1. PWM Olly Indrajani 2012

2.  Given a large enough exposure, all substances have the potential to be poisons.  Poisoning occurs when exposure to a substance adversely affects the function of any system within an organism.  The setting of the poison exposure may be occupational, environmental, recreational, or medicinal.  Poisoning may result from varied portals of entry, including inhalation, insufflation, ingestion, cutaneous and mucous membrane exposure, and injection.

3.  Although the poisoned patient may present with varied symptoms and complaints, the chief presenting complaint or symptom may suggest a diagnosis  Recognition of grouped symptoms and findings consistent with a toxidrome can guide diagnosis and treatment in the poisoned patient.

6.  Oral ingestion was the commonest route of exposure (Fig 1)  Most exposures occurred at the patient’s own residence, and most patients (75%) were managed on-site with assistance from a poison information center and did not require an emergency department visit  Only 3% of patients required critical care.

8.  Largest number of deaths were:  analgesics  Antidepressants  sedative/hypnotics/antipsychotics  Stimulants  “street” drugs  cardiovascular drugs  alcohols

9.  Of all deaths:  5% increase compared to 1999  88% occurred in 20- to 99-year old individual  The mortality rate was higher in intentional rather than unintentional exposures (79% vs 10.5%, respectively).

14.  History and physical examination  Vital signs  Ocular findings  Mental status, behaviour and muscle tone  Poison control center consultation  Laboratory evaluation:  Anion gap  Osmolal gap  Oxygen saturation gap  Toxicology screening

15.  Although the history is important, it may be unreliable or incomplete  Consider that family members, friends, and pharmacists may have additional information

16.  In the absence of a classic presentation or toxidrome, separating patients with suspected poisoning into broad categories based on:  vital signs  ocular findings  mental status  muscle tone can help determine drug or toxin class

18.  Anticholinergic and sympathomimetic substances increase heart rate, BP, and temperature  In contrast organophosphates, opiates, barbiturates, β-blockers, benzodiazepines, alcohol, and clonidine cause hypothermia, bradycardia, and respiratory depression.

21.  Anticholinergics and sympathomimetics cause mydriasis  In contrast to anticholinergics overdose, the pupils remain somewhat light responsive in cocaine intoxication  Horizontal nystagmus is common in alcohol intoxication  Other drugs causing nystagmus are lithium, carbamazepine, solvents, meprobamate, quinine, and primidone  Phencyclidine and phenytoin cause horizontal, vertical, and rotary nystagmus

25.  Often required before confirmation of intoxication  With cervical spine precautions in place (unless trauma has been excluded), airway patency must be ensured in all cases  Endotracheal intubation is not always necessary when cough and gag reflexes are present and there is adequate spontaneous ventilation, but when there is concern regarding airway protection and clinical deterioration it is better to secure the airway  Intubation is indicated in acute respiratory failure

26.  Other specific indications include the need for high levels of supplemental oxygen in carbon monoxide poisoning and the need to protect the airway for gastric emptying  Endotracheal intubation decreases (but does not eliminate) the risk of aspiration  which is approximately 11% in the comatose patient with drug overdose)

27.  Depending on the intoxication, patients may present with hypotension or hypertension, bradyarrhythmias or tachyarrhythmias  The pathogenesis of hypotension varies and may include hypovolemia, myocardial depression, cardiac arrhythmias, and systemic vasodilation  Treatment should be individualized, but an initial strategy of rapid IV normal saline solution infusion is indicated in most instances  Vasopressors may be required for refractory hypotension.

28.  The vasopressor of choice depends on the type of intoxication  Hypertension occurs in the setting of sympathomimetic drugs, anticholinergics, ergot derivatives, phenylpropanolamine overdose, and withdrawal from nicotine, alcohol, and sedatives  Treatment of the hypertension depends on its chronicity and severity and the inciting agent  Hypertension-induced (reflex) bradycardia generally should not be treated.

29.  Thiamine (100 mg by vein) is administered to treat and/or avoid Wernicke-Korsakoff syndrome in comatose patients  Comatose patients should receive dextrose, 50 g IV  Naloxone rapidly reverses coma, respiratory depression, and hypotension induced by opioids. An initial dose of 0.2 to 0.4 mg is administered IV (or endotracheally).

30.  Skin decontamination requires removal of the toxin with nonabrasive soap and water  Contaminated clothing may serve as a reservoir for continued exposure and must be removed with caution and placed in plastic bags or other containers that are impervious to the toxin  Ocular decontamination may require prolonged periods of irrigation with normal saline solution

31.  Gastrointestinal (GI) decontamination refers to therapies that may decrease the amount of poison absorbed from the GI tract lumen.  The following methods of GI decontamination are available: A. Induced emesis B.Gastric emptying or Gastric lavage (GL) C. Activated charcoal combined with a cathartic D.Whole-bowel irrigation(WBI)

32.  Considered only in fully alert patients, and is virtually never indicated after hospital admission  Contraindications to its use include poisoning with corrosives, petroleum products, or antiemetics.

33.  Induced emesis utilizes syrup of ipecac to induce vomiting, theoretically emptying the stomach and reducing absorption of an ingested agent.  Syrup of ipecac induces vomiting by activation of both local and central emetic sensory receptors.  Induced emesis has largely been abandoned in clinical practice.  The most recent policy statements released by both the American Academy of Pediatrics(2003) and the American Association of Poison Control Centers (2005) discourage the use of syrup of ipecac in the out-of-hospital setting.

34.  GL through a 28F to 40F Ewald tube is similarly aimed at physically removing a toxin  Prior to inserting the Ewald tube, the mouth should be inspected for foreign material and equipment should be ready for suctioning  Large gastric tubes (37F to 40F) are less likely to enter the trachea than smaller nasogastric tubes, and are necessary to facilitate removal of gastric debris

35.  Nonintubated patients must be alert (and be expected to remain alert) and have adequate pharyngeal and laryngeal protective reflexes  In semicomatose patients, GL should be performed only after a cuffed endotracheal tube has been inserted.

36.  GL is performed by instilling 200-mL aliquots of warmed tap water until there is clearing of aspirated fluid  Stomach contents should be retained for analysis  Tap water may avoid unnecessary salt loading compared to normal saline solution  Neither irrigant has been shown to significantly alter blood cell or electrolyte concentrations  After clearing, the Ewald tube may be replaced by a nasogastric tube for subsequent intermittent suctioning and/or administration of activated charcoal.

37. does not recommend routine use of GL in the management of poisoning unless a patient has ingested a potentially life-threatening amount of a poison and the procedure can be undertaken within 60 min of ingestion

38. INDICATIONS  Ingestion of a substance with high toxic potential and: ■ Within 1 hour of ingestion ■ Ingested substance is not bound by activated charcoal or has no effective antidote. ■ Potential benefits outweigh risks. CONTRAINDICATIONS ■ Substance not meeting above indications ■ Spontaneous emesis ■ Diminished level of consciousness/unprotected airway reflexes (intubate first) ■ Ingestion of hydrocarbons or caustic agents ■ Foreign body ingestion ■ Patient is at high risk for esophageal or gastric injury (GI hemorrhage, recent surgery, etc.).

39. TECHNIQUE ■ Recommended tube size is 36–40 French for adults, 22–28 French for children. ■ Secure airway via intubation, if necessary. ■ Position patient in left-lateral decubitus position, with head lowered below level of feet. ■ Confirm tube placement following insertion. ■ Aspirate any available stomach contents. ■ Lavage with 250 mL (10–15 mL/kg in children) aliquots of warm water or saline. ■ Continue until fluid is clear and a minimum of 2L has been used. ■ Instill activated charcoal through same tube, if indicated. COMPLICATIONS ■ The primary risks are vomiting, aspiration, and esophageal injury or perforation.

40. INDICATIONS  Activated charcoal (AC) is ingested by the patient in order to adsorb poisons within the GI tract lumen. ■ Patient presents within 1 to 2 hours after ingestion. ■ Patient has ingested a potentially dangerous amount of a poison adsorbed by charcoal CONTRAINDICATIONS ■ Ingested substance is poorly adsorbed by AC (eg, iron, lithium, heavy metals,toxic alcohols). ■ Diminished level of consciousness/unprotected airway reflexes (AC can be given by naso- or orogastric tube following intubation) ■ Patient presents over 2 hours after ingestion. ■ Ingestion of caustic agents ■ Cases where endoscopy will be required

41. DOSE ■ The recommended dose of AC is a 10:1 ratio relative to the ingested poison(ie, ingestion of 1 g of poison requires 10 g of AC). Hence, the commonED practice of administering 50 to 100 g (1 g/kg) of AC to an overdose patient may be inadequate for larger ingestions. RISKS ■ The primary risk of single- dose AC is vomiting. ■ Constipation and diarrhea ■ Bowel obstruction does not occur from single- dose AC. ■ Repeated doses of cathartics given with charcoal may cause dehydration or electrolyte abnormalities. INDICATIONSCONTRAINDICATIONS

43. INDICATIONS ■ Removal of ingested drug packets (eg, body stuffers) ■ Large ingestion of a sustained-release drug ■ Potentially toxic ingestion that cannot be treated with activated charcoal (eg, lithium, lead, iron) CONTRAINDICATIONS ■ Diminished level of consciousness/unprotected airway reflexes (intubate first) ■ Decreased GI motility or bowel obstruction ■ Significant GI hemorrhage ■ Persistent emesis

44. DOSE  Polyethylene glycol (PEG) solution is administered at a rate of 1–2 L/hour.  This rate of administration usually requires a naso- or orogastric tube.  Endpoints for therapy are the appearance of clear rectal effluent or a total irrigation volume of 10 L. COMPLICATIONS  The primary risk associated with WBI is vomiting.  Patient discomfort: Bloating, cramping, and flatulence  WBI with balanced PEG solutions does not generally cause electrolyte abnormalities.

45. The goal of enhanced elimination is to increase the clearance of a poison from the body after it has been systemically absorbed. The following methods of enhanced elimination are available: A. Multiple-dose activated charcoal B. Urinary alkalinization C. Hemodialysis

47. Uses repeated doses of activated charcoal (every 2–4 hours) to increase poison clearance. MDAC exerts its effects through disruption of enterohepatic circulation or direct adsorption across the GI mucosal surface. RISKS The risks associated with MDAC are similar to those with AC; however,there is a greater risk of bowel obstruction with MDAC.

48. INDICATIONS Drugs that have enterohepatic circulation and can possibly be treated with MDAC include: ■ Phenobarbital ■ Carbamazepine (Tegretol) ■ Theophylline ■ Aspirin ■ Dapsone CONTRAINDICATION S MDAC is contraindicated in the same settings as AC.

49. Urinary alkalinization attempts to increase renal elimination of a drug by increasing urine pH. Urinary acidification to increase the clearance of weak bases is not recommended due to the risk of renal injury. RISKS Can precipitate hypokalemia and decrease ionized calcium levels

50. INDICATIONS ■ Urinary alkalinization only affects the clearance of drugs that are weak organic acids. ■ Aspirin (most common use for alkalinization) ■ Phenobarbital ■ Formic acid CONTRAINDICATION S ■ Poisoning with agents that are not weak organic acids and are not primarily cleared by the kidneys ■ Patients who cannot tolerate excess sodium/water loading (eg, CHF, renal failure)

51. Hemodialysis (HD) directly removes toxins from a patient’s plasma, using the same technology applied to renal failure. RISKS ■ HD requires central venous access, with all the usual accompanying risks (bleeding, pneumothorax, etc.). ■ HD must be used cautiously in patients that are hemodynamically unstable.

52. INDICATIONS For HD to be useful in a poisoned patient, the ingested poison should have the following characteristics: ■ Low molecular weight ■ Low plasma protein-binding ■ Small volume of distribution ■ Poor endogenous clearance ■ HD can also treat severe acidosis caused by a toxin, even if the toxin it self is not readily dialyzable. CONTRAINDICATION S ■ Toxins that do not satisfy the conditions listed above.

55.  Regional poison control center consultation is highly recommended in cases of suspected poisoning and to help guide management in confirmed cases  These centers provide 24-h emergency and up-to date technical information. They are staffed by nurses, pharmacists, pharmacologists, and physicians trained and certified in toxicology

56.  SIKer Nas BADAN POM RI Jln. Percetakan Negara No. 23 Jakarta 10560 Telp :021-4259945 Fax : 021-42889117 ( setiap hari kerja ) HP : 0813-10826879 ( di luar jam kerja ) Email SIKer: informasi@pom.go.id pusatiomker@cbn.net.idinformasi@pom.go.id pusatiomker@cbn.net.id

57.  SIKER DAERAH SURABAYA Jl. Karangmenjangan No.20 - Surabaya 60286 Telp : 031- 5048833 Fax : 031- 5048833 e-mail : ulpksby@sby.prima.net.id