REMOVAL OF THE POISONOUS MATERIAL 2

The treatment of poisoning consists of the application of three main procedures as rapidly as possible. These are: 1. Maintain vital functions. 2. Remove ingested poison. 3. Delay absorption.

Therefore, if a poisonous plant is ingested, the stomach should be emptied as quickly as possible. Emesis is part of the firs-line medical management of the poisoned patient. Unless contraindicated emesis should be induced immediately. Contraindications include coma, ingestion strychnine and the ingestion of corrosives.

Once material is absorbed, treatment must proceed along symptomatic lines. I- Emetics 1-Warm saline or Mustard water the use of warm saline or mustard water to induce vomiting is impractical, most of children refuse to drink these, in addition, warm saline water could cause and has caused fatal salt poisoning.

2- Syrup of Ipecac Ipecacuanha( Ipecacuanha Root )of the BP is the dried root or rhizome and root of Cephaelis ipecacuanha( Fam. Rubiaceae). Ipecac contains the alkaloids emetin, cephaeline, psychotrine, psychotrine methyl ether and emetamine.

Syrup of ipecac, 1.5-2g of ipecac powder in 100 ml of water ( not the fluid extract, which is 14 times more potent and extremely toxic) is routinely used in poisoning to induce emesis rapidly and safely. Syrup of ipecac has a highly rate of success, produce efficient emesis, has short latency and has no dangerous side effects.

Syrup of ipecac is indicated for a wake patients and emesis should occur within an average of minutes after the oral administration of single dose. If vomiting does not occur, a second dose is given, emesis is induced in over 90% of patients within an average time of 30 minutes following the first dose of ipecac, the patient should be sitting upright with the head forward. Following this, fluids should be forced orally, the patient kept walking, and manual stimulation of the pharynx occasionally tried to hasten emesis.

Caution should be used not to give too much ipecac syrup, since the emetine in it can cause cardiac toxicity. The adult dose is 30 ml with ml. If emesis does not occur, the dose is repeated n minutes. In children, the dose depends on age is: From 9-12 months, the dose is 10 ml with water, with no repeat dose. From 1-12 years, the dose is 15 ml with water. And may be repeated once. Children over 12 years of age, the dose is same as for adults.

3. Cupric sulfate 0.25g of cupric sulfate in a glass of water will induce vomiting more quickly than ipecac. The use of cupric sulfate is not recommended because: It is hemolytic It is hepatotoxic About 10% of it can be recovered from the vomitus.

4. Zinc sulfate Zinc sulfate is not recommended either because it has the same properties as cupric sulfate.

5. Apomorphine hydrochloride It is formed when morphine is treated with HCL in a sealed tube, and one molecule of water is lost. The compound decomposes readily and must be rejected if a green color is produced when it is shaken with water (1 to 100).

Apomorphine is an emetic and is particularly valuable in cases of poisoning because it may be administered subcutaneously and especially effective after massive ingestion of poisonous material. Usual dose, emetic, subcutaneously, is 1mg per kg of body weight (maximum 6 mg) mg per kg body weight of naloxone hydrochloride is given intravenously, intramuscularly or subcutaneously to terminate the narcotic effects of apomorphine.

Before the administration of apomorphine, 1-3 glasses of fluid should be given since effective emesis does not readily occur if the stomach is empty.

II. Antidotes Poison and antidote go together like hand and gloves. An antidote is any substance that nulls the effects of poison on the spot and prevents its absorption, or blocks its destructive action once absorbed. Most of the antidotes are depending on the type of poisonous material. The following substances are useful in gastric lavage as nonspecific antidotes:

1.Tannic acid Tannic acid is not a single homogenous compound, but is a mixture of esters of gallic acid with glucose whose exact composition varies according to its source. Tannic acid is mildly acidic and precipitates alkaloids and some glucosides.

Because tannic acid has hepatotoxic properties, it should be used with care and only in the recommended dilution (30-50g in 1 liter of water is an effective concentration). Moreover, the tannates formed often redissolved and later hydrolyze in acidic ambient, tannic acid should not be allowed to remain in the stomach.

2. Potassium Permanganate It is an oxidizing agent which reacts well with organic substances and effectively neutralizes alkaloids. Potassium permanganate is a strong irritant, must be diluted (1:10000 solution or a solution not stronger than 1: 5000), and no un- dissolved particles come in contact with the stomach or other tissues.

3. Sodium Bicarbonate 5% solution is recommended for gastric lavage as neutralizing solution. It is not recommended for acids because the liberated carbon dioxide might cause gastric distention and thus cause perforation of the stomach, which is already partly corroded by the acid.

4. Magnesium oxide or hydroxide It is a neutralizing agent for acidic substances (25 g of magnesium oxide in 1 liter of water). Unlike sodium bicarbonate, it does not release carbon dioxide and does not cause gastric distention.

5. Calcium salts 15-30g of calcium lactate or gluconate in 1 liter of water. It is helpful for oxalate poisoning and in preventing tetany from the hypocalcaemia that occurs in certain types of poisoning.

6. Starch solution g of starch in 1 liter of water. It is very effective in neutralizing iodine.

7. Activated charcoal ( Norit-AR) Activated charcoal is made by industrial process which involves the controlled heating of burned wood, peat, bone, nutshells or coal. Temperature is held close to 540°C while an atmosphere of water vapor, carbon dioxide, oxygen, zinc chloride, sulfuric acid, phosphoric acid, or a combination of some of these substances covers the partly burned source materials. Processes vary in detail but they all somehow activate the final product.

Activated charcoal is a potent adsorbent that rapidly inactivates many poisons if it is given promptly before much of the poison can be absorbed g of activated charcoal in 240 ml of water or a mixture of soupy consistency is a good concentration for oral use or lavage. A minor drawback to using activated charcoal is that, because it is black and gritty, many children will refuse to drink it.

Palatable formulation made by mixing activated charcoal with inert (non absorbable lubricating agents such as carboxy methyl cellulose or bentonite clay) and with the possible addition of flavoring agent such as sodium saccharin. Recently, the alcohol sugar sorbitol is being included in an activated charcoal preparation to speed up its intestinal transient time.

Activated charcoal should not be given until after emesis is successfully induced. It should never be given simultaneously with syrup of ipecac, because the emetic effect of ipecac may be adsorbed and inactivated, but it may be given simultaneously with the emetic parenteral apomorphin hydrochloride.

Charcaol will not work in the case of cyanide poisoning. Cyanide poisoning by cyanogenic glycoside (e.g., amygdalin in members of the Rosaceae ) should be managed using commercial cyanide antidote kit. The kits provide specific details and usually include amyl nitrite, sodium nitrite, and sodium thiosulfate.

The sodium nitrite converts some of the blood hemoglobin to methemoglobin, which in turn combines prefentially with cyanide in competition with the respiratory enzyme cytochrome oxidase. Sodium thiosulfate converts some cyanide (including cyanomethemoglobin) into the more stable and less toxic thiocyanate.

8. Universal Antidote There have always been attempts to discover a single antidot which would be effective against the entire range of poisonous plants, animals and minerals. Universal antidote consists of: 2 parts activated charcoal 1 part tannic acid 1 part magnesium oxide

Recent studies have been shown that universal antidote is generally less effective than activated charcoal. Universal antidote is no longer recommended, since its active principle, tannic acid, may it self be toxic. Also activated charcoal can inactivate ipecac and thus should not be used concomitantly.

Symptomatic therapy and supportive measures are very important factors contributing to recovery. Supportive measures include control of body temperature, maintenance of respiratory and cardiovascular function, control of pain and central nervous system signs, and treatment of shock.

3. Gastric Lavage If vomiting cannot be induced and syrup of ipecac not available, gastric lavage should be restored to at once. It is indicated any time within three hours after ingestion of the poisonous plant. Gastric lavage is not indicated for removal of poisonous material in hysterical, comatose, or otherwise uncooperative patients.

D. Catharsis and Intestinal Lavage Useful in removal of unabsorbed poisonous material or poisons that have been excreted into the intestine. Do not use any irritant cathartics ( aloes, cascara).