2. 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
3. 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%)
4. 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
5. ▪ 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.
6.
7.
8.
9.
10. 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
11.
12. Hot as a hare
Dry as a bone
Red as a beet
Mad as a hatter
Blind as a bat
bowel, bladder
lose their tone, &
heart runs alone
13. Hot as a hare
Dry as a bone
Red as a beet
Mad as a hatter
Blind as a bat
bowel , bladder lose
their tone, &
heart runs alone
14. Hot as a hare
Dry as a bone
Red as a beet
Mad as a hatter
Blind as a bat
bowel , bladder
lose their tone,
&heart runs alone
31. Very diverse and varied - depends on the poison
Clinical examination should be focused on the
possible manifestations of common poisons in the
geographical area
37. Treat the patient, not the poison
Assess
General appearance
Work of breathing
Circulation
ABCDs
IV access and monitors
High Suspicion
59. ECG
Digoxin toxicity
TCA overdose - sinus tachycardia, QT prolongation,
increased QRS
Beta-blockers - conduction abnormalities
Imaging
. 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.
60. Opiates
Cocaine metabolite
Amphetamine
Benzodiazepines
Barbiturates
* No urine screen can confirm intoxication, only exposure
61.
62.
63. Reduce absorption of the toxin
Enhance elimination
Neutralise toxin
64.
65. 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
66. 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
67. Gastric decontamination
▪ Forced emesis if patient is awake
▪ Gastric lavage
▪ Activated charcoal 25 gm 2 hourly
▪ Sorbitol as cathartic
68. 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
69. 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
70. 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
71. 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
72. 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
77. 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
81. Iron Desferroxamine
Copper Penicillamine, Dimercaprol, CaEDTA
Lead CaEDTA, Dimercaprol (BAL)
Mercury DMPS, DMSA, BAL
Arsenic BAL & derivatives
Antimony BAL & derivatives
82. 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.
83. 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
84. National Poisons Information Centre (NPIC)
Department of Pharmacology
All India Institute of Medical Sciences
New Delhi, India
Tel. No.: 26589391, 26593677,
Fax: 26850691, 26862663
Email: npicaiims@hotmail.com
provides round-the-clock, 7 days-a-week, 365
days service on telephone.
85. 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
Editor's Notes
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