Poison and Antidotes

Indwiani Astuti
Dept. Pharmacology & Therapy
FAC. M-PHN UGM
 Introduction

• POISONS
• A poison may be defined as any substance administered in
whatever way ( by mouth, injection , inhalation , skin )
produces ill health, diseases or death.
• A poison is a compound that produces a deleterious change
on or in the body
• The hallmark of a poison is the change elicited in a body
function.
• Self medication is a major cause of drug poisoning
• Toxicity is based on the number of exposures to a poison
and the time it takes for toxic symptoms to develop.
• Acute toxicity is due to short-term exposure and happens
within a relatively short period of time. Chronic toxicity is
due to long-term exposure and happens over a longer
period
 Important for Dx & Tx
• How Poisons Enter the System.
• Symptoms of Poison
• Never lose a Moment.
• Effect of Some Poisons.
• A case of poisoning is the mightiest of emergencies—
one of life or death. Every minute counts.
Poisoning can be classified as :
• (A) Intentional poisoning – taking substances without
intention of causing harm to self. E.g. :- Suicide
• (B) Unintentional poisoning – Taking substances without
knowing its toxic effects. E.g. :- Accidental

• Signs and symptoms of poisoning:-

• Reduced breathing rate
• Nausea
• Vomiting and Diarrhoea
• Alteration in heart rate
• Muscle cramps
• Partial Consciousness.
 • (C) Heavy Metal poisoning –
This poisoning occurs due to intake of salt of As, Pb ,
Hg or Fe resulting into the toxic effect
• Treatment :- Activated charcoal given initially to
absorb heavy metal ↓ followed by emetics to
eliminate any poison left in the stomach.
 • (D) Cyanide poisoning :-
This poisoning may occur by inhalation of fumes of
hydrocyanic acid (HCN) or inorganic cyanide salt.
Consumption of 300 mg of KCN may cause death.
Treatment :- Sodium nitrite and Sodium thiosulphate
injections as an antidotes
 Classification of Poisons.
• To facilitate the study of the subject some system of management should be
adopted. No classifications of poisons is entirely satisfactory, and the following is
offered as probably as good as any other for public use:
• 1. Gases and volatile substances.
• 2. Metals.
• 3. Minerals and metallic salts.
• 4. Corrosive poisons, acids and alkalies.
• 5. Vegetable poisons, in form of drugs.
• 6. Vegetable poisons in natural state.
• 7. Bacterial and food poisons.
• 8. Animal secretions.
 ANTIDOTES
Antidotes are the substances which react specifically without the ingested
poison or toxic substances or with potent drugs in case of overdose.

CLASSIFICATION :-
According to their mechanism of actions, they are classified as:

Physiological Antidotes –
They are antagonists i.e. produce the effect opposite to that of the poison
E.g.:-Antagonists and Physostigmine are two antidotes for each other.
Sodium nitrite in CN- poisoning.
• A) Chemical Antidotes –
They react by combining with the poison and change
its chemical nature by converting poison into inactive
compounds.
• (B) Mechanical Antidotes E.g. – Sodium thiosulphate
convert toxic cyanide into non-toxic thiocyanate.
EDTA as chelating agent for heavy metal poisoning.
They act by preventing the absorption of poison into
the body or expel out the poison by emesis
E.g. :- Activated charcoal absorbs the poison to
absorption into intestinal wall.
• Physical properties –
• Large, prismatic crystalline powder
• Effervesces in dry air
• Practically soluble in H2O and insoluble in alcohol
• Melting point- 50°c
• Chemical properties –
• Decomposition of aq. Solution as Sodium thiosulfate Sodium
sulfate Sodium
• 4Na2S2O3 ⟶ 3Na2SO4+ Na2S5 ⟶ Na2S + 4S
• Barium chloride reacts without to give white ppt. of barium
thiosulphate
• Na2S2O3 + BaCl2 ⟶ BaS2O3↓ + 2NaCl
Mechanism of antidotes
• Slow infusion of sodium thiosulfate
↓
react with CN- in the blood
↓
Convert CN- to SCN- (thiocyanate)
↓
SCN- excreted out from the body by kidney.
• Na2S2O3 + CN- ⟶ SCN- + Na2S2O3
(Active cyanide) (inactive thiocyanate)
• Uses :-
*Used as antidote in cyanide poisoning as IV
*Effective antidote in Pb, Hg and iodine poisoning.
*Use as antioxidant for solution containing iodides
*Standard titrant in Iodimetric analysis.
• Dose = 0.3 – 1g (10ml) administrated by intra muscular and Intra venous
route.
• SODIUM THIOSULPHATE [Na2S2O2]
• Synonyms :- Sodium hyposulfite, Anti-chloral
Preparation– Prepared by boiling Sodium
Sulphite Na2S2O2 with Sulphur (S)
Na2SO3 + S —∆⟶ Na2S2O3 (Sodium
thiosulfate)
• By reacting sodium hydroxide with Sulphur.
6NaOH + 4S ⟶ Na2S2O3 + 2 Na2S + 3H2O
 Poison Antidote Adult dosage
toxic sign
Acetaminophen N- Acetylcysteine 140 mg/kg PO, followed by 70
mg/kg q4h for 17 does
( NAC )

- pesticide poisoning -Atropine sulfate - 1-5 mg IV(IM,SC)q15min

- Organophosphate - Pralidoxime * - 1 g IV (PO) over 15-30 min q
(2-PAM)® 8-12 h in 3 doses
eg :Fisostigmine
( Antilirium )® (Protopam)®
,… (*in severe poisoning)

Cyanide Amyl nitrite Inhalation for 15-30 sec q min

followed by
300 mg (50 ml 3% solution) IV
sodium nitrite over 3 min
followed by
sodium thiosulfate 12.5 g (50 ml 25% solution) IV
over 10 min
 Poison Antidote Adult dosage
toxic sign
Iron Deferoxamine 1 g IM (IV at a rate 15 mg/kg/h
if hypotension) q8h prn
( Desferal )®
Extrapiramidal signs - Diphenhydramine - 25-50 mg IV ( IM,PO ) prn

- Benztropine - 1-2 mg IV ( IM,PO ) prn

Warfarin - Vitamin K1 - 10 mg IM, SC, or IV

& related drugs ( phytonadion )
- Fresh frozen plasma - Variable
Digoxin Antidigoxin Fab - acute ingestion :
dose (vials) = [ serum level
fragment
( ng/ml ) × 0.8 ] / 0.5
( Digibind )® - Chronic ingestion :
( Digifab )® dose (vials) = [ serum levl
( ng/ml ) × weight (kg) ] / 100 ,
infused in 0.9% salin over 15-3
min ; repeat if toxicity persists
 Poison Antidote Adult dosage
toxic sign
Isoniazid (INH) Pyridoxine Equal to INH ingestion up to
5 g over 30-60 min
( Vitamin B6 )
Methanol Ethanol 0.6 g/kg in D5W IV (PO) over
30-45 min, followed initially by
110 mg/kg/h to maintain a
blood level of 100-150 mg/dl

Methemoglubinemia Methylen blue 1-2 mg/kg ( 0.1-02 ml/kg 1 %

solution ) IV over 5 min ,
repeated in 1 h prn

Ethylen glycol -Fomepizole -15 mg/kg IV, followed by 10

mg/kg IV q12h for 4 doses,
(EG) ( 4-mp )
followed by 15 mg /kg IV the
( Antizol )® EG level <20 mg/dl
- Ethanol - 0.6 g/kg in D5W IV (PO) over
30-45 min, followed initially by
110 mg/kg/h to maintain a
blood level of 100-150 mg/dl
 Poison Antidote Adult dosage
toxic sign
Heavy metals Chelators :
( arsenic, copper, gold, - Calcium disodium - 1 g IV ( IM, PO ) prn
mercury,… ) edetate ( EDTA)
- Dimercaprol ( BAL ) - 2.5-5 mg/kg IM q4-6h

-Penicillamine -250-500 mg PO q6h

-2,3Dimercaptosuccinic - 10 mg/kg PO tid × 5d

acid ( DMSA,Succimer) , then bid × 14 d

Benzodiazepines Flumazenil 0.2 mg IV in 30 sec, followed

by 0.3 mg at 1 min intervals to
( Diazepam,…)
a total dose of 3 mg

Carbon monoxide Oxygen 100 % , hyperbaric

 Alphabetical Table of Principal Poisons With
Antidotes For Immediate Use.
• POISONS. ANTIDOTES.
• ABSINTHE.—Give an active emetic; then flaxseed tea freely; stimulate.
• ACETATE OF LEAD.—Same as SUGAR OF LEAD.
• ACETIC ACID.—Same as CITRIC ACID.
• ALCOHOL.—Treat by emetics, hartshorn and external warmth. See page 1339.
• ALKALI, VOLATILE.—Drink freely of water with vinegar or lemon juice in it.
• AMMONIA.—Lemon juice, diluted vinegar or acetic acid.
• AQUA FORTIS.—Magnesia or soap dissolved in water, every two minutes.
• ARSENIC.—Give prompt emetic of mustard and salt—tablespoonful of each.
Follow with sweet oil, butter or milk.
• BED-BUG POISON.—Give milk or white of eggs in large quantities.
• BELLADONNA.—Active emetic; stimulate.
• BITTER ALMONDS—Same as PEACH KERNELS.
• BLUE VITRIOL.—Same as SULPHURIC ACID.
• CANTHARIDES.—Evacuate stomach; give mild drinks.
• CARBOLIC ACID.—Give flour and water, or other glutinous drinks.
• CARBONATE OF SODA.—Prompt emetic; soap or mucilaginous drinks.
• CAUSTIC POTASH.—Drink freely of water with vinegar or lemon juice in it.
• CAUSTIC SODA—Drink freely of water with vinegar or lemon juice in it.
• CHEESE.—Same as MILK.
• CHLORAL HYDRATE.—Cold water on head and face; artificial respiration; galvanic
battery.
• CHLORIDE OF LIME—Give acids; evacuate bowels; stimulate.
• CHLOROFORM.—Emetic of tablespoonful of mustard in warm water. Follow with
stimulating treatment.
• CITRIC ACID.—Chalk or magnesia water; flaxseed tea; lime water.
• COAL GAS.—See GAS.
• COBALT.—Prompt emetic; soap or mucilaginous drinks.
• COPPERAS.—Prompt emetic; soap or mucilaginous drinks.
• CORROSIVE SUBLIMATE.—Milk or white of eggs, freely.
• CREOSOTE.—Starch or flour mixed with water; or white of eggs and milk; or
evacuate stomach with an emetic.
• DIGITALIS.—Evacuate; lie prone; stimulate.
• ERGOT.—Evacuate; give purgatives; stimulate.
• ETHER.—See CHLOROFORM.
• FISH.—Emetic, followed by saline purgatives and alkaline drinks; or promptly
evacuate stomach and bowels, and then stimulate.
• FOWLER'S SOLUTION.—Prompt emetic of mustard and salt— tablespoonful of
each. Follow with sweet oil, butter or milk.
• GAS.—Remove patient to air, use artificial respiration, apply heat to extremities;
send for doctor.
• HAIR OF CATERPILLAR.—Apply cloths saturated with camphor. Don't rub.
• HONEY, POISONOUS.—Black coffee, smell of camphor, and rub with same.
• ICE CREAM.—Same as MILK.
• IODINE..—Starch, flour, or arrowroot, mixed with water.
• IVY, POISON.—Same as SUMACH. See page 1394.
• LEAD WATER.—Milk or white of eggs in large quantities.
• LEAD, WHITE, RED, LITHARGE.—Prompt mustard or salt emetic, then castor oil;
heat to bowels.
• LIME.—Vinegar or lemon juice, then starch water.
• LUNAR CAUSTIC.—A strong brine of salt; then milk and sweet or castor oil.
• LYE.—Give vinegar or oil.
• MAD-DOG BITE.—Tie band tightly around limb above wound; cut out and cauterize wound;
apply antiseptic dressing; give purgative and warm drinks; send to Pasteur Institute.
• MATCHES—See PHOSPHORUS.
• MEATS, PUTREFIED.—Emetic, followed with vinegar or lemon juice.
• MERCURY.—White of eggs freely; afterwards evacuate; mild drinks.
• MILK.—Cleanse stomach and bowels; apply heat; stimulate.
• MORPHINE.—Strong coffee, followed by ground mustard or grease in warm water to produce
vomiting; keep in motion.
• MURIATIC ACID.—Magnesia, or soap dissolved in water, every two minutes.
• MUSHROOMS.—Same as TOADSTOOLS.
• NICOTINE—Same as TOBACCO.
• NIGHTSHADE.—Same as BELLADONNA.
• NITRATE OF SILVER.—Give common salt in water, freely.
• NITRE.—An emetic, then drinks of barley water, followed with castor oil.
• NITRIC ACID.—Same as AQUA FORTIS.