S.NO.

CONTRIBUTORY OBJECTIVES
1. To establish rapport among people 1 min Introduction about self : Myself Tejinder pal kaur,student of MSc nursing-1st year in SGL College of nursing ,Jalandhar

TEACHING TIME CONTENT MATTER LEARNING ACTIVITIES

Teacher gives self introductio n

AV AIDS EVALUA TION

2.

To assess the previous knowledge

2 min

Question: Q:1 Define poisoning? Q:2 what is poison ? Q:3. Enlist the common poisons ?

Teacher assessed the previous knowledge of students

3.

Introduce topic

2 min

INTRODUCTION Poisoning is one of the important accidental hazards among children. It may occur through ingestion, inhalation, injection or skin contact of poisonous substances. The children below five years of age are the common victim of this problem. It may occur as acute exposure of poisonous substance or may also occur due to chronic exposure of poisons. Accidental poisoning in children is a serious challenge to the health care due to its continuing

Teacher give introductio n of poisioning -

morbidity and morality. Most cases of accidental poisoning are preventable .Nursing personals are mostly responsible for the preventive measures to be taken at hospital and home. Health education is considered as the vaccine for prevention of accidental poisoning like other accidental hazards.

4.

To define poisoning?

1 min

DEFINITION OF POISONING Exposure to a chemical or other agent that adversely affects functioning of an organism. Circumstances of Exposure can be intentional, accidental, environmental, medicinal or recreational. Routes of exposure can be ingestion, injection, inhalation or cutaneous exposure. Teacher explain the definition of poisoning with the help of LCD LCD What do you mean by poisoni ng?

5.

To define the poison? 1 min

Poison: The poison has its origin from old Teacher French where it means MAGIC explain POTION. The dictionary meaning of the word poison means: a substance that causes death or injury when swallowed or absorbed by a living organism. A poison is any substance that if taken into the body in sufficient quantity, can cause temporary or permanent damage. with the help of LCD LCD What is poison?

6.

To explain the classificatio n of poisoning?

3 min

CLASSIFICATION: Poisons are classified according to the action they produce: Corrosives. Irritants. Neurotics. Others i. CORROSIVES: They are the poisons, which destroy the tissues by their direct chemical reaction. E.g. strong mineral acids, their carbonates and alkalis. Dilute mineral acids are corrosives but act as irritants. Teacher explain the classificati on with the help of flash cards. Flash cards Enlist the types of poison?

ii. IRRITANTS: They are the poisons which by their specific action set up irritation and inflammation. They are of following types: Inorganic: Non metallic: phosphorus, iodine, bromine. Metallic: arsenic, mercury, lead, copper, zinc. Organic: Vegetables: aloes, Colocynths, castor seeds, croton oil, and abortifarients like ergot etc. Animal Secretions: snake venom, insect bite (scorpion bite). Organic Acids: oxalic acid, acetic acid etc. Mechanical: Powdered glass Diamond dust Chalked hair Dried sponge poisons which by their specific action on the nervous system (brain, spinal cord and nerve endings) and also on the heart, produce injurious effects like delirium, coma, Teacher explain the classificati on with the help of flash cards What include s in corrosi ves poisioni ng?

iii. NEUROTICS: They are

titanic spasm, symptoms of syncope or asphyxia etc. OTHERS: Cerebral Poisons: barbiturates etc. Anesthetics e.g. chloroform ether etc. Inebriants e.g. alcohol, carbolic acid etc. Delirients e.g. datura cannabis etc. Spinal Poisons: Nuxvomica. Cardiac Poisons: Digitalis, tobacco etc. Asphyxiants: Poisonous irrespirable gases like CO2 , CO, coal gas. ROUTES OF TAKING POISON: 7. To describe the routes of taking poison? 2 min Orally i.e. by ingestion: to be principally absorbed from the gastric mucosa. In particular cases the vegetable irritants are absorbed from duodenum and upper part of intestine. Empty stomach absorbs quicker. Inhalation through air passages (bronchial mucosa). Teacher explain the classificati on with the help of leaflets leaflets Define the route of poisioni ng ? Narcotics e.g. opium,

Absorption through skin either intact or broken. Injection into the blood vessels or into the subcutaneous tissues. Introduction into the natural orifices such as rectum, vagina, urethra, eye etc. Application on a wound. Spinal route i.e. intrathecal injection. Application surface. to a serous

8.

To explain the the channels of elimination?

1 min

CHANNELS OF ELIMINATION: Primarily, the poisons are eliminated through: Urine (by kidneys). Stool and bile. Milk, Saliva, sweat etc. & other mucous and serous secretions. Teacher explain with the help of LCD LCD What are channel s of elimina tion

9.

To explain the sign and symptoms of poisoning?

3min

SIGNS AND SYMPTOMS OF POISONING: These vary, depending on the nature of the poison and the method of their entry into the body. These are: Teacher explain sign and symptoms with the help of pamphlets pamphl ets What are general sign and sympto ms of

Delirious convulsions without previous history of such conditions

 Abdominal pain. Bluish lips. Chest pain. Confusion. Cough. Diarrhea. Difficulty breathing. Dizziness. Double vision. Drowsiness. Fever. Headache. Heart palpitations. Special Symptoms: They differ according to the nature and class of poison. Corrosive Poisons: marks of corrosive will found externally. Irritants: symptoms may be mistaken for cholera, gastroenteritis, perforation of stomach, intestine or some other internal organs or intestinal obstruction causing peritonitis etc. Cerebral Poisons: symptoms may be mistaken for apoplexy, uraemia, diabetic coma, epilepsy, head injury, meningitis, cerebral malaria etc. Teacher explain sign and symptoms with the help of pamphlets

poisoni ng?

Cardiac Poisons: symptoms may stimulate heart failure. 10. To describe the types of poisoning? 20 min TYPES OF POISONING: Acid Poisoning: Acids which are used; nitric acid, sulphuric acid,hydrochloric acid, oxalic acid and acetic acid. The incidence is suicidal or homicidal or may be accidental. Symptoms: Burns on or around the lips. Burning in the mouth, throat and stomach often followed by heavy vomiting. Intense thirst. Treatment: Do not induce vomiting in order to prevent perforation. Stomach tube should never be used as there is a great risk of perforation. Strong alkalis (carbonates) should not be used because they will evolve CO2 , which will cause rupture of stomach by distension. Give half liter of water or milk to which milk of magnesia types with the help of LCD LCD Teacher explain What is include d in acid poisoni ng?

(50gm) has been added. If milk or water is not available then olive oil, butter, white of egg and barley water can be given. Alkali Poisoning: Alkalis commonly used are ammonia, potassium hydroxide and sodium hydroxide, bleachers, detergents, washing soda etc. The incidence may be either suicidal or accidental. Symptoms: Membrane of the mouth may be white and swollen. There may be soapy appearance in the mouth. Abdominal pain. Vomiting may contain blood and mucus. Treatment: Stomach tube and emetics should never be used. Vegetable acids in a much diluted form like table vinegar (acetic acid), citric Acid, tartaric acid, ordinary lemon juice etc. should be used to counter act the effect. Demulcents like milk, barley, What is treatm ent for alkali What are sympto ms of alkali poisoni ng?

white of egg, olive oil etc is given. Protein containing foods like milk, egg white etc. exert a considerable buffering action against alkalis. Inj. Morphine sulphate is administered for pain. Inj. Atropine sulphate is also given to reduce the motility of stomach. In case of poisoning by Ammonia vapor, steam is given to inhale and anodynes for pain. In case of edema of glottis tracheostomy may be needed. When the acute episode is over, complications like esophageal structure may have to be dilated. Cortisone may be given to prevent its occurrence. Common Indian Plant Poisoning: i. Castor Oil Plant; such poisoning is common in children Symptoms: Pain in throat and abdomen. Nausea & vomiting.

poisioni ng?

Enlist the commo

 Treatment: Give plenty of water and induce vomiting. Gastric lavage. Inj. Morphine Sulphate is given for pain. Administration of I/V fluid. ii. Jamal Gota: Symptoms: Burning pain in mouth, throat and abdomen. Salivation, vomiting and gripping pain. Treatment: Give plenty of water, milk or egg white and induce vomiting. iii. Cannabis Sativa: Bhang, majun, ganja, hashish is used. Symptoms: Excitement. Visual hallucination. Euphoria, laughter. Marked increase in appetite. Homicidal tendencies. Giddiness, tingling and numbness. Narcosis. Dilated pupils and deep sleep. In large dose respiratory failure and death may occur.

n Indian plant poisioni ng?

 Treatment: Give plenty of fluids. Induce vomiting. DHATURA or KALA DHATURA. Dried leaves and dried seeds are used as poisoning. Symptoms: Bitter taste. Dry mouth and throat. Burning pain in the stomach. Difficulty in swallowing and talking. Giddiness, ataxia. Dry hot skin, rise in temperature. Muttering delirium tries to run away from bed. Tries to pull imaginary threads from tips of his fingers. Develops dreadful hallucinations of sight and hearing. Convulsions and coma. fluids orally and induce vomiting. v. Cocaine: This is obtained from coca plant. Symptoms: Difficulty in swallowing. Treatment: Give plenty of

iv. Dhatura: It is either SAFED

Difficulty in speaking. Pain in abdomen. Vomiting. Diarrhea. Salivation. Rapid pulse dilated pupil. Give plenty of fluids to induce vomiting. Aconite: also known as MITHA ZEHER, DUDHIA VISH.

Treatment: vi.

Symptoms: Severe burning and tingling of lips, mouth, tongue and throat. Dysphagia, salivation. Vomiting. Abdominal colic. Vertigo. Muscle spasm and twitching. Impairment of vision. Give plenty of fluids and induce vomiting. vii. Mushroom Poisoning: Poisonous mushrooms may grow wherever non poisonous mushrooms grow. Symptoms: Burning of throat and stomach. Pain in abdomen. Vomiting.

Treatment:

Diarrhea Urine may contain blood. Cyanosis, rapid pulse. Convulsions. Headache, giddiness, cramps. Visual disturbances. Coma. Castor oil should be given to drink. Induce vomiting. Opium: It is also known as AFIM. Opium has a number of alkaloids (about 25) chief of which are Morphine, Codeine, Narcotine, Thebaine, Papaverine, Narasine etc.

Treatment:

viii.

Symptoms: a) Stage of Euphoria: Increased sense of well being. Talkativeness. Fast pulse. Convulsions in children.

b) Stage of Stupor:

Headache. Giddiness. Desire to sleep. Cyanosis. Itching all over the body.
c) Stage of Narcosis: Coma.

Pinpoint pupil. Difficulty in respiration. Treatment:

The stomach is washed out first with plain water and the first wash is preserved for chemical examination. The patient is kept awake and is not allowed to sleep by flapping the chest and face with moist towels or by pulling the hairs. The idea of keeping the patient awake is not to allow him to go into the stage of coma. Body heat is maintained by hot water bags and warm blankets. Bowel wash may be given with KMnO4 lotion as opium is excreted in the lower intestine. In case of Morphine poisoning by injection, treatment is virtually the same except that excision of the site of injection and washing the part with strong KMnO4 solution are the additional requirements. Drug Poisoning: like phenobarbitone, mandra, aspirin etc. Symptoms: Euphoria.

 Talkativeness. Headache. Giddiness. Desire to sleep. Aspirin over dose: Abdominal pain. Vomiting. Drowsy. Ringing in the ears. Difficulty in breathing. Profuse sweating. Treatment: Hot coffee or tea is given. Plenty of fluids is given. Vomiting is induced. Metal poisoning: Symptoms:

i. Lead: Metallic taste in mouth. Abdominal pain. Nausea and vomiting. Stools may be bloody dark in color. Headache, drowsiness, cramps, numbness. Convulsions. In chronic poisoning, a blue line is seen on gums. Treatment: Give plenty of warm water.

 Milk, white of egg, barley water can be given. Induce vomiting. The stomach is washed with 1% solution of Magnesium or Sodium sulphate followed by water. Inj. Morphine sulphate is given to relieve pain. Chelating agents like calcium disodium versenate are very useful .5 ml of 20% solution in 250-500ml of NS or 5% glucose is administered by slow I/V drip taking an hour. This method removes lead from tissues both in acute and chronic poisoning. ii. Mercury: Inhalation of mercury vapor is poisonous. The chief poisonous salt of mercury is Mercuric Chloride. Accidental cases may happen due to douche or I/V injection of mercurial diuretics. Symptoms: Metallic taste in mouth. Burning pain in mouth and stomach. Tongue and throat is corroded with grey white coating.

 Nausea and vomiting. Stool may be bloody dark in color. Headache, convulsions, numbness. Treatment: Stomach wash: if the patient is seen within 1/2 hr., stomach wash is effective. Inj. Morphine Sulphate should is given for pain. I/V 5% glucose/saline should be given to correct dehydration. Orally pencillamine also provides a good antidote. Mannitol is used to promote diuresis. Salt free diet is given i.e. milk, rice, bread. As albumin of mercury is rapidly soluble in presence of NaCl and absorption of mercury is also favored in the presence of NaCl. iii. Copper: Metallic copper is not a poisonous substance copper sulphate or blue virtol is a metallic irritant. It has replaced opium as a suicidal poisoning now days; because opium is not available without

prescription. Symptoms: Strong styptic metallic taste with a sense of constriction in the throat. Increased salivation and thirst. Burning pain in stomach. Vomiting. (color is bluish/ greenish) Headache. Diarrhea with passage of liquid and browny stool. Sometimes convulsions, paralysis of limb, insensibility. Coma. No emetic is necessary as the patient started vomiting very soon. Stomach is washed out with 1% solution of Potassium Ferro cyanide which forms insoluble cupric Ferro cyanide. Demulcents like egg albumin are given. It is considered to be as antidote as it produces insoluble copper albuminate. I/V infusion of saline or glucose is needed to combat dehydration. Inj. Morphine sulphate for Treatment:

pain. iv. Arsenic poisoning:Toxic effect caused by the ingestion or inhalation of arsenic or a substance containing arsenic, an ingredient in some pesticides, herbicides, dyes and medicinal solutions. Symptoms: a) Acute: Pain. Vomiting and bloody diarrhea. Mental confusion or disorientation. b) Moderate: Feeling of pins and needles in hands or feet. Gastrointestinal problems. Metallic taste or Garlicky breathe odor. Headache. Mood swings Memory loss

c) Intermittent:

Flu-like symptoms. Fatigue. Muscle and joint pain. Rashes. Headaches. Brittle nails. Irritability.

 Treatment: Gastric lavage or whole-bowel irrigation. This is especially effective in treating cases of recent ingestion. Hydration with IV fluids to prevent dehydration and kidney failure. Chelation therapy aids in removing the toxic chemicals from the body by attracting the atoms to the compound of the less toxic medication and thus expelling them from the body. The chelating agents are Dimercaprol and Succimer i. Organic Chemical Poisoning: DDT: Dichloro diphenyl trichloroethane. Symptoms: Nausea and vomiting. Vertigo, tremors. Convulsions. Coma. Respiratory failure. Give plenty of water to induce vomiting. ii. Petroleum distillates: Diesel oil, Kerosene, Paint thinner.

Treatment:

 Symptoms: Burning pain in throat. Feeling of warmth in stomach, colic. Excessive thirst. Drowsiness. Face may be paled or cyanosed. Smell of oil is also present in urine and in stools. Unconsciousness and collapse. Convulsions. Wash out stomach with plain water. Head end is kept low during stomach wash. Give stimulants and emetics. Artificial respiration may be necessary. High carbohydrate diet and Vitamin B complex is given to prevent damage to liver. iii. Naphthalene: Naphthalene is available in the form of balls which is used as moth repellant. Symptoms: Pain in abdomen. Vomiting. Confusion.

Treatment:

 iv.

Headache. Excitement. Convulsions. Coma. Cyanide:It is very lethal poison. It can be taken via ingestion or inhalation.

Symptoms: Headache, dizziness. Hypotension. Dyspnea, drowsiness. Convulsions. Cyanosis. Foam in the mouth. Respiratory failure. Characteristic smell of bitter almonds. Treatment: Start resuscitation immediately. Amyl nitrite should be inhaled every 1-2minute. Stomach lavage with 5-10% Sodium Thiosulphate. Alcohol Poisoning: Methyl alcohol is commonly used. Symptoms: Flushed face. Smell of alcohol in breathe. Red conjunctivae. Unsteady gait.

Foolish speech. Cold and clammy skin. Face becomes cyanosed. Subnormal temperature. Coma and shock. Gastric lavage should be done. Artificial respiration should be provided if required. Ammonia inhalation should be given.

Treatment:

11.

To explain antidotes?

30sec

ANTIDOTES These are agents that relieve or counteracts. Anything that counteracts or relieves a harmful or unwanted conditions. Agents that counteract or neutralize the effect of poison.

Teacher explain antidotes with the help of LCD LCD Define antidot es?

12.

To enumerate the laboratory diagnostics in poisoning?

2 min

LABORATORY DIAGNOSTICS These tests provide an idea about Teacher the possible toxin before the reports of others tests are available:1. Urine tests Urine should be examined for abnormal color. Like in Phenol poisoning- urine is smoky dark green color. Ethylene glycol poisoning oxalate crystals In this ferric chloride test may help in identifying the incriminated toxin .add 5-10 drops of freshly prepared 10% ferric chloride solution to 10 ml of boiled and acidified urine.results shows Red color exposure to salicylates Purple green phenothiazine poisoning Voilet color Ketones alcohol 2. Blood tests Blood tests are done for detection of poison like - phenol poisoning - exposure to explain laboratory diagnosis with the help of LCD LCD Enlist the laborat ory diagnos tic for poisioni ng?

acetone salicylate and isopropyl

Blood appears chocolate color in patients melthemoglobinemia and pink in case of potassium cyanide poisoning

Measurement of anion gap and osmolol gap detects accumulation of unmeasured ions osmotically active agents in blood.

3. Gastric aspirate Addition of 2 drops of 30% hydrogen peroxide and deferoxamine (0.5 ml-125 mg) to 1 ml gastric fluid leads to color change in iron poisoning. 13. To explain the manageme nt of poisoning? 10 min MANAGEMENT Phases of management of children with poisoning Early suspicion and appropriate management forms the main stay of therapy. If the child is brought in the 1. Pre-toxic phase- Then the decontamination is the highest priority and treatment is based on history. The maximum potential toxicity based on greatest possible exposures should be assumed. Teacher explain phases with the help of chart chart What are phases of manag ement of poisoni ng?

2. Toxic phase The time between the onset of poisoning and the peek effects, management is based primarily on clinical and laboratory findings. Resuscitation and stabilization are the first priority. 3. Resolution phase- The supportive care and monitoring should continue until clinical and laboratory abnormalities have resolved. General management of poisoning AT HOME When the parent or the baby sitter calls the emergency source for information about the care of a child who is poisoned , the person who answer must stress . 1. The approach to child 2. Termination of exposure to the person 3. The method for the immediate removal of the poison in the home. 1. The approach to child Child who ingested poison is not only physically ill but is also emotionally distressed. It Teacher explain with the help of LCD LCD

is also important for the parents or baby sitter to remain calm so that the child can be comforted. Prompt treatment is necessary , because the amount of poison absorbed depends on the interval between its ingestion and its removal .Excessive manipulation are to be avoided. 2. Termination of exposure to the person-Since the ingestion of addition poison would increase the danger ,any of the poisonous material remaining in the child ,mouth should be removed promptly before it can swallowed and the soiled clothing should be replaced. 3. The method for the immediate removal of the poison in the home The immediate treatment of poisoning is caused, by an ingested substance is to removed it by inducing vomiting while the child is still at home if this is not contraindicated. Contra indications of induction of vomiting The poison is a strong What are the contrin dication s of inductio n of vomitin

corrosive (acid or alkali) which would further damage mucosa The poison is hydrocarbon ,which would cause hydrocarbon pneumonia if aspirated. The child has lost the gag reflex or is in severe shock , is unconscious, or is convulsing Or any of which could increase the danger of aspiration. VOMITTING is induced by administering syrup of IPECAC , an emetic. This drug is effective because it stimulates the vomiting center and also has an irritating effect on the mucosa of stomach .The amount of the drug given depends on the childs age. AT HOSPITAL 1. Emergency stabilization measures. 2. Identification of poison. 3. Removal of poisonous substance and toxin. 4. Specific antidote therapy. 5. Supportive therapy. 6. Counseling to parents and

g?

Name the syrup given to induce vomitin g?

children Steps of management 1. A. EMERGENCY Airway maintenance STABILIZATION MEASURES. Establishing airway may be difficult in children with poisoning due to caustic and thermal upper airway injuries ,neck and facial injuries or angioedema.In any child with altered mental status ,respiratory depression and pupillary constriction , a trial of naloxene should be given before intubation .Bag and mask ventilation is associated with higher risk of aspiration .This can be minimized by synchronized and gentle ventilation and aspiration of gastric contents prior to ventilation . B. Breathing- Adequacy of breathing should be assessed by respiratory effort, chest movement, air entry and oxygen saturation. C. Circulation Fluid boluses, repeated if needed, under monitoring for fluid

overload ,constitute the initial management of shock particularly in poisoning due to cardio toxic agents and children with cardiopulmonary diseases. In an unresponsive shock, dopamine is the agent of choice except in poisoning due to tricyclic antidepressant. 2. Laboratory investigation for detection of or identification of poison. 3. Prevention of further absorption of poison Dilution This involves application of water in an effort to reduce toxin.The mechanism depends upon the site of exposure. In patient with corrosive burns and organophosphorous poisoning, all clothes should be removed and the contaminated area washed with liberal amount of water and soap. Neutralization of an agent (using alkali for acid exposure or vice versa) is harmful and contra-indicated. GI decontaminationGastric emptying is a cardinal principal of management of

ingested toxins. The desired outcome is prevention of continued absorption of poison from the gut into the bloodstream in asymptomatic children .The procedure of choice for decontamination ,if needed, is activated charcoal ,with whole bowel irrigation being used for a few indication. Orogastric lavage may be considered for uncommon situations. The role of gastric lavage in children is not clear.It is contraindicated in corrosive poisioning.Gastric lavage should be performed only after the gag reflex has been assessed. Binding agents- Activated charcoal ,clays , and cholysteramine may be used at a dose of1-2 g/kg. The drug is available as a 400 mg tablet and should be crushed before administered, made into slurry and administered. Cathartics Whole bowel irrigation

4.Enhancing eliminationProcedures directed toward enhancing elimination is

indicated in patients with significantdelay following poisioning or hen methodsfor prevention of absorption are ineffextive or not applicable. Manipulation of pH and dieresis Dialysis Exchange transfusion 5.Administration of antidotes antidote counteract the effects of poisons by neutralizing them or by antagonizing their physiological effects. Antidotes significantly reduce the morbidity and mortality, but are potentially toxic. 6.Supportive therapy- The goals of supportive therapy include maintenance of hemostatasis and prevention and treatment of complication. Indications for intensive care include Evidence of severe poisoning, coma, respiratory depression, hypotension, cardiac conduction abnormalities. Need for antidote or Progressive clinical enhanced elimination therapy

deterioration.

14.

To summarize the topic

2min

SUMMARIZATION Today we have discussed Introduction Definition of poisionind? Definition of poison? What is classification of poison ? Describe the management of children with poisioning at home?

Teacher summariz e the topic -

15.

To recapitalize the topic

5 min

RECAPITUALIZATION Q-Define poisioning? Q-Enlist typesof poisioning? Q-

Teacher ask the question and students actively participate -

16.

To refer more books

BIBLIOGRAPHY
Derisbach.Robert.H. (1963) Handbook of poisoning, .editon fourth published by lange medical ..publishers. U.S.A. pp 2 -16. Basu.S.C. (1995) Hand book of medical jurisprudence and

toxicology edition second published by current distributers, Calcutta. pp 277283, 294-310, 348-356. Gupta.L.C. and gupta. abhitabh (1995) manual of first aid .edition first published by jaypee brothers medical publishers (p) ltd. new delhi. pp 235-250. Indrani.T.K.(2003) First aid for nurses edition first.published by jaypee brothers medical publishers. (p) ltd. New Delhi. pp 148-151. Datta parul,Peadiatric Nursing,2007,1 st edition,Jaypee publishers,Pp
Ghai op , Essential peadiatrics,(2009) 7 th edition,CBC publishers,Pp-676-680