1. Conscious and alert Patient
1) Establish and stabilize adequate vital signs of Patient
(CV, Respiration, CNS)
2) Clinical evaluation
(Lab test, blood chemistry, liver enzymes)
3) Determine the cause for the symptoms
(body temperature, pupil size, breath)
4) Removal of unabsorbed or the remaining portion of poison from the site of exposure

2. 4) Removal of unabsorbed portion of poison
Depends on the route of exposure & type of Poison:
Injection, inhalation, dermal, eye, PO (ingestion)
Gastric emptying
Emesis and agents-induced emesis
Gastric Lavage
Adsorption of poison
Cathartics
Neutralization
Antidotes (dispositional, pharmacological & physiological antidotes)
Enhance elimination (Diuresis, changing urine pH)
Artificial/Mechanical removal

3. 4) Removal of poison/toxic agent from the body
Immediate action to minimize further toxicity:
Bitten/Injection Put Band
Inhalation Take pt. away from that environment, place pt. in fresh air
Skin exposure  Remove cloths, use extensive amount of water or soap & water, debridement, Don’t use solvents
Eye Exposure  Wash with water (eye irrigation), OR NSS, no eye drops or solution,
use 2% Floriseen to detect corneal damage
If damaged cornea – stain is present
If not damaged cornea – will not stain
Don’t use this to protect/detect type of poison

4. 4) Removal of poison/toxic agent from the body
Treatment of acute poisoning must be prompt & very rapid. 2 goals for such treatment:
1) is to keep the concentration of the toxic agent at the target tissue as low as possible by
a) preventing absorption
b) enhance elimination
2) combat the pharmacological/toxicological effect at the injured organ/tissue

5. 4) Removal of poison/toxic agent from the body
Oral Exposure  Dilution Poison (Dilute w/ plain water or milk)
Give lots of water
↓ local irritant effect
Delays absorption
Milk
More preferred because it coats stomach
It retards absorption of poison, due to adsorption onto protein
Contains proteins & is a demulcent (soothing) to mucous membrane
• Don’t dilute corrosives unless the child is in act of swallowing
Don’t dilute corrosives if time has passed because more damage will be done (patient may gag)
• Nothing should be given by mouth because esophagus is already damaged (Saponification of the fat cells), some fluid may leaks to the lung
• Also corrosives liquefy esophagus

6. 4) Removal of poison/toxic agent from the body
• Gastric Emptying
* Emesis  indicated after poisoning by PO ingestion of most chemicals, but has some limitation
* Should be considered if the toxic agent ingested contains dangerous compound (pesticide)
* Used more in children Vomit easily no tube in stomach
* Warm water & warm water + mustard induce vomiting
* Can be induced mechanically (stroking the posterior Pharynx)- not very effective

7. 4) Removal of poison/toxic agent from the body (Emesis)
Emesis can cause:
•  gastric perforation & necrosis of esophagus
• Pneumonia: ingestion of petroleum products e.g., kerosene, gasoline or furniture polish may cause chemical pneumonitis
• Stroke - usually in adults (For this reason emesis is risky & adsorption is prefer)
• Absolute contraindication to
• Corrosives (strong acid/base solution, e.g. drain solution)
• Pt. ingested large dose of CNS stimulus, emesis may precipitate convulsion
• Because emesis involved many muscle, Seizure may be triggered
• Volatile substance (if poison has potential to produce vapor & gas). (Vapors toxic to lungs)

8. 4) Removal of poison/toxic agent from the body (Agent-induced emesis)
2 types of agents:
Ipecac syrup: (Local, direct action on GI & central effects, CTZ)
Apomorphin: Centrally Acting – stimulation of Chemoreceptor Trigger Zone (CTZ)
Ipecac syrup (a mixture of dried plant + glycerol + syrup)
Contains emetine, causing toxicity to heart (at high dose)
Has been used for amoeba infection
At low dose – NO SIDE EFFECT, 65% return
Very effective in Phenothiazines (antiematic) over dose
DO NOT USE CHARCOAL WITH IPECAC   ITS EFFECTIVENES
Do not use for wt loss  cardiomyopathy, ventricular fibrillation
• Syrup (30 ml Adults, 15 ml children > 1yr., 10 ml children < 1 yr.)
• Works within min
• Another dose can be administered if vomiting does not occurs

9. 4) Removal of poison/toxic agent from the body (Agent-induced emesis)
2) Apomorphine (centrally acting-D2 agonist)
• Derivative of Morphine – Narcotic
• Strong emetic effect
• Unstable in solution, prepared immediately before use
80% Return
Not effective PO, given by SQ advantage over Ipecac if the Pt is uncooperative (6 mg/Kg, adult & 0.06mg/kg children),
-Produce
• Respiratory depression (should not be used with CNS depressants overdose) • Prolong effect – stay long period of time – vomiting
• Dehydration
• • Every time when you use Apomorphin you should have Naloxone on Hand

10. 4) Removal of poison/toxic agent from the body (Gastric Emptying)
• Gastric Lavage: (Mechanical way to empty stomach = Physically taking or pumping out)
- Adults:
Use a catheter that is introduced into stomach through the nasal/oral cavity
French catheter – comes in different size – use depending upon age
Catheter should be larger enough so it does not enter trachea (Trachea has cartilaginous rings & is rather narrow)
Position the Pt correctly
Usually aspirate before introducing cleansing fluid of Normal Saline Solution (NSS) ml (safer than water specially with children)
Then ml of washing fluid (NSS)
Repeat process until return is clear & free of poison (10-12 washings)
Total volume between 2-4 L
When lavage is complete, stomach may be left empty, or give antidote

11. 4) Removal of poison/toxic agent from the body (Gastric Emptying)
Gastric emptying (should be done ASAP), will be ineffective 4-6 hrs after indigestion of toxin except:
When poison caused a delay in gastric emptying (e.g., TCA)
If hepatic recirculation of poison is occurring
Drug will remain in GI
Absolute contraindication:
Corrosives
Esophagus is already damaged & you don’t want to introduce catheter
In the presence of Convulsion/seizure
Relative contraindication
Unconsciousness/coma/Gage Reflex lost
Volatility
Before gastric lavage, Respiratory tract can be protected by intubation’s before introducing catheter

12. 4) Removal of poison/toxic agent from the body (Adsorption of Poison)
No/Less risky than emesis
Give same or batter effect
Adsorbents – for whatever gastric contents are left over after either emesis or lavage
Instill slurry of activated charcoal (25%)
Activated fine /pure highly adsorptive powder,
administered in the form of Suspension (50g in 8 oz water) with a tube
Adsorbs a majority of poison & drugs, poison can stick to charcoal
Total doses: g for adults & 20 – 30g for children (2-4 hrs)

13. 4) Removal of poison/toxic agent from the body (Adsorption of Poison)
 Fuller’s Earth or Bentonite
Used for poisoning with the pesticides (Paraquat or Diquat)
Hit & Run poison
Delayed toxic
• More powerful than charcoal
• Smaller particle w/ bigger surface area

14. 4) Removal of poison/toxic agent from the body (Adsorption of Poison)
Universal Antidote:
Thought to be an adsorbent
Consist of 2 parts (burned toast and not activated charcoal) + I part of Mg oxide + 1 part Tannic Acid (strong tea)
Mg oxide – Neutralizes
Tannic Acid – Precipitant for nitrogenous substances like cocaine & Heroine
Burned toast – Adsorbent
Evidence indicated that this mix is less effective than plain charcoal (Activated)

15. Removal of poison/toxic agent from the body Cathartics (laxatives):
Used to minimize absorption by expel poison rapidly through GI
 Agents that cause elimination through feces
 Indicated after ingestion of coated tablets and the time after ingestion is hour
 Use only saline or salt cathartics, such as (most common)
 Magnesium Sulfate (MgSO4) & Magnesium Phosphate (MgPO4)
 Sodium Sulfate (NaSO4) & Sodium Phosphate (NaPO4)
 Never use oil cathartics such as castor oil because it absorb poison
 Sorbitol
Used in children, acts promptly and have minimal toxicity
Should not used too much, it can cause dehydration due to diarrhea
 Whole gut (Bowl) lavage, used in the case of:
 extended release tablet
 body stuffers (any unspecified substance)
By polyethylene Glycol – Colyte®, Golytely®

16. Removal of poison/toxic agent from the body (Neutralization)
Not acid/base Neutralizers and Not universal
 Prevent absorption of poisons after we have a clear identification of poison
 Will not remove local irritant effect but will prevent systemic effects
 Fe 2+ supplements – ferrous state
Ferrous Carbonate is not absorbed
Use NaHCO3 to form Ferrous Carbonate – not absorbed will also prevent acidosis
 Mercury poisoning – very toxic
Higher oxidation state is absorbed Hg++
Hg+ is not absorbed
Reducing agents should be used to reduce Hg++, such as Sodium Formaldehyde will reduce the Hg++ → Hg+

17. Removal of poison/toxic agent from the body (Neutralization)
 When we neutralize weak acids, we use neutralizers that don’t generate CO2 (e.g., Al Hydroxide, KMnO4 (1:1000-1:10,000)
 Alkaloids are easily oxidized – Nitrogenous Poison
 Starch can be used to prevent absorption of poisons, (prevents absorption of Iodine because it bind to it & neutralizes it)
 When mixed, Iodine + starch produce BLUE color
 Starch –Very dilute solution of Potassium permanganate (KMnO4) to neutralize Alkaloids (1:1000 OR 1:10,000)
 Can’t neutralize Strong Acid/Alkalis
 Only diluted solution can be used for neutralization of  Very weak alkalis – lemon juice
 Very weak base – MgO/ Al hydroxide