Toxicology

1. CASE DISCUSSION
Dr.K.SHANMUGASUNDARAM,
M.D.(General Medicine)

2. Toxindromes
S.No. Toxindrome Specific Cf Examples
1 Sympathomimetic Hypertension, seizures Caffeine, Cocaine,
Amphetamine
2 Cholinergic - Muscarinic DUMBELS OPC
3 Nicotinic HTN, Fasci, Weak, Confusion,
4 Anti-Cholinergic Constipation, Retention of
Urine, Hallucination, Delerium
Atropine, Datura, TCA
5 Opioid Coma, Pin point, Resp, Brady,
Tension, Thermia
Morphine, Pethidine,
Heroine
6 Sedative / Hypnotics LSD,Rohypnol,
Diazepam

3. CASE SCENARIO 1
 A 48yrs old male, admitted history of snake
bite over right foot, with swelling and pain of
right foot.
 C/o pain and swelling at the site of snake bite
 C/o severe abdominal pain, vomiting

4.  WBCT >20min, after 10 vials of ASV,
Clotting time normal. ECG normal.
 Cellulitis improving
 After 3 days pt. developed sudden onset
bilateral parotid swelling, non-tender.

5.  Diagnosis: Snake bite right foot, cellulitis,
hemotoxicity, Bilateral parotid enlargement,
Renal failure, ? Pancreatitis

6. INVESTIGATIONS
 CBC : TC 11300, Hb-12.5 , Plt 1.56 lakh to
TC 14350, Plt 88000 on day 3
 RFT 37/1.7 to 56/1.8 to 52/2.1
reduced to 43/1.5 on day 6
 Sr. Amylase normal
 Output 2100 ml
 USG abdomen normal

7. TREATMENT:
 In view of DIC 4 units of FFP transfusion done.

8.  Pt. discharged on day 7.
 Completely recovered from hemotoxicity,
cellulitis was decreasing, RFT improving,
parotid swelling subsided.

14. CASE SCENARIO 2
 60yrs old male consumed 40ml of liquid
poison, some weedicide, kept at his
agricultural farm 1hr before admission at
casualty.
 Stomach wash given  Aspirate was green
coloured.
 When probed about history, he was able to
recollect only that poison was bright green
colour. No other details available.

15.  Universal toxicology protocol followed.
 He had complaints of burning sensation in the
mouth and upto epigastric region. 2 hrs later
he had an episode of hematemesis.
 Treated symptomatically.

16.  Next day he developed oliguria, dry cough,
B/L crepts on auscultation with falling spO2.
 ABG showed hypoxia metabolic acidosis.
 Deranged RFT AND LFT.
 Was started with high flow 02 support with
NRBM and later changed to CPAP.
 Planned for HD and immediately taken.
 Even after these measures pt. deteriorated
and succumbed to death.

17.  Identify the poison?
 What went wrong during treatment?

18. CASE SCENARIO 3
 25 male
 Breath smell of alcohol
 Snake bite right hand
 No cellulitis
 Ptosis

19. CASE SCENARIO 4
• Around 50 /M
• Found unconscious road side, breath smell of
alcohol
• Pt drowsy
• Hypoglycemia corrected
• Ct brain normal.
• Gc deteriorated and intubated.

20. • Deranged rft
• Cellulitis right leg, bleeding
• Suspect snake bite

21. CASE SCENARIO 5
• 40 female
• Multiple wasp bite
• Developed chest pain
• Ecg changes

23. • Kounis syndrome
• Steroids, antihistamines, antiplatelets.
• Don’t thrombolyse.

24. CASE SCENARIO 6
• 60 years male
• Multiple wasp bite
• Treatment given.
• Clinically improving.
• Day 3, slurring of speech.

25. • Further developed altered sensorium.
• Ct brain multi infarct state.
• Both cases improved in due course.

26. CASE SCENARIO 7
 A 69 years old male admitted with history of
alleged consumption of oleander seed 7 in
number. Crushed and taken by mouth.
 C/o vomiting, abdominal pain, no c/o chest
pain, breathlessness, palpitation, syncope.
 No co-morbidities.

27.  On admission, pt. was conscious, oriented
 Vitals signs BP 110/70,
 pulse rate 52/min, regular, SpO2-97, CVS -
S1S2 present
 RS- B/L air entry present, ECG as shown below

28.  Diagnosis: Oleander seed poisoning

29. Treatment given:
 Stomach wash
 Nil per oral
 Ryle's tube aspiration
 IVF @120ml/hr
 Inj. Atropine 0.6 mg iv stat /sos (if HR<60/min)
 Inj. Pan iv od
 Inj. Thiamine 100mg iv od
 Tab. Orciprenaline 10mg tds
 Serial ECG monitoring

32. CASE SCENARIO 8
• 45 male
• Agricultural tablet poisoning 1 tab
• Stomach wash, Supportive management
given.
Deteriorated, respiratory arrest.

33.  Identify the poison?
 What went wrong during treatment?

34. CASE SCENARIO 8

37. • Identify toxindrome/ poison

38. Thank u