This document discusses important toxins and poisonings that medical professionals must be aware of. It covers the following key points: - Identifies common toxic substance groups like opioids, sedatives, and toxins causing various "toxidromes" or symptom clusters. - Explains how to conduct an initial assessment of a poisoned patient, including stabilizing vital signs, gathering exposure details, considering decontamination or antidotes. - Describes common toxidromes caused by substances like sympathomimetics, anticholinergics, cholinergics, opioids, and sedatives/hypnotics; and their associated signs and symptoms. - Emphasizes the importance

1. IMPORTANT TOXINS:
WHAT YOU MUST
KNOW
Dr. Badria Alhatali, M.D
Medical Toxicologist
Department of Environmental and Occupational
Health
Ministry of Health
Monday, March 5, 2018 1

2. Objectives
Identify some of the drug groups or toxic
substances that require immediate attention
Have comprehensive coverage about the
most essential steps taken in managing
certain poisoned patients
Utilizing clues from history, physical exam or
diagnostic findings to identify the poisons
involved
Monday, March 5, 2018 2

3. WHY SHOULD I KNOW
ABOUT THIS?
Monday, March 5, 2018 3

4. Monday, March 5, 2018 4

5. The dose makes
the poison
Monday, March 5, 2018 5

6. Outpatient Morbidity In MOH Institutions
According To Disease Group Since 1996 To
2013
3259
1262
1015
797
877
1996 2000 2005 2010 2013
Injuries and Poisoning
6Monday, March 5, 2018

7. Outpatient Morbidity in MOH Institutions by Age
Group During 2013 (rate per 10,000 Total
Population)
0 0 0 0 0 0 0 0 0 0 0 0 09 3 2 5 11 10 11 7 5 3 3 3 41 1 1 1 0 0 0 0 0 0 0 1 01 0 0 0 0 0 0 0 0 0 0 0 01 1 0 0 0 0 0 0 0 0 0 0 08 9 13 13 8 6 5 5 6 6 8 7 118 23 18 13 2 1 2 2 2 2 2 2 3
849
733 738
544
304
173 163 161 169
198
240
262
353
0
100
200
300
400
500
600
700
800
900
0-4 y 5-9 y 10-14 y 15-19 y 20-24 y 25-29 y 30-34 y 35-39 y 40-44 y 45- 49 y 50-54 y 55-59 y 60+ y
poisoning by narcotics poisoning by other drugs & biological substances
toxic effects of organic and corrosive substances Toxic effects of pesticides
Toxic effects of noxious Toxic effetcs of contact with venomous animals
Toxic effects of other substances cheifly non-medicinial as to source Other unspecifies injuries and posioning and toxic effects
7Monday, March 5, 2018

8. CDC, 2009
24%
76%
Intentional Unintentional
POISONING-
related DEATHS
were the 2nd
highest cause of
unintentional injury
deaths in all ages
in the same year
8Monday, March 5, 2018

9. Poisoning And Toxic Exposure Is A
Common Presentation To The
Emergency Department
Monday, March 5, 2018 9

10. Monday, March 5, 2018 10

11. Approach to the poisoned patient
Immediate assessment and stabilization
Laboratory assessment
Decontamination
Administration of an antidote
Elimination enhancement of the toxin
Disposition
Monday, March 5, 2018 11

12. ABCs of Toxicology
• A irway
• B reathing
• C irculation
• D iagnosis and D econtaminate
• E nhance Elimination
• F ind an antidote
• G et Tox Consult if needed
Check glucose, give Naloxone
Monday, March 5, 2018 12

13. Everything could be tox…
• Altered pt
• Acidotic pt
• Hypotensive pt
• Hypertensive pt
• Screaming pt
• Sleeping pt
Monday, March 5, 2018 13

14. History, The 5Ws of toxicology
 Patient’s age, weight
 Name and dose of medication,
coingestants and amount ingested
 Time of ingestion, single vs. multiple
ingestions
 Route of exposure, geographical location
 Intentional vs. unintentional
Who
What
When
Where
Why
Monday, March 5, 2018 14

15. 30-second Toxicology Exam
o Complete VS
o Mental status
o Skin: color, temperature,
and sweating
o Pupil size
oBowel sounds and bladder
function
oNeuro: reflexes, tremor, tone
Monday, March 5, 2018 15

16. Toxidromes
Group of signs and symptoms associated with exposure to a
particular substance or class of substancesMonday, March 5, 2018 16

17. Toxidromes
Sympathomimetic Toxidrome
Anticholinergic (Antimuscarinic) Toxidrome
Cholinergic Toxidrome
Opioids Toxidrome
Sedative-Hypnotic Toxidrome
Gresham, Chip, and Jennifer Wilbeck. "Toxicology in the emergency department: a review for the advanced practice nurse."
Advanced emergency nursing journal 34.1 (2012): 43-54.Monday, March 5, 2018 17

18. Sympathomimetic Toxidrome
NEJM, 2013Monday, March 5, 2018 18

19. Sympathomimetic Toxidrome
Tachycardia
Hypertension
Hyperthermia
Confusion with agitation
Seizures
Rhabdomyolysis
Monday, March 5, 2018 19

20. BENZO
BENZO
BENZO
Sympathomimetic Toxidrome
Nitroprusside,
PhentolamineMonday, March 5, 2018 20

21. http://genpsych.com/2015/09/03/benzodiazepine-abuse-detox-and-treatment-in-nj/
Monday, March 5, 2018 21

22. Anticholinergic (Antimuscarinic)
Toxidrome
Monday, March 5, 2018 22

23. Anticholinergic (Antimuscarinic)
Toxidrome
Mydriasis
Anhidrosis
Tachycardia
Ileus
Urinary retention
Confusion
Agitation
Myoclonus
Altered mental status
Hallucinations
Tremor
Peripheral Muscarinic Blockade CNS Muscarinic BlockadeMonday, March 5, 2018 23

24. HOT as a Desert
BLIND as a Bat
RED as a Beet
DRY as a Bone
MAD as a Hatter
FULL as a Flask
Monday, March 5, 2018 24

25. Monday, March 5, 2018 25

26. BENZO
BENZO
BENZO
Anticholinergic Toxidrome
Nitroprusside,
PhentolamineMonday, March 5, 2018 26

27. Cholinergic Toxidrome
Monday, March 5, 2018 27

28. Cholinergic Toxidrome
DUMBBBEL
Diarrhea
Urination
Miosis
Bradycardia
Bronchorrhea
Bronchospasm
Emesis
Lacrimation
SLUDGE
Salivation
Lacrimation
Urination
Diarrhea
GI complaint
Emesis
Monday, March 5, 2018 28

29. What else goes wrong?
•Nicotinic effects
M- Mydriasis
T - Tachycardia
W - Weakness
(t) H - Hypertension
F -Fasiculations
Monday, March 5, 2018 29

30. Monday, March 5, 2018 30

31. Cholinergic Toxidrome
• Antagonize muscarinic symptoms
• Atropine
• Stop aging of enzyme blockade
• 2-PAM
• Prevent and terminate seizures
• Diazepam
• Supportive care
Monday, March 5, 2018 31

32. Monday, March 5, 2018 32
Opioids Toxidrome

33. What goes wrong?
• Coma
• Miosis
• Respiratory depression
• Orthostatic hypotension
• Flushing (histamine)
• Pulmonary edema
• Seizures (meperidine, propoxyphene)
Monday, March 5, 2018 33

34. Monday, March 5, 2018 34

35. Monday, March 5, 2018 35
Sedative-Hypnotic
Toxidrome

36. What goes wrong?
• CNS depression, lethargy
• Can induce respiratory depression
• Can produce bradycardia or hypotension

37. Monday, March 5, 2018 37
Sedative-Hypnotic Toxidrome

38. Sedative-Hypnotic Toxidrome
o Supportive Care
o Flumazenil
• Is an antagonist at the benzo receptor
• RARELY INDICATED
• May reverse conscious sedation
• May precipitate status epilepticus
Monday, March 5, 2018 38

39. Monday, March 5, 2018 39
GI Decontamination:

40. Monday, March 5, 2018 40
Drugs to
Remember

41. Monday, March 5, 2018 41

42. Monday, March 5, 2018 42

43. 43
CALL
24560019,
24562898
Monday, March 5, 2018