1. Principles of Managing the Poisoned or Overdosed Patient
Dr. Seyed Reza Mousavi
Assistant professor of MUMS

2. Most Commonly Reported Exposures in Adolescents and Adults, 2004
1. Analgesics 2. Sedatives, hypnotics, antipsychotics 3. Cleaning substances 4. Antidepressants 5. Bites and envenomation 6. Cardiovascular drugs 7. Alcohols 8. Pesticides 9. Food products, food poisoning 10. Cosmetics and personal care products

3. The common cause of acute poisoning

4. Get vital sign and tests H Head to toes examination I
ACLS guideline
Modified A
Airway
Antidote B
Breathing
Behavioral control C
Circulation
Coma antidotes D
Drug
Drug elimination E
Evaluation
Exposure F
Fluid management G
Get vital sign and tests H
Head to toes examination I
Initiate consultation
Advanced Cardiac Life Support (ACLS)

5. Assessment of the Poisoned Patient
Initial assessment involves obtaining:
A detailed history of the time and route of exposure
The substance or substances involved
The estimated amount of toxin taken
Prehospital or emergency department interventions

6. Toxidromes
A toxic syndrome, or “toxidrome,” is a set of characteristic signs and symptoms associated with a certain category of poisons.
The 4 most common toxidromes are narcotic, sympathomimetic, cholinergic, and anticholinergic.

7. Anticholinergic
Cholinergic
Sympathomimetic
Narcotic
Flushing
Salivation
Hypertension
Hypoventilation
Tachycardia
Lacrimation
Bradycardia
Mydriasis
Urination
Tremor
Decreased mental status
Dry skin
Defecation
Excitation
Hypotension
Urinary retention
Gastrointestinal upset
Seizures
Hypothermia
Psychosis
Emesis
Diaphoresis
Miosis
Bronchorrhea

8. Laboratory Evaluation
Serum glucose
Electrolyte levels
Blood gas analysis and anion gap calculation
Renal and hepatic function tests
Toxicologic screen tests

9. Toxicological Tests urine blood Qualitative (present/absent)
Quantitative (drug levels)
Drugs with a large volume of distribution
Drugs with a small volume of distribution
Salicylates
phenotiazine
TCA
Barbiturates
Benzodiazepines
Morphine, Tramadol, Methadone
Cannabis, PCP
Amphetamine, Methamphetamine, MDMA
Cocaine
Paraquat
Arsenic,Talium
Acetaminophen
Iron
Lithium
Digoxin
Theophylline
Phenobarbital
Methanol, Ethylene glycol
Lead
Carboxyhemoglobin
Cholinesterase RBC
PCP: Phencyclidine, angel dust

10. Other Diagnostic Studies
Abdominal X Ray:
Enteric-coated pills
Lead paint chips
Button batteries
The drug-filled condoms of “body packers.”
Iron tablet

11. ECG: cause Abnormal Normal (milliseconds) B blocker Ca channel blocker
Digoxin
PR prolongation
The PR Interval
Cyclic antidepressants, Quinidine, Phenothiazines, Amantadine, Diphenhydramine, Carbamazepine, Cocaine
A widening of the QRS complex
The QRS Complex
Cocaine,
Adrenergic agonists,
Ergot alkaloids
ST elevation
The ST Segment
QTc prolongation
>440
The QT Interval

12. Management of the Poisoned Patient
When caring for any poisoned patient, 3 basic patient goals should be kept in mind:
Limit absorption
Enhance elimination
Manage the complications

13. The extent to which any one of these goals can be accomplished depends on:
The substance involved
The route of contamination
The time since exposure
The amount of toxin taken

14. Limit Absorption
Administration of Ipecac Syrup
Gastric lavage
Activated charcoal(1 g/kg) + Sorbitol(1 ml/kg)
Whole bowel irrigation (500 mL mL /h)

15. Gastric lavage
Indications include:
1) symptomatic patients who present within 1 hour of ingestion of a toxic substance
2) symptomatic patients who have ingested an agent that slows gastrointestinal motility
3)patients who have ingested a sustained-release Medication
4) Patients who have ingested massive or life- threatening amounts of a substance

16. Activated charcoal
Ingested Substances Not Well Adsorbed by Activated Charcoal:
Heavy metals
Cyanide
Iron
Potassium
Hydrocarbons
Organic solvents
Caustic agents
Alcohols

17. Activated charcoal + sorbitol
Indications include:
1) Patients who have ingested a potentially toxic amount of a poison

18. whole bowel irrigation
This is done by administration of large doses of polyethylene glycol electrolyte solutions (500 mL mL /h) Indications include: 1) Iron bezoars 2) Sustained-release or Enteric-coated medications 3) Ingested packets of illicit drugs

19. Enhance Elimination Hemodialysis Multiple-dose activated chrcoal
Urinary Alkalinization

20. Hemodialysis

21. Hemodialysis Mechanism of action:
Toxicants diffuse through a semipermeable membrane down a concentration gradient from blood to dialysate.
This procedure eliminates those poisons with:
Low molecular weight(< 500 daltons)
Limited protein binding
Small volume of distribution(< 1 L/kg)

22. Hemodialysis…

23. Hemodialysis… Indications:
Ethanol, Methanol(>25 mg/dl), Ethylene glycol (>25 mg/dl)
Bromide
Chloral hydrate
Lithium(>4mEq/L), Potassium
Procainamide
Quinidine
Salicylate (>100 mg/dl)
Theophyline (>90 μg/ml)
Phenobarbital(>100 mg/dl)

24. Hemodialysis… Indications:
Severe intoxication with a substance normally eliminated by the kidney in the setting of renal failure.
Severe acidosis where the patient is unresponsive to therapy.

25. Hemodialysis… Adverse effects: Hypotension
Fluid & electrolyte disturbance
Seizure

26. Hemodialysis… Pitfalls:
Ethanol & Femopizole eliminated with hemodialysis.
Blood level of toxicants may rebound after termination of dialysis.
Hemodialysis cannot be performed in severely hypotensive patients.

27. Multiple-dose activated chrcoal

28. Multiple-dose activated chrcoal…
Mechanism of action:
Repeated administration of activated charcoal interrupting enterohepatic recirculation and gasterointestinal dialysis
The suggested dose is 0.5 g/kg every 2 to 4 hours, at least thrice.
Most effective for drugs that:
Undergo substantial enterohepatic recirculation
Small volume of distribution(< 1 L/kg)
Limited protein binding
Which are adsorbed by activated charcoal
Repeated administration of activated charcoal may enhance of the toxicant by adsorbing drug or metabolite that is secreted in bile(interrupting enterohepatic recirculation).
Toxicant may diffuse across the intestinal wall down the concentration gradiant from mesenteric vasculature into the gasterointestinal lumen, where it can adsorbed by activated charcoal(gasterointestinal dialysis)

29. Multiple-dose activated chrcoal…
Indications:
Theophilne
Phenobarbital
Phenytoin
Valporate
Carbamazepine
Quinine
Dapson
Cardiac glycosides

30. Urinary Alkalinization

31. Urinary Alkalinization…
Mechanism of action:
Sodium bicarbonate is administrated to raise the urine pH above 7.5
Drugs in which the parent compound is a weak acid undergo significant urinary excertion because ionized forms do not readily cross cell membranes.

32. Urinary Alkalinization…
Indications:
Urinary alkilazation should be used for mild to moderate intoxication only.
Salicylate
Phenobarbital
Methotroxate
Rhabdomyolysis

33. Urinary Alkalinization…
Contraindication:
Renal failure
Adverse effects:
Volume overload
Alkalosis
Hypokalemia
hypomagnesemia

34. Manage Complications
A decreasing level of consciousness Careful airway protection
Seizures Benzodiazepines
High temperature Benzodiazepines

35. Antidote Administration
Naloxone Opioid toxicity
Oxygen Carbon monoxide poisoning
N-acetylcysteine Acetaminophen
Dextrose Hypoglycemic drug
Ethanol Methanol & Ethylene glycol
Glucagon B-blocker
Amyl nitrate Cyanide
Atropine Organophosphate
BAL, Penicillamine, EDTA Heavy metal
Antivenins Snake bite & Scorpion sting

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