3. Objectives
• General approach to the poisoned patient
• Toxidromes
• Specific antidotes
• Decontamination and enhanced elimination
4. POISONING
• Poisoning continues to be a preventable cause of morbidity and
mortality especially in children and adolescents.
• Patients may present with a specific history of exposure,
• Some may present with unexplained signs or symptoms and no
history of exposure.
5. • A poisoning occurs when exposure to a substance adversely affects
the function of any system within an organism.
• The setting of exposure may be occupational, environmental,
recreational, medicinal or suicidal.
• Poisoning may result from varied portals of entry including,
inhalation, ingestion, cutaneous Exposure and injection
6. • Poisoning emergencies commonly present to emergency
departments.
• The clinical effects encountered in poisoned patients are dependent
on numerous variables,
• such as the dose, the length of exposure time, and the pre-existing health of
the patient.
7. • The prognosis and clinical course of recovery of a patient largely
depends on the quality of care delivered within the first few hours in
the emergency setting.
• Patients can present with various clinical symptoms, including
abdominal pain, vomiting, tremor, altered mental status, seizures,
cardiac dysrhythmias, and respiratory depression.
8. • Attempts to identify the poison should never delay life-saving
supportive care.
• First patient has to be stabilized,
• Then we needs to consider how to minimize the bioavailability of
toxin not yet absorbed,
• which antidotes (if any) to administer, and if other measures to
enhance elimination are necessary
9. Pattern of TASH poisoning
• Acute poisoning is an important problem.
• And out of the of 116 adult patients presented to Tikur Anbessa
Specialized University Hospital from January 2007 to December 2008
showed that females outnumbered males and that mean age was 21
years.
10. • Most being (96.5%) intentional self-harm poisonings. Household
cleansing agents were the leading causes (43.1%) followed by
organophosphate (21.6%) and phenobarbitone (10.3%).
11. Pediatrics
• A study done on childhood poisoning showed that is not an
uncommon problem. And that Most of the children were poisioned
with drugs prescribed for themselves or family poisioning. Most of
the incidents were unintentional.
• Most of the incidents occurred at home. ( Tigist Bacha)
12. Gondar University
• Organophosphates, rat poison and alcohol were implicated in the
majority of the cases for suicidal as well as para-suicidal intentions.
13. General Approach
• The general approach to the diagnosis and management of the
poisoned patient can be described using a two-pronged model,
• The first is basic emergency medical care
• The second is obtaining history, performing a focused physical
examination, and deciding on the appropriate diagnostic tests to be
performed.
16. History Taking
• Historical facts should include the type of toxin or toxins,
• Time of exposure (acute versus chronic)
• Amount taken,
• And route of administration (i.e., ingestion, intravenous and
inhalation)
• Why the exposure occurred (accidental, suicide attempt, euphoria,
therapeutic misadventure).
17. • History of psychiatric illness or previous suicide attempts.
• inquire about all drugs taken, including prescription, over-the-counter
medications, vitamins, and herbal preparations
• Info from family, friends and para medic personnel, if any, can be
helpful.
18. • In case of occupational exposure, personnel should obtain a
description of the work environment and contact people at the site
for relevant information.
19. Identify the substance
• Identify the substance
• Obtaining the original toxic substance
• Containers found near or on patient
• Through accurate history
20. Physical Exam
• performing an overly detailed physical examination is a low priority
compared with patient stabilization.
• A directed examination can, however, yield important diagnostic
clues.
• Once the patient is stable, a more comprehensive physical
examination can reveal additional signs suggesting a specific poison.
21. • dynamic change in clinical appearance over time may be a more
important clue than findings on a single P/E.
• Vital sign: detecting signs such as tachycardia, hyperthermia, and
hypotension through addressing the patient’s vital sign help in making
the differential Diagnosis.
27. • Neurologic examination:
• A systematic neurologic evaluation is important, particularly with
patients exhibiting altered mental status.
• Toxicologic causes of coma rarely cause focal neurologic deficits.
• Seizures are a common presentation of an unknown overdose,
28. • Common poisons that cause soma:
• Lead, lithiuim
• Ethanol, ethylene glycol
• TCA,
• Heavy metals, oral hypoglycemics
• Carbon monoide
29. • Poisons that cause Seizures:
• Organophosphates
• TCAs
• Sympathomimetics
• Isoniazid, insulin
• Methylxanthines
• Benzodiazepin withdrawal
31. • Other general neurologic signs include fasciculations
(organophosphate poisoning), rigidity (tetanus and strychnine),
• tremors (lithium and methylxanthines),
• speech-mumbling (anticholinergics),
and dystonic posturing (neuroleptic agents).
32. SKIN
• Skin: a careful examination of the skin should be performed.
• The absence of diaphoresis is an important clinical distinction
between sympathmimetics and anticholinergics.
• Bullous lesions may be associated with sedative hypnotic drug-
induced coma, and barbiturate poisoning.
33. • Blue skin indicates methemoglobinemia or hypoxia.
• Odor: some poisons produce odors characteristic enough to suggest
the diagnosis,
• garlic –organophosphate insecticides
• sulfur dioxide and hydrogen sulfide produce a noxious rotten-egg smell.
• Some odors may be more subtle and cannot be detected easily.
34. Labs
• Several simple, readily available laboratory tests may provide
important diagnostic clues.
• electrolytes,
• blood urea nitrogen, creatinine,
• serum glucose,
• a measured bicarbonate level,
• arterial blood gases
• a pregnancy test is essential in females of child bearing age.
35. Plasma Concentrations
• Are essential for: CO poisoning, Paracetamol, Salicylates,
theophyline, TCA, Lithium, digoxin and metals.
36. Toxidromes
• Identification of the constellation of signs and symptoms that define a
specific toxicologic syndrome.
• may narrow a differential diagnosis to a specific class of poisons.
40. • Many toxidromes have several overlapping features and toxidrome
findings may be affected by individual variability & comorbid
conditions.
41. Decontamination
• Decontamination:Terminating topical exposures.
• Contaminated clothing should be removed and safely disposed of.
• Wash skin and hair with soap and water while wearing gloves.
• Eye exposures: irrigate with copious amounts of water or saline for
10-15 minutes.
42. Ipecac syrup
• induces emesis through direct irritant action on the stomach &
central action at the chemoreceptor trigger zone.
• Not currently recommended in hospitals
• lack of evidence for improved outcomes and risks including delayed
administration of oral antidotes and other decontamination products,
aspiration, and complications from prolonged emesis and retching.
43. • Risks: pulmonary aspiration, epistaxis, laryngospasm, hypoxia, sinus
bradycardia & mechanical injury
• Contraindications: patients with decreased LOC, unprotected airway,
ingestion of corrosives, volatile substances and GI hemorrhage.
44. Gastric Lavage
• Indication: ingestion of large amounts of tablets and capsules with a
high inherent toxicity with 2 hrs.
• Method:
• Insert a large bore orogastric tube(32-40 F)
• Place patient head down, left lateral decubitus
• Aspirate fluid from stomach prior to fluid lavage
• Install water or saline into stomach: 200-300ml
• Aspirate fluid back & repeat till aspirate clears
45. Early post-ingestion activated charcoal
• Minimizes systemic absorption from the GIT
• Indication: consider use within 1hr of ingestion of the
poisonous substance.
• Method:
• Route: oral or instill via NG tube
• Adult dose: 50-100g (1-1.5g/kg) as a slurry in 400-800ml
water
• Shake vigorously to ensure adequate dispersion
46. • Risks: no systemic effects, but may induce vomiting, constipation,
diarrhea
• Contraindicated: decreased LOC or unprotected airway.
• Avoid (no value): strong acids, alkali, corrosives, heavy metals,
cyanides, lithium, hydrocarbons (paraffin), methanol and ethylene
glycol.
47. Multi-dose activated charcoal
• Enhance elimination of drugs already absorbed
• Interrupting enterohepatic circulation.
• Indication: ingestion of large doses of
Carbamazepine, dapsone, phenobarbitone, quinine,
theophlline, Salicylates, sustained release
formulations.
• Method: after first dose of charcoal, follow up dose of
25g every 2hrs or 50g every 4hrs,
• Until clinical conditions and lab parameters improve.
• Contraindications: diminished bowel sounds, proven
ileus or small bowel obstruction
48. Whole bowel irrigation
• Uses a laxative agent such as polyethylene glycol to fully flush the
bowel of stool and unabsorbed xenobiotics.
• Contraindicated in ileus, bowel obstruction or perforation, and in
patients with hemodynamic instability.
• May be considered for substantial ingestions of iron, sustained
release products, enteric coated products and lead poisioning.
49. Urinary alkilinization
• Infusion of sodium bicarbonate to raise urinary pH to enhance
clearance of toxins excreted by kidneys
• 1-2 mEq/kg NaHCO3 IV push
• 3 ampules of NaHCO3 in 850 cc of D5W at 1.5X maintenance fluid
rate
• Target urinary pH 7.5-8.5
• Monitor electrolytes
50. Extracorporal Removal:
• Hemodialysis
• Less effective when toxin has large volume of distribution (>1 L/kg),
has large molecular weight, or highly protein bound.
• Acetone, Barbiturates, Bromide, Ethanol, Ethylene glycol, Salicylates,
Lithium
• Peritoneal Dialysis
• Alcohols, long acting salicylates, Lithium
51. Antidotes
• Although most poisonings are managed primarily with appropriate
supportive care, there are several specific antidote agents that may
be employed.
54. Summary
• The management of the poisoned patient who has an unknown
exposure can be diagnostically and therapeutically challenging.
• The history and physical examination, along with a small dose of
detective work, can often provide the clues to the appropriate
diagnosis.
55. • Ultimately, the management of the critically poisoned patient centers
on careful supportive care.
• Care of the critically poisoned patient may be further maximized with
appropriate decontamination, antidote administration, elimination
enhancement and pharmaceutical interventions.
56. Approach to poisioned pt
• ABC
• Oxygen, monitors, IV access
• Full set of vitals including O2 sat
• Gather history and collateral information
• Check glucose
• Physical exam: skin, cardio, resp, GI, neuro
• Disability : GCS, pupils
• Drugs: onsider universal antidotes
• Decontamination
• Draw Labs
• *Contact poison centre if available*
• Specific antidotes and supportive care
