toxicology presentation about the updates in management of acutely poisoned patient

1. Recent recommendations in
general management of acute
poisoned patient
American Academy of Clinical
Toxicology(AACT) , the European Association
of Poison Centres and Clinical Toxicologists
guidelines(EAPCCT)
Haifa Alshwikh

2. “Alle Dinge sind Gift und nichts ist ohne
Gift, allein die Dosis macht es, dass
ein Ding kein Gift ist.”—
Paracelsus
"All things are poison and
nothing is without poison;
only the dose makes a thing
not a poison.“
even water and oxygen—can be toxic if
too much is taken, drunk, or
absorbed

3. STATISTICS :
2 to 5 million poisonings and drug overdoses occur annually in the
United States
poison exposures account for 5 to 10 percent of all emergency
department visits and greater than 5 percent of adult intensive
care unit (ICU) admissions
The annual incidence of poisoning is increasing, with a 4.6 percent
increase in cases noted between 2000 and 2001

4. Approach to poisoned patient
ABCDE
RAPID FIRST LOOK: EXAMINATION, MONITORING, AND TESTING
( vital signs, mental status , pupil size)
DIAGNOSIS
(history , examination, investigations)
MANAGMENT
GIT decontamination
(emesis , activated charcol, gastric lavavge , whole bowel irrigation , Endoscopy/surgery)
Enhanced elimination
(multiple activated charcol, forced diuresis, hemodialysis)
Antidote therapy
Supportive treatment

5. FIRST PRIORITIES
THE ABCDE APPROACH
The steps are organized according to the issues
that pose the most immediate life threats and
consist of
airway, breathing, circulation, disability
(neurologic stabilization), and exposure.
Problems are managed immediately in the
order encountered
the resuscitation leader should ensuring the
safety of health care workers
( A single patient contaminated with a highly potent toxin
(eg, a radioactive isotope or nerve agent such as sarin)
can disable an entire emergency department (ED))

6. is a routine use of coma cocktail still warranted?
The so-called “coma cocktail” of dextrose, naloxone, and thiamine , flumazenil is
an outdated concept and has been replaced by selective use of each
component as necessary
- if there's a doubt about whether hypoglycemia is present, then glucose should
be empirically administered.
-Naloxone should be used only for those cases in which a narcotic overdose
appears likely.
-Similarly thiamine administration should be limited to patients suspected of
chronic alcohol abuse and who exhibit at least one of the three symptoms of
WE
-Flumazenil should not be used, even when benzodiazepine causing toxicity is
suspected, because it can precipitate benzodiazepine withdrawal, seizures.
http://www.ncbi.nlm.nih.gov/pubmed/12483195

7. The theory that thiamine must be given prior to dextrose to avoid
precipitating Wernicke's encephalopathy is largely unsupported.
(Uptake of thiamine into cells is slower than that of dextrose and withholding
dextrose until the administration of thiamine is complete may prove
detrimental to those with actual hypoglycemia)

8. DIAGNOSIS OF POISONING
History
routine and
toxicological
laboratory
evaluations
physical
examination

9. History
When the patient is unable or unwilling to give a reliable history ,
information should be sought from paramedics, police, and the
patient's employer, family, friends, primary care clinician, and
pharmacist.
environment should be conducted for
-pill bottles
-suicide note
-Knowledge of drugs prescribed for the patient or the patient's family
or friends to which (s)he could have had access
-Unknown pills or chemicals may be identified by consultation with a
regional poison control center, computerized poison identification
system, or product manufacturer (eg, material data safety sheet)

10. Physical examination
The mental status, vital signs, and pupillary examination are the
most useful elements and allow classification of the patient into
either a state of CNS excitation or depression
Several classes of toxins manifest as characteristic combinations of
symptoms and signs (so called “toxidromes”). The “toxidrome-
oriented” physical examination consists of:
vital signs
level of alertness
pupil size and position
mucous membranes
skin temperature and moisture
presence or absence of bowel sounds

11. Toxidrome FlowChart Diagnosis
https://en.wikipedia.org/wiki/Toxidrome

12. laboratory studies
glucose
Urine RE
serum electrolytes
BUN, creatinine
liver function tests
calcium
Arterial blood gas
pregnancy testing is strongly recommended in all women of childbearing age
Measurements of serum osmolality
serum lactate may be necessary in patients with acid-base, cardiovascular,
neurologic, or respiratory disturbances
presence of an anion gap metabolic acidosis may be the first clue to a toxic
ingestion and should prompt measurement of serum salicylates, ethylene
glycol, and methanol and examination of the urine for oxalate crystals; serum
creatinine, glucose, ketones, and lactate also should be measured to detect
other causes of the high gap acidosis.
Measurement of isopropyl alcohol concentration in blood should be obtained in
patients with an elevated osmolal gap without metabolic acidosis

13. DOES THE TOXIC SCREEN IN BLOOD , URINE RECOMMENED IN
POISONED PATIENT AND DOES IT AFFECT OVERALL MORTALITY ?
comprehensive qualitative toxic screening of urine, blood, or other body fluids
(commonly by liquid and gas chromatography and mass spectrometry) is
expensive, commonly requires six hours for results, often does not predict or
define the severity of poisoning, detects unsuspected drugs in only a minority of
patients, rarely leads to changes in patient management and disposition, and is
unlikely to affect patient outcome
Thus, comprehensive toxic screening should be performed on blood
and urine only in patients with severe or unexplained toxicity
Toxic screens

14. Other investigations
Electrocardiography (cardiotoxic agents)
Radiographic studies — Imaging studies are not required in every patient but
may be useful in several situations :
Certain radiopaque toxins (summarized by the mnemonic "CHIPS") may be
visualized by plain film radiographs
C Calcium salts
H Heavy metals
I Iodinated compounds (eg, thyroxine)
P Psychotropics (eg, phenothiazines, lithium, cyclic antidepressants)
S Salicylates , Sustained released preparations
Noncardiogenic pulmonary edema and/or the acute respiratory distress
syndrome due to exposure to certain toxic agents may be suggested by the
appearance of the chest radiograph

15. Abdominal radiograph showing radiopaque
iron (ferrous sulfate) tablets visualized in the
stomach of an intentional overdose patient
(arrow).
Courtesy of Michael J Burns, MD.
Abdominal radiograph showing
radiopaque drug packets ingested by a
"body packer."

16. Drug Duration of delectability in urine
Amphetamines 2 to 3 days
Cocaine 2 to 3 days
Marijuana 1 to 7 days (light use); 1 month with
chronic moderate to heavy use
Opiates 1 to 3 days
Phencyclidine 7 to 14 days
Drugs of abuse" immunoassay screens can be used to detect opiates, benzodiazepines,
cocaine metabolites, barbiturates, tricyclic antidepressants, tetrahydrocannabinol, and
phencyclidine in urine

17. POISONING MANAGEMENT
Treatment variably includes :
GIT Decontamination
Enhanced elimination techniques
Antidotal therapy
Supportive care

18. GIT decontamination
Activated
charcol
Gastric
lavage
Syrup of
ipecac
Whole
bowel
irrigation
Endoscopy
or surgery

19. The decision to perform GI decontamination is based upon :
-type of poison
-time from ingestion to presentation
-predicted severity of poisoning
The various methods of GI decontamination can be used alone or in
combination
GIT decontamination

20. Activated charcol
Gastric
Gastric lavavge
syrup of
ipecac (SOI
Whole bowel
irrigation
Endoscopy/surger
y —
Dose : ( 1g/kg) ,
25-100 g usually
needed in adult
mixed with water
Technique:
Trendelenburg
position ,
200-300ml tap
water and
continue till
clearance of the
content ( up to 5 L
)
Formula ( alkaloid
( emetine &
cephaline )
Induce emesis in
20 min
Dose :
30 ml / mouth in
water
Technique —
polyethylene
glycol (PEG-ELS)
electrolyte lavage
solution ( mouth
or NGT)
rate 2 L /h in until
the rectal effluent
clear ,(5 to 50 L)
Fluid and
electrolyte
abnormalities
generally do not
occur with WBI
life-threatening
intoxicant has
been ingested
which cannot be
effectively
removed by less
invasive means
Eg: heavy metals,
refractory to
whole bowel
irrigation or
gastric lavage ,
drug pakers with
int obstruction
C/I : bowel
obstruction and
perforation,
corrosives ,
unprotecetd
airway , HC
C/I :
corrosives , HC ,
l.o.c
Complications:
Aspiration ,
electrolyte
imbalance,arryth
mia , pulm lavavge
, laryngospasm,
C/I : depressed
mental status ,
corrosives , HC
C/I: depressed
mental status ,
bowel obstruction
or perforation ,
masssive GI
bleeding

21. Enhanced
elimination
techniques
multiple-dose
activated
charcoal,
forced diuresis
Forced alkaline
diuresis
Forced acid
diuresis
hemodialysis,
hemoperfusion,
hemofiltration

22. General indications for enhanced elimination techniques
include:
1-Ingestion of a poison whose elimination can be enhanced
2-Failure of a patient to respond to maximal supportive care
3-The clinical course is predicted to be complicated
In all cases, the expected benefits of the use of an enhanced
elimination technique must be carefully balanced with the risk of
potential complications associated with the technique

23. Multiple activated
charcol
Forced alkaline
diuresis
Forced acid diuresis HEMODIALYSIS AND
HEMOPERFUSION
dose :
1 g/kg of activated
charcoal with
sorbitol followed by
0.5 to 1 g/kg of
activated charcoal in
aqueous suspension
every2-4 hours is
recommended
achieve a urine pH of
7.5
IV bolus of 1-2
mEq/kg of 8.4 percent
sodium bicarbonate,
followed by
continuous infusion of
sodium bicarbonate.
(150 mEq Nahco3 into
1 L of 5 % dextrose )
C/I : renal failure,
pulmonary oedema
and cerebral oedema
,heart disease
complications :
Hypokalemia
hypocalcemia
urine pH < 5.5
giving ammonium
chloride or
ascorbic acid
used to treat
intoxications with
weak bases
such as
amphetamines,
quinidine or
phencyclidine
Hemodialysis (HD)
Hemoperfusion
refers to the
circulation of blood
through an
extracorporeal circuit
containing an
adsorbent such as
activated charcoal

24. Agents responsive for
MDAC
ABCD
A antimalarial
B barbiturates
C carbamazipine
D dapsone
Toxins accesible for
hemodialysis
I STUMBLE
I isoprenaline
S salicylates
T theophylline
U uremia
M methanol
B barbiturates
L lithium
E ethylene glycol

25. ANTIDOTES THERAPY
Antidotes dramatically reduce morbidity and mortality in certain intoxications, but
they are unavailable for most toxic agents and therefore are used in only about
1 percent of cases

26. Supportive care:
Hypotension (intravenous fluids)
Hypertension ( 1st line :
nonspecific sedatives such as a benzodiazepine
2nd line :
phentolamine, labetalol, or nitroprusside.
The use of beta-blockers alone for patients with sympathetic
hyperactivity (eg, cocaine intoxication) is not recommended
because it may result in unopposed alpha-adrenergic stimulation
and intensified vasoconstriction

27. Sodium bicarbonate is first line therapy for ventricular tachycardias
(TCAs)
Bradyarrhythmias (in patients with calcium channel blocker or beta
blocker intoxication, the administration of calcium and
glucagon may obviate the need for further measures)
Seizures generally are best treated with benzodiazepines
Seizures caused by certain agents may require specific antidotes
for their successful termination (eg, pyridoxine for
isoniazid toxicity, glucose for hypoglycemic agents)

28. Criteria for ICU admission of poisoned patient
The presence of any of these 9 clinical criterias predicted a complicated
hospital course that could be best managed in an ICU:
-PaCO2 >45 mmHg
- need for emergency intubation
-The presence of seizures
-Unresponsiveness to verbal stimuli ( GCS < 7 )
-Second- or third-degree atrioventricular block
-Systolic blood pressure less than 80 mmHg
-QRS duration ≥0.12 seconds
-Need for whole bowel irrigation to enhance GI elimination of poison
-Need for emergency hemodialysis, hemoperfusion, hemofiltration

29. American Academy of Clinical Toxicology and
the European Association of Poison Centres
and Clinical Toxicologists recommendations
Position paper update: gastric lavage for gastrointestinal
decontamination
B. E. BENSON 1 , K. HOPPU 2 , W. G. TROUTMAN 1 , R. BEDRY 2 , A. ERDMAN 1 , J. H Ö JER 2 , B. M É GARBANE 2 ,
R. THANACOODY 2 , and E. M. CARAVATI 1
1 American Academy of Clinical Toxicology, McLean, VA, USA
2 European Association of Poisons Centres and Clinical Toxicologists, Brussels, Belgium

30. Benefit from GI decontamination is most likely when it can be
performed within one hour of poison ingestion , most adults do
not present to emergency departments until a mean of three to
four hours after a toxic ingestion, GI decontamination is
unlikely to affect patient outcome in most clinical circumstances
Regardless of the method employed, efficacy decreases with
greater delay between ingestion and treatment.

31. Routine use of gastric lavage in the management of poisoned
patients is not recommended by the American Academy of
Clinical Toxicology or the European Association of Poison Centres
and Clinical Toxicologists
Clinical studies have failed to show that gastric lavage improves the
severity of illness
For the vast majority of patients, especially those that present late
or are asymptomatic on presentation, gastric lavage is not likely
to add benefit
The use gastric lavavge in patients who present more than one hour
following ingestion is exclusive in the agents that are highly toxic
and not bound well by AC or cause delay in gastric emptying.

32. Gastric lavage is less effective than activated charcoal (AC) in
reducing the absorption of simulated toxins but is roughly
equivalent in efficacy to ipecac .
In 2003, the American Academy of Pediatrics advised against the
continued routine use of ipecac in the home and also
recommended disposal of any ipecac that remained in homes
Ipecac should NOT be administered routinely in the management of
poisoned patients since there is no evidence from clinical studies
that it improves important outcomes.
Clinical Toxicology (2013), 51, 140–146
Copyright © 2013 Informa Healthcare USA, Inc.

33. Activated charcol is The only GI decontamination measure needed
to treat an overdose , its a first-line agent for the treatment of
poisonings, especially if more than several hours have passed
since ingestion.
AC appears superior to syrup of ipecac or gastric lavage alone for
preventing the absorption of ingested intoxicants , Gastric
lavage followed by or preceded and followed by AC may be more
effective than AC alone at preventing drug absorption

34. WBI is probably more effective than gastric lavage or ipecac but
probably less effective than AC in preventing poison absorption
when the intoxicant can be bound by charcoal.
Whole bowel irrigation is reserved primarily for patients who have
ingested toxic foreign bodies (eg, drug packets), sustained-
release or enteric-coated drugs, or toxic materials not bound by
activated charcoal (eg, heavy metals).
hemodynamically stable and cooperative patients are best
candidate for WBI intensive cathartic treatment
Concurrent use of WBI and AC is not advisable as PEG-ELS may
reduce the binding capacity of AC

35. In most toxicological emergencies, effective antidotes are not
Available , Symptomatic treatment and supportive care are still
the primary approach to treatment
The administration of antidotal therapy, when indicated, should not
be delayed by attempts at decontamination. Some antidotes may
be bound or removed by agents used during decontamination
Urinary acidification has been abandoned, as efficacy has not been
established and iatrogenic toxicity (severe acidosis) can occur.

36. Conclusion:
stabilization of the patient is being considered as the main stay Of management
of poisoning emergencies.
There has been a major change in the treatment of poisoned patients, especially
in the area of gastric decontamination. The trend is away from the use of
ipecac, except in limited situations.
activated charcoal has attained a prominent role, not only as an adjunct either
with ipecac or gastric lavage but also as the sole decontamination agent.
Gastric lavage still plays an important role if it can be performed early, or if drugs
are involved that may delay gastric emptying.
Whole–bowel irrigation is safe and effective in limited situations such as iron,
lithium, or sustained release medications, and for body packers.
Antidotes play an important role in specific situations.
Review Paper
Recent Advances in the Management of Poisoning Cases
*Dasari Harish, **K H Chavali,**Amandeep Singh, ** Ajay Kumar