1. ACUTE POISONING - MANAGEMENT Ayman M. Kamaly, MD Professor of Anesthesiology Ain Shams Universitykamaly3@hotmail.com

2. INTRODUCTION Acute poisoning is a common medical emergency in any country. The exact incidence of this problem in our country remains uncertain.

3. For effective management of an acutely poisoned victim, 5 steps are required: I. I. Resuscitation and initial stabilization II. II. Diagnosis of type of poison III. III. Nonspecific therapy IV. IV. Specific therapy V. V. Supportive care

4. I.Resuscitation and Initial Stabilization Initial management: ABCDs A Airway B Breathing C Circulation

5. Lessons from History... A young princess ate part of an apple given to her by a wicked witch

6. She was found comatose and unresponsive, as if in a deep sleep, Airway positioning and mouth to mouth ventilation were performed, and she was fully recovered.

7. Lessons: Best Antidote = Good Supportive Care Best Antidote = Good Supportive Care (Love’s first kiss) Airway Airway issues is a still the major cause of morbidity in toxicology as in other aspects of emergency.

8. Circulation = Plumbing Pump working? Pump working?  Inotrope Enough volume (is it primed)? Enough volume (is it primed)?  Hypovolemia?  IV fluid challenge Adequate resistance (no leaks)? Adequate resistance (no leaks)?  Inadequate vascular resistance?  Norepinephrine, phenylephrine

9. Initial management: ABCDs Treat problems as you find them!! A Airway, B Breathing, C Circulation, D Drugs, D Decontamination, D Detoxication, D Disability – GCS/AVPU and Pupils, DGLUCOSE. DON’T EVER FORGET GLUCOSE.

10. Don’t forget GLUCOSE A stroke is never a stroke until it’s had 50 of D50 “A stroke is never a stroke until it’s had 50 of D50” ??! Empiric administration of dextrose??! Check the blood sugar using a reliable bedside test ONLY80 Administer dextrose ONLY if the RBS is <80 mg/dl.

11. II.Diagnosis of Type of Toxin ? What? ? When? ? How much? (mg/kg) ? What else? ? Why? A) History Be a Detective

12. Collateral history – Paramedics – Family / friends – Notes !!! – Look in pockets – carefully!!! Look for Clues

14. B) Examination

16. Investigations All Patients – Glucose – Paracetamol & Salicylate As indicated – LFT – RFT, Lytes – Co-ag / INR – CK – ABG / VBG Urine toxicology screen

17. Investigations – Pinkish urine --->>> phenothiazine, – Chocolate colored --->>> met-hemoglobinaemia, – Oxalate crystals --->>> ethylene glycol, – Ketonuria (without metab. changes) --->>> Salicylate

18. Investigations Abdominal X-Ray (Radiopaque Toxins) – Chloral hydrate, iodides, – Heavy metals, iron, – Sustained release pills, – Solvents (Chloroform, CCL4)

19. Aim: Aim: – Reduce absorption – Reduce absorption of poison from the gut, – Increase excretion – Increase excretion of absorbed poison. III.Non-Specific Therapy

20. 1) Emesis Ipecac Syrup of Ipecac Amount of recovered toxin is highly variable ONEhour Effective within ONE hour Contraindicated: – Comatose/Convulsing – Ingested corrosive or hydrocarbon* A. Reducing absorption

21. 2) Gastric Lavage Lt Lat Position + head down to prevent aspiration & ↓ pushing lavage into duodenum. If unconscious  ETT 1-2hours Effective within 1-2 hours Contraindicated: – Strong corrosive or – Volatile hydrocarbons

22. 3) Activated Charcoal Small particle size & enormous surface area, Bind most drugs & toxins, Dose: 1 g/kg Exceptions: – Iron, Lithium, Metals, – Methanol, Ethanol, Hydrocarbons, – DDT

23. Activated Charcoal (cont.) More effective than Ipecac, Gastric Lavage First choice for most Over Doses

24. 4) Whole Bowel Irrigation Polyethylene glycol (2 L/hr) Isotonic soln. of Polyethylene glycol (2 L/hr) Not absorbed from intestine Not absorbed from intestine (  mechanical flush) Good for: – Iron, Lithium, – Sustained-release pills, – Foreign bodies, – Drug “packets”

25. 1)Forced Alkaline Diuresis Principle: Principle: Renal tubular epith is impermeable to ionized (+) molecules. If the urinary pH is changed so as to produce more of ionized form, it is trapped in the tubular fluid & is excreted in the urine. Useful in: – Salicylates, – Phenobarbital, – Lithium B. Increasing Excretion

26. Forced Alkaline Diuresis (Cont.) Method: Method: – D5% - ½ NS + bicarbonate 20-35 mEq/L to produce a urine output of 3-6 ml/kg/hr & a urine pH 7.5- 8.5. – Diuretics are often needed to maintain high urine flows. – KCl is added to prevent ↓K +, Contraindications: Contraindications: – Shock, – Hypotension, CHF, – Renal failure

27. 2) Multiple-Doses Activated Charcoal 1 g/kg/1-4 hrs To maintain intestinal toxin conc. near-zero (Gastrointestinal Dialysis). Indicated in toxins with : – Long ½ life, Digoxin, Phenobarbitals, Theophylline – Enterohepatic circulation ( Digoxin, Phenobarbitals, Theophylline), – Sustained-release preparations, – Massive toxin dose to be effectively adsorbed by single charcoal dose

28. 3) Dialysis (Peritoneal/Hemo) H 2 O soluble & Low MW For H 2 O soluble & Low MW compounds. Useful in: – Ethanol, Methanol, – Salicylates, – Theophylline, – Ethylene glycol, – Phenobarbital – Lithium

29. IV.Specific Therapy

30. Try to maintain functions of CNS, CVS, Renal, … Care for coma, seizures, hypotension, arrhythmias, hypoxia, … V.Supportive Therapy

31. Cutaneous, Ocular Exposure to toxins could be through routes other than ingestion (Cutaneous, Ocular) NOT available for every toxin Antidotes are NOT available for every toxin

32. However; when Antidote is Present the effect is Dramatic However; when Antidote is Present the effect is Dramatic

33. clean !! The 1 st sample of gastric lavage should be collected in “clean” container (Contamination !!). sealed Container should be sealed using a glue paper before sending for toxicological screening. Legal Aspects

34. After sealing Blood & Urine collection tubes and bottles, pt’s information should be written on the labels & affixed @ the juncture between the cap & the bottle. !! POLICE should be informed !!

35. Clinical Scenarios

36. Paracetamol Very common: 40% poisons admissions Often asymptomatic Can be lethal – 200-300 deaths/year 4 hours Check blood level at 4 hours Two treatment lines normal and high risk

37. Prescott Nomogram

38. Paracetamol metabolism Metabolised by: – Glucuronidation (60%), – Sulphation (35%) – Oxidation (10%) by Cytochrome p450 produces NAPQI (toxic  hepatocellular necrosis) glutathione NAPQI detoxified by conjugation with glutathione.

39. High Risk pt. Increased oxidation pathway (enzyme induction) – Chronic alcohol use – Drugs Reduces glutathione stores – Malnutrition – Eating disorders – Chronic liver disease

40. N-Acetylcysteine 8hours Most effective within 8 hours Precursor for glutathione production !! Can cause anaphylactoid reactions !! Consider starting before paracetamol result if: – Presenting > 8 hrs & > 150mg/kg taken – Other accompanying overdose.

41. Patient 1 20 year old woman who takes a handful of paracetamol tablets No drug history No alcohol use Fit and well Blood level is 80mg/L after 4 hrs.

42. No need to treat Patient is not high risk Level at 4 hours is below even the high risk line

43. Patient 2 70 year old man Takes 20 paracetamol 6 hours before presenting Alcoholic No drug history Blood level 100mg/L

44. Treat High risk patient Level above the high risk line

45. Patient 3 17 year old epileptic 25 tab Panadol 2 hours before attendance Taking carbamazepine Blood level at 4 hours is 120mg/L

46. Treat High risk patient Level above the high risk line

47. Patient 4 35 year old man who presents after taking 24 paracetamol over a period of 24 hours No drug history Fit and well Blood level 20mg/L

48. Treat Staggered overdoses are difficult Level is above the treat-line in context to time Need to monitor Liver function, clotting and renal function May need discussing with Liver Unit if abnormal

49. 268366742482331426840902

50. Some Famous Historic Poisonings

52. Thank You.. !!