1. John Hiscox 2016

2. ED Toxicology Toxbase Thank you for paying attention Any Questions?

3. When should I admit a person to hospital after an episode of poisoning or overdose? Admit a person to hospital if: They have worrying symptoms after taking a poison or drug. They are asymptomatic, but the poison or drug is unknown, is potentially life threatening, or has a delayed action. The poisoning was intentional. Consider admitting children, older people, pregnant women, people with pre-existing comorbidities, or people taking concomitant medication, even if the drug is considered to have a good safety profile.

4. When should I admit a person to hospital after an episode of poisoning or overdose? Admit the person to hospital immediately if they develop worrying symptoms suggestive of poisoning, or have taken a poison or drug which could be potentially life threatening, or have a delayed onset of action: Symptoms which are worrying include respiratory difficulty, palpitations, and dizziness. However, minor gastrointestinal upset (nausea, diarrhoea) is generally not considered to be an absolute indication for admission to hospital in people who have taken non- toxic substances or substances with a low toxicity. Drugs which are potentially life threatening include opioids, benzodiazepines, cocaine, antidepressants, antipsychotics, antiepileptics, quinine, verapamil and diltiazem. Common delayed-action drugs and poisons include aspirin, iron supplements, paracetamol, lithium, tricyclic antidepressants, co- phenotrope (diphenoxylate with atropine, Lomotil ® brand), and paraquat. Also consider when a drug has been taken in a form which delays release (delayed- or modified-release tablets or capsules).

5. Where can I get more information about poisonings? TOXBASE in the first instance for general information (see www.toxbase.org but in the event of any difficulty contact 0131 242 1381/1383).www.toxbase.org National Poisons Information Service (NPIS) UK Teratology Information Service (UKTIS), formerly National Teratology Information Service (NTIS) in the event of poisoning in a pregnant woman (see www.uktis.org, 0844 8920909).www.uktis.org UK Medicines Information (UKMI) service for general medicine information including dosing and drug interactions (see www.ukmi.nhs.uk).www.ukmi.nhs.uk

6. How do I manage a person who does not need admission to hospital? Admission to hospital is not usually indicated for accidental poisoning with agents considered to be non-toxic or of low toxicity, or if a person has accidentally taken an additional tablet of their own medication. However, all intentional poisonings, even if the poison is considered of low toxicity will need admission for further assessment.

7. How do I manage a person who does not need admission to hospital? Advise the person about expected adverse effects. Consider a full assessment for people more vulnerable to complications. Review: Details of the drug taken The person's past medical history (especially renal and liver impairment) and medication history. The person's age and social circumstances.. Restart the person on their medication when possible. If there is any uncertainty regarding a poisoning or when to restart medication after an additional tablet has been taken, further advice should be sought

8. How do I manage a person who refuses admission to hospital after a poisoning?

9. How do I assess a person's capacity?

10. ED Management Prevention of absorption: Activated charcoal is the treatment of choice for most poisons and is used if the person presents within an hour of ingestion (longer if a modified release preparation or antimuscarinic properties). The charcoal binds to the poison and prevent further absorption into the blood. It is particularly useful when small amounts of a drug are toxic such as antidepressants. Active elimination is suitable for a limited number of drugs: Activated charcoal given in repeated doses also enhances the elimination of some drugs even after they have been absorbed such as carbamazepine, phenobarbitone, quinine, theophylline and dapsone. Alkalinisation of the urine for salicylate poisoning. Haemodialysis for ethylene glycol, lithium, methanol, phenobarbital, salicylates, and sodium valproate. Removal from the gastrointestinal tract: Gastric lavage is rarely done. It is indicated only if a life-threatening amount has been ingested within the previous hour. It may be useful for drugs such as lithium and iron that are not absorbed by charcoal. Lavage should never be done if a petroleum distillate or a corrosive substance has been ingested.

11. ED Management Antidotes (if available) may be given for certain poisons, which either prevent the poison from working or reverse the effects of the poison. N-acetylcysteine Digoxin-specific antibody fragments Flumazenil injection Glucagon injection Naloxone injection Desferrioxamine mesilate Fomepizole General supportive measures include sedative medication if the person is agitated, ventilation if the person stops breathing, and antiepileptic medication if seizures develop.

12. ED Management Investigations in ED ? Bloods ( timing) ECG X-rays Urine / gastric contents