Assessment triangle: -general appearance (sleepy, obtunded, wired, delirious,etc.) -work of breathing (too fast, too slow, too deep, too shallow) -circulation (hypertensive, hypotensive) Most toxic exposures can be treated with basic life support measures Oxygen, dextrose, and naloxone: diagnostic and therapeutic Toxidrome: constellation of symptoms which are most likely to indicate the ingestion of a certain class of medication. H&P plus lab eval.
Altered mental status: rule out other causes as clinically indicated: trauma (including abuse), infection, metabolic abnormality (DKA), etc.
Paracelsus = German physician, father of modern pharmacology
Approach to a poisoned child
Guide –Dr Jyoti Singh
What is a poison? ▪ In common usage - poisons are chemicals or chemical products that are distinctly harmful to human ▪ More precisely - a poison is a foreign chemical (xenobiotic) that is capable of producing a harmful effect on a biologic system
Most common Pediatric Exposure Cosmetics and personal care products (13%) Cleaning substances (10%) Analgesics (7.8%) Foreign Bodies (7.4%) Topicals (7.4%) Cold and Cough Preparations (5.5%) Plants (4.6%) Pesticides (4.1%)
May be difficult because of non-specific symptoms High index of suspicion - especially occult poisoning ▪ history may be unreliable ▪ look for corroborative history - missing pills, empty container Course that a poison runs (toxidromes) ! - may help Toxicology screening - helpful only in a few
▪ It is the association of several clinically recognizable features, signs, symptoms, phenomena or characteristics which often occur together, so that the presence of one feature alerts the physician to the presence of the others.
S alivation *D iaphoresis/diarrhea L acrimation *U rination U rination *M iosis D efecation *B radycardia/bronchospasm G I secrestion/upset *E mesis E mesis *L acrimation excess *S alivation excess
Hot as a hareDry as a boneRed as a beetMad as a hatterBlind as a batbowel, bladderlose their tone, &heart runs alone
Hot as a hareDry as a boneRed as a beetMad as a hatterBlind as a batbowel , bladder losetheir tone, &heart runs alone
Hot as a hareDry as a boneRed as a beetMad as a hatterBlind as a batbowel , bladderlose their tone,&heart runs alone
ECG Digoxin toxicity TCA overdose - sinus tachycardia, QT prolongation, increased QRS Beta-blockers - conduction abnormalitiesImaging . CXR- hydrocarbon ingestion .Abdominal X-ray-- iron ingestion & radioopaque ingestion. .Oesophagoscopy -for caustic ingestion. . Abdominal usg- recently been used as a means of identifying presence of pharmaceutical material in GIT.
Opiates Cocaine metabolite Amphetamine Benzodiazepines Barbiturates* No urine screen can confirm intoxication, only exposure
Reduce absorption of the toxin Enhance elimination Neutralise toxin
Removal from surface skin & eye Emesis induction Gastric lavage Activated charcoal administration & cathartics Dilution - milk/other drinks for corrosives Whole bowel irrigation Endoscopic or surgical removal of ingested chemical
Skin decontamination ▪ Important aspect – not to be neglected ▪ Remove contaminated clothing ▪ Wash with soap and water (soaps containing 30% ethanol advocated) ▪ However, no evidence for benefit even in OP poisoning
Gastric decontamination ▪ Forced emesis if patient is awake ▪ Gastric lavage ▪ Activated charcoal 25 gm 2 hourly ▪ Sorbitol as cathartic
Gastric lavage ▪ Gastric lavage decreases absorption by 42% if done 20 min and by 16% if performed at 60 min ▪ Performed by first aspirating the stomach and then repetitively instilling & aspirating fluid ▪ Left lateral position better - delays spont. absorption ▪ No evidence that larger tube better ▪ Simplest, quickest & least expensive way ▪ Choice of fluid is tap water - 5-10 ml/kg
Gastric lavage ▪ Preferrably done on awake patients ▪ Presence of an ET tube does not preclude aspiration, though preferred if GCS is low ▪ No human studies in OP poisoning showing benefit of gastric lavage
Single dose activated charcoal 0.5-1 gm/kg, adolescents 50-100 grams PO; maximum dose 100 grams More benefit if administered within 1 hour of ingestion, but still good for poison which slows gastric motility (anticholinergic, opiates, salicylates) Strongly consider for acetaminophen overdose > 4 hours
P – Pesticides, petroleum distillates, unprotected airway H – Hydrocarbons, heavy metals, > 1h delay in administration A – Acids, alkali, alcohol, altered level of consciousness, aspiration risk I – Iron, ileus, intestinal obstruction L – Lithium, lack of gag reflex S – seizures
Nonabsorbable, isotonic polyethylene glycol Toxins “pushed” through GI tract; prevents absorption Concentration gradient created by this allows absorbed toxin to diffuse back into GI tract Used where toxins NOT absorbed by charcoal
Plasmapheresis Works very well with highly protein (albumin) bound drugs Not a routine methodology, but has been used to remove theophylline and digoxin/ digibind complexes Exchange transfusion Use in smaller infants where vascular access for extracorporeal techniques can’t be done
Iron DesferroxamineCopper Penicillamine, Dimercaprol, CaEDTALead CaEDTA, Dimercaprol (BAL)Mercury DMPS, DMSA, BALArsenic BAL & derivativesAntimony BAL & derivatives
Calcium channel blockers: bradycardia and hypotension; 1 - 10 mg tablet of nifedipine Camphor: respiratory depression and seizures; 15 mL of Vicks vapo-rub (700 mg of camphor) Clonidine: severe bradycardia; 0.1 mg Tricyclic antidepressants: cardiovascular and CNS toxicity; 10-20mg/kg Opioids: CNS and respiratory depression; 2.5 mg of hydrocodone.
Lomotil: anticholinergic overdose (tachycardia, seizures, coma); ½ tablet Salicylates: cerebral edema, acidosis, coma; ½ teaspoon of wintergreen fatal Sulfonylureas: severe hypoglycemia; 1 tablet Toxic alcohols: cardiac and CNS depression; 2.9mL of 95% ethylene glycol has been fatal
National Poisons Information Centre (NPIC)Department of PharmacologyAll India Institute of Medical SciencesNew Delhi, India Tel. No.: 26589391, 26593677, Fax: 26850691, 26862663 Email: email@example.com round-the-clock, 7 days-a-week, 365 days service on telephone.
Poisoning a common problem in our country A high index of suspicion required to diagnose Know common toxidrome & antidotes Charcoal is only given if likely to benefit Patients receiving decontamination must have airway protection Don’t panic and follow a plan of action Decreasing absorption Enhancing elimination Neutralising toxins Avoid potentially harmful Rxs - risk vs benefit