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  1. 1. POISONING Myrna D.C. San Pedro, MD, FPPS
  2. 2. Poison • Any substance that is harmful to the body • When ingested, inhaled, injected, or absorbed through the skin • Does not include adverse reactions to medications taken correctly
  3. 3. Classification • Intentional poisoning: A person taking or giving a substance with the intention of causing harm, e.g. Suicide and Assault • Unintentional poisoning: If the person taking or giving a substance did not mean to cause harm, e.g. For recreational such as in an “Overdose” or Accidentally taken by a toddler • “Undetermined”: When the distinction between intentional and unintentional is unclear
  4. 4. U.S. Occurrence
  5. 5. Pesticide Poisoning in the Philippines
  6. 6. <10%
  7. 7. 71.3% Insecticides 10.2% Herbicides 10.9% Not Known
  8. 8. 79.5%
  9. 9. *Top Poisons (Those 19 Years and Below) 1. Methamphetamine 2. Multiple drugs 3. Mixed pesticide 4. Ethanol 5. Isoniazid 6. Marijuana 7. Salicylic Acid (Salicylates) 8. Malathion (Organophosphates) 9. Paracetamol (Acetaminophen) 10.Caustic Substances
  10. 10. Data Needed • Phone Number • Address • Evaluation of Severity • Weight and Age • Route of Exposure • Time of Exposure • Past Medical History • Type of Exposure • Amount of Exposure • Informant’s Relationship to Victim
  11. 11. Types of Exposure • Acute: Exposure < 24 hours  Single: a single or continuous exposure (e.g. carbon monoxide)  Repeated: multiple interrupted exposures where there may be accumulation (e.g. aspirin overdose) • Chronic: > 24 hours or long-term exposure, for weeks or months (e.g. lead poisoning) • Acute “on chronic”: Acute exposure against a background of chronic exposure to the same agent (e.g. organophosphorus pesticide exposure on a chronically exposed child) • “Hit and run”: Acute exposure leading to delayed effects once the toxicant is gone (e.g. thalidomide exposure during gestation leading to phocomelia)
  12. 12. Acute Poisoning • Pharmaceuticals: sedatives, analgesics, contraceptives, cardiovascular drugs • Household products: bleaches, detergents, solvents, kerosene • Cosmetics: perfumes, shampoo, nail products • Substances of abuse: alcohol, tobacco, illicit drugs • Pesticides: insecticides, rodenticides, herbicides • Plants and mushrooms: berries, seeds, leaves • Seafood Poisoning: paralytic shellfish poisoning, fish poisoning • Venomous bites and stings: snake, scorpions, bees, jellyfishes, spiders
  13. 13. Chronic Poisoning • Metals Lead Mercury • Pesticides in food or fields Organophosphates Carbamates Warfarins Organochlorines: Persistent Organic Pollutants (POPs), has potential developmental neurobehavioral and endocrine effects, e. g. DDT
  14. 14. Prevention 1. Primary: to prevent occurrence a) Discard old prescriptions b) Have only few tablets per bottle at a time c) Use child-proof packaging d) Keep medicines in high locked cabinets e) Keep potentially dangerous substances properly labeled and stored in places not easily accessible to toddlers 2. Secondary: to lessen injury after exposure a) Create poison control centers
  15. 15. Is your home poison proof? Remove the risk. Put poisons away. Straight away.
  16. 16. • Discard old prescriptions •Keep potentially dangerous • Have only few substances properly labeled tablets per bottle at a time
  17. 17. •Keep medicines in high •Use child-proof packaging locked cabinets
  18. 18. •Keep potentially dangerous substances properly labeled and stored in places not easily accessible to toddlers
  19. 19. Exposure to Lead in Children
  20. 20. Initial Medical Care • Initial attention should be on life support, primarily on cardiorespiratory care • Shock, arrhythmias and convulsions must be dealt with urgently and as in the case of any critically ill • When the patient’s condition is stable, the specific treatment or antidote can be given
  21. 21. Preventing Absorption • Emesis: Syrup of Ipecac, 15-30 ml followed by water results in vomiting in > 95% less than 5 yr  Contraindications: 1) When there is significant risk of aspiration 2) A comatose or convulsing patient 3) Ingestion of strong acids or bases  About 8-30% recovery of ingested substance • Lavage: Warm saline or warm tap water  Complication is esophageal perforation  Used to remove fragments of tablets & capsules • Charcoal: Activated charcoal most effective and safest to prevent absorption given as water slurry, 15-30 gm in a child and 30-100 gm in adolescent; repeat 20 gm q 2 hr until charcoal in stool • Cathartic: Sorbitol max 1 gm/kg, MgSO4 max 250 mg/kg, sodium citrate max 250 mg/kg, or phosphosoda max 250 mg/kg  Used to hasten emptying of GIT
  22. 22. Requiring Simultaneous Antagonist and Life Support • Carbon Monoxide  Oxygen 100% ASAP to reduce concentration of CO in the blood  Those with high toxin levels may need hyperbaric oxygen therapy • Opiates  Naloxone minimum of 0.4 mg to any patient irregardless of age or weight  If unresponsive, up to 2.0 mg given IV rapidly to larger children and adolescents and may be repeated as needed  Newborns to 6-month-old infants should be given a dose of 10-100 g/kg
  23. 23. • Cyanide  Oxygen immediately then antidote  Antidote kit: 1) Amyl nitrite inhalers broken under nose for 30 sec/min while sodium nitrite solution being readied 2) Sodium nitrite 3% solution 0.33 ml/kg (10 mg/kg) to maximum 10 ml/patient with normal hemoglobin 3) Sodium thiosulfate 25% solution given next at 1.65 ml/kg to maximum of whole ampule  Hydroxocobalamine-thiosulfate mixture in doses of 4-10 g, an alternative  These antidotes produce methemoglobin that help remove cyanide by competition for the cytochrome
  24. 24. • Substances Causing Methemoglobinemia (Aniline Dyes, Nitrobenzene, Azo Compounds & Nitrites) Unresponsive to oxygen If there is at least 20% methemoglobinemia, patient’s drop of blood will be relatively brown when dried on filter paper Methylene blue at 0.1-0.2 ml/kg (1-2 mg/kg)/dose of 1% solution is therapeutic Exchange transfusion may be needed if two doses failed
  25. 25. • Cholinergic Agents (Organophosphates & Carbamates)  Manifestations are salivation, lacrimation, urination, defecation and fasciculations  Atropine 0.05 mg/kg to maximum initial dose of 2-5 mg to be given while patient decontaminated with soap and water  If unresponsive, repeated doses of atropine may be necessary  Pralidoxime, a cholinesterase regenerator, may be given when cholinesterase level falls to 25% of normal or lower, at a dose of 25-50 mg/kg over 30 min IV every 8-12 hr in young children to maximum of 1 g/dose in older children
  26. 26. Everything is poison, there is poison in everything. Only the dose makes a thing not a poison. --Paracelsus, Father of Toxicology