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Poisoning
This document discusses various aspects of poisoning management, including classification, routes of poisoning, signs and symptoms of specific poisons like acids, benzodiazepines, lead, and snakes. It also covers management strategies like gastric lavage, ipecac syrup, activated charcoal, whole bowel irrigation, forced alkaline diuresis, and chelation therapy. The goal of management is removal or neutralization of toxins while stabilizing the patient.
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Poisoning
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- 2. The developmentof dose related adverse effects following exposure to chemicals, drugs or other xenobiotics. Poisoning occurs when any substance interferes with normal body functions after it is swallowed, inhaled, injected, or absorbed. POISONING
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- 4. ROUTES OF POISONING Inhalation: Gases:ammonia, chlorine Vapors: carbon monoxide Sprays: insecticides Volatile liquid chemicals: change easily from liquid to gas
- 5. Ingestion: Household and industrialchemicals, medications Improperly prepared/ preserved food Plant materials Petroleum products
- 6. Common poisonous plants JIMSONWEED/ DATURA BELLADONA
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- 8. Injection: Intra venous –Benzodiazepines, barbiturates, tricyclic antidepressants etc. Intramuscular – Benzodiazepines, opioids etc. Subcutaneous – Botulinum toxin Intra- dermal – Local anesthetics, organophosphates
- 9. Absorption: Corrosives or irritants Throughbloodstream Insecticides and chemicals
- 11. ACID POISONING Superficial burnsafter only 1 second of contact Full thickness burns after 30 seconds SIGNS & SYMPTOMS Swollen lips, brown or black streaks Edematous tongue Pharyngeal pain, hoarse & husky voice, chalky-white teeth Corrosion of mucous membranes of mouth, throat, esophagus
- 12. Intense thirst Stridor, drooling Epigastricpain spread over abdomen & thorax Constipation Sunken eyes, pupils dilated
- 13. COMPLICATIONS Upper airway obstruction& injury GI haemorrhage Esophageal and gastric perforation Sepsis Tracheobronchial necrosis, atelectasis
- 14. BENZODIAZEPINES POISONING Anxiolytic &hypnotic agents. USES Anxiety disorders Seizure disorders Insomnia Mania
- 15. SIGNS AND SYMPTOMS MILD:Drowsiness , Ataxia , Weakness MODERATE TO SEVERE :Vertigo , slurred speech, nystagmus, lethargy , hypotension, respiratory depression, coma (stage 1 & 2 ).
- 16. COMA 1 (Stage1): Responsive to painful stimuli but not to verbal or tactile stimuli, no disturbance in respiration or BP COMA 2 (Stage 2):Unconscious, not responsive to painful stimuli
- 17. LEAD POISONING Clinical symptoms->70µg/100ml in blood Normal adult ingest- 0.2 to 0.3mg of lead/day All lead compounds are toxic MOST Dangerous- lead arsenate,lead oxide,lead carbonate. Least toxic-lead sulphide.
- 18. CLINICAL FEATURES Abdominal colic Constipation Lossof appetite Blue lines on gums Stippling of red cells Anemia Wrist drop Foot drop Insomnia Headache Mental confusion
- 19. MANAGEMENT Saline purge (removelead from the gut) d-penicillamine(promote Pb excretion in urine) Substitution Isolation Good housekeeping Periodic medical examination of workers
- 20. SNAKE BITE Snakevenom is a Combination of enzymes & Non- Enzymatic polypeptides. Acidic CLINICAL FEATURES Burning pain Swelling and discolouration Serosanguinous discharge
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- 22. MANAGEMENT: LOCAL Tourniquet: Betweenwound & heart, Pressure adequate to occlude lymphatics only, Released for few seconds every 10 minutes. Immobilize affected limb: Elastocrepe bandage may be applied Clean with Normal Saline if bite <1hr old: Short skin incision and suction
- 23. SPECIFIC MANAGEMENT Antivenom isimmunoglobulin purified from the serum or plasma of a horse or sheep that has been immunised with the venoms of one or more species of snake ASV IN INDIA: Polyvalent COBRA KRAIT RUSSEL’S VIPER SAW SCALED VIPER
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- 25. Others: -Local swelling involvingmore than half of the bitten limb. -Rapid extension of swelling. -Development of an enlarged tender lymph node draining the bitten limb
- 26. TIMING OF ASV Besteffects are observed within four hours of bite Efficacious even 6-7 days after the bite from vipers
- 27. MECHANICAL VENTILATION If patienthas respiratory distress or bulbar paralysis- intubate and ventilate. If delayed can cause aspiration or hypoxia and cardiac arrest. Even if the facility for MV is not available ambuing can save the day. This helps even during transport.
- 28. FOOD POISONING Microorganisms: Staphylococcus aureus Salmonellatyphi Shigella Vibrio cholera Streptococcus E. coli Protozoa: Entamoeba histolytica Giardia lamblia
- 29. SIGN AND SYMPTOMS Nausea Vomiting Abdominalcramps Chills Diarrhea Fever Headache Vertigo Numbness of face and neck Convulsions
- 30. TREATMENT Symptomatic treatment shouldbe done Salmonella: we can provide ciprofloxacin Fluid replacement and electrolyte replacement should be done Streptococcus: penicillin, erythromycin E. coli: ciprofloxacin
- 32. ANTIDOTES COMMONLY USED SUBSTANCESANTIDOTES Acetaminophen Narcotics Cyanide Carbon monoxide N-acetylcysteine Naloxone Nitrates Oxygen
- 33. SUBSTANCES ANTIDOTES Atropine Ethanol Iron Dextrose 50% Lead,mercury, arsenic Lead Physostigmine Vitamin k Organophospates Methanol Deferoxamine Insulin Dimercaprol EDTA Atropine Anticoagulants; warfarin
- 34. MANAGEMENT Initial resuscitation &stabilization: First priorities are ABC’s I/V access – I/V fluids Endo tracheal intubation - to prevent aspiration Unconscious patients Respiratory depression/ failure Convulsions- give anticonvulsants
- 35. Management for aresponsive patient • Execute a Primary Survey (Inquire as to what poison was consumed, the amount and how long ago it was taken ) • Reassure the victim • Monitor the vital signs of the victim • Don’t encourage vomiting • Contact Poisons Information Centre; 1800 116 117 / 26589391 / 26593677 (Get medical advice or assistance)
- 36. An unconscious orunresponsive patient Seek an ambulance immediately on 102 or 108 Execute a Primary Survey (Try to determine what poison was consumed, the amount and how long ago it was taken) Monitor the vital signs of the victim If available give patient supplemental oxygen
- 37. Management of IngestedPoisons Swallowed poisons may be corrosive. Corrosive poisons include alkaline and acid agents that can cause tissue destruction after coming in contact with mucous membranes. Control of airway, ventilation, and oxygenation are essential Syrup of ipecac to induce vomiting in the alert patient( never use with corrosive poisons) Gastric lavage for the obtunded patient, gastric aspirate is saved and sent to the laboratory for testing
- 38. Activated charcoal isadministered only if the poison is adsorbed by charcoal (phenobarbital, carbamazepine) Cathartic, when appropriate. e.g. lactulose
- 39. GASTRIC LAVAGE It isthe aspiration of stomach contents and washing out of the stomach by means of large bore gastric tube It is contraindicated:- After acid or alkali ingestion In the presence of seizures Recent esophageal / gastric surgery Unconscious patient
- 40. Done with water,1:5000 potassium permanganate , 4% Tannic acid, saturated lime water or starch solution with orogastric or Ewald’s tube Performed until clear fluid is obtained or a maximum of 3 L
- 41.
- 42. Lavage decreases ingestantabsorption by an average of :- • 52 % if performed within 5 min of ingestion • 26 % if performed at 30 min • 16 % if performed at 60 min
- 43. CAUTION; GASTRIC LAVAGE Gastriclavage is not without hazard. Death due to inadvertent pulmonary placement of the tube and subsequent instillation of lavage fluid may occur Epistaxis commonly occurs when the tube is inserted nasally; oral placement is preferred Gastric lavage is employed when emetic therapy can’t be used
- 44. IPECAC SYRUP INDUCEDEMESIS Administered orally Dose :- 30 ml – adults 15 ml – children 10 ml – small infants Contraindications: Corrosives CNS depression or seizures Rapidly acting CNS poisons ( cyanide, strychnine )
- 45. Caution; ipecac solution Homeremedy methods of inducing vomiting such as manual stimulation of the posterior pharynx Drinking salt water or mustard water, eating raw eggs These measures are often unsafe and ineffective, The only recommended method of producing emesis is administration of syrup of ipecac
- 46. Always ascertain thatthe gag reflex is intact before giving ipecac Frequently re assess the person; someone who was awake when the ipecac was administered may be obtunded when emesis occurs, and aspiration may result
- 47. ACTIVATED CHARCOAL Charcoal adsorbsingested poisons within gut lumen allowing charcoal- toxin complex to be evacuated with stool or removed by induced emesis / lavage Dose – 1 g/kg body wt. Given orally as a suspension ( in water ) or through NG tube Contraindications: Mineral acids, alkalis, cyanide, fluoride ,iron
- 48. WHOLE BOWEL IRRIGATION Administrationof bowel cleansing solution containing electrolytes & polyethylene glycol Orally or through gastric tube Rate – 2 L/hr. ( 0.5 L /hr. in children) End point- rectal fluid is clear Position – sitting Contraindications : Bowel obstruction Unprotected airway
- 49. FORCED ALKALINE DIURESIS Infusionof large amount of NS+NAHCO3 Used to eliminate acidic drug that mainly excreted by the kidney e.g. salicylates Serious fluid and electrolytes disturbance may occur Need expert monitoring
- 50. EXTRACORPOREAL REMOVAL Dialysis – Acetone,Barbiturates, Bromide, Ethanol, Ethylene glycol, Salicylates, Lithium – Less effective when toxin has large volume of distribution (>1 L/kg), has large molecular weight, or highly protein bound Peritoneal Dialysis – Alcohols , long acting salicylates, Lithium
- 51. CHELATION Heavy metal poisoning Complexof agent & metal is water soluble & excreted by kidneys Eg. British antileucyte, EDTA, • BAL – Arsenic, Lead, Copper, Mercury • EDTA- Cobalt, Iron, Cadmium
- 52. GUT LAVAGE used inmanaging selected poisonings, e.g. herbicides The procedure involves instillation of warmed electrolyte solution into the stomach via a tube regulated by a peristaltic pump delivering approximately 75 ml/min the goal of gut lavage is to rid the bowel of toxic substances
- 53. CATHARTICS Administered to hastenexcretion of a toxic substance and thus minimize further absorption from the bowel Commonly used cathartics are magnesium sulfate, sodium sulfate, and magnesium citrate Oil-based cathartics (castor oil) are contraindicated because of the danger of aspiration pneumonitis
- 54. NURSING ADVICES Keep syrupof ipecac readily available in all house holds where children live or visit. It is important to know and understand direction for the use of syrup ipecac. Give phone number of the nearest poison control center or other appropriate care facility. Encourage adults to move dangerous substances to high shelves and childproof locks on doors of these cabinets.
- 55. Advise adults thatmany house, garden, and wild plants are poisonous and should be removed from children’s environment. Familiarize self with poisonous plants in your area. Use childproof safety caps on containers of medications and other potentially dangerous substances.
- 56. Keep products intheir original containers. Use poison symbols to identify dangerous substances. Dispose of outdated medications and household products.
- 57. Nursing diagnosis • Riskfor injury/ suffocation related to contact with chemical or poisonous agents. • Risk of choking related to increased danger of accidental suffocation • Post-traumatic reaction related to painful and prolonged reaction to attempted self harm
- 58. Recent Advances inthe Management of Poisoning Cases • Deaths due to poisoning are on the rise over the years, despite advanced knowledge regarding their pharmacokinetics and pathology, and newer and better techniques being developed for the management of poisoning cases. Though the general principles of treatment of a poisoned patient remain the same, traditional methods like gastric lavage, for example, have taken a back seat. There has been gaining popularity of newer methods like use of activated charcoal and a variety of newer antidotes.
- 59. Some Newer Antidotes •Hydroxycobalamin: cyanide poisoning • Digoxin specific antibodies (Fab antibodies): indicated in life threatening arrhythmia/hyperkalemia caused by intoxication with cardiac glycosides.
- 60. • Octreotide: Asynthetic polypeptide that antagonizes pancreatic insulin release, it is indicated in overdose of insulin or oral hypoglycemic agents, mainly sulphonylurea. • Succimer (2,3dimercaptosuccinicacid): it is a chelating agent used for the treatment of lead, mercury and arsenic poisoning. It is the water soluble analogue of dimercaprol and can be taken orally.