TOXICOLOGY IN CRITICAL CARE

BY KHAIRUNNISA. MANSOOR
INSTRUCTOR
ACKNOWLEDGEMENT: CCN TEAM
Objectives

• Identify the signs and symptoms of drug overdose

• Discuss the classification of drugs that may produce signs and
symptoms of overdose.
• Discuss the treatment modalities of drug overdose with rationales.
• Discuss the medico-legal process in drug over dose with known
psychiatric history and without psychiatric history.
Toxicology

• "The science of poisons."

• Toxicology is more closely related to the drug over dose effect
• What is it that is not a poison? All things are poison and
nothing is without poison. Solely, the dose determines that a
thing is not a poison.
• Dparacelsus (1493–1541), the renaissance father of toxicology, in histhird defense [11]
Factors affecting an individual’s reaction to a
drug
• The reaction to a given toxin depends on the toxin dose, but even with
the same dose, there are variations in the way each individual responds to
the toxin.
• The effect depends upon acquired tolerance, the presence of other drugs
in the system which may affect enzymatic activation and/or inhibition
and route of exposure, poisoning may be local or systemic (dermal,
inhalation, ingestion)
Effects of drug overdose

• Local effect on target organ, can be more than one, such as the
targets for alcohol are the central nervous system and the liver.

• Systematic effect at cellular level include fibrosis, damage to an

enzyme system , disruption of protein synthesis, Production of
reactive chemicals in cells, DNA damage
 Reasons for drug overdose
UNINTENTIONAL
• in a home setting, involve one agent, involve children who are under the age of 6 and result in minor
or mild toxic reactions. May occur due to mislabeling, misreading of labels, mistaken identification
of unlabeled products either at home or work, uninformed self-medication and dosing errors
committed by patients, nurses, physicians, and pharmacists.
• The most fatal unintentional/ accidental overdose/poisoning is due to carbon monoxide. Often,
patients with carbon monoxide poisoning are dead prior to the arrival of emergency personnel.

INTENTIONAL
• alcohol poisoning
• suicidal attempt with drugs (47% of all poisonous exposures and 84% of all fatal poisonings.) The
most frequently implicated drug overdose is acetaminophen.
Assessment
• Triage (Is the patient life is in immediate danger)
• History
• Provides the patient’s exposure to which drug/toxin
• Time and duration of the exposure
• Underlying psychiatric illness.
• If patient confused, unconscious or unwilling to cooperate then ask family
members and /or friends
• Search of the patient’s belongings for useful clues such as the drug
ingested or the container containing the drug. The imprint on a pill or the
label on a container
Assessment
• Allergies
• First aid treatment provided before the arrival at ER
• Any underlying disease or any other related injuries
• Physical examination
• Recognize the presences of toxidrome
Toxidrome is a group of signs and symptoms associated with overdose or
exposure to a particular category of drugs and toxins.
help to identify the drug or toxin to which patient was exposed.
Toxidrome signs and symptoms
Assessment
• Cardiovascular assessment for hyper/ hypotension, hyper/hypothermia
• Respiratory assessment for difficulty breathing and oxygenation status
Patient’s
• Skin examination for excessive sweating, jaundice cyanosis
• GI assessment for hyperactive bowels, diarrhea, and abdominal cramping,
mouth for a clue to the poisoning agent. For example, with cyanide
poisoning, the patient may have an odor of bitter almonds.
• Neurological assessment for GCS, pupil size and reaction and seizures
Assessment
Laboratory studies
• Acetaminophen
• Carbamazepine
• Iron
• Ethanol
• Lithium
• Aspirin
• Valproic acid
Managing Drug Overdose
Immediate stabilization interventions using ABC approach:
• Clear the airway of any foreign bodies or vomitus.
• Secure airway using either an oral airway device, a laryngeal mask airway, or an
endotracheal tube or at least keep patient in the lateral position as it moves the
flaccid tongue away from the airway.
• Assess breathing by observing the chest rise in the setting of immediate resuscitation.
Subsequently, it is assessed by evaluating the pulse oximetry and if in doubt, by
measuring arterial blood gases. Patients with respiratory failure should be
immediately intubated and ventilated.
• Assess circulation by continuous evaluation of the blood pressure, pulse, and urinary
output. An intravenous line should be placed as soon as possible, and routine labs
should be sent off.
Managing Drug Overdose
Interventions using antidotes:
Managing Drug Overdose
Decontamination Methods
Occular exposure: splash into eyes :
• Flushed eyes with luke warm water or normal saline solution.
Continuous blinking during irrigation
Dermal exposure:
• Wash contaminated skin with soap and water. The patient’s clothes
should be removed and double bagged to prevent the care provider
contamination.
 Managing Drug Overdose
Decontamination Methods
Inhalation exposure:
• Should move to fresh air ASAP
Ingestion exposure:
• Should drink 8 oz of milk or water to dilute the ingested irritants such as
bleach.
• Ingestion should not be diluted if they are accompanied by seizures,
depressed mental status or loss of gag reflex as it cause aspiration and
mucosal burn.
Managing Drug Overdose
Gastrointestinal decontamination
• Gastrointestinal decontamination refers to the practice of functionally
removing an ingested toxin from the gastrointestinal (GI) tract in order to
decrease its absorption
1. Gastric evacuation (forced emesis or gastric lavage),
2. Intra-gastric binding (most commonly by single or multidose activated
charcoal), or
3. Speeding transit of toxins to decrease total absorption time (whole bowel
irrigation or cathartics).
Managing Drug Overdose
Gastrointestinal decontamination
The decision to perform GI decontamination is based upon
• The specific poison(s) ingested,
• The time from ingestion to presentation,
• Presenting symptoms, and
• The predicted severity of poisoning.
GI decontamination is most likely to benefit patients who:
●Present for care soon after ingestion (usually within one hour)
The benefits of gastric emptying by either emesis or gastric lavage remains
controversial.
Managing Drug Overdose
Interventions using Decontamination techniques
Gastric lavage
• Mostly use saline solution
• Gastric lavage solutions should be kept at body temperature to avoid
hypothermia.
• Gastric lavage is performed via a large-bore (36 or 40 french tube in
adults) orogastric tube.
• The available evidence does not support the routine use of gastric
lavage.
Managing Drug Overdose
Interventions using Decontamination techniques
Contraindicated
• Petroleum concentrates ( Gasoline, furniture polish)
• Corrosives (strong acids, strong bases) (Drain cleaner)
• CNS stimulants, because the act of vomiting may trigger convulsion

Complication:
• Esophageal perforation,
• Pulmonary aspiration,
• Electrolyte imbalance
Managing Drug Overdose
Gastrointestinal decontamination
Activated charcoal
• Can be used to bind ingested poisons in the gastrointestinal tract before
they can be absorbed.
• Given either orally or nasogastric .
• A single dose (50g in adults) should be given up to one hour after the
ingestion of a substantial amount of toxin. After this time adsorption is
reduced
Managing Drug Overdose
Gastrointestinal decontamination
Contraindicated
• Alcohols, ferrous salts and lithium are not readily adsorbed to charcoal and
this treatment is not indicated for poisoning with these substances.
• Diminish the bowel sound= not indicated in bowel obstruction.
Complication:
• Aspiration pneumonitis can occur after emesis.
 Managing Drug Overdose
Interventions using Decontamination techniques
Whole bowel irrigation
• Large volume of polyethylene glycol with electrolyte solution given to
flush the bowel mechanically .
• Contraindicated in bowel obstruction or perforation
Managing Drug Overdose
Interventions using Decontamination techniques

Cathartics
• Not use alone as a treatment.
• Magnesium citrate or 70% sorbitol is used as cathartics
• No clear evidences that it improves the outcome

• Hemodialysis: when all above conservative treatment is failed.

Managing Drug Overdose
• Pralidoxime is an antidote to organophosphate pesticides and
chemicals.
• Atropine is the initial drug of choice in symptomatic patients
poisoned with organophosphates or carbamates.
• Flumazenil finds its greatest use in the reversal of benzodiazepine
induced sedation from minor surgical procedures
• N-acetylcysteine if the patient has a toxic serum acetaminophen
concentration or has indicators of hepatocellular damage
• Naloxone reversed the opioid poisoning such as Morphine
Medico-legal process

• With known psychiatric history

• Without psychiatric history.
Summary and Quiz
 REFERENCES

• HTTPS://WWW.SCRIBD.COM/DOC/102258966/EMERGENCY-MANAGEMENT-OF-PATIENTS-
WITH-DRUG-OVERDOSE
• HTTPS://CEUFAST.COM/COURSE/DRUG-OVERDOSE-AND-ANTIDOTES