This document discusses poisoning and its management. It begins by defining what a poison is and the different types of poisoning, including deliberate, accidental, environmental, and industrial exposures. It then describes common symptoms of poisoning and considerations for managing poisoned patients, including resuscitation, toxicological diagnosis, and therapeutic interventions like decontamination and antidotes. The diagnostic process involves obtaining a thorough history, conducting a physical exam looking for clues, and ordering targeted toxicology investigations to determine the poison involved and properly manage the patient.

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1.
Poisoning & its
Management
by
Md. Monirul Islam
Pharmacy Discipline
Khulna University
Bangladesh

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2. Introduction
With the availability of a vast number of chemicals and
drugs, poisoning is a common medical emergency in any
country. The reasons for toxic exposures are as wide and
varied from recreational use to abuse of medications to
accidental home or occupational exposures, deliberate
self harm and environmental pollution. The clinical
spectrum of poisoning hence include acute, acute in
chronic and chronic intoxications. The clinical guidelines
are limited to acute poisonings of common toxins in the
context to maintain focus on the principles of emergency
management of poisoning. Fig: Poisons
3. Poison
A poison is any substance that is harmful to the body. There are many different types of
poison. Many poisonous substances are products people have around the house. Even
medicines that aren't taken as directed can be harmful.
“What is it that is not a poison? All things are poison and nothing is without poison. Solely,
the dose determines that a thing is not a poison.” Paracelsus (1493–1541), the Renaissance
Father of Toxicology, in his Third Defense”.
4. Poisoning
Poisoning occurs when any substance interferes
with normal body functions after it is swallowed,
inhaled, injected, or absorbed. Poisonings are a
common occurrence.
In 80% of the cases, the victim is a child under the
age of five. Curiosity, inability to read warning
labels, a desire to imitate adults, and inadequate
supervision lead to childhood poisonings. Fig: Route of poisoning

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The elderly are the second most likely group to be poisoned. Mental confusion, poor
eyesight, and the use of multiple drugs are the leading reasons why this group has a high
rate of accidental poisoning. A substantial number of poisonings also occur as suicide
attempts or drug overdoses.
5. Types of poisoning
1. Deliberate:
o Overdose as self-harmor suicide attempt.
o Child abuse
o Third party (attempted homicide, terrorist, warfare).
2. Accidental:
o Most episodes of paediatric poisoning.
o Dosage error:
 Iatrogenic
 Patient error
o Recreational use.
3. Environmental:
o Plants
o Food
o Venomous stings/bites
4. Industrial exposures.
5. Poisoning Causes
Substances that may act as poisons include the following:
Cleaning products
Household products, such as nail polish remover and other personal care products
Paint thinner

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Fig: Different types of poisons
Pesticides used in the house or in the yard
Chemicals used in the yard, such as herbicides, fertilizers and fungicides
Metals, such as lead
Mercury, which can be found in old thermometers and batteries
Prescription and over-the-counter drugs when combined or taken the wrong way
Illegal drugs
Carbon monoxide gas
Contaminated food
Plants, such as poison ivy and poison oak
Venom from certain snakes and insects
6. Symptoms of poisoning
The effects of poisoning depend on what substance patients are exposed to, and the type
and amount of exposure. Poisoning can cause short-term effects, like a skin rash or
vomiting. In serious cases, it can cause brain damage, coma or death.
The following are some possible symptoms of poisoning:
 Vomiting
 Diarrhea
 Nausea

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 Redness or sores around the mouth
 Drooling or dry mouth
 Dilated pupils (pupils that are bigger than
normal) or constricted pupils (pupils that are
smaller than normal)
 Rash
 Confusion
 Shaking or seizures
 Trouble breathing Fig: Symptoms of poisoning
 Unconsciousness (fainting)
7. Concerns about poisoning
When managing patients with toxic exposures there are several concerns that the physician
is faced with including the following:
• Is the substance toxic? How toxic is it?
• Was there a toxic exposure?
• How can I manage the patient?
– Home with advice.
– Observe and Discharge.
– Admit.
8. Management of poisonings
The holistic management of toxic exposures should include the following considerations
based on a risk assessment approach:
I. Resuscitation and stabilization
II. Toxic Diagnosis
III. Therapeutic interventions
 Decontamination
 Enhanced elimination of absorbed toxins
 Antidotes
IV. Supportive care

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8.1. Resuscitation and stabilization
On arrival of a patient with poisoning, the initial priorities are the maintenance of airway,
breathing and circulation. If the patient has an altered level of consciousness, his cervical
spine must be immobilized till an injury can be ruled out. If respiratory inadequacy is
present, endotracheal intubation is required.
Hypotension in poisoned patients is most often due to loss of fluids or toxin induced
vasodilatation. Hence, crystalloids are the first choice of treatment of hypotension. Before
infusing fluids, blood should be withdrawn for investigations (including sugar, urea,
electrolytes and acid-base status). Rectal temperature should be obtained in all patients
with altered sensorium.
After initial resuscitation, all patients with altered sensorium should receive a ‘cocktail’ of
50% dextrose, naloxone and thiamine. At present, it is recommended to check the blood
sugar using a reliable bedside test and to administer dextrose only if the blood sugar is
below 80 mg/dl. However, if the sticks are not available, it is still advisable to administer
dextrose to all patients with altered sensorium, including those with focal neurologic
deficits.
Another component of the ‘cocktail’ recommended in patients with altered mental status is
naloxone. It is able to rapidly counteract the sedation and respiratory depression induced by
opiates. The dose is 2 mg in all age groups. However, if the patient is an opioid addict and is
not apnoeic, the initial dose may be reduced to avoid withdrawal features.
8.2. Toxicological diagnosis
Several considerations are needed in making a toxicological diagnosis and in some instances
this may be challenging with the lack of information from the patient either due to
deliberate concealment and genuine lack of appreciation or awareness of the situation or
secondary to altered mental states of the victim.
Establishing the specific toxin or toxins responsible for the poisoning is crucial to the
management of final outcome. If attempts to obtain the specific agent are in vain the
physician could perform a careful examination to look for a toxidrome which are a
constellation of signs and symptoms that point towards establishing a particular class of

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toxins that is likely contributing to the patients’ presentation. Some examples of toxidromes
are given below-
Sympathomimetic toxidrome
Cholinergic toxidrome
8.2.1 Clinical evaluation of the poisoned patient
The clinical evaluation of the poisoned patient has the primary objective of triaging
poisoned patients into mild, moderate and severe categories of poisoning by obtaining a
targeted history, performing a careful physical examination and specific laboratory
evaluation. This will not only help prognosticate but also determine the extent of
therapeutic interventions and type of in-patient resources that need to be committed in
each case.
Signs & Symptoms
- Salivation
- Lacrimation
- Urinary incontinence
- Defaecation
- Gastric cramping, hypermotility
- Emesis
Possible toxins
- Organophosphate compounds
- Carbamate insecticides
Signs & symptoms
- Anxiety
-Delirium
- Hypertension
- Tachycardia
- Hyperpyrexia- Mydriasis
- Diaphoresis
Possible toxins
- Cocaine, Amphetamines, phencyclidine
(PCP), Lysergic acid (LSD)
- Withdrawal from narcotics,
benzodiazepine, alcohol, long term beta-
blocker therapy

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8.2.2 History
• Fact finding mission – From patient, paramedics, family, friends, circumstantial evidence
such as empty packets, vomitus with pill fragments.
• Who was exposed? Demographic information including age, sex, weight.
• What was ingested? Name of agent and type of formulation e.g. tablets or liquid,
extended release, ingredients on combination tablets, concentration of active compounds
etc.
• What else was ingested? Any other co-ingestant especially medications from other
physicians, alcohol, traditional medications and health supplements.
• How much exposure?
• When did poisoning occur? Exact timing of ingestion or timings of ingestion episodes.
• What were the post exposure symptoms?
• How was patient exposed to toxin?
• Why exposed? The reason for toxic exposure accidental versus intentional.
• AMPLE history? As for any patient with trauma an AMPLE history comprising history of
allergies, medications patient is regularly on, past medical problems, last meal and drink,
and events that led to the poisoning as outlined above should be obtained.
8.2.3 Examination
• Use all your senses to search for the clues:
– LOOK
o Track marks in cubital fossa and groin suggestive of intravenous drug abuse.
o Residue deposits around mouth nose, body surface.
o Unusual colour of vomitus, urine.
– FEEL
o Temperature, sweating.
– SMELL
o Alcohol and other unique odours.

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• Assess ABCDE:
– Airway & Breathing
o Ability to protect airway.
o Respiratory rate & depth.
o Oxygen saturation.
– Circulation
o Pulse rate and regularity.
o Blood pressure.
– Disability
o Glasgow Coma Scale (GCS).
o Pupil size and equality.
o Do random glucose to exclude hypoglycaemia.
– Exposure
o To look out for external evidence of trauma such as head injury that may provide an
alternative explanation for patient’s condition.
8.2.4 Toxicological investigations
Targeted investigations are to be done in toxic exposures that supplement clinical
evaluation.
The following is a list of some of the useful investigations.
• Random bedside glucose.
• ECG (electrocardiogram).
• Serum electrolytes and renal function.
• Liver function test.
• Creatine kinase.
• Full Blood Count.
• Clotting screen: PT/PTT/INR.
• Arterial blood gas.
• Specific toxin level e.g. serum paracetamol, salicylate, phenobarbital, theophylline,
• Serum osmolality and osmolality gap.
• Abdominal X-ray may be useful in diagnosing certain radiopaque toxins
• Others e.g. CXR, CT.

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8.3 Therapeutic interventions for poisoning
8.3.1 Gastric decontamination
Removal of unabsorbed poison from the gut can be achieved by several means including
induction of emesis, gastric lavage, and use of activated charcoal and cathartics. Before
performing a procedure for gastric emptying, it is important to consider:
i) Whether the ingestion is potentially dangerous,
ii) Can the procedure remove a significant amount of toxin, and
iii) Whether the benefits of a procedure outweigh its risks?
Gastric emptying is not indicated if the patient had prior repeated vomiting or the toxin is
absorbed rapidly, or patient presents late after ingestion.
Syrup of ipecac : Syrup of ipecac is used to induce emesis with the intention to remove the
poison from the stomach. Presently, ipecac may be considered in an alert conscious patient
who has ingested a potentially toxic amount of a poison within the last one hour. It should
be avoided in ingestion of hydrocarbons and corrosives.
Gastric lavage : For inserting an orogastric lavage tube, the patient should be placed in left
lateral position with the head-end lowered. A large bore tube (36 F in adults) is inserted into
the stomach and its position is checked by injecting air through the tube into stomach and
simultaneously auscultating over the epigastrium. The lavage is then performed by using
fluid aliquots of 3-4 ml/kg. The lavage is continued till the return is clear.
Cathartics : Cathartics have been used for several years with the hope of increasing the
excretion of the toxins from the gut. Commonly used cathartics are magnesium sulphate (30
g for adults and 250 mg/kg in children), magnesium citrate (4 ml/ kg up to a maximum of
300 ml) and sorbitol (1 g/kg as 70% solution).
Activated Charcoal : Use of activated charcoal has revolutionized the treatment of
poisoning. Due to its small particle size and enormous surface area, it can adsorb large
amount of toxins. The usual dose is 1 g/kg body weight or 10 parts of charcoal for every one
part of toxin, whichever is greater.

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Whole bowel irrigation: In this method, isotonic solution of polyethylene glycol-electrolytes
is administered orally in a dose of 2 litre/hour in adults and 0.5 litres/hour in children. The
procedure is continued for 4-6 hours or till the rectal effluent is clear.
8.3.2. Enhancing Excretion
Once the absorption of a toxin has been reduced by various methods, the next logical step is
to enhance the elimination of already absorbed toxin from the body.
Forced alkaline diuresis: One of the commonly used methods to increase the elimination of
a toxin is forced diuresis with alteration in urine pH. The renal tubular epithelium is
relatively impermeable to the ionized molecules. If the urinary pH is changed so as to
produce more of ionized form of a chemical, it is trapped in the tubular fluid and is excreted
in the urine. This is the basis for alkaline diuresis which is useful in salicylates, Phenobarbital
and lithium intoxication. For alkaline diuresis, 5% dextrose in half-normal saline containing
20-35 mEq/L of bicarbonate is administered at a rate so as to produce a urine output of 3-6
ml/kg/hour and a urine pH 7.5- 8.5.
Multiple-doses of activated charcoal: Multiple doses of activated charcoal have been
recommended in treating certain poisonings. Because of multiple doses, free charcoal is
available in the intestines to bind any toxin which has significant enterohepatic circulation.
Further, free toxin in the blood tends to diffuse out of the blood into the intestines where it
binds the charcoal, thereby maintaining the concentration of free toxin in the intestines
near zero. This is termed “gastrointestinal dialysis”. Depending upon the severity of
poisoning, the doses are 0.5-1 g/ kg body weight every 1-4 hours.
Dialysis: Peritoneal and haemodialysis are useful for water-soluble compounds of low
molecular weight. Dialysis is useful in ethanol, methanol, salicylates, theophylline, ethylene
glycol, phenobarbital and lithium intoxications. Peritoneal dialysis is a slow process and it
should not be used if facilities for haemodialysis are available.

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8.3.3. Antidote
An antidote is a drug used to neutralize or counteract the effects of poisoning. There are
many drugs and chemicals that can cause toxicity, but only about 40 specific antidotes
available for use in acute and chronic poisoning. The use of antidotes should be guided by
assessment of the risk-benefit ratio.
Naloxone is used to rapidly counteract the sedation and respiratory depression induced by
opiates.
Ethanol is recommended in methanol, ethylene glycol poisoning in a loading dose of 0.75
g/kg which is followed by maintenance dose of 0.1 g/kg/hr.
8.4. Supportive Therapy
Since the antidotes are available only for a few toxins, treatment of most cases of poisoning
is largely supportive. It is important not to waste time in locating an antidote; instead
supportive therapy should be instituted after which an attempt may be made to get the
antidote. The aim of the supportive treatment is to preserve the vital organ functions till
poison is eliminated from the body and the patient resumes normal physiological functions.
Therefore, functions of central nervous system, cardiopulmonary system and renal system
should be supported with proper care for coma, seizures, hypotension, arrhythmias,
hypoxia, and acute renal failure. The fluid, electrolyte and acid-base status should be closely
monitored in all patients.
9. Poisonprevention
 Only take prescription medications that are prescribed by a healthcare professional.
 Never take larger or more frequent doses of your medications, particularly
prescription pain medications, to try to get faster or more powerful effects.
 Never share or sell your prescription drugs.
 Follow directions on the label when you give or take medicines.
 Turn on a light when you give or take medicines at night so that you know you have
the correct amount of the right medicine.
 Keep medicines in their original bottles or containers.

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 Monitor the use of medicines prescribed for children and teenagers, such as
medicines for attention deficit hyperactivity disorder, or ADHD.
 Dispose of unused, unneeded, or expired prescription drugs.
 Always read the label before using a product that may be poisonous.
 Keep chemical products in their original bottles or containers. Do not use food
containers such as cups, bottles, or jars to store chemical products such as cleaning
solutions or beauty products.
 Never mix household products together. For example, mixing bleach and ammonia
can result in toxic gases.
 Wear protective clothing (gloves, long sleeves, long pants, socks, shoes) if you spray
pesticides or other chemicals.
 Turn on the fan and open windows when using chemical products such as household
cleaners.
10. Conclusion
Poisoning is a significant global public health problem. According to WHO data, nearly a
million people die each year as a result of suicide, and chemicals account for a significant
number of these deaths. It is estimated that deliberate ingestion of pesticides causes
370,000 deaths each year. The number of these deaths can be reduced by limiting the
availability of, and access to, highly toxic poisons.

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11. References
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Three Public Hospital Emergency Departments in Singapore 2001 – 2003. J Emerg
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008-0080-9. PMCID: PMC2672975.
3. Ponampalam R. An Unusual Case of Paralytic Ileus after Jellyfish Envenomation.
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4. Lerner WM, Warner KE. The challenge of privately-financed community health
programs in an era of cost containment: A case study of poison control centers. J Pub
Health Pol 1988;9:411-28.
5. Harrison DL, Draugalis JR, Slack MK, et al. Cost-effectiveness of regional poison
control centers. Arch Intern Med 1996;156:2601-8.
6. Miller TR, Lestina DC. Costs of poisoning in the United States and savings from
poison control centers: a benefi t-cost analysis. Ann Em Med 1997;29:239-45.
7. Mvros R, Dean BS, Krenzelok EP. Poison center funding - who should pay? J Toxicol
Clin Toxicol 1994;32:503-8.
8. Aggarwal P, Wali JP (eds.) Diagnosis and Management of Acute Poisoning, Oxford
University Press Delhi 1997; pp 1-38.
9. Wikipedia free encyclopedia website: http://en.wikipedia.org