This presentation discusses the basic principles of management of a poison or overdose case presenting to any health facility

2. Definitions
• Poison: Any substance that can cause severe organ damage or death if
ingested, breathed in, or absorbed through the skin
• Toxin: A poisonous substance, especially a protein, that is produced by
living cells or organisms and is capable of causing disease when introduced
into the body tissues but is often also capable of inducing neutralizing
antibodies or antitoxin.

3. Definitions
•Toxicity: Degree to which a substance can damage an
organism.
• Acute toxicity involves harmful effects in an organism through a single
or short-term exposure.
• Subchronic toxicity is the ability of a toxic substance to cause effects for
more than one year but less than the lifetime of the exposed organism.
• Chronic toxicity is the ability of a substance or mixture of substances to
cause harmful effects over an extended period, usually upon repeated
or continuous exposure, sometimes lasting for the entire life of the
exposed organism.

4. Definitions
• Toxicology: The study of the nature, effects, and detection of poisons
(toxins) and the treatment of poisoning.

5. Treatment of Poisoning: Principles
Resuscitation Risk Assessment Supportive Care and
Monitoring
InvestigationsDecontamination
Enhanced
Elimination Antidotes Disposition

6. Resuscitation: The ABCDE way!
Check for Goal Possibility Possible Measures
Airway Maintain patency Patent/Obstructed Position: Left lateral, Head down
Suctioning
Intubation +/- Guedel’s Airway
Breathing Maintain adequate
oxygenation and
ventilation
Spontaneous/Apnoeic
SpO2 levels
Start Oxygen at 2L/min via face
mask
Intubation +/- Guedel’s Airway
Check for falling SpO2
Circulation Maintain perfusion
to vital organs
Feel for Pulses
BP recordable(?)
Attach Monitor, look for rhythm
consider inotropes
(dobutamine)
Start Crystalloids (Normal Saline
preferred) +/- Consider
vasopressors (adrenaline)

7. Resuscitation: The ABCDE way!
Check for Goal Possiblity Possible Measures
Disability Assess level of
Consciousness;
Correct life threatening
conditions
Institute Resuscitative
Antidotes
Glasglow Coma Scale or AVPU
scale
Hypoglycaemia; Hypethermia;
Seizure(focal/generalised)
Antidotes
Dextrose bolus
injection; active
cooling;
benzodiazepam
(diazepam)
Exposure Assess Toxidromes1 Cholinergic/Anticholinergic
Delirium, Agitation,
Neuroleptic Malignant
Syndrome
Manage Accordingly
1Toxidromes: Physiologically based abnormalities that are known to occur with specific classes of substances and typically are
helpful in diagnosis

8. Risk Assessment
• Distinct Quantitative Cognitive Step
• Ascertain:
• Agent(s)
• Dose(s)
• Time since ingestion
• Clinical features and progress
• Patient factors and co-morbidities
• Methods:
• History by patient himself/herself; attendants
• Missing medicines at home, previous medical records, agents available at
home

9. Supportive Care and Monitoring: Rationale
• Major causes of poisoning morbidity and mortality are acute effects
of poison on cardiovascular, central nervous or respiratory systems:
supportive care thus required
• Monitoring is essential to detect the progress of the intoxication and
the timing of institution, escalation and withdrawal of supportive care
and other measures.

10. Supportive Care and Monitoring
• Initially should be done in ED
• Duration of Monitoring determined by:
• Agent(s) ingested
• Formulation involved
• Disposition from ED depends on:
• Current clinical status
• Expected clinical status
• Patient shifted to either Emergency Observation Unit or Intensive
Care Unit

11. Supportive Care Measures

12. Investigations in Poisoning or Overdoses
• Are either:
• Screening Tests:
• Qualitative and quantitative evaluation for active ingredient, its metabolite or other
affected biochemical parameters
• May direct therapy
• Blood, Urine, Stool, Other body fluids e.g. gastric aspirate
• Specific Tests
• Should be requested selectively, if anticipated to assist risk assessment or management
• Includes Complete Blood Counts, Liver Function Test, Renal Function Test, Arterial Blood
Gas Analysis, Chest X-ray

13. Decontamination
• High Hazard Potential: Not to be used routinely
• Clinical judgment based on potential benefits, potential risks and available
resources
• Absorption virtually completed within 1 hr- so decontamination should be done
as early as possible

14. Decontamination
Induced Emesis Gastric Lavage Activated Charcoal Whole Bowel Irrigation
Syrup of Ipecac Sequential administration and
aspiration of small volumes of
fluid from stomach via a
orogastric tube
Single Dose Polyethylene glycol- electrolyte solution (PEG-
ELS)
Unreliable Unreliable Reversibly adsorbs
most ingested toxins
Rarely performed: Sustained release and Enteric
Coated formulations, OR
Agent not binding to charcoal and good clinical
outcome not expected with supportive care and
antidote administration and the patient presents
before established severe toxicity
Not
Recemmended
Abandoned from most of the
ED
Indicated within 1 hr of
ingestion
Major risk: pulmonary
aspiration
50 g (adults) or 1g/kg
(child)
Potential Indications:
Iron overdose >60 mg/kg; Slow release
potassium chloride ingestion >2.5 mmol/kg; Life-
threatening slow-release verapamil or diltiazem
ingestions; Symptomatic arsenic trioxide
ingestion; Lead ingestion; Body packers

15. CAUTION!!
• Do not try Activated Charcoal for:
• Hydrocarbons and Alcohols: Ethanol, Isopropyl Alcohol, Ethylene glycol,
methanol
• Metals: Lithium, Iron, Potassium, Lead, Arsenic, Mercury
• Corrosives: Acids, Alkali

16. Enhanced Elimination
• Increase the rate of removal of an agent with the aim of reducing the
severity and duration of clinical intoxication
• In practice, these techniques are useful only in the treatment of
poisoning by a few agents that are characterised by:
• Severe toxicity
• Poor outcome despite good supportive care and antidote administration
• Slow endogenous rates of elimination
• Suitable pharmacokinetic properties

17. Techniques for Enhanced Elimination
Multiple Dose Activated
Charcoal (AC)
Urinary Alkalinisation Haemodialysis,
Hemofiltration,
Plasmapheresis,
Exchange Transfusion
Charcoal Hemoperfusion
Repeated dose AC – fills
GIT with AC – acts by
interruption of entero-
hepatic circulation and
gastrointestinal dialysis
Alkaline urine promotes
the ionisation of highly
acidic drugs and prevents
reabsorption
Sodium bicarbonate,
bolus + infusion
Carbamazepine
Dapsone
Phenobarbitone
Quinine
Theophylline
Phenobarbitone
Salicylate
Lithium
Metformin Lactic Acidosis
Potassium
Salicylate
Theophylline
Toxic alcohols
Valporic Acid
Theophylline

18. Antidotes
• Antidotes are drugs
• have specific indications, contraindications, optimal administration methods,
monitoring requirements, appropriate therapeutic end-points and adverse
effect profiles.
• The indications to administer an antidote to an individual patient are
based upon a risk-benefit analysis.
• An antidote is administered when the potential therapeutic benefit is
judged to exceed the potential adverse effects, cost and resource
requirements.
• An accurate risk combined with pharmaceutical knowledge o f the
antidote is essential to clinical decision-making.

19. Few Antidotes…
Poison/Overdose Antidote
Organophosphate Atropine
Atropine Physostigmine
Mehtanol Ethanol and fomepizole
Cyanide Thiosulfate
Opioids Naloxone
Beta agonists, Theophylline Esmolol (Beta-blocker)
Digoxin Digoxin immune Fab
Heparin Protamine
Warfarin, Coumarins Vitamin K
Benzodiazepines Flumazenil
Paracetamol Acetylcysteine
Iron and iron salts Desferioxamine
Carbon monoxide Oxygen (Hyperbaric)

20. Disposition
• Proper Medical and Psychosocial disposition required
• A patient may be:
• Discharged from ED after few hours of observation
• Transferred to Emergency Observation Unit
• Transferred to Intensive Care Unit
• Referred to Better Center

21. Next Class…
• We will be discussing on some specific poisons
• Assignment: What is the common poisoning or
overdose in your community? Find out the trade name
as well the compound it contains.