ACUTE POISONING
GUIDELINES FOR INITIAL
MANAGEMENT
Prof. Dr. Saad S Al Ani

Senior Pediatric Consultant
Head of Pediatric D...
INTRODUCTION
• The majority of poisonings are
accidental, especially in the under-5
age group
• Intentional overdoses and ...
CONT.
•

•

Deaths in children from poisoning are
becoming increasingly rare
Factors responsible for this decline
include:...
HOW CHILDREN DIFFER FROM ADULTS
•

•

Pediatric patients may be particularly
vulnerable to certain toxins at specific
stag...
CONT.
• Toddlers, as they develop exploratory
hand-to-mouth activity, may be
exposed to a wide range of potential
hazards
...
GENERAL PRINCIPLES
Assess:
 Type

of ingestion (drug, preparation)
 Time of incident
 Amount of ingestion (include all ...
GENERAL PRINCIPLES
Cont.
 Is the ingestion potentially harmful?
 Beware of the possibility of mixed overdose
 Beware of...
GENERAL PRINCIPLES
Management
 Airway
 Breathing
 Circulation
 Removal of poison (if necessary)
 Emesis
 No role in ...
GENERAL PRINCIPLES
Cont.


Activated Charcoal
The treatment of choice for most ingestions.
Most effective when given with...
GENERAL PRINCIPLES
Cont.
Activated Charcoal Contraindications:
•Patients with altered conscious state
•The following agent...
GENERAL PRINCIPLES
Cont.
Whole Bowel Irrigation has a limited role
in treatment of some slow release
preparations
 Gastri...
GENERAL PRINCIPLES

Cont.
All acts of deliberate self harm must be
taken extremely seriously.
 All intentional self poiso...
INITIAL ASSESSMENT AND MANAGEMENT

The

initial priority in treating poisoned
children is the standard ABC
(airway, breat...
A: ASSESS AIRWAY PATENCY
By

looking, listening, and feeling for
air movement.
 If there is no air movement, try to open...
CONT.
Certain

ingested agents may predispose
to airway edema and
obstruction, including caustic
agents, angiotensin-conv...
B: ASSESS THE ADEQUACY OF BREATHING

It is important to remember that
succinylcholine may cause prolonged
block in childre...
CONT.
Observing

ventilatory frequency, use of
accessory muscles, breath sounds, and
oxygen saturations.
 Reduced respir...
C: ASSESS THE CIRCULATION
In

terms of cardiovascular status (heart
rate, arterial pressure, and capillary
refill) and th...
CONT.
Hypotension

should initially be treated
with a 20 ml/ kg crystalloid bolus,
remembering that if it is caused by
sp...
CONT.
Arrhythmias

associated with poisoning
are best treated by:
i. Correcting precipitating factors (e.g.
hyperkalaemia...
CONT.
Children

in cardiac arrest should be
treated according to standard guidelines
(e.g. The Advanced Cardiac Life
Supp...
SALICYLATES POISONING

12/23/201
3

Acute poisoning

Prof. Dr. Saad S Al Ani

Khorfakkan Hospital
SALICYLATES POISONING
Assessment
Symptoms
Tinnitus
Seizures
Vomiting
Hyperthermia
Hyperventilation Dehydration

Lethargy
C...
SALICYLATES POISONING
Cont.
•

Initial respiratory alkalosis (may be
transient), followed by paradoxical
aciduria (pH <6),...
SALICYLATES POISONING
Patients Requiring Treatment
 Acute ingestion ≥ 150mg/kg
 All symptomatic patients
 Ingestion of ...
SALICYLATES POISONING
 Investigations

Serum salicylate level at presentation (on
patients requiring treatment), and 2 hr...
SALICYLATES POISONING




Management

Asymptomatic
 Charcoal 1g/kg (if <1 hour since ingestion unless
enteric coated pr...
SALICYLATES POISONING
Cont.


Symptomatic
 All symptomatic patients require urgent medical
assessment and investigations...
SALICYLATES POISONING
Symptomatic (Cont.)
 I.V. bicarbonate infusion 1mmol/kg/hr, after
initial slow bolus of 2mmol/kg, (...
PARACETAMOL POISONING

12/23/201
3

Acute poisoning

Prof. Dr. Saad S Al Ani

Khorfakkan Hospital
PARACETAMOL POISONING
 Patients
1.
2.
3.

Requiring Management
Acute ingestion of > 200 mg/kg
Ingestion of unknown quanti...
PARACETAMOL POISONING
Assessment
 Consider the possibility of co
ingestions, either accidental or deliberate

http://www....
PARACETAMOL POISONING
Management
 Activated charcoal is not useful in liquid
ingestions due to rapid absorption
 Activat...
PARACETAMOL POISONING
 There

is no benefit in measuring
paracetamol level earlier than 4 hours
 It is safe to wait for ...
PARACETAMOL POISONING
Cont.
 Patients who present > 8 hours after a toxic
ingestion / symptoms of toxicity (RUQ pain or
t...
PARACETAMOL POISONING
 There

is little evidence to guide management
in repeated supratherapeutic doses. Potential
toxici...
PARACETAMOL POISONING

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_
Managem...
PARACETAMOL POISONING

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_
Managem...
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_
Management/
12/23/201
3

Acute...
PARACETAMOL POISONING
N- Acetyl cysteine (NAC) Infusion
Instructions
 The standard administration of NAC is a 3
stage inf...
PARACETAMOL POISONING
Cont.
 For patients > 110 kg, calculate the dose based
on 110 kg body weight.
 NAC may be diluted ...
PARACETAMOL POISONING
For
1.

2.

3.

adolescent / adult:
150 mg/kg in 250 or 500 ml over 1
hour
50 mg/kg in 500 ml over ...
IRON POISONING

12/23/201
3

Acute poisoning

Prof. Dr. Saad S Al Ani

Khorfakkan Hospital
IRON POISONING
Background
 Iron

is found in several different forms in
different medicines.
 The important ingestion is...
IRON POISONING
Table: Iron Medications

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For...
IRON POISONING
Percentage elemental iron:
• Ferrous fumarate 33%
• Ferrous chloride 28%
• Ferrous sulfate 20%
• Ferrous ch...
ASSESSMENT
Patients Requiring Assessment
1. Ingestion of > 40 mg/kg elemental iron.
(approximately > ½ tablet/kg or 6.5 ml...
HISTORY AND EXAMINATION
Initial symptoms:
 Usually occur within 20 minutes
 Nausea, vomiting, diarrhea, abdominal
pain, ...
HISTORY AND EXAMINATION
Latent period:
 There is often 6-24 hour latent period when
initial symptoms resolve, before over...
HISTORY AND EXAMINATION
Other symptoms:
 Usually appear at 6-24 hours and last 12-24
 Tachycardia, vasoconstriction, hyp...
HISTORY AND EXAMINATION
Multiple organ failure:
 Occurs 12-48 hours after ingestion
 Particularly hepatic failure

http:...
IRON POISONING
Management
 ABC

 Supportive

therapy to maintain adequate
blood pressure and electrolyte balance is
esse...
IRON POISONING
Investigations
Asymptomatic patients:
 If tablet ingestion do AXR and if negative does not need further in...
IRON POISONING
All symptomatic patients should have the
following investigations:
 AXR if tablet ingestion
 ABG/CBG (aci...
IRON POISONING
Cont.


Serum iron
 Peak levels are usually seen at 4 hours.
 Levels taken after four hours may underest...
IRON POISONING
Cont.
 FBE (leukocytosis)
 U&E & Cr
 X-match
 Clotting (reversible early coagulopathy and late
coagulop...
IRON POISONING
Cont.
 Decontamination
 Charcoal is of no benefit.
 Decontamination of choice is whole bowel irrigation
...
IRON POISONING
Antidote:
 Desferroxamine is a chelating agent which
forms a water soluble desferroxamine-iron
complex.

h...
IRON POISONING
Consider desferroxamine in:
 Serum iron levels > 90 micromol/l
 Level 60 - 90 micromol/l and tablets visi...
IRON POISONING
 Dose:

Desferroxamine 15 mg/kg/hr I.V. The rate
is reduced after four to six hours so that the total
intr...
IRON POISONING
 It

is difficult to determine the endpoint for
chelation therapy.
 Significant poisoning usually require...
IRON POISONING
Cont.
It is recommended to continue desferroxamine
until:
 Patient is asymptomatic.
 decontamination comp...
HYDROCARBON POISONING

12/23/201
3

Acute poisoning

Prof. Dr. Saad S Al Ani

Khorfakkan Hospital
HYDROCARBON POISONING
Hydrocarbons Include:
 Petrol
 Kerosene
 Lighter Fluid
 Mineral Turpentine
 Paraffin Oil
 Lubr...
HYDROCARBON POISONING
Assessment
 Main complication is Aspiration Pneumonitis
 C.N.S. toxicity can be evident (either de...
HYDROCARBON POISONING
 Symptoms:
 Coughing,

choking, respiratory distress
ataxia, drowsiness, coma, convulsions
persist...
MANAGEMENT

Keep nil orally charcoal is contraindicated.
 Asymptomatic
 Observe 6hours
 Discharge if remains asymptomat...
MANAGEMENT (CONT.)
 Symptomatic







If develops respiratory symptoms
(aspiration), do CXR & O2 saturation
Give O2...
ALKALIS POISONING

12/23/201
3

Acute poisoning

Prof. Dr. Saad S Al Ani

Khorfakkan Hospital
ALKALIS POISONING

Alkalis include:
 Drain cleaners, Oven cleaners
 Automatic dish washing liquids & powders
 Laundry d...
ALKALIS POISONING
 pH

of >11.5 is likely to cause significant GI
ulceration
 Attempt to obtain container to check
conte...
ALKALIS POISONING(CONT.)
Corrosive potential varies with concentration of
specific ingredients and preparations, ie liquid...
ASSESSMENT
 Toxicity

Exposure may lead to severe burns of GIT,
especially esophagus
Absence of mouth or pharyngeal ulcer...
MANAGEMENT
 Activated

charcoal is contraindicated
 If asymptomatic treat with fluid dilution:
10ml/kg of water (max 250...
ANTICONVULSANT POISONING

12/23/201
3

Acute poisoning

Prof. Dr. Saad S Al Ani

Khorfakkan Hospital
ANTICONVULSANT POISONING


CARBAMAZEPINE, PHENYTOIN, SODIUM
VALPROATE, PHENOBARBITONE

Assessment
 CNS
 Ataxia, drowsin...
PATIENTS REQUIRING TREATMENT
 All

symptomatic patients
 Acute ingestion of unknown quantity
 Carbamazepine ingestion o...
MANAGEMENT
Charcoal 1g/kg unless altered conscious state (protect
airway first)
 Mild symptoms (e.g. ataxia, blurred visi...
TRICYCLIC OVERDOSE

12/23/201
3

Acute poisoning

Prof. Dr. Saad S Al Ani

Khorfakkan Hospital
TRICYCLIC OVERDOSE

Assessment
Symptoms
 Anticholinergic
 vomiting, blurred vision, ataxia, tachycardia, urinary retenti...
MANAGEMENT
Charcoal 1g/kg unless altered conscious state (protect
airway first)
 Require ECG, cardiac monitoring
 Asympt...
BENZODIAZEPINE POISONING

Assessment
Symptoms
 CNS depression, drowsiness, coma
 Respiratory depression
 Hypotension
 ...
PATIENTS REQUIRING OBSERVATION

 Ingestion

of ≥3 times recommended dose

for age
 All symptomatic patients
 Ingestion ...
MANAGEMENT
 Charcoal

is not usually of benefit (due to
low order of toxicity)
 If depressed state of consciousness, pro...
THEOPHYLLINE POISONING

12/23/201
3

Acute poisoning

Prof. Dr. Saad S Al Ani

Khorfakkan Hospital
THEOPHYLLINE POISONING
Assessment
 CNS
 Agitation, hyperventilation, headache, convu
lsions
 Cardiovascular
 Arrhythmi...
PATIENTS REQUIRING TREATMENT

ingestion of ≥ 10mg/kg
 Any ingestion while on maintenance
theophylline
 Ingestion of unkn...
INVESTIGATIONS
Theophylline levels should be determined on all patients
requiring charcoal
 Serial levels are required at...
MANAGEMENT

Asymptomatic
 Charcoal 1g/kg
 Observe 4 hours. If no symptoms,
discharge if not slow release medication.
 I...
MANAGEMENT(CONT.)
Symptomatic
 Charcoal 1g/kg initially unless altered conscious state
(protect airway first) then 0.5g/k...
ETHANOL POISONING

http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_
Management/...
ETHANOL POISONING
Ethanol Containing Preparations














Light beer 2% Beer 5%
Cider 5%
Wine 10%
Wine co...
ETHANOL POISONING
Fatalities generally occur with blood levels > 86.8mmol/L
(breath alcohol >0.4)
Assessment
Symptoms
 Na...
ETHANOL POISONING(CONT.)
Hypothermia
 Hypokalemia, metabolic acidosis
 Unexplained drowsiness, hypothermia or hypoglycem...
MANAGEMENT
 Charcoal

is of no benefit
 Check blood glucose in younger children
 Asymptomatic or Mild Symptoms (decreas...
MANAGEMENT(CONT.)
Symptomatic (more than just mild symptoms or
continued symptoms after 2 hours)
 Blood ethanol measureme...
REFERENCES
 American Association

of Poison Control Centers:
http://www.aapcc.org/dnn/Home.aspx
 American Academy of Cli...
THANK YOU

12/23/201
3

Acute poisoning

Prof. Dr. Saad S Al Ani

Khorfakkan Hospital
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  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/ 12/23/2013 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/ 12/23/2013 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/ 12/23/2013 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/ 12/23/2013 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/ 12/23/2013 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/ 12/23/201 3 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/ 12/23/201 3 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/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  10. 10. GENERAL PRINCIPLES Cont. Activated Charcoal Contraindications: •Patients with altered conscious state •The following agents: 1.Ethanol/glycols 6.Potassium and other metallic ions 2.Alkalis 7.Fluoride 3.Boric acid 8.Cyanide 4.Lithium 9.Hydrocarbons 5.Iron compounds 10.Mineral acids http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  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/ 12/23/201 3 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/ 12/23/201 3 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/ 12/23/2013 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/ 12/23/2013 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/ 12/23/2013 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/ 12/23/2013 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/ 12/23/2013 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/ 12/23/2013 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/ 12/23/2013 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/ 12/23/2013 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/ 12/23/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  22. 22. SALICYLATES POISONING 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  23. 23. SALICYLATES POISONING Assessment Symptoms Tinnitus Seizures Vomiting Hyperthermia Hyperventilation Dehydration Lethargy Coma Hypoglycemia Non cardiogenic pulmonary edema http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  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/ 12/23/201 3 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/ 12/23/201 3 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/ 12/23/201 3 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/ 12/23/201 3 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/ 12/23/201 3 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/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  30. 30. PARACETAMOL POISONING 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  31. 31. PARACETAMOL POISONING  Patients 1. 2. 3. Requiring Management Acute ingestion of > 200 mg/kg Ingestion of unknown quantity Repeated supratherapeutic ingestion of > 100mg/kg/day http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 12/23/201 3 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/ 12/23/201 3 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/ 12/23/201 3 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/ 12/23/201 3 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/ 12/23/201 3 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/ 12/23/201 3 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/ 12/23/201 3 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/ 12/23/201 3 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/ 12/23/201 3 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/ 12/23/201 3 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 dextrosesaline 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/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  42. 42. PARACETAMOL POISONING For 1. 2. 3. adolescent / adult: 150 mg/kg in 250 or 500 ml over 1 hour 50 mg/kg in 500 ml over 4 hours 100 mg/kg in 1000 ml over 16 hours http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  43. 43. IRON POISONING 12/23/201 3 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/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  45. 45. IRON POISONING Table: Iron Medications http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  46. 46. IRON POISONING 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). http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  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/ 12/23/201 3 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/ 12/23/201 3 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/ 12/23/201 3 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/ 12/23/201 3 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/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  52. 52. IRON POISONING 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/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  53. 53. IRON POISONING 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/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  54. 54. IRON POISONING 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/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  55. 55. IRON POISONING 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/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  56. 56. IRON POISONING 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/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  57. 57. IRON POISONING 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/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  58. 58. IRON POISONING 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/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  59. 59. IRON POISONING 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/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  60. 60. IRON POISONING  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/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  61. 61. IRON POISONING  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/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  62. 62. IRON POISONING 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/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  63. 63. HYDROCARBON POISONING 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  64. 64. HYDROCARBON POISONING 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/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  65. 65. HYDROCARBON POISONING 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/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  66. 66. HYDROCARBON POISONING  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/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  67. 67. MANAGEMENT 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/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  68. 68. MANAGEMENT (CONT.)  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/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  69. 69. ALKALIS POISONING 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  70. 70. ALKALIS POISONING 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/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  71. 71. ALKALIS POISONING  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/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  72. 72. ALKALIS POISONING(CONT.) 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/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  73. 73. ASSESSMENT  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/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  74. 74. MANAGEMENT  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/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  75. 75. ANTICONVULSANT POISONING 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  76. 76. ANTICONVULSANT POISONING  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/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  77. 77. PATIENTS REQUIRING TREATMENT  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/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  78. 78. MANAGEMENT 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/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  79. 79. TRICYCLIC OVERDOSE 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  80. 80. TRICYCLIC OVERDOSE 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/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  81. 81. MANAGEMENT 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/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  82. 82. BENZODIAZEPINE POISONING 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/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  83. 83. PATIENTS REQUIRING OBSERVATION  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/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  84. 84. MANAGEMENT  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/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  85. 85. THEOPHYLLINE POISONING 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  86. 86. THEOPHYLLINE POISONING 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/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  87. 87. PATIENTS REQUIRING TREATMENT ingestion of ≥ 10mg/kg  Any ingestion while on maintenance theophylline  Ingestion of unknown quantity  All symptomatic patients  Acute http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  88. 88. INVESTIGATIONS 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/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  89. 89. MANAGEMENT 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 levels http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  90. 90. MANAGEMENT(CONT.) 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/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  91. 91. ETHANOL POISONING http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_ Management/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  92. 92. ETHANOL POISONING 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/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  93. 93. ETHANOL POISONING 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/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  94. 94. ETHANOL POISONING(CONT.) 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/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  95. 95. MANAGEMENT  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/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  96. 96. MANAGEMENT(CONT.) 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/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  97. 97. REFERENCES  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/ 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
  98. 98. THANK YOU 12/23/201 3 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

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