Poisoning and management

8/9/2019 Poisoning and management

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GENERAL PRINCIPLES

OF POISOING


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• Poisoning is contact with a substance that results intoxicity Sy!"to!s #ary$ but certain co!!on syn%ro!es!ay suggest "articular classes o& "oisons

• Treatment is supportive for most poisonings; specificantidotes are necessary for a few.


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' Acute "oisoning ( excessi#e single %ose$ or se#erals!aller %oses o& a "oison ta)en o#er a short inter#al o&ti!e

* Chronic "oisoning ( s!aller %oses o#er a "erio% o&ti!e$ resulting in gra%ual worsening eg Arsenic $Phos"horus $ Anti!ony etc


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' +o!ici%al ( )illing o& a hu!an being by another hu!anbeing by a%!inistering "oisonous substance %eliberately

* Suici%al ( when a "erson a%!inister "oison hi!sel& to en%his, her li&e

- Acci%ental ( Eg +ousehol% "oisons. nail "olish re!o#er $acetone$ %e"ilatories. /ariu! sul"hi%e

0 Occu"ational ( in "ro&essional wor)ers Eg insectici%es$noxious &u!es


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Corrosi#esa1 Strong aci%s. + * SO 0 $ +NO - $ +Cl

b1 Strong al)alis. +y%rates 2 Carbonates o& Na 3 $ 4 3 2 N+ -

c1 5etallic salts ( 6inc chlori%e$ Ferric chlori%e$ 4CN $Sil#er nitrate$ Co""er sul"hate


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Irritantsa Inorganic ( i1 Non!etallic ( Phos"horus$ Io%ine

Chlorine

ii1 5etallic ( Arsenic$ Anti!ony$ Lea% iii1 5echanical ( Pow%ere% glass$ hair

b Organic

7egetable ( Abrus "recatorius$ Castor$ Croton$Calotro"is Ani!al ( Sna)e 2 insect #eno!$ Canthari%es


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Syste!ica1 Cerebral

CNS %e"ressants ( Alcohol$ o"ioi%s$ hy"notics$ general anestheticsCNS sti!ulants ( A!"heta!ines$ Ca&&eine

8eliriant ( 8atura$ Cannabis$ Cocaine

b1 S"inal ( Nux #o!icac1 Peri"heral ( Coniu!$ Curare%1Car%io#ascular . Aconite$ 9uinine$ +CNe1 As"hyxiants ( CO$ CO * $ +*S

01 5iscellaneous ( Foo% "oisoning$ /otulis!


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• Following con%itions shoul% arouse sus"icion o& "oisoning:

Su%%en a""earance o& sy!"to!s a&ter &oo% or %rin) in an

otherwise healthy "erson

Sy!"to!s ( uni&or! in character$ ra"i%ity

Su%%en onset %eliriu!$ "aralysis$ cyanosis$ colla"se etc


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Fun%a!entals o& "oisoning

!anage!ent' Initial resuscitation an% stabili;ation

* Re!o#al o& toxin &ro! the bo%y

- Pre#ention o& &urther "oison absor"tion

0 Enhance!ent o& "oison eli!ination

< A%!inistration o& anti%ote

= Su""orti#e treat!ent

> Pre#ention o& re . ex"osure


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Fun%a!entals o& "oisoning !anage!ent

Initial resuscitation an% stabili;ation (I,7 access ( I,7 &lui%sEn%o tracheal intubation . to "re#ent as"iration

?nconscious "atients

Res"iratory %e"ression, &ailureCon#ulsions. gi#e anticon#ulsants

Re!o#al o& toxin &ro! the bo%y

Co"ious &lushing with water or saline o& the bo%y inclu%ing s)in&ol%s$ hair

Inhalational ex"osureFresh air or oxygen inhalation


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Pre#ention o& "oison absor"tion' Gastric la#age

?se&ul i& %one be&ore - hr o& ingestion o& a "oison

8one with water @ exce"t in&ants ( NS1$ ':


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• Co!"lications

a As"iration @co!!on1

b Eso"hageal , gastric "er&oration

c ube !is"lace!ent in the trachea


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Contrain%icationsa Corrosi#e "oisoning ( GE "er&oration

b Petroleu! %istillate ingestants. As"iration "neu!onia

c Co!"ro!ise% un"rotecte% airway

% Eso"hageal , gastric "athology

e Recent eso"hageal , gastric surgery


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La#age %ecreases absor"tion by an a#erageo& :.


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* I"ecac Syru" in%uce% e!esis?se% &or ho!e !anage!ent o& "atients with :. Acci%ental ingestions

Reliable history5il% "re%icte% toxicity

A!inistere% orally

8ose :. - !l ( a%ults'< !l ( chil%ren' !l ( s!all in&ants


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5OA I"ecac irritates the sto!ach 2 sti!ulates C 6 center7o!iting occurs about * !in a&ter a%!inistration

8ose !ay be re"eate% i& #o!iting %oes not occur

Contrain%icationsa Gastric , eso"hageal tears or "er&orationb Corrosi#esc CNS %e"ression or sei;ures% Ra"i%ly acting CNS "oisons @ cyani%e$ strychnine$

ca!"hor 1


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- Acti#ate% charcoal

Greater e&&icacy

Less in#asi#eGi#en orally as a sus"ension @ in water 1 or through NGtube8ose ( ' g,)g bo%y wt

Charcoal a%sorbs ingeste% "oisons within gut lu!enallowing charcoal. toxin co!"lex to be e#acuate% withstool or re!o#e% by in%uce% e!esis , la#age


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/arbiturate Poisoning• /arbiturates are a lea%ing cause o& acute "oisoning

because o& their rea%y a#ailability

•he "oisoning is characteri;e% by stu"or or co!a$are&lexia an% in late cases$ se#ere res"iratory %e"ression

an% car%io#ascular insu&&iciency

•It is a "otentially &atal &or! o& "oisoning with o#erall!ortality o& about >B


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• /arbiturates are che!ical %eri#ati#es o& barbituric aci%an% %e"en%ing on their %uration o& action$ they can beclassi&ie% as long acting @ = hours1$ inter!e%iate acting@-.= hours1 an% short acting @ - hours1

• All barbiturates bin% to Ga!!a a!ino butyric aci%rece"tors an% "rolong the o"ening o& chlori%e channels$thus inhibiting excitable cells o& the central ner#oussyste!

• /arbiturates are &reHuently in#ol#e% in o#er %osage


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• 8eath occurs &ro! res"iratory &ailure$ se#ere hy"otension$#aso!otor &ailure$ non car%iogenic "ul!onary oe%e!a$hy"other!ia @which aggra#ates shoc)1 or oliguria withrenal &ailure

• /arbiturate "oisoning is characteri;e% by "rogressi#eCNS %e"ression cul!inating in "aralysis o& brainste! an%!e%ulla In early stages$ "atient is con&use% an% lethargicwith "oor coor%ination$ ataxia an% %ysarthria


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5anage!ent o& barbiturate

"oisoning1. Cardiorespiratory support

2. Measures to prevent absorption:

a. Gastric lavage : I& no !ore than *.0 hours ha#e "asse%since ingestion o& the barbiturate$ gastric la#age is %oneb. Activated charcoal : Is an inert non toxic a%sorbent

which bin%s high !olecular weight co!"oun%s %ue tointer!olecular attractions 'g,4g is a%!inistere% throughnasogastric tube Cathartic li)e !agnesiu! sul"hate can beuse% along with it &or &urther re!o#al o& barbiturates buthy"er!agnese!ia can occur


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3. Measures for removal of barbiturates:

•Fre uent doses of activated charcoal

•Forced diuresis !ith al"alinisation of urine : in longaction barbiturates which are largely excrete% by the )i%ney

•#aemodialysis and haemoperfusion

•$upportive care


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O"ioi% "oisoningO"ioi%s are a class o& %rugs that ha#e actions si!ilar too"iu! O"ioi%s act on the brain an% "ro%uce a nu!ber o&e&&ects he users also ex"erience the &ollowing e&&ects:

•8rowsiness: %ue to %e"ressant e&&ect on the brain

•Su""ression o& cough: %ue to the e&&ect o& o"ioi%s on thebrain cough centre

•Constriction o& the "u"ils in the eyes

•Consti"ation: %ue to the e&&ect o& o"ioi%s on the gut syste!


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• O"ioi% o#er%ose %oes not ha""en i!!e%iately$ it sets inusually o#er the course o& ' hour to J !inutesK as the"erson slowly &ails to res"on% an% breathing beco!es!ore %i&&icult


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• Following - sy!"to!s,signs con&ir!s that the in%i#i%ualhas o#er%ose% on o"ioi%s:

' Co!a

* Pin"oint "u"ils: Constriction o& the "u"ils$ in which the"u"ils beco!e s!aller in si;e than nor!al

- Res"iratory %e"ression: 8i&&iculty in breathing$ in whichthe rate o& res"iration @less than '*,!inute1 in o#er%ose


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arning Signs o& O"ioi% o#er%ose• Can t be wo)en u" by noise or "ain

• /lue li"s an% &ingernails %ue to lac) o& oxygen

• Slow breathing @less than ' breath e#ery < secon%s1

• Gas"ing$ gurgling$ or snoring

• Cho)ing soun%s

• Passing out$ 7o!iting

• Pale &ace$ ire% bo%y


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• Naloxone 8ose

• 0 ( * !g "er %ose he %ose can be re"eate%$ i&

necessary$ at * ( - !in inter#als

• I& there is no res"onse a&ter a total o& ' !g o& Naloxone

has been gi#en$ consi%er the "ossibility that the "erson!ay be su&&ering &ro! con%itions other than o"ioi%o#er%ose


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Organo"hos"horus "oisoning• Organo"hos"horous @OP1 co!"oun%s ha#e been

e!"loye% as "estici%es$ "etroleu! a%%iti#es an% che!icalwar&are ner#e agents

• Organo"hos"hates wor) by inhibiting acetylcholinestersethereby lea%ing to an accu!ulation o& acetylcholine an%o#er sti!ulation o& !uscarinic an% nicotinic rece"tors

• Co!!on organo"hos"hate "estici%es inclu%e !alathion$%ichlor#os$ trichlor&on$ an% &enitrothion,!alathion


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Clinical Fin%ings• Signs an% sy!"to!s can be %i#i%e% into !uscarinic$

nicotinic an% central ner#ous syste! e&&ects

•Muscarinic effects @o#er sti!ulation acetylcholinerece"tors o& the "arasy!"athetic syste!1:/ronchos"as!$ bronchorrhoea$ sali#ation$ urination$%iarrhoea$ hy"otension$ bra%ycar%ia an% #o!iting

• %icotinic effects @o#er sti!ulation acetylcholinerece"tors o& the sy!"athetic syste!1: +y"ertension$!y%riais$ tachycar%ia an% sweating


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Clinical Fin%ings• Nicotinic e&&ects at neuro!uscular Munction: Con&usion$

agitation$ co!a$ res"iratory &ailure

•Central ner#ous syste! e&&ects: 5uscle wea)ness$&asciculations an% "aralysis @sei;ures !ay occursecon%ary to hy"oxia or %ue to ner#e agents1


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$igns $ymptoms

5il% 8i;;iness$ anxiety$ hea%ache$tightness o& breath

Rhinorrhea$ sweating$ sali#ation$nausea$ wea)ness$ coughing$lacri!ation$ !il% bra%ycar%ia an%hy"otension

5o%erate Restlessness$ con&usion$%ys"noea$ %isorientation$ab%o!inal "ain$ #o!iting$

%iarrhoea$ %rowsiness

Pallor$ !iosis,!y%riasis$bra%ycar%ia,tachycar%ia$hy"otension,hy"ertension$

!uscle twitching$ &asciculation$res"iratory %e"ression$bronchorrhea$ bronchos"as!$loss o& consciousness


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$ymptoms

Se#ere Con#ulsions$ res"iratory &ailure$"ul!onary e%e!a$ &lacci% "aralysis$in#oluntary !icturation,%e&ecationcyanosis$ %ee" co!a

Fatal Co!a$ con#ulsions$ hy"ersecretionsan% a"nea within a &ew !inute a&ter ex"osure


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5anage!ent• Ensure a%eHuate airways "rotection

• Ensure a%eHuate oxygenation ( gi#e high &low oxygen #ia a&ace !as)

• Ensure a%eHuate circulation ( insert cannula an% gi#e i # &lui%s

• Gi#e atro"ine until "atient is &ully atro"inise% Start with


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5anage!ent• 5onitor "atient o#er '< !inutes I& the %ose o& atro"ine is

too low cholinergic &eatures will reoccur I& the %ose o&atro"ine is too high agitation$ "yrexia$ re%uce% bowelsoun%s an% urinary retention will occur ( then re%uceatro"ine in&usion

• I& "atient "resents within *0 hours o& ex"osure an% hassigns o& !o%erate to se#ere organo"hos"hate "oisoninggi#e obido&ime 2'(mg ivi ( re"eat a&ter * hours


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5anage!ent• 5onitor "atient &or secretions$ "ulse rate @use car%iac

!onitor1$ "u"il si;e$ bloo% "ressure$ oxygen saturationan% "ulse

• he ai! o& treat!ent is to excessi#e oral an% res"iratorysecretions an% "re#ent res"iratory &ailure A%eHuateatro"inisation is in%icate% by re%uction o& secretions

• Control &its with boluses o& %ia;e"a! ( gi#e ' !g i #8ia;e"a! is also use&ul &or %eliriu! an% agitation in these"atients


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Atro"ine Poisoning•

Clinical !ani&estations are cause% by CNS e&&ects$"eri"heral ner#ous syste! e&&ects$ or both:

• Flushing

• 8ry s)in an% !ucous !e!branes

• 8ilate% "u"il with loss o& acco!!o%ation

• Altere% !ental status @A5S1

• Fe#er$ %ryness o& !outh$


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A%%itional !ani&estations inclu%e the&ollowing

• Sinus tachycar%ia

• 8ecrease% bowel soun%s

• Functional ileus

• ?rinary retention

• +y"ertension

• re!ulousness$ 5yoclonic Mer)ing


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• he anti%ote &or anticholinergic toxicity is "hysostig!ine

• I& !ar)e% excite!ent "resent gi#e %ia;e"a!

• Arti&icial res"iration


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+ea#y 5etals

•large a!ounts o& any o& hea#y !etals cause acute orchronic toxicity @"oisoning1

•+ea#y !etal toxicity can result in %a!age% or re%uce%!ental an% central ner#ous &unction$ lower energy le#els$an% %a!age to bloo% co!"osition$ lungs$ )i%neys$ li#er$an% other #ital organs


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• Long.ter! ex"osure !ay result in slowly "rogressing"hysical$ !uscular$ an% neurological %egenerati#e"rocesses that !i!ic Al;hei!er s %isease$Par)inson s%isease$ !uscular %ystro"hy$ an% !ulti"le sclerosis


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• Acute oxicity: cra!"ing$ nausea$ an% #o!itingK "ainKsweatingK hea%achesK %i&&iculty breathingK i!"aire%cogniti#e$ !otor$ an% language s)illsK !aniaK an%con#ulsions

• Chronic oxicity: @i!"aire% cogniti#e$ !otor$ an% languages)illsK learning %i&&icultiesK ner#ousness an% e!otionalinstabilityK an% inso!nia$ nausea$ lethargy$ an% &eeling ill


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Chelators• Chelation is the &or!ation o& a !etal ion co!"lex in which

the !etal ion is associate% with a charge% or uncharge%electron %onor re&erre% to as a ligan% It usually attachesor coor%inates using one$ two or !ore electron "air %onor

ato!s @oxygen$ nitrogen an% sul&ur1


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ReHuire!ents &or the i%eal chelating agent

• he co!"oun% shoul% be soluble in aHueous !e%iu!

• he chelating agent shoul% be stable in the circulation

• I& it is gi#en orally$ it shoul% be absorbe% by the GI tract

an% it shoul% be cleare% by the )i%ney

• he co!"oun% shoul% be acti#e at "hysiological "+


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ReHuire!ents &or the i%eal chelating agent

• he co!"oun%s shoul% chelate only the s"eci&ic !etals

• he chelator itsel& shoul% not be toxic

• he chelator.!etal co!"lex shoul% be less toxic than the!etal alone


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5E ALS AN8 8R?GS @C+ELA ORS1O CONSI8ER

Lea% Ethylene%ia!ine.tetraacetic aci% @E8 A1*$-.%i!erca"tosuccinic Aci% @Succi!er1*$-.%i!erca"to"ro"anol @/AL$ 8i!erca"rol1Penicilla!ine

Ca%!iu! Ethylene%ia!ine.tetraacetic Aci% @E8 A1

5ercury N.acetyl."enicilla!ine @NAP1Penicilla!ine

*$-.%i!erca"to"ro"anol @/AL$ 8i!erca"rol1*$-.%i!erca"tosuccinic Aci% @Succi!er1

Arsenic N.acetyl."enicilla!ine @NAP1

Iron 8e&eroxa!ine


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Arsenic

• Acute arsenic "oisoning sy!"to!s are sore throat &ro!breathing$ re% s)in at contact "oint$ or se#ere ab%o!inal"ain$ #o!iting$ an% %iarrheal$ o&ten within ' hour a&teringestion

• Other sy!"to!s are anorexia$ &e#er$ !ucosal irritation$an% arrhyth!ia

• Car%io#ascular changes are o&ten subtle in the earlystages but can "rogress to car%io#ascular colla"se


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Arsenic• Progressi#e "eri"heral an% central ner#ous changes$ such

as sensory changes$ nu!bness an% tingling$ an% !uscleten%erness

• )urning sensation *+needles and pins+, in hands andfeet


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5echanis!s o& toxicity

• 5e!branes: "rotein %a!age o& ca"illary en%otheliu!increase% #ascular "er!eability lea%ing to #aso%ilationan% #ascular colla"se

• Inhibition o& sul&hy%ryl grou" containing en;y!es

• Inhibition o& anaerobic an% oxi%ati#e "hos"horylation@substitutes &or inorganic "hos"hate in synthesis o& high.energy "hos"hates1


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Sy!"to!s• Acute . %a!age to !ucosa$ sloughing$ hy"o#ole!ic

shoc)$ &e#er$ GI %isco!&ort,"ain$ anorexia

• Chronic . wea)ness$ GI$ he"ato!egaly @Maun%ice cirrhosis1$ !elanises$ arrhyth!ias$ "eri"heral neuro"athy$"eri"heral #ascular %isease @blac) &oot %isease1

• Carcinogenicity . e"i%e!iologic e#i%enceK li#erangiosarco!a$ s)in an% lung cancer


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reat!ent• 8i!erca"rol @*$ - %i!erca"to"ro"anol$ also )nown as

/ritish anti Lewisite or /AL1 earlier use%

• *.-.%i!erca"to.'."ro"anesul&onate @85PS1 or !eso *$ -.%i!er.ca"tosuccinic aci% @85SA1 hese are !ore watersoluble than /AL$ an% can be a%!inistere% orally withlower toxicity

• Acute: su""orti#e thera"y: &lui%$ electrolyte re"lace!ent$bloo% "ressure su""ort @%o"a!ine1

• Chronic: Penicilla!ine w,o %ialysis

Poisoning and management

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