES MORE RAPIDLY THAN O2.
 SIGNS AND SYMPTOMS : HEADACHE ,NAUSEA,BREATHLESSNESS,DIZZINESS, LOSS
OF CONSCIOUSNESS,SKIN COLOR BLUE .
 MANAGEMENT :CARRY THE PATIENT TO FRESH AIR IMMEDIATLEY ,OPEN ALL
DOORS AND WINDOWS.
 LOOSEN TIGHT CLOTHES.
 INITIATE CPR IF REQUIRED ;ADMINISTER 100% O2

26. ORGANOPHOSPHATE POISONING
ORGANOPHOSPHORUS AND CARBAMATE
INSECTICIDES
(PARATHION,MALATHION,CARBAMTES,CARABRYL)A
RE WIDELY USED IN AGRICULTURE AND HOME
GARDENING .

27. PATHOPHYSIOLOGY
 INHIBITION OF ACETYLCHOLINESTERASE (AChE)
 Ach FOUND IN CENTERAL AND PERIPHERAL NERVOUS
SYSTEM, NEUROMUSCULAR JUNCTIONS, AND RBCs
 ORGANOPHOSPHATE INACTIVATE AChE BY
PHOSPHORELATION

28. ONCE AChE HAS BEEN INACTIVATED, Ach
ACCUMULATES THROUGH OUT THE NERVOUS
SYSTEM, RESULTING IN OVERSTIMULATION OF
MUSCARINIC AND NICOTINIC RECEPTORS.
CLINICAL EFFECTS ARE MANIFESTED VIA ACTIVATION
OF THE AUTONOMIC AND CENTRAL NERVOUS
SYSTEM AND AT NICOTINIC RECEPTORS ON SKELETAL
MUSCLE

29. SIGN AND SYMPTOMS
DIVIED INTO 3 CATEGORIES
1. MUSCARINIC EFFECTS (MIOSIS, SALIVATION, LACRIMATION,
URINATION, DIARRHEA, GI UPSET, EMESIS, BRADYCARDIA,
BRONCHOSPASM )
2. NICOTINIC EFFECTS (MUSCLE FASCICULATION,CRAMPIMG ,HYPERTION
TACHYCARDIA MYDRIASIS )
3. CNS EFFECTS (ANXIETY RESTLESNESS
CONFUSION,ATAXIA,TREMORS,SEIZURES,COMA)

30. MANAGEMENT
AIRWAY CONTROL AND ADEQUATE
OXYGENATION
INTUBATION MAY BE NECESSARY
IMMEDIATE AGGRESSIVE USE OF ATROPINE
MAY ELIMINATE THE NEED FOR INTUBATION
MAINSTAYS OF MEDICAL THERAPY IN
ORGANOPHOSPHATE POISIONING INCLUDE
ATRPOINE ,PRALIDOXIM AND DIAZEPAM

31. ATROPINE
ADULT DOSE: 1-2 MG IV BOLUS, REPEAT q1-
5MIN
DOUBLING EACH SUBSEQUENT DOSE TO
RAPIDLY CONTROL OF PATIENTS IN SEVERE
RESPIRATORY DISTRESS
PEDIATRIC DOSE: 0.05MG/KG IV REPEAT q1-5
MIN

32. SNAKE BITE
THE VENOM OF POISONOUS SNAKE ARE
PREDOMINATELY:
NEUROTOXIC (CORAL SNAKES)
IT CAUSES RESPIRATORY PARALYSIS
CYTOLYTIC (RATAL SNAKES AND PIT VIPERS)
IT CAUSES TISSUE DISTRUCTION BY DIGESTION OF THE
ENDOTHELIAL LINING OF BLOOD VESSELS

33. SIGN AND SYMPTOMS
LOCAL PAIN
REDNESS
SWELLING
PERI ORAL TINGLING
METALLIC TASTE
NAUSEA AND VOMITING
COAGULOPATHY
PTOSIS, DIPLOPIA
DYSPHAGIA AND RESPIRATORY DISTRESS

34. MANAGEMENT “DO IT R.I.G.H.T”
1. R. = REASSURE THE PATIENT.
 70% OF ALL SNAKE BITES ARE FROM NON-VENOMOUS SPECIES. ONLY
50% OF BITES BY VENOMOUS SPECIES ACTUALLY ENVENOMATE THE
PATIENT
2. I. = IMMOBILISE IN THE SAME WAY AS A FRACTURED LIMB.
 USE BANDAGE OR CLOTH TO HOLD THE SPLITS, NOT TO BLOCK THE
BLOOD SUPPLY OR APPLY PRESSURE.DO NOT APPLY ANY COMPRESSION
3. G.H. = GET TO HOSPITAL IMMEDIATELY.
4. T. = TELL THE DOCTOR OF ANY SYSTAMIC SYMPTOMS

35. CONT
ABC
IF THERE IS EVIDENCE BITE WHERE THE SKIN
HAS BEEN BROKEN GIVE TETANUS TOXOID
ROUTINE USE OF ANTIBIOTIC IS NOT
NECESSARY, ALTHOUGH IT SHOULD BE
CONSIDERED IF THERE IS EVIDENCE OF
CELLULITIS OR NECROSIS

36. POLYVALENT ANTIVENIN (RATTLE SNAKE
AND CORAL SNAKE )
CROFAB
4-6 VIALS BY SLOWLY, IV DRIP INTO 250-
500ML NORMAL SALINE. DOSE CAN BE
INCREASED ACCORDING TO SEVERITY OF THE
PATIENT
ANAVIP
10 VIALS BY SLOWLY , INTRAVENOUS
INFUSION OVER 60 MINTUES

37. SUPPORTIVE TREATMENT
ANALGESICA FOR PAIN – TAB PCM
ANTIBIOTICS FOR INFECTION
ANTI-TETANUS PROPHYLAXIS
REPLACEMENT OF COAGULATION FACTORS/
PLATELETS (IF THERE IS ANY ACTIVE BLEEDING
OR BLEEDING IN TO A VITAL ORGAN)

38. TIGHT (ARTERIAL) TOURNIQUETS ARE NOT
RECOMMENDED –WHY?
THIS METHOD WAS EXTREMELY PAINFUL AND VERY
DANGEROUS IF THE TOURNIQUET WAS LEFT ON FOR
TOO LONG ( MORE THAN ABOUT 40 MINUTES) AS THE
LIMB MIGHT BE DAMAGED BY ISCHAEMIA.
CONFINING THIS TOXIN IN A SMALLER AREA, BY USE
OF COMPRESSION TECHNIQUES CREATES A GREATER
RISK OF SERIOUS LOCAL DAMAGE.

39. TIGHT (ARTERIAL) TOURNIQUETS ARE NOT
RECOMMENDED
WHEN THE TOURNIQUET IS REMOVED THERE IS
A PROBLEM OF VENOM RAPIDLY ENTERING THE
SYSTEM CAUSESES RESPIRATORY FAILURE IN THE
CASE OF NEUROTOXIC BITES.
THE VIPER VENOM CONTAINS PRO COGULANT
ENZYMES WHICH CAUSE THE BLOOD TO
CLOT.WHEN THE TORNIQUET IS RELEASED THE
CLOT WILL RAPIDLY ENTER THE BODY AND
CAUSE EMBOLISM AND DEATH .