Management of Toxicity

Management of Toxicity
Causes of self-poisoning:
Accidental:
Children less than 5 years by sugar coated tablets.
Inhalation of organophosphorus pesticides.
Overdose.
Causes of self-poisoning:
Deliberate:
Suicidal attempts (in response to depression or specific life events).

Management Principles:
1 Immediate and supportive measures.
2 Absorption prevention.
3 Elimination of toxicant.
4 Specific antidote.
1) Immediate and Supportive measures
Remove patient from contact with poison, for example gases.
Preserve any evidence, for example bottles, thrown tablets,

written notes….
Assess vital signs (Pulse, body temperature, B.P, respiratory rate

& pupil size).
Ensure clear
Remove patient from contact with poison, for example gases.
Preserve any evidence, for example bottles, thrown tablets, written notes….
Assess vital signs (Pulse, body temperature, B.P, respiratory rate & pupil size).
Ensure clear
= Airway
= Breathing
= Circulation
A=Air way
 Causes of air way obstruction:
Drug-induced mucosal swelling.
Increased salivation.
Posterior displacement of
the tongue.
Swallowing of foreign bodies.

A=Air way
 Symptoms of airway obstruction:
Dyspnea.
Tachypnea
Air hunger.
Cyanosis.
Hoarseness(stridor).
Diaphoresis.
Drooling.
.
A=Air way
Management of airway obstruction:
Suction of excessive secretions.
Chin lift maneuver.
A=Air way
Chin lift maneuver.
Nasopharyngeal intubation  Alert patients.
Oropharyngeal intubation  Comatosed patients.
A=Air way
Chin lift maneuver.
Oropharyngeal intubation  Comatose patients.
A= Air way

Chin lift maneuver.
Oropharyngeal intubation  Comatose patients.
A=Air way
• Suction of excessive secretions.
• Chin lift maneuver.
• Nasopharyngeal intubation  Alert patients.
• Oropharyngeal intubation  Comatose patients.
• Finally  Emergency Cricothyrotomy.

B = Breathing
 Causes of respiratory depression:
• Drug-induced respiratory depression (Sedatives & hypnotic

such as barbiturates & BDZs).
• Pulmonary edema & pneumonitis.
• Bronchospasm.
B = Breathing
Management of respiratory depression:
Nasotracheal intubation  Alert patients.

Orotracheal intubation  Comatosed patients.
C =Circulation
The shock is the clinical picture in which the patient shows signs
of inadequate tissue perfusion.
 Symptoms of shock:
SHOCK
Coma
C =Circulation
 Management of shock:
Initially:
• Trendlenburg position.
• Saline Infusion.
C =Circulation
 Management of shock:
If the patient doesn't respond to 2L infusion & the signs of shock
persist, the vasopressors should be used:
N.B.
Dopamine 1) Dopamine at low dose  stimulates
dopamine receptors  renal & mesenteric
2-5 µg/kg/minute vasodilatation.
vasopressors up to 20 µg/kg/
minute 2) Dopamine at medium dose  stimulates
cardiac β1 receptors ↑cardiac contractility
& C.O.P.
Norepinephrine 3) Dopamine at high dose  stimulates α1
0.1-0.2 µg/kg/minute. receptors  systemic vasoconstriction.
2) Preventing absorption (Gut Decontamination)
 It is usually not effective if more than 4-6 hrs passed
after poison ingestion.
 It is used only for orally ingested poisons.
 Methods of gut decontamination:

Gastric Activated Whole
Emesis Cathertics Bowel
Lavage Charcoal
Irrigation
Emesis
Method:
By the use of syrup of ipeca.
The active ingredients are two alkaloids, emetine
&cephaeline.
Dose:
In children 6-9 months  5 ml ipeca syrup + 120 ml water.
9-12 months  10 ml ipeca + 120 ml water
1- 12 years 15 ml ipeca + 120 ml water.
> 12 year  30 ml ipeca + 250-350 ml water.
The dose can be repeated if emesis has not occurred in 30 minutes.

Emesis
Don’t use for emesis
• Water alone: hyponatremia
• Finger down throat: incomplete, dangerous, unsuccessful
• Cu & Zn SO4: not reliable & if absorbed may cause poisoning.
• Apomorphine: may cause lethargy, depress resp. center,
hypotension
Complications:
Prolonged
Lethargy Drowsiness Diarrhea
vomiting
2) Preventing absorption
(Gut Decontamination)
Emesis
Contraindication:
1- Children up to 6 months of age.
2- Comatose patient because of increased risk of aspiration.
3- Seizures (due to compromised gag reflex).
4- Certain toxins:
- Hydrocarbons& volatile substances.
- Corrosives (Caustics).
5- Ingestion of sharp objects.

Gastric Lavage
Method:
• performed by introducing warm water alternating
with saline
• use nasogastric (alert patients & children) or an
orogastric (comatose patient) tube into the stomach
• & the removal of stomach contents
by suction.
• For comatosed patients (with absent gag
reflex) or hydrocarbons use cuffed
endotracheal tube to prevent
aspiration.
Gastric Lavage
Precautions:
Warm solution should be used.
To avoid hypothermic shock
Warm water alternating with saline
To avoid hyponatremia
The patient should be placed on his left side.
liver blocks the junction between stomach & small intestine, and therefore
the toxin is kept in the stomach available for lavage.
G.L can be used in comatosed patients with concurrent insertion

of cuffed endotracheal intubation.
Gastric Lavage
Complications:
Esophageal Epistaxis Empyema

perforation
Gastric Lavage
Contraindications:
Varicoses.
Gastric ulcers.
Corrosives (Caustics) intoxication.
Ingestion of sharp objects.
Cardiac dysrhythmias (must be controlled before initiating G.L

because insertion of the tube may create a vagal response
leading to life-threatening dysrhythmia or cardiac arrest.
Gastric Lavage
Other washing solutions for specific toxins:
Poison Solution
Formaldehyde Ammonium Acetate
Oxalic acid, fluoride Ca gluconate
Silver nitrate Normal saline
Alkaloids, mushroom K permenganate
Ferrous sulfate NaHCO3
Alkaloids Tannic acid
Iodine Starch solution
• Formaldehyde + ammonia Hexa/penta-methylene
tetramine (inert)
• Ferrous iron + NaHCO3 FeCO3 (poorly absorbed)
• alkaloids + K permanganate OR tannic acid ppt
• Iodine + starch blue colour as indicator
• HF + Ca gluconate ppt
Activated Charcoal
Method:
Activated charcoal effectively adsorbs a variety of drugs &
chemicals.
Dose:
1-2 g/kg or 50 gm (10 table spoonful)
It is mixed with 70% sorbitol to avoid constipation & resorption.

Activated Charcoal
Complications:
Constipation. Intestinal Aspiration

obstruction. pneumonitis
Activated Charcoal
Contraindications:
In comatosed patient unless the cuffed intubation is used.
Activated charcoal doesn't bind well to:
Boric acid.
Pesticides.
Ferrous salts (as ferrous sulphate).
Cyanide.
Caustics.
Alcohols.
Petroleum distillates.
Cathertics
(Purgation)
Saline/salt Saccharide Oil based

Magnesium Citrate
Sodium Phosphate Sorbitol Not used now
because of
N.B. although safe, increased risk of
but not given to lipoid pneumonia
children < 1 y, &
with caution in 3 y
age
Cathertics
Complications:
Abdominal Prolonged Electrolyte

distention & diarrhea. disturbances
cramps. (when given by
the gastric lavage
technique).
Cathertics
Contraindications:
• Magnesium cathartics should be avoided in patients with renal
failure &/or C.N.S problems. WHY??
(Renal failure  ↓ Magnesium excretion  Magnesium accumulation
Electrolyte disturbance and C.N.S depression)
• Sodium salts should be avoided in patients with renal failure,
heart failure, &/or hypertension.
• Absence of bowel sounds.

• Intestinal obstruction
• Pre-existing electrolyte disturbance,
• GI bleeding, perforation, peritonitis.
• Poisoning with corrosives
• Severe diarrhea
Whole Bowel Irrigation
(WBI)
It is the complete irrigation of the bowel by PEG (Colyte®).
The patient receives PEG until clear effluent is attained.

3) Elimination Enhancement
Non
Extracorporeal
Extracorporeal
system
system
Hemodialysis
Hemoperfusion Peritoneal Dialysis
Exchange Transfusion Forced Diuresis

Hemodialysis
Requirements:
When large amounts of drug are retained in plasma.
The drug molecular weight should be less than 500 Dalton so can
pass easily across the dialysis membrane.
The drug should be water soluble.
The drug should be of low protein binding.
Heparin should be administrated before dialysis to avoid blood

coagulation.
Hemodialysis
Hemodialysis
Indications:
Severely intoxicated patients who don't respond to early

supportive management.
Renal failure (where forced diuresis can't be applied).
Prolonged coma.
If lethal amounts of drug was absorbed despite gut

decontamination.
Presence of significant quantity of a toxin that is metabolized to a

toxic metabolite.
Hemodialysis
Complications:
Hypotension.
Electrolyte disturbance.
Bleeding.
Air embolism.
Thrombocytopenia.
Infection.
Hemodialysis
Contraindications:
Presence of antidote.
Patient receiving anticoagulants (heparin).
Coagulopathy or bleeding ulcer.

Hemoperfusion
 It is a method for removing toxic material by pumping blood

through a cartridge of adsorbent material such as activated
charcoal or resin.
Advantages:
Hemoperfusion can be used with:
-Drugs of high molecular weight.
-Protein bound drug (Phenytoin).
- Poorly water soluble drugs.

- N.B. Heparin is used here.
Hemoperfusion
Contraindication & Complications
???
Exchange transfusion
It is infrequently used.
It is the removal of the patient's blood & replacement with

fresh whole blood.
Indications:
Iron toxicity.
Chloramphenicol toxicity.
Patients who are refractory to other enhanced elimination

methods or antidotes.
Complications:
Mismatches.
Chills.
Hypotension.
Infection.
Bleeding.
Peritoneal Dialysis
 The toxins diffuse from mesenteric capillaries across the

peritoneal membrane into a washing solution in the peritoneal
cavity.
Peritoneal Dialysis
 The toxins diffuse from mesenteric capillaries across the

peritoneal membrane into a washing solution in the peritoneal
cavity.
Advantages:
It is well tolerated.
It doesn’t require heparinization.

Peritoneal Dialysis
Indications:
when hemodialysis or hemoperfusion is unavailable or

contraindicated, such as patients with bleeding disorders or
receiving anticoagulant therapy.
Can be used in patients with acute renal failure.

Peritoneal Dialysis
Complications:
Pain.
Peritonitis.
Electrolyte disturbance.
Infection.
Forced Diuresis
Principle:
Many drugs are weak acids or weak bases.
At physiological pH, most drugs are partially ionized (polar).
It is known that the ionized form is increased when the drug is placed in a
medium opposite to its nature (i.e. the acidic drug is significantly ionized in
alkaline medium & the basic drug is ionized in acidic medium).
The ionized form is unable to cross through cell membranes.
The goal of forced diuresis is to enhance renal excretion by increasing the

amount of the ionized form in the urine  the drug is trapped in renal
tubules & not reabsorbed Increased excretion
Forced Diuresis
Requirements:
Low protein binding.
Limited metabolism & tissue distribution.
High renal clearance (normal kidney functions).

Forced Diuresis
Forced Alkaline Diuresis Forced acidic Diuresis
Used for acidic toxins such as Used for basic drugs, but its use is now
salicylates, phenobarbital. limited because the adverse effects are
common and the process is technically
The urine is alkalinized by I.V infusion of difficult.
sodium bicarbonate.
The method is carried out using
Complications  pulmonary or cerebral ammonium chloride (oral or I.V).
edema – electrolyte disturabances.
Complications  ammonia
encephalopathy.
4) Antidotes
1) Competitive Antidote
 When the antidote competes with the toxin at its

site of action (same receptor).
 Examples:
• Atropine acts at muscarinic receptors to block the toxic effects

of Acetylcholine.
• Naloxone acts at opioid receptors to reverse the effects of

narcotic analgesic.
• Flumazenil competes with BZDs at its binding site near the

GABA receptors.
4) Antidotes
2) Non-Competitive Antidote
 When the antidote reverses the effect of the toxin

at a different site
 Example:
• Organophosphorous pesticides act by inhibiting the

enzyme “acetylcholinestrase”.
• Atropine acts to dampen the binding of excessive

acetylcholine to muscarinic recetors.
4) Antidotes
3) Chelating Antidote
 When the antidote forms a non toxic water soluble

complex with the toxin, to be excreted out of the
body
 Example:
BAL: for most metals such as gold, lead, mercury & arsenic.
EDTA: for lead.
Penicillamine: for lead & copper.
Deferrioxamine: for iron.
Dicobalt EDTA: for cyanide.

4) Antidotes
4) Antidote affecting toxin metabolism
 When the antidote acts at a particular site in the metabolic

pathway of the toxin to prevent its toxicity &/or accelerates
its metabolism to a non toxic metabolite.
 Example:
Alcohol dehydrogenase
Methanol Formaldehyde + Formic acid
(Toxin) Cause optic nerve toxicity (Blindness)
4) Antidotes
 When the antidote act at particular site in the metabolic

pathway of the toxin to prevent its toxicity &/or accelerate
 Example:
Alcohol dehydrogenase
Methanol Formaldehyde + Formic acid
(Toxin) Cause optic nerve toxicity (Blindness)
Ethanol Acetaldehyde + acetic a’

(Antidote)
Non Toxic Metabolite
4) Antidotes
 Example:
Toxicity
Cyanide Sodium Thiosulphate

(Antidote)
+ Nitrites cyanoMetHb ++++++++++++++++++++++
Sodium Thiocyanate
(More water soluble
& less toxic).
4) Antidotes

 Example:
N-Acetylcysteine: provides substrate for conjugation of

the toxic metabolite (NAPQI) of paracetamol.
4) Antidotes
5) Antibody Antidote
 When the antidote neutralizes the toxin by binding to it.

 Example:
Specific antibody fragment (Fab) for digoxin:
It is prepared by injecting sheep or horse with the toxic substance

 formation of antibodies for the toxicant  Ag-Ab Complex 
fractionation to remove the antigenic fragment & retain the
specific Antigen Binding Fragment (Fab).
4) Antidotes
6) Antibody affecting enzyme-poison complex
 Example:
Oximes (ex: pralidoxime, PAM):

it is used in the treatment of
OPCs toxicity. It acts by
reactivating acetylcholine
esterase.

Management of Toxicity

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Management of Toxicity

Uploaded by

Copyright:

Available Formats

Management of Toxicity

Children less than 5 years by sugar coated tablets.

Inhalation of organophosphorus pesticides.

Suicidal attempts (in response to depression or specific life events).

1 Immediate and supportive measures.

Remove patient from contact with poison, for example gases.

Preserve any evidence, for example bottles, thrown tablets,

Assess vital signs (Pulse, body temperature, B.P, respiratory rate

Remove patient from contact with poison, for example gases.

 Causes of air way obstruction:

Drug-induced mucosal swelling.

Swallowing of foreign bodies.

Management of airway obstruction:

• Finally  Emergency Cricothyrotomy.

 Causes of respiratory depression:

• Drug-induced respiratory depression (Sedatives & hypnotic

• Pulmonary edema & pneumonitis.

Management of respiratory depression:

Nasotracheal intubation  Alert patients.

 It is used only for orally ingested poisons.

 Methods of gut decontamination:

The dose can be repeated if emesis has not occurred in 30 minutes.

2- Comatose patient because of increased risk of aspiration.

3- Seizures (due to compromised gag reflex).

5- Ingestion of sharp objects.

G.L can be used in comatosed patients with concurrent insertion

Esophageal Epistaxis Empyema

Corrosives (Caustics) intoxication.

Ingestion of sharp objects.

Cardiac dysrhythmias (must be controlled before initiating G.L

• Ferrous iron + NaHCO3 FeCO3 (poorly absorbed)

• alkaloids + K permanganate OR tannic acid ppt

• Iodine + starch blue colour as indicator

It is mixed with 70% sorbitol to avoid constipation & resorption.

Constipation. Intestinal Aspiration

Saline/salt Saccharide Oil based

Abdominal Prolonged Electrolyte

• Absence of bowel sounds.

It is the complete irrigation of the bowel by PEG (Colyte®).

The patient receives PEG until clear effluent is attained.

Hemoperfusion Peritoneal Dialysis

Exchange Transfusion Forced Diuresis

When large amounts of drug are retained in plasma.

The drug should be water soluble.

The drug should be of low protein binding.

Heparin should be administrated before dialysis to avoid blood

Severely intoxicated patients who don't respond to early

Renal failure (where forced diuresis can't be applied).

If lethal amounts of drug was absorbed despite gut

Presence of significant quantity of a toxin that is metabolized to a

Patient receiving anticoagulants (heparin).

Coagulopathy or bleeding ulcer.

 It is a method for removing toxic material by pumping blood

-Protein bound drug (Phenytoin).

- Poorly water soluble drugs.

Contraindication & Complications

It is infrequently used.

It is the removal of the patient's blood & replacement with

Patients who are refractory to other enhanced elimination

 The toxins diffuse from mesenteric capillaries across the

 The toxins diffuse from mesenteric capillaries across the

It doesn’t require heparinization.

when hemodialysis or hemoperfusion is unavailable or