a basic approach to the poisoned patient, based on cases seen in a regional hospital in kzn south africa

1. TOXICOLOGY
ANAPPROACH TO THE POISONED PATIENT
BY: DR Y MAHOMED

2. THE MAIN FOCUS OF TODAYS
TALK
APPROACH TO UNCONSCIOUS POISONED PT
APPROACH TO THE POISONED PTWITHA
POOR COLLATERAL HISTORY
CLASSIFICATION OF THE POISONED PT

3. REMEMBER THATTOXICOLOGY ISA
SUB-SPECIALITY OF ITS OWN
IF YOU HAVE THREE MONTHS TO
SPARE WE CAN DISCUSS EACH
INDIVIDUAL TOXIN
BUT I WILL COVER SOME
INDIVIDUAL TOXINS

4. YOUR BESTTOOLS IN A
UNRESPONSIVE POISONED PT
YOUR EYES: LOOKAT EVERYTHING
YOUR HANDS : TOUCH THE PT
BLOODANALYSIS
ABG
GLUCOSE
ECG: HEAPS OF INFORMATION

5. TOXIDROMES
A SET OF CLINICAL FEATURES CONSISTENT
WITHA PARTICULAR DRUG CLASS OR
TOXIN
BY EXAMINING THE PTYOU CAN PLACE
THE PT INTO ONE OF THE TOXIDROMES

6. FIRST CHOLINERGIC AND ANTI-
CHOLINERGIC SUBSTANCES

7. CHOLINERGIC ANTI-CHOLINERGIC
EG. ORGANOPHOSPHATE EG. ATROPINE, TCA’S
SMALL PUPILS DILATED PUPILS
HYPERSALIVATION DRY MUC. MEMBRANES
LACRIMATION DRY EYES
DIAPHORETIC DRY FLUSHED SKIN
URINATION URINE RETENTION
DEFECATION CONSTIPATION
HYPOTHERMIC HYPERTHERMIC
BRADYCARDIA TACHYCARDIA
ALTERED MENTAL STATE ALTERED MENTAL STATE
VS

9. EASY?
IF YOU CAN REMEMBER
ONE THEN THE OTHER IS
VERY EASY
ITS EASIER TO
REMEMBER THE
CHOLINERGIC TOXINS
BECAUSE WE SEE THEM
MORE OFTEN

10. MANAGEMENT OF
ORGANOPHOSPHATE POISONING
ATROPINE, BUT ONLYWHEN WE HAVE ENOUGH!!
ALSO IF THERE ISA SIGNIFICANT
BRADYCARDIA
WE CAN DRY SECRETIONS IN OTHER WAYS
HOW MUCH
1 VIAL PER 10KG, SOA 50 KG PT GETS 5 VIALS,
UPTO 10VIALS/5G MAX
DON’TWASTE IT

11. MX OF ANTICHOLINERGIC
POISONING
SODIUM BICARBONATE
1-2meq/KG
8.5% SODA BIC IS 1meq/ml, SOA 50KG
PT GETS 50ML
AIM FORA pH OF 7.45-7.55
IDEALLYTHE PT SHOULD RECEIVE PHYSOSTIGMINE ,
BUTTHATS FORAN ICU SETTING

12. WHATABOUT ACTIVATED
CHARCOAL?
ITTASTES LIKE
FARTS WRAPPED IN
FEET, BYTHE WAY!!
SURE ,BUTTHEREA
FEW PROVISOS

13. INDICATIONS FOR
ACTIVATED CHARCOAL
THE PT ISAWAKE OR HASA PROPERLY PLACED NGT AND IS
INTUBATED
NO CORROSIVE SUBSTANCES HAVE BEEN INGESTED
NO BOWEL ILLEUS
NO GIT PERFORATIONS
IDEALLY IT SHOULD BE GIVEN WITHIN 1 HR OF INGESTION
WE HAVE USED IT UP TO 4 HRS LATER
BUTWITH MIXED RESULTS

14. BACK TO OUR
TOXIDROMES
OPIODS, SYMPATOMIMETICSAND HALLUCINOGENS
AKA “THE GOOD STUFF!!”

15. OPIOIDS
ESSENTIALLYTHE
PT HAS TRIED TO
VOLUNTARILYTURN
THEIR BRAIN OFF

16. SOA SLOW PULSEAND BREATHING RATE
PT BECOMES MORE COMATOSE
PUPILS BECOME PINPOINT
NOTICE HOW IMPORTANT PUPILS
ARE IN THE EXAMINATION
TRULYTHE WINDOWS TO THE
SOUL

17. MANAGEMENT OF OPIOD OD
NALOXONE, BUT TITRATED
DON’T GIVE THE WHOLE VIAL
AT SOME OF OUR TERTIARY CENTRES THEY
HAVE STOPPED USING ITALTOGETHER, OR
IT IS ONLY USED UNDER CONSULTANT
SUPERVISION

18. MIX THE 1ML WITH 3ML SALINE TO GET 0.1 MG PER
ML
GIVE 1ML EVERY 5-10MIN UNTIL HR, BPAND RESP
RATE STARTTO NORMALISE
THEREAFTER SEEK SENIORADVICE
WE CAN PRECIPITATEACUTE OPIOD WITHDRAWAL
THE EFFECT OF THE OPIOD MAY OUTLASTTHE
ACTION OF NALOXONE SO KEEPAN EYE ON YOUR
PT

19. SYMPATOMIMETICS
THE BODY IS NOW IN
SERIOUS OVERDRIVE
HENCE THE HOT ,
ANGRY , SWEATY,
WIDE EYED PTWITH
CHEST PAIN

20. MANAGEMENT OF THE SYMP.
OD
CHECK GLUCOSE
ECG: VERY OFTEN HAVE STEMI’S
THESE PTS NEED PCI
RESTRAINAND SEDATE
VALIUM,AS MUCHAS NEEDED
COOL THE PT

21. OPIODS SYMPATOMIMETICS
EG. MORPHINE, HEROIN EG. COCAINE
BRADYCARDIA TACHYCARDIA
BRADYPNEA TACHYPNEA
HYPOTENSION HYPERTENSION
COLD HOT
SMALL PUPILS LARGE PUPILS
COMATOSE AGITATED
VS

22. THE LAST TWO
TOXIDROMES
BENZODIAZEPINESAND HALLUCINOGENS

23. BENZODIAZIPINES
THE SEDATED OD PT
SOMNOLENT
ATAXIC
SLURRED SPEECH
CONFUSED
NYSTAGMUS
THOSE EYESAGAIN
RESPAND CARDIAC DEPRESSION
ESP IF TAKEN WITHALCOHOL

24. MANAGEMENT
MAINLY SUPPORTIVE
FLUMAZENIL ISANANTIDOTE, BUT IS ONLY
GIVEN INA HIGH CARE SETTING,AS IT MAY
CAUSE PROLONGED SEIZUREACTIVITY

25. SO WHAT ABOUT SEIZURES?
QUITE COMMON IN
POISONED PATIENTS
MOST LIKELYTONIC
-CLONIC
CAN BE FOCAL BUT
VERY RARELY

26. MANAGEMENT OF SEIZURES
BENZODIAZIPINESAND MORE BENZODIAZIPINES
AND THEN MORE BENZODIAZEPINES IF NEEDED
FOLLOWTHE STATUS EPILEPTICUS PROTOCOL IF SEIZURES DO NOT
RESOLVE
EXCEPT FOR ISONIAZID POISONING
GIVE PYRIDOXINE (VIT B6) ONA GRAM-GRAM BASIS
OR 5G IF YOU DON’T KNOWTHEAMOUNT OF
ISONIAZID TAKEN

27. HALLUCINOGENS
THE ‘HIGH’ PT
SEEN WITH MAGIC
MUSHROOMS, PEYOTE
ETC
HALLUCINATING PT
WITH DISORGANISED
BEHAVIOUR

28. MANAGEMENT
LUCKILY FEW OVERDOSES IN THIS CATEGORY
ARE FATAL
THESE PTS HAVE THE BEST STORIES
YOU GIVE SUPPORTIVE MANAGEMENT
BENZOS FORAGITATION
TNT FOR HYPERTENSION

29. SOME SPECIFIC TOXINS
OUR OTC MEDS

30. PARACETAMOL
SUSPECT IT INANY
UNCONSCIOUS OD PT
ESPECIALLY IF
JAUNDICED
OR WHERE THERE ISN’T
A CLEAR HISTORY OF
WHATWAS INGESTED

31. MANAGEMENT
AWHOLE PRESENTATION ON ITS OWN
REMEMBER BASELINE LFT’S
INGESTION OFAS LITTLEAS 10-15 TABS CAN BE
SERIOUS
NORMALLY PARA-SUICIDES, “PANADO IS SAFE!”
TX WITHACETYLCYSTEINE

32. SALICYLATES
PTS PRESENTWITH
MIXED RESPIRATORY
ALKALOSISAND
METABOLICACIDOSIS
OD CAN BEACUTE OR
CHRONIC

33. CLINICAL PRESENTATION
NAUSEA
PYREXIA
TINNITUS
HYPERVENTILATION
HYPOKALEMIA IS OFTEN QUITE MARKED
GASTRIC OUTLET OBSTRUCTION, DUE TO COALESCING OF TABLETS IN
STOMACH
CMP’S , SERIALABG’SAND PT/INR’SAREALSO IMPORTANT

34. MANAGEMENT
SODIUM BICARBONATEAS DESCRIBED BEFORE
KCL
OFTEN THEY NEED SERIAL LEVELSAND
REPLACEMENT
SUPPORTIVE MANAGEMENT
FLUIDS, SOME PTS, ESPECIALLY IN SEVEREACUTE OD,
MAY BE 4-6 LITRES BEHIND ON FLUID

35. BETA-BLOCKER AND CA-
CHANNEL BLOCKERS
OFTEN CAUSE
MARKED
HYPOTENSION
THE HYPOTENSION
MAY START MANY
HOURSAFTER
INGESTION

36. PTS OFTEN DEVELOP SEVERE TACHY
OR BRADY-ARRYTHMIAS
CAN LEAD TO SUDDEN CARDIAC
DEATH
BE CAREFUL IN THESE PTS, ALWAYS
SEEK SENIORASSISTANCE

37. MANAGEMENT
‘GIK’ PROTOCOL IS STANDARD
ALSO CALLED HIGH-DOSE INSULIN EUGLYCAEMIC THERAPY
50ML 50% glucose
1u/kg insulin/ act-rapid
both given as a bolus
along with a kcl infusion
get an abg before and after infusion

38. ADD CALCIUM GLUCONATE OR CHLORIDE
FOR CA CHANNEL BLOCKER DRUGS
IF YOU HAVE GLUCAGON THIS IS THE
TREATMENT OF CHOICE, BUT IT IS VERY
HARD TO COME BY
IN THE CASE OF CARDIACARRESTTHESE
PTS NEED EXTENDED CPR, SOME CENTRES
ADVOCATE A MINIMUM OF 45 MIN

40. IN SUMMARY
BASICS!! YOURABC’S
STABILIZE
LOOK :- EYES, MOUTH, SKIN
TOUCH:-PULSE, TEMPERATURE, SWEAT
TEST:- HGT,ABG, BASELINE BLOODS, ECG
CLASSIFY
THEN TREAT

41. THANK YOU
THE END