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Toxicology Definitions and Treatment Principles
1.
2. Definitions
ā¢ Poison:
ā¢ Any substance that can cause severe organ damage or death if
ingested, breathed in, or absorbed through the skin
ā¢ Toxin:
ā¢ A poisonous substance, especially a protein, that is produced
by living cells or organisms and is capable of causing disease
when introduced into the body tissues but is often also
capable of inducing neutralizing antibodies or antitoxin.
3. Definitions
ā¢ Toxicity:
ā¢ Degree to which a substance can damage an organism
ā¢ Toxicology:
ā¢ The study of the nature, effects, and detection of poisons
(toxins) and the treatment of poisoning.
4. Treatment of Poisoning: Principles
Resuscitation Risk Assessment Supportive Care and
Monitoring
InvestigationsDecontamination
Enhanced
Elimination Antidotes Disposition
5. Resuscitation: The ABCDE way!
Check for Goal Possibility Possible Measures
Airway Maintain
patency
Patent
Obstructed
Position: Left lateral,
Head down
Suctioning
Intubation +/- Guedelās
Airway
6. Resuscitation: The ABCDE way!
Check for Goal Possibility Possible Measures
Breathing
Maintain
adequate
oxygenation and
ventilation
Spontaneous
Apnoeic
SpO2 levels
Start Oxygen at 2L/min via
face mask
Intubation +/- Guedelās
Airway
Check for falling SpO2
7. Resuscitation: The ABCDE way!
Check for Goal Possibility Possible Measures
Circulation
Maintain
perfusion to
vital organs
Feel for Pulses
BP recordable(?)
Attach Monitor, look for
rhythm consider
inotropes (dobutamine)
Start Crystalloids
(Normal Saline
preferred) +/- Consider
vasopressors
(adrenaline)
8. Resuscitation: The ABCDE way!
Check for Goal Possiblity
Possible
Measures
Disability
Assess level of
Consciousness;
Correct life
threatening
conditions
Institute
Resuscitative
Antidotes
Glasgow Coma Scale
or AVPU scale
Hypoglycaemia;
Hypethermia;
Seizure(focal/generalis
ed)
Antidotes
Dextrose bolus
injection; active
cooling;
benzodiazepam
(diazepam)
9. Resuscitation: The ABCDE way!
Check for Goal Possiblity
Possible
Measures
Exposure
Assess
Toxidromes
Cholinergic/Anticholinergic
Delirium, Agitation,
Neuroleptic Malignant
Syndrome
Manage
Accordingly
10. Risk Assessment
ā¢ Distinct Quantitative Cognitive Step
ā¢ Ascertain:
ā¢ Agent(s)
ā¢ Dose(s)
ā¢ Time since ingestion
ā¢ Clinical features and progress
ā¢ Patient factors and co-morbidities
Methods:
ā¢ History by patient
himself/herself;
attendants
ā¢ Missing medicines at
home, previous
medical records,
agents available at
home
11. Supportive Care and Monitoring
ā¢ Fate:
ā¢ Emergency Observation Unit
ā¢ Intensive Care Unit
ā¢ Initially should be done in
ED
ā¢ Duration of Monitoring
determined by:
ā¢ Agent(s) ingested
ā¢ Formulation involved
ā¢ Disposition from ED
depends on:
ā¢ Current clinical status
ā¢ Expected clinical status
17. Enhanced Elimination
ā¢ Increase the rate of removal of an agent with the aim of
reducing the severity and duration of clinical intoxication
ā¢ Only useful in poisoning with few agents that are
characterised by:
ā¢ Severe toxicity
ā¢ Poor outcome despite good supportive care and antidote
administration
ā¢ Slow endogenous rates of elimination
ā¢ Suitable pharmacokinetic properties
18. Techniques for Enhanced Elimination
Urinary Alkalinisation
ā¢ Alkaline urine promotes the ionisation of highly acidic drugs
and prevents reabsorption
ā¢ Sodium bicarbonate, bolus + infusion
ā¢ Useful for Phenobarbitone, Salicylate
Other methods:
ā¢ Multiple Dose Activated Charcoal
ā¢ Hemoperfusion
ā¢ Hemodialysis
ā¢ Plasmapheresis
ā¢ Exchange Transfusion
ā¢ Charcoal Hemoperfusion
19. Antidotes
ā¢ Antidotes are drugs
ā¢ Indication based upon a risk-benefit analysis
ā¢ Administered only when therapeutic benefit exceeds:
ā¢ Potential adverse effects
ā¢ Cost and resource requirements.
ā¢ An accurate risk combined with pharmaceutical knowledge
of the antidote is essential to clinical decision-making.
21. Few Antidotesā¦
Poison/Overdose Antidote
Digoxin Digoxin immune Fab
Heparin Protamine
Warfarin, Coumarins Vitamin K
Benzodiazepines Flumazenil
Paracetamol Acetylcysteine
Iron and iron salts Desferioxamine
Carbon monoxide Oxygen (Hyperbaric)
22. Disposition
ā¢ Medical and Psychosocial disposition
ā¢ A patient may be:
ā¢ Discharged
ā¢ Transferred
ā¢ Referred
ā¢ Emergency Observation
Unit
ā¢ Intensive Care Unit
23. Some Common Toxicological values
Drug/Enzyme Normal Range (Ī¼g/mL)
Phenytoin 10-20
Phenobarbitone 15-40
Paracetamol 10-20
Carbamazepine 4-12
Serum Cholinesterase 4000-11500
24. Lets try solving theseā¦
ā¢ A patientās blood sample was sent tested for serum
paracetamol level and was found to be 300mg/dL. What is
your diagnosis and how will you manage this case?
ā¢ A patient with organophosphorus poisoning presented to
you in Emergency Department. How will you manage the
case?
Editor's Notes
Acute toxicity involves harmful effects in an organism through a single or short-term exposure.
Subchronic toxicity is the ability of a toxic substance to cause effects for more than one year but less than the lifetime of the exposed organism.
Chronic toxicity is the ability of a substance or mixture of substances to cause harmful effects over an extended period, usually upon repeated or continuous exposure, sometimes lasting for the entire life of the exposed organism.
Examples where early administration of an antidote is necessary to ensure a successful resuscitation include
intravenous sodium bicarbonate in tricyclic antidepressant poisoning,
naloxone in severe opioid intoxication
digoxin-specific antibody fragments for patients with suspected digoxin intoxication with cardiovascular compromise.
Antidotes during resuscitation:
intravenous sodium bicarbonate in tricyclic antidepressant poisoning
naloxone in severe opioid 1 intoxication
digoxin-specific antibody fragments for patients with suspected digoxin intoxication with cardiovascular compromise
Examples where early administration of an antidote is necessary to ensure a successful resuscitation include
intravenous sodium bicarbonate in tricyclic antidepressant poisoning,
naloxone in severe opioid intoxication
digoxin-specific antibody fragments for patients with suspected digoxin intoxication with cardiovascular compromise.
1Toxidromes: Physiologically based abnormalities that are known to occur with specific classes of substances and typically are helpful in diagnosis
Major causes of poisoning morbidity and mortality are acute effects of poison on cardiovascular, central nervous or respiratory systems: supportive care thus required
Monitoring is essential to detect the progress of the intoxication and the timing of institution, escalation and withdrawal of supportive care and other measures.
Major causes of poisoning morbidity and mortality are acute effects of poison on cardiovascular, central nervous or respiratory systems: supportive care thus required
Monitoring is essential to detect the progress of the intoxication and the timing of institution, escalation and withdrawal of supportive care and other measures.
Are either:
Screening Tests:
Qualitative and quantitative evaluation for active ingredient, its metabolite or other affected biochemical parameters
May direct therapy
Blood, Urine, Stool, Other body fluids e.g. gastric aspirate
Specific Tests
Should be requested selectively, if anticipated to assist risk assessment or management
Includes Complete Blood Counts, Liver Function Test, Renal Function Test, Arterial Blood Gas Analysis, Chest X-ray
High Hazard Potential: Not to be used routinely
Clinical judgment based on potential benefits, potential risks and available resources
Absorption virtually completed within 1 hr- so decontamination should be done as early as possible
have specific indications, contraindications, optimal administration methods, monitoring requirements, appropriate therapeutic end-points and adverse effect profiles.