1. MANAGEMENT OF POISONED PATIENTS
Dr. Shamil AL-Nuaimi
MBchB, MSc, PhD
Assistant Professor
Toxicology & pharmacology

2. ‘Grandfather of Toxicology’
Paracelsus ( )
‘Grandfather of Toxicology’
"All things are poison and nothing is without poison, only the dose permits something not to be poisonous."
“The dose makes the poison”
therapeutic
effect
toxic
increasing dose

3. General Information
All chemicals have potential to be poisons if given a large enough dose
Poisoning occurs when exposure to a substance adversely affects function of any organ system

4. Management lines: 1-Clinical Stabilization. 2-Clinical History.
3-Physical Examination.
4-Investigations:
-Laboratory
-Radiology
-ECG

5. 5-Prevention of further absorption: -Topical.
-Inhalation.
-Gastrointestinal.
6-Enhancement of Poison Elimination:
- Alkalinization of Urine.
-Dialysis.
7-Use of Specific Antidote.
8-Supportive Care.

6. Resuscitation First priorities are ABC’s
Vital sign including pulse and hypoglycemia must be corrected
Only in very rare incidences does administration of antidote precede stabilizing ABC’s and vital signs

7. ASSESSMENT
A health care facility’s systematic approach to the assessment of the poisoned or overdosed patient includes performing triage,
A) Obtaining the patient’s history,
B) Performing a physical examination, and
C) Conducting laboratory studies.

8. Initial management of the poisoned patient
If the patient’s life is in immediate danger, the goals of immediate treatment are patient stabilization and evaluation and management of airway, breathing, circulation and dextrose (ABCDs).

9. (Proper Positioning of the Patient)

10. (Ensure Patent Airway)

11. (Insert Airway Tube if needed)

12. History Need to obtain as much information as possible about exposure
Number of exposed persons, type of exposure, amount or dose, route
Patient's intent must be determined
Information from patient, witness helpful
Check for empty bottles or containers, smells or unusual containers

13. Physical Exam Undress patient completely for thorough examination
Check clothing for objects or substances
Assess general appearance of patient
Agitation, confusion, or obtundation
Exam skin for bruising, cyanosis, flushing
Exam eyes for pupils size, nystagmus, reactivity, dysconjugate gaze, increased lacrimaiton

14. Physical Exam Oropharynx for increase salivation or excessive dryness
CV: rhythm, rate, regularity
Lungs: bronchorrhea or wheezing
Abd: bowel sounds, tenderness or rigidity
Ext: fasiculations, tremor
Neuro: CN, reflexes, muscle tone coordination, cognition, ability to ambulate

15. (Blue line of chronic lead poisoning)

16. Toxidrome
A toxidrome is a group of signs and symptoms associated with overdose or exposure to a particular category of drugs and toxins.
Recognizing the presence of a toxidrome may help identify the toxin(s) or drug(s) to which the patent was exposed, and the crucial body systems that may be involved.

17. Toxic syndromes (toxidromes):
-Narcotic Toxic Syndrome.
-Cholinergic Toxic Syndrome.
-Sympathomimetic Toxic Syndrome.
Narcotic toxic syndrome:
Categorize the patient
Coma + Miosis (Pin Point Pupil) + Hypotension + Bradycardia + Low respiratory rate +Hypothermia

18. Pinpoint Pupils (Narcotics)
Normal Pupils

19. (Pinpoint Pupils)

20. Toxic syndromes (Toxidromes)

21. (Some Poisons have Special odor)

22. Toxicological Screen
In the acute care setting toxicological screen is very limited and does not contribute significantly
Toxicological screens may play a role in evaluation of children

23. List of Drugs
Commonly
Measured in
Hospital Settings

24. Decision to treat according to concentration:
-Lithium
-Digoxin
-Iron
-Phenobarbital
-Theophylline
-Aspirin
-Paracetamol

25. Action Plasma level: Ex.
A patient with a non toxic Digoxin concentration could have symptoms of toxicity.
Or a patient with elevated Digoxin level could have no symptoms of toxicity.
The rule is to :
Treat the patient and not the laboratory data!

26. Anion Gap & Osmolal Gap: 1-Anion Gap:
Help in the Differential diagnosis of poisoning.
Difference between Sodium vs. Chloride + Bicarbonate
Anion gap = Na Conce. mEq/L – (Cl+HCO3)
Normal Level is < 12

28. 2-Osmolal Gap: Difference between: Measured plasma osmolality Vs.
Calculated plasma osmolality
Cal =2 X Na+ (Glucose/18)mg/dl + BUN/2.8 mg/dl
Normal:
<10 mOsm at freezing point measurement.

30. C-Radiographic examination:
-Limited role.
-Lack of Radiopacity. (Undetectable by x ray).
Ferrous or Potassium salt could produce significant opacities.
Enteric coated formulations or restrained release could be opaque, Lead pica (in children)
-CXR.
-Plain X ray Of the Abdomen.
-CT Scan.

33. General- management I.provision of supportive care
II.prevention of poison absorption
III.enhancement of elimination of poison
IV.administration of antidotes

34. I. Supportive care Vital signs, mental status, and pupil size
cardiac monitoring, ECG
Protect airway
Intravenous access
cervical immobilization if suspect trauma
Rule out hypoglycaemia

35. II.Preventing absorption
Decontamination;
A) dermal,
B) ocular,
C) inhalation, and
D) ingestion exposures follow.

36. Gross Decontamination
Generally; achieved by; undressing patients and washing them thoroughly with copious amounts of water
Should occur outside of emergency department
All towels and clothing should be put into hazardous waste bags
Patient should initially be in isolated area

37. Eyes
Ocular exposure’s should be treated immediately by copious irrigation
Usually 2 L Normal Saline
Use of tetracaine may be needed
Alkalies require specific considerations
Lengthy continuous irrigation until pH < 8.0
Need ophthalmologic consult

38. GI Decontamination
Three general methods involve removing toxin from stomach via the mouth, binding it inside gut lumen, or mechanically flushing it through GI tract
Each method has benefits and risks

39. Gastric Emptying Emesis: achieved by using syrup of ipecac
Dosing: 15 ml for 1-12 years and 30 ml for adults; may repeat once if no emesis in 12 hr
90% vomit within 20 minutes of first dose and 97% vomit with second dose
Usually 3-5 episodes of emesis and resolve in two hours; if protracted emesis occurs consider toxin as etiology

40. Ipecac con’t
Contraindications: ingestions with potential for change in mental status, active or prior vomiting, caustic ingestion, toxin with more pulmonary than GI toxicity (hydrocarbons), ingestion of toxins with potential for seizures
Complications: aspiration, Mallory-Weiss tear, intractable vomiting
Use of Ipecac very limited

41. Gastric Emptying
Orogastric lavage: French tube used in adults and French tube in children.
Measure from chin to xiphoid and confirm with air insufflation
Lavage with room temperature water until it runs clear
Charcoal should be used before withdrawal of tube

42. Orogastric lavage con’t
Contraindications: large pills, nontoxic ingestion, non-life threatening, caustic ingestion, airway integrity not secured, more toxic to lung than GI
Complications: insertion into trachea, aspiration, esophageal or gastric perforation, decreased O2, inability to withdrawal tube
Drug removal range from 35-56%
Indicated if within 1 hr of ingestion

44. Toxin Adsorption in Gut
Activated Charcoal
Multiple-Dose Activated Charcoal
Cathartics
Whole-Bowel Irrigation

45. Activated Charcoal Most appropriate agent to decontaminate GI tract
Adsorbs toxin in gut lumen
Benefits include capability to decontaminate without requiring invasive procedures
Safety proven in adults and children
Dose 1g/kg

46. Activated Charcoal
Should not be given if esophageal or gastric perforation suspected or emergent endoscopy possibly needed
Complications rare; aspiration or impaction possible
Indications: any drug known to absorb it or after unknown ingestions by pt’s with protected airways

47. Multi-Dose Charcoal One dose usually sufficient
Indications for multi-dose activated charcoal:
ingestion of large doses, substances that form bezoars, slow release toxins, toxins that slow gut function, toxins with enterohepatic or enteroenteric circulation
Repeat dose is g/kg

48. Drugs/Toxins Well Adsorbed by Activated Charcoal
Drugs/Toxins Not Well Adsorbed
by Activated Charcoal
■ Acids
■ caustic alkalis
■ Alcohols
■ Iron
■ Lithium
■ Metals cyanide
mineral acids,
organic solvents,
Drugs/Toxins Well Adsorbed by Activated Charcoal
■ Acetaminophen
■ Amphetamines
■ Antihistamines
■ Aspirin
■ Barbiturates
■ Benzodiazepines
■ Beta blockers
■ Calcium channel blockers
■ Cocaine
■ Opioids
■ Phenytoin
■ Theophylline
■ Valproic acid

49. (Activated Charcoal)

50. Cathartics Osmotic cathartic usually given with activated charcoal
70% sorbitol (1 g/kg) or 10% magnesium citrate
Shown to decrease transit time of activated charcoal
No definitive clinical human data suggest that a cathartic limits toxins bioavailability or changes pt’s outcome

51. Whole-Bowel Irrigation
Common indications:
Heavy metals
Iron
Lithium
Sustained or delayed release formulations
Potential for bezoar formation
Dose 2L/h adults, children is ml/kg

52. Bowel Irrigation End point is clear rectal effluent
Contraindications: preceding diarrhea, absent bowel sounds or obstruction
Complications: bloating, cramping, rectal irritation
Antiemetic frequently required
Avoid phenergan (slows gut motility)

53. ΙΙΙ.Enhanced Elimination
Alkalinization
Acidification of urine
Forced diuresis
Hemodialysis/Hemoperfusion

54. Alkalinization
Beneficial in certain ingestions: phenobarbital, chlorpropamide, salicylates, methanol
Alkalinization achieved by IV dose of bicarbonate at 1-2 mEq/kg, followed by intermittent boluses or continuous bicarbonate drip for urine pH
Profound hypokalemia may result, must aggressively replace

55. Acidification of Urine
Can somewhat enhance elimination of amphetamines, phencyclidine, and some other drugs.

56. Forced Diuresis Never been shown effective for any ingestion
Technique should not be used

57. Hemodialysis/Hemoperfusion
Dialysis reserved for specific toxins: salicylates, methanol, ethylene glycol, lithium, theophylline, amanita (mushrooms)
Benefits: removal of toxins already absorbed by gut, ability to remove parent compound and active metabolite

58. Dialysis con’t
Less effective when toxin has large volume of distribution (>1 L/kg), has large molecular weight, or highly protein bound
Dialysis rarely contraindicated
No dialysis for small children, exchange transfusion should be considered

59. Haemodialysis is effective to clear some drugs some drugs

60. Hemoperfusion
Used for decontamination of patient's systemic circulation
Involves placing a filter filled with activated charcoal into dialysis circuit
Alleviates constraints of protein binding and molecular size
Toxins must be well absorbed by charcoal and have small volume of distribution

61. IV. Antidotes (Antitoxins) and Antagonists),
In pharmacology, an antagonist is a substance that counteracts the action of another drug.
Although the general public often believes there is an antidote for every drug or toxin, the opposite is closer to the truth.
There are, in fact, very few antidotes.

62. Question’s 1) The first priority in resuscitation of a poisoned pt is
a) antidote
b) vital signs
c) ABC’s
d) correction of hypoglycemia

63. Question’s
2) In the physical exam all of the following are correct except
a) undress pt completely
b) assess general appearance
c) complete neuro exam
d) check clothes for objects
e) all the above are correct

64. Question’s 3) Gross decontamination should occur a) in the field
b) outside ED
c) in triage
d) in pt’s room

65. Question’s
4) Which of the following is a method of removing a toxin from the stomach
a) via the mouth (emesis)
b) binding in the gut (charcoal)
c) mechanically flushing through GI tract
d) all of the following are correct

66. Question’s 5) All of the following can be dialyzed except
a) phenobarbital
b) salicylates
c) methanol
d) lithium
e) ethylene glycol