1. Overdose & Toxicity “Poisons & Poisoning”
Fakhr Zohair Al-Ayoubi, Msc
Clinical Pharmacist in:
CCU & Cardiology Department
Poison Information Center
KKUH May 2010

2. Introduction Poisoning is an important public health problem
In 2009, 2 million human poison exposures were reported to all poison centers in the US.
Deaths from Poisoning:
Total 19,269
Unintentional14,078
Suicide 5,191
Medical costs is estimated at $3 billion in the US
Clinical Toxicology 1999, Vol. 37, No. 7
Miller and Lestina, CDC, 1997

3. Definition of Poisoning
Toxicology
The basic since of poisons (old)
The study of the adverse effects of chemical agents on biological system (new)
Poison
Any substance that causes injury or illness or death of a living organism

4. Definition of Overdose
Overdose “dose too heavily”
Ingestion or application of a drug or other substance in quantities ↑↑ than recommended or generally practiced.
Its considered harmful & dangerous, & it can result in death.

5. Definition of Overdose
Overdose “dose too heavily”
This mean that there is a common safe dosage & usage for the drug; therefore, the term is only applied to drugs, not poison though it should be noted that even certain poisons are harmless at a low enough dosage.

6. Types of Poisoning/Overdose
Accidental “Self-harm”
Many are this type
Pediatric (most common)
Usually the result of either irresponsible behavior or the misreading of product labels.
Intentional “Suicide”
Throughout the ages
The act of deliberately killing oneself murder, causing your own death suicide & execution.

7. Type of Poisons Prescription drug Over The Counter drugs (OTC)
Herbal medications or preparations
Household chemicals
Industrial chemicals

8. What do pharmacist provide in the center?
immediate action real time answer ( for health care & public)
Expert & accessible ( coaching)
Promoting education for all (awareness)
Registry , statistic : (paracetamol child resistance caps)

9. Clinical Pharmacist Role in Poising Management
Identification of the poison
Pharmacokinetic / Toxokinetic
Antidotes dosing & update
Patient treatment plans
Monitoring outcomes
Improving health care & Lay public awareness
Am J Health-Syst Pharm,2006

10. Poison Resources Primary resources: Journals Secondary resources
Poisondex
Iowa system
Tertiary resources:
Text books:
Clinical Toxicology
Am J Health-Syst Pharm,2006

11. Poison Resources
GUIDE TO POISONOUS AND TOXIC PLANTS   From US Army Center for Health Promotion and Preventive Medicine
Common Antidote Chart   Common Antidote Chart From California Poison Control
Management of Poisoning - A handbook for health care workers  By World Health Organization

12. Poison Resources
American Association of Poison Control Centers (AAPCC)  The AAPCC provides a forum for poison centers and interested individuals to promote the reduction of morbidity and mortality from poisonings through public and professional education and scientific research. It also sets voluntary standards for poison center operations.

13. Poison Resources
Basic Analytical Toxicology - WHO  By World Health Organization Guidelines for poison control - WHO  By World Health Organization. Contains antidote information for drug poisoning. Clinical Toxicology - Paddock Labs  Clinical Toxicology published by Paddock Lab of Canada. Includes current and practical information on the management of various types of poisoning and overdose emergencies.

14. Poison Resources
Diseases and Disorders links pertaining to poisoning  A list of links compiled by Karolinska Institutet (a medical university in Sweden), covering topics from bites and stings, to poisoning related to foods, gas, lead, iron, plant, arsenic, mercury, cadmium, nickel, and permanganate, drug toxicity, and hazardous substances. TOXNET  From the National Library of Medicine in the U.S., this site is a collection of of databases on toxicology, hazardous chemicals, and related areas. Arizona Poison and Drug Information Center Home  Provides accessible poison and medication-related emergency treatment advice, referral assistance and comprehensive information on poisons and toxins, poison prevention, and the safe and proper use of medications.

15. Poison Resources
Poisons Information Monographs  International Programme on Chemical Safety Poison monographs of: Chemical, Pharmaceuticals, Animals, Plants, Bacteria and Fungi Toxic Exposure Treatment Guides  IPCS International Programme on Chemical Safety AACT - American Academy of Clinical Toxicology  An organization uniting scientists and clinicians in the advancement of research, education, prevention and treatment of diseases caused by chemicals, drugs and toxins.

16. Poison Resources
EXTOXNET - The Extension Toxicology Network  Provides info. on various types of pesticide toxicology and environmental chemistry. These include: discussions of toxicological issues of concern (TICs); toxicology newsletters; other resources for toxicology information; toxicology fact sheets; Pesticide Information Profiles (PIPs); and Toxicology Information Briefs (TIBs). Consumer Products Safety - Health Canada 

17. General Management Decontamination Supportive care.
Prevent further exposure to the poison.
Removal of the unabsorbed poison from the stomach.
Inactivation of the poison remaining in the stomach.
Enhancement of excretion.
Administration of an antidote.
Symptomatic treatment.

18. General Management General  Absorption  Elimination
Specific antidotes

19.  Absorption Gastric lavage
Indications include coma or impending coma, seizures, or a depressed gag reflex.
Only if within 1 hour & life-threatening amount
Oro-gastric tube should be used.
Should be done only in older children.
Never for corrosives & chronic cases

20.  Absorption.... Cont. Activated charcoal
Has no real contraindications and is the treatment of choice to prevent absorption of the poisoning when the patient is in the emergency room.
It is ineffective against cyanides, heavy metals, Na, K, Cl, ethanol, acids, and bases.
50 g single or repeated dose ( elimination)

21.  Absorption.... Cont. Cathartic
Decrease absorption by increasing the rate of excretion
Mg Sulphate should not be used if the patient has renal failure
Sorbitol

22.  Elimination Multiple dose activated charcoal Charcoal haemoperfusion
Quinine, phenobarbitone, Carbamazepine
Charcoal haemoperfusion
Barbiturates, theophylline
Diuresis
may be done using hemodialysis, hemoperfusion, & peritoneal dialysis.

23.  Elimination....Cont. Exchange transfusion
Only if the patient is unresponsive to appropriate care.
Urinary alkalinization
Whole Bowel Irrigation

24. Physiological Antidotes Classifications
Antagonists:
Stimulate where the poisons depressed & vise versa e.g:
Diazepam in strychnine poisoning.
Atropine in organophosphorous (antagonize muscarinic action).
Pilocarpine antagonize peripheral action of atropine.

25. Physiological Antidotes Classifications.... Cont..
Chelators:
Antidotes forms chelates which are less toxic &easily excreted through the kidneys e.g.:
BAL (British anti-lewisite) in arsenic poisoning.
EDTA (Ethylene Diamine Tetra-Acetate) in heavy metals poison.
Desferrioxamine (Desferal) chelator in cases of iron poisoning.
Penicillamine used as oral chelator in lead poisoning.

26. Physiological Antidotes Classifications.... Cont..
Competitors:
Compete with the poisons at the sites of their action.
Naloxone in morphine poisoning but recently used as a narcotics antidote with no CNS depressant action.
Ethyl alcohol in cases of methanol poisoning.

27. Telephone Protocol For Handling Poison Calls
I .Initial assessment
Substance
Symptoms
What has been done
II. History
Basic information
Amount
III. Assessment
Toxicity of the substance
Circumstances of exposure
Competency of the caller

28. Telephone Protocol For Handling Poison Calls
IV. Treatment plan (one of the following)
No treatment
First aid and observe at home
Syrup of ipecac and observe at home
Refer t o MD, ER,etc
V. Follow up
Made at 0.5 hr,2-4hrs,12hrsor 24hrs
Has the victim remained asymptomatic
Were instructions followed
Was treatment effective
Poison prevention teaching12
Referral

29. I .Initial assessment a) Substance involved: 1) Toxic substance
b) Are symptoms present?
1) irritated, discolored or swollen lips, gums, tongue; coughing, convulsions, acting unusual, can't wake up,
c) What has been done?
is immediate first aid necessary e.g. dilution, washing area.
has incorrect first aid been done e.g. salt water as emetic.
is immediate ER referral indicated?

30. II. History A. Basic Information: 1) Name of caller
relationship of caller to victim - parent, friend, babysitter, MDRN.
2) Name and age of victim.
3) Weight of victim
4) Phone number.
5) Time of exposure how long has it been?
6) Route of exposure
ingestion, inhalation, percu taneous, occular.

31. II. History B. Substance: 1) Brand name and other identification form
2) Medication:
read prescription label.
is there a drug imprint code?
what was it supposed to do?
3) Plant
has it recently been sprayed?
4) Is it possible anything else involved
look around for any other bottles, broken plants

32. II. History C. Amount: 1) Describe situation
tell me exactly what happened?
did you see him/her swallow?
2) Extract quantitative details
how many/much was there originally?
count/measure how much is left
when was it purchased?
used often?

33. II. History D. symptoms: Present Medical condition.
does he/she take any medicineregularly?
has he/she been sick lately?

34. III. Assessment: A. Toxicity of substance.
Poisindex
Reference texts and articles.
Manufacturer emergency number
Consultants and experts.

35. III. Assessment B. Circumstances of Exposure Accidental occupational
Suicide
Accidental
occupational
Environmental
Drug abuse.

36. III. Assessment C. Competency of caller.
will they be able to carry out instructions and make observations?
How important does caller consider exposure to be?

37. IV. Treatment Plan: A. No treatment necessary
1) Will they be available for follow-up?
2) Do they understand what to watch for?
B. First aid and observe at home.
1) Is syrup of Ipecac available?
2) Is caller competent and calm home.
3) Will they be available for follow-up?
4) Do they understand what to watch for?
C. Syrupe of Ipecac
1) Arrange transportation
2) Call ahead.
3) Have they bring container, plant with them
D. Refer to MD, ER, clinicin the following situations
highly toxic substance; unknown substance; , unknown amount; signs plant, etc. symptoms not obvious, e.g. EKG changes; unstable situation.

38. V. Follow-up: 1) Anything at all unusual?
2) Sleeping, eating, etc. normally?
A. Has the victim remained asymptomatic?
1) How much Ipecac did you give
2) Did you give water afterward?
3) How long did you wash the eye?
B. Were instructions followed?
1) Did victim vomit?
2) How many times?
3) Were pill fragments present?
4) Is he/she eating all right now?
C. Was treatment effective?
1) Education and first aid ..
2) Poison proof now-low the odds of a repeat.
D. Poison prevention teaching
1) Public health nurse
2) Workers clinic
3) Suicide prevention
E. Referral