Acute poisoning guidelines for initial management

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What are the initial steps in management of acute poisoning ,presentation ,types ,Salicylates ,paracetamol ,Iron ,and others,

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Acute poisoning guidelines for initial management

  1. 1. ACUTE POISONING GUIDELINES FOR INITIAL MANAGEMENT Prof. Dr. Saad S Al Ani Senior Pediatric Consultant Head of Pediatric Department Khorfakkan Hospital Sharjah ,UAE saadsalani@yahoo.com
  2. 2. INTRODUCTION • The majority of poisonings are accidental, especially in the under-5 age group • Intentional overdoses and substance abuse are seen in older children http://emedicine.medscape.com/pediatrics_general/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  3. 3. CONT. • Deaths in children from poisoning are becoming increasingly rare • Factors responsible for this decline include: 1. Introduction of child-resistant containers 2. Reducing the pack sizes of aspirin and acetaminophen 3. More effective management http://emedicine.medscape.com/pediatrics_general/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  4. 4. HOW CHILDREN DIFFER FROM ADULTS • Pediatric patients may be particularly vulnerable to certain toxins at specific stages of childhood. • Breast fed infants may be exposed to drugs or toxins excreted in breast milk; neonates have immature metabolic capabilities http://emedicine.medscape.com/pediatrics_general/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  5. 5. CONT. • Toddlers, as they develop exploratory hand-to-mouth activity, may be exposed to a wide range of potential hazards http://emedicine.medscape.com/pediatrics_general/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  6. 6. GENERAL PRINCIPLES Assess: Type of ingestion (drug, preparation) Time of incident Amount of ingestion (include all medication that was potentially in the bottle or packet when calculating) Weight of child http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  7. 7. GENERAL PRINCIPLES Cont. Is the ingestion potentially harmful? Beware of the possibility of mixed overdose Beware of the possibility of inaccurate dose reporting on history taking If mixed or undetermined ingestion Paracetamol level should be done http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  8. 8. GENERAL PRINCIPLES Management Airway Breathing Circulation Removal of poison (if necessary) Emesis  No role in the hospital setting http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  9. 9. GENERAL PRINCIPLES Cont.  Activated Charcoal The treatment of choice for most ingestions. Most effective when given within first hour. http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  10. 10. GENERAL PRINCIPLES Cont. http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital Activated Charcoal Contraindications: •Patients with altered conscious state •The following agents: 6.Potassium and other metallic ions1.Ethanol/glycols 7.Fluoride2.Alkalis 8.Cyanide3.Boric acid 9.Hydrocarbons4.Lithium 10.Mineral acids5.Iron compounds
  11. 11. GENERAL PRINCIPLES Cont.  Whole Bowel Irrigation has a limited role in treatment of some slow release preparations Gastric Lavage has a very limited role in treatment and should not be used without consultation. Specific antidotes may be available and serum drug levels may help in treatment decisions http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  12. 12. GENERAL PRINCIPLES Cont.  All acts of deliberate self harm must be taken extremely seriously. All intentional self poisonings in adolescents require admission If unexplained symptoms exist a urinary drug screen may be indicated http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  13. 13. INITIAL ASSESSMENT AND MANAGEMENT The initial priority in treating poisoned children is the standard ABC (airway, breathing, and circulation) resuscitation approach http://emedicine.medscape.com/pediatrics_general/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  14. 14. A: ASSESS AIRWAY PATENCY By looking, listening, and feeling for air movement.  If there is no air movement, try to open the airway with simple maneuvers such as the jaw thrust or the use of airway adjuncts. http://emedicine.medscape.com/pediatrics_general/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  15. 15. CONT. Certain ingested agents may predispose to airway edema and obstruction, including caustic agents, angiotensin-converting enzyme inhibitors, and plants containing calcium oxalate crystals (e.g. Dieffenbachia and Philodendron house plants) http://emedicine.medscape.com/pediatrics_general/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  16. 16. B: ASSESS THE ADEQUACY OF BREATHING It is important to remember that succinylcholine may cause prolonged block in children who have a reduced cholinesterase concentration due to exposure to cocaine or organophosphate compounds: prolonged apneas of up to 7 h have been described. http://emedicine.medscape.com/pediatrics_general/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  17. 17. CONT. Observing ventilatory frequency, use of accessory muscles, breath sounds, and oxygen saturations.  Reduced respiratory effort may require bag-valve-mask ventilation until a definitive airway can be secured http://emedicine.medscape.com/pediatrics_general/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  18. 18. C: ASSESS THE CIRCULATION In terms of cardiovascular status (heart rate, arterial pressure, and capillary refill) and the effect of circulatory inadequacy on other organs (mental state, urine output, skin temperature, and colour). http://emedicine.medscape.com/pediatrics_general/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  19. 19. CONT. Hypotension should initially be treated with a 20 ml/ kg crystalloid bolus, remembering that if it is caused by specific toxins such as β- blockers, the specific antidote should also be given, for example, glucagon http://emedicine.medscape.com/pediatrics_general/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  20. 20. CONT. Arrhythmias associated with poisoning are best treated by: i. Correcting precipitating factors (e.g. hyperkalaemia and acidosis) ii. Administering the appropriate antidote; http://emedicine.medscape.com/pediatrics_general/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  21. 21. CONT. Children in cardiac arrest should be treated according to standard guidelines (e.g. The Advanced Cardiac Life Support protocol), although it is important to address the need for a specific antidote, for example, sodium bicarbonate for tricyclic antidepressant (TCA) poisoning http://emedicine.medscape.com/pediatrics_general/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  22. 22. SALICYLATES POISONING 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  23. 23. SALICYLATES POISONING Assessment http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital Symptoms SeizuresTinnitus HyperthermiaVomiting DehydrationHyperventilation HypoglycemiaLethargy Non cardiogenic pulmonary edemaComa
  24. 24. SALICYLATES POISONING Cont. • Initial respiratory alkalosis (may be transient), followed by paradoxical aciduria (pH <6), then metabolic acidosis & Hypokalemia (± ongoing respiratory alkalosis). http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  25. 25. SALICYLATES POISONING Patients Requiring Treatment Acute ingestion ≥ 150mg/kg All symptomatic patients Ingestion of unknown quantity http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  26. 26. SALICYLATES POISONING  Investigations  Serum salicylate level at presentation (on patients requiring treatment), and 2 hrly if symptomatic or enteric coated preparation. (Need to call the RCH lab to get test run urgently as it is sent to RMH for analysis) Urea & electrolytes, creatinine, acid- base, glucose http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  27. 27. SALICYLATES POISONING  Management  Asymptomatic  Charcoal 1g/kg (if <1 hour since ingestion unless enteric coated preparation)  Observe 6 hours & discharge if still asymptomatic  If enteric coated preparations, serial salicylate levels (2 hourly)  Admit if levels have not plateaued at 6 hours post ingestion  I.V. bicarbonate infusion 1mmol/kg/hr to correct any acidosis (pH <7.3) http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  28. 28. SALICYLATES POISONING Cont.  Symptomatic  All symptomatic patients require urgent medical assessment and investigations as above.  Charcoal 1g/kg unless altered conscious state (protect airway first)  I.V. fluid resuscitation to correct dehydration (use N. Saline) http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  29. 29. SALICYLATES POISONING Symptomatic (Cont.)  I.V. bicarbonate infusion 1mmol/kg/hr, after initial slow bolus of 2mmol/kg, (keep urine pH >7.5)  Potassium replacement as required  Worsening symptoms, convulsion, coma, contact I.C.U. for respiratory support hemodialysis  Salicylate level >7mmol/l following an acute poisoning contact I.C.U. for consideration of hemodialysis. http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  30. 30. PARACETAMOL POISONING 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  31. 31. PARACETAMOL POISONING  Patients Requiring Management 1. Acute ingestion of > 200 mg/kg 2. Ingestion of unknown quantity 3. Repeated supratherapeutic ingestion of > 100mg/kg/day http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  32. 32. PARACETAMOL POISONING Assessment Consider the possibility of co ingestions, either accidental or deliberate http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  33. 33. PARACETAMOL POISONING Management Activated charcoal is not useful in liquid ingestions due to rapid absorption Activated charcoal 1 g/kg may be considered in a cooperative patient seen within 1 hour of tablet or capsule ingestion. Serum paracetamol level at (or as soon as possible after) 4 hours post ingestion determines the need for N-acetyl cysteine (NAC) administration. (see nomogram) http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  34. 34. PARACETAMOL POISONING There is no benefit in measuring paracetamol level earlier than 4 hours It is safe to wait for the paracetamol level to decide on the need for NAC in all cases that present within 8 hours of ingestion. http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  35. 35. PARACETAMOL POISONING Cont.  Patients who present > 8 hours after a toxic ingestion / symptoms of toxicity (RUQ pain or tenderness, nausea, vomiting) should be commenced on NAC immediately.  The decision to continue or cease NAC is then based on the paracetamol level.  Delaying NAC administration beyond 8 hours is associated with a progressive increased risk of liver injury. http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  36. 36. PARACETAMOL POISONING There is little evidence to guide management in repeated supratherapeutic doses. Potential toxicity should be assessed when:  > 200 mg/kg (or 10g) ingested over a 24 hour period  > 150 mg/kg/day (or 6 g) ingested over a 48 hour period  > 100 mg/kg/day ingested over a 72 hour period http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  37. 37. PARACETAMOL POISONING http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  38. 38. PARACETAMOL POISONING http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  39. 39. http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  40. 40. PARACETAMOL POISONING N- Acetyl cysteine (NAC) Infusion Instructions The standard administration of NAC is a 3 stage infusion giving a total dose of 300 mg/kg: 1. 150 mg/kg over the first hour 2. 50 mg/kg over the next 4 hours 3. 100mg/kg over the next 16 hours http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  41. 41. PARACETAMOL POISONING Cont. For patients > 110 kg, calculate the dose based on 110 kg body weight. NAC may be diluted in 5% dextrose or 0.9% saline (normal saline).  It can also be diluted in combination dextrose- saline solutions not exceeding these concentrations including 0.45% saline in 5% dextrose, and 0.9% saline in 5% dextrose. http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  42. 42. PARACETAMOL POISONING For adolescent / adult: 1. 150 mg/kg in 250 or 500 ml over 1 hour 2. 50 mg/kg in 500 ml over 4 hours 3. 100 mg/kg in 1000 ml over 16 hours http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  43. 43. IRON POISONING 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  44. 44. IRON POISONING Background Iron is found in several different forms in different medicines. The important ingestion is the amount of elemental iron not the iron salt. http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  45. 45. IRON POISONING http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital Table: Iron Medications
  46. 46. IRON POISONING http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital Percentage elemental iron: • Ferrous fumarate 33% • Ferrous chloride 28% • Ferrous sulfate 20% • Ferrous chloride 28% • Ferrous gluconate 12% Iron is also found in plant fertilizers (e.g. sulphate of iron -20% elemental iron).
  47. 47. ASSESSMENT Patients Requiring Assessment 1. Ingestion of > 40 mg/kg elemental iron. (approximately > ½ tablet/kg or 6.5 ml syrup/kg) 2. Ingestion of an unknown quantity. 3. Any symptomatic patients http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  48. 48. HISTORY AND EXAMINATION Initial symptoms:  Usually occur within 20 minutes  Nausea, vomiting, diarrhea, abdominal pain, hypotension, Hematemesis, fever  Gastrointestinal symptoms related to the corrosive nature of iron may occur without systemic toxicity, however any symptoms require iron levels.  Lack of symptoms within the first 6 hours makes significant toxicity unlikely. http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  49. 49. HISTORY AND EXAMINATION Latent period: There is often 6-24 hour latent period when initial symptoms resolve, before overt systemic toxicity Thus improvement over this time may be a result of improvement or deterioration http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  50. 50. HISTORY AND EXAMINATION Other symptoms: Usually appear at 6-24 hours and last 12-24 Tachycardia, vasoconstriction, hypotension and shock Metabolic acidosis can occur. These are related to fluid shifts from intravascular to extravascular compartments and cellular hypoxia http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  51. 51. HISTORY AND EXAMINATION Multiple organ failure: Occurs 12-48 hours after ingestion Particularly hepatic failure http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  52. 52. Management ABC Supportive therapy to maintain adequate blood pressure and electrolyte balance is essential I.V. fluid resuscitation 20 ml/kg Potassium and glucose administration as necessary. http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital IRON POISONING
  53. 53. Investigations Asymptomatic patients: If tablet ingestion do AXR and if negative - does not need further investigation or observation If unknown amount or >60mg/kg ingested need serum iron levels 4 hourly until falling http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital IRON POISONING
  54. 54.  All symptomatic patients should have the following investigations:  AXR if tablet ingestion  ABG/CBG (acidosis)  Glucose (hyperglycaemia) http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital IRON POISONING
  55. 55. Cont.  Serum iron  Peak levels are usually seen at 4 hours.  Levels taken after four hours may underestimate toxicity because the subject iron may have either been distributed into tissues or be bound to ferritin.  In the case of slow release or enteric coated tablets, levels should be repeated at six to eight hours as absorption may be erratic.  Once desferroxamine is commenced, iron levels are not accurate at most labs using automated methods (including RCH) http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital IRON POISONING
  56. 56. Cont.  FBE (leukocytosis)  U&E & Cr  X-match  Clotting (reversible early coagulopathy and late coagulopathy secondary to hepatic injury)  LFTs  AXR may be helpful in evaluating gastrointestinal decontamination after treatment if tablets have been ingested. http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital IRON POISONING
  57. 57. Cont.  Decontamination  Charcoal is of no benefit.  Decontamination of choice is whole bowel irrigation (WBI) with naso-gastric colonic lavage solution 30ml/kg/hr until rectal effluent clear (contraindicated if there are signs of bowel obstruction or haemorrhage).  WBI is indicated:  If AXR reveals tablets, or capsules ingested  In symptomatic patients http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital IRON POISONING
  58. 58. Antidote: Desferroxamine is a chelating agent which forms a water soluble desferroxamine-iron complex. http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital IRON POISONING
  59. 59. Consider desferroxamine in:  Serum iron levels > 90 micromol/l  Level 60 - 90 micromol/l and tablets visible on XRay or symptomatic (nausea, vomiting, diarrhea, abdominal pain, haematemesis, fever)  Any patient with significant symptoms of altered conscious state, hypotension, tachycardia, tachypnea, or worsening symptoms irrespective of ingested dose or serum iron level.  Do not wait for iron level if altered conscious state, shock, severe acidosis (pH <7.1), or worsening symptoms but commence Desferroxamine without delay. http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital IRON POISONING
  60. 60.  Dose: Desferroxamine 15 mg/kg/hr I.V. The rate is reduced after four to six hours so that the total intravenous dose in general does not exceed 80 mg/kg/24 hours.  Desferroxamine -iron complex is renally excreted.  If oliguria or anuria develop, peritoneal dialysis or hemodialysis may become necessary to remove ferrioxamine. http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital IRON POISONING
  61. 61. It is difficult to determine the endpoint for chelation therapy. Significant poisoning usually requires 12 - 16 hours, http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital IRON POISONING
  62. 62. Cont. It is recommended to continue desferroxamine until:  Patient is asymptomatic.  decontamination complete  anion-gap acidosis resolved  Iron level (if measurable) is <54 micromol/L  Desferroxamine has been associated with pulmonary toxicity and should be used with caution if indications persist >24 hours. http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital IRON POISONING
  63. 63. 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital HYDROCARBON POISONING
  64. 64. Hydrocarbons Include:  Petrol  Kerosene  Lighter Fluid  Mineral Turpentine  Paraffin Oil  Lubricating Oil  Furniture Polishes  2 Stroke Fuel  Diesel Fuel  White Spirit http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital HYDROCARBON POISONING
  65. 65. Assessment  Main complication is Aspiration Pneumonitis  C.N.S. toxicity can be evident (either depression or excitement) http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital HYDROCARBON POISONING
  66. 66. Symptoms: Coughing, choking, respiratory distress ataxia, drowsiness, coma, convulsions persistent burping (particularly seen after petrol ingestion http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital HYDROCARBON POISONING
  67. 67. Keep nil orally charcoal is contraindicated. Asymptomatic  Observe 6hours  Discharge if remains asymptomatic  Arrange review by LMO the following day http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital MANAGEMENT
  68. 68.  Symptomatic  If develops respiratory symptoms (aspiration), do CXR & O2 saturation  Give O2 to maintain saturation > 94%  If stable, admit to general medical ward  If increasing O2 requirements or increased respiratory distress contact I.C.U.  If altered conscious state at any time contact I.C.U. http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital MANAGEMENT (CONT.)
  69. 69. 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital ALKALIS POISONING
  70. 70. Alkalis include: Drain cleaners, Oven cleaners Automatic dish washing liquids & powders Laundry detergents, Ammonia Portland cement http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital ALKALIS POISONING
  71. 71. pH of >11.5 is likely to cause significant GI ulceration Attempt to obtain container to check contents and strength of substance. http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital ALKALIS POISONING
  72. 72.  Corrosive potential varies with concentration of specific ingredients and preparations, ie liquid preparations are more likely to cause esophageal burns than powders.  Check preparations with Poisons Information Centre to determine whether ingested substance is weak, strong, irritant or corrosive in nature. http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital ALKALIS POISONING(CONT.)
  73. 73. Toxicity Exposure may lead to severe burns of GIT, especially esophagus Absence of mouth or pharyngeal ulcers does not preclude gastro- oesophageal lesions Symptoms: May be minimal Pain Nausea & vomiting, drooling or refusing to eat and drink Stridor, respiratory distress http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital ASSESSMENT
  74. 74. Activated charcoal is contraindicated If asymptomatic treat with fluid dilution: 10ml/kg of water (max 250ml) If asymptomatic after 4 hours and able to eat and drink the patient can be safely discharged If any symptoms, contact surgical registrar, & admit for oesophagoscopy http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital MANAGEMENT
  75. 75. 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital ANTICONVULSANT POISONING
  76. 76.  CARBAMAZEPINE, PHENYTOIN, SODIUM VALPROATE, PHENOBARBITONE Assessment  CNS  Ataxia, drowsiness, coma, convulsions  GIT  Nausea & Vomiting  CVS  Hypotension, Arrhythmias  Drug levels are available for some anticonvulsants e.g. carbamazepine, phenytoin, phenobarbitone http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital ANTICONVULSANT POISONING
  77. 77. All symptomatic patients Acute ingestion of unknown quantity Carbamazepine ingestion of >20mg/kg (for patients not on maintenance treatment) or the greater of more than twice the daily dose or 20mg/kg for patients on maintenance treatment http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital PATIENTS REQUIRING TREATMENT
  78. 78.  Charcoal 1g/kg unless altered conscious state (protect airway first)  Mild symptoms (e.g. ataxia, blurred vision)  observe 4 hours, discharge if symptom free  Moderate or persistent symptoms (after 4 hours of observation)  Admit for observation  Severe symptoms  Depressed conscious state or cardiac arrhythmias contact I.C.U. . http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital MANAGEMENT
  79. 79. 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital TRICYCLIC OVERDOSE
  80. 80. Assessment Symptoms  Anticholinergic  vomiting, blurred vision, ataxia, tachycardia, urinary retention  Antiadrenergic  vasodilatation  Sodium Channel blockade  widened QRS (>0.12 ms)  QT prolongation  reduced cardiac contractility & hypotension  CNS Depression  drowsiness, coma, convulsions  Symptomatic patients require urgent medical assessment http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital TRICYCLIC OVERDOSE
  81. 81.  Charcoal 1g/kg unless altered conscious state (protect airway first)  Require ECG, cardiac monitoring  Asymptomatic: observe for 6 hours post ingestion and discharge if have a normal ECG just prior to discharge  All symptomatic patients should be admitted  If widened QRS on ECG commence Sodium Bicarbonate infusion 1mmol/kg/hr, after initial slow bolus of 2mmol/kg  If altered conscious state, widened QRS or arrhythmia contact I.C.U. & protect airway http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital MANAGEMENT
  82. 82. Assessment Symptoms CNS depression, drowsiness, coma Respiratory depression Hypotension Beware additive toxicity with other CNS & Respiratory depressants http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital BENZODIAZEPINE POISONING
  83. 83. Ingestion of ≥3 times recommended dose for age All symptomatic patients Ingestion of unknown quantity http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital PATIENTS REQUIRING OBSERVATION
  84. 84. Charcoal is not usually of benefit (due to low order of toxicity) If depressed state of consciousness, protect airway and contact ICU Antidote available - Flumazenil, not indicated for ingestions and should only be used after discussion with consultant staff. http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital MANAGEMENT
  85. 85. 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital THEOPHYLLINE POISONING
  86. 86. Assessment CNS  Agitation, hyperventilation, headache, convu lsions Cardiovascular  Arrhythmias GIT  nausea & vomiting (may be intractable), thirst, diarrhea http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital THEOPHYLLINE POISONING
  87. 87. Acute ingestion of ≥ 10mg/kg Any ingestion while on maintenance theophylline Ingestion of unknown quantity All symptomatic patients http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital PATIENTS REQUIRING TREATMENT
  88. 88.  Theophylline levels should be determined on all patients requiring charcoal  Serial levels are required at 2 hours then every 2 hours until peak reached or decline demonstrated.  If slow release preparation has been taken: admit, continue levels at 4 hourly intervals after decline or plateau to ensure detection of secondary peak  Seizures are common at levels >330 micromol/L  Haemoperfusion commonly needed at levels > 550 micromol/L.  U&E, Cr and Glucose on all patients. http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital INVESTIGATIONS
  89. 89. Asymptomatic  Charcoal 1g/kg  Observe 4 hours. If no symptoms, discharge if not slow release medication.  If ingestion of slow release preparation, admit for observation and serial drug levelshttp://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital MANAGEMENT
  90. 90. Symptomatic  Charcoal 1g/kg initially unless altered conscious state (protect airway first) then 0.5g/kg 4 hourly, and whole bowel irrigation with colonic lavage solution 30ml/kg/hr.  Cardiac monitoring  I.V. fluid resuscitation & maintenance of adequate hydration is vital  If depressed conscious state, arrhythmias or intractable vomiting contact I.C.U. as likely to need intubation  Severe intoxication may require haemoperfusion  If agitated, may need sedation with a benzodiazepine or phenobarbitone. http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital MANAGEMENT(CONT.)
  91. 91. http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital ETHANOL POISONING
  92. 92. Ethanol Containing Preparations  Light beer 2% Beer 5%  Cider 5%  Wine 10%  Wine coolers 5%  Fortified wine 20%  Spirits 45%  Liqueurs 30%  Perfumes& colognes >60%  Aftershaves 80%  Mouth washes (some) 25%  Methylated spirit 95% (does not contain methanol) http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital ETHANOL POISONING
  93. 93.  Fatalities generally occur with blood levels > 86.8mmol/L (breath alcohol >0.4) Assessment Symptoms  Nausea, vomiting, abdominal pain  Hypoglycemia  Ataxia, lethargy, coma, convulsions  Respiratory depression http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital ETHANOL POISONING
  94. 94.  Hypothermia  Hypokalemia, metabolic acidosis  Unexplained drowsiness, hypothermia or hypoglycemia in adolescents may be ethanol induced. In adolescents ethanol ingestion often accompanies ingestion of other drugs. Patients Requiring Treatment  symptomatic patients http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital ETHANOL POISONING(CONT.)
  95. 95.  Charcoal is of no benefit  Check blood glucose in younger children  Asymptomatic or Mild Symptoms (decreased inhibition, slight incoordination)  Observe for 2 hours  Give frequent carbohydrate containing drinks  Breath alcohol if possible  If remains symptomatic or symptoms worsen admit http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital MANAGEMENT
  96. 96. Symptomatic (more than just mild symptoms or continued symptoms after 2 hours)  Blood ethanol measurement, U& E, Glucose  I.V. fluid  Temperature regulation  Admit.  If unconscious or convulsions contact I.C.U. http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital MANAGEMENT(CONT.)
  97. 97.  American Association of Poison Control Centers: http://www.aapcc.org/dnn/Home.aspx  American Academy of Clinical Toxicology: http://www.clintox.org/index.cfm  Centers for Disease Control and Prevention, Section on Environmental health: http://www.cdc.gov/Environmental http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital REFERENCES
  98. 98. 6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital THANK YOU

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