PRINCIPLES OF

POISON
MANAGEMENT
 Poison
• Any substance liquid, solid or gas that impairs
health or cause death by its chemical action
when introduced into the body or onto the
skin
• Ingestion, inhalation ,lnjection, absorption
thru the skin
 Terms
• Poisoning
– Overdose of drugs, medicaments, chemicals and
biologic substances
• Self- poisoning and Parasuicide
– Deliberate ingestion of more than the therapeutic
dose of a drug leading to suicide (death)
• Accidental Poisoning
– Non-intentional ingestion or exposure
• Substance Abuse/dependence
– Maladaptive pattern of substance use with
impairment or distress as manifested three or more of
the following factors during a 12 month period.
– American Psychiatric Assoc criteria for drug
dependence:
• Tolerance
• Withdrawal symptoms
• Substance is taken with greater amount for a longer period
than prescribed
• Unsuccessful efforts to decrease use
• Continuous use despite knowledge of persistent harm
caused or exacerbated by the drug
 Ingested poisons
• Causes
– Overdose of medicine
– Accidental ingestion of children of medicines,
household chemicals
– Combining drugs and alcohol
– Storing poisons in drink containers
– Carelessness
• Absorption takes place in the intestine
 Inhaled poisons
• As a result of fire
• Longer the exposure without treatment, poorer the
prognosis
• Common Sources:
– Carbon monoxide
– Carbon dioxide
– Chlorine gas
– Fumes from liquid chemicals and sprays
– Industrial gases
– Incomplete combustion of natural gases
 Absorbed poisons
• Chemical or poisonous plants that enter thru
the skin
• Skin reactions: mild irritation, severe chemical
burns, redness, heat, itching, rash, burn
 Food poisoning
• Food contains bacteria or toxins that bacteria
produced is eaten
• Hard to detect since signs and symptoms vary
greatly
• Abdominal pain, vomiting, diarrhea,
hyperactive bowel sounds
 General Approach
• I. Emergency Stabilization
• II. Clinical Evaluation
• III. Elimination of the
poison
• IV. Excretion of absorbed
substances
• V. Administration of
antidotes
• VI. Supportive therapy and
observation
• VII. Disposition
 Emergency Stabilization
• Maintain airway and
breathing
• Maintain adequate
Circulation
• Treat convulsions
• Correct metabolic
abnormalities
• Treat the coma
 Emergency Stabilization
• Directed towards the life threatening
problems.
• Some patients have patent airways but
decrease in sensorium due to worsening
intoxication may compromise airway patency
• Hypoxia, ventilatory failure or bronchospasm
employs the use of airway adjuncts
 Emergency Stabilization
• Hypotension is corrected by giving IV fluids
such as Plain NSS, crystalloid solutions
• Pressor agents such as Dopamine or
Norepinephrine drips may be used if
hypotension is persistent
• Monitor urine output or CVP line
 Emergency Stabilization
• Treatment of convulsions
should be directed towards
the etiology or the effects
of the poison
• Maintain oxygenation at all
times
• Diazepam, phenytoin,
phenobarbital, pyridoxine
(B6) at 5-10 grams
 convulsions
• Direct effect of the poison
• Cerebral hypoxia
• Hypoglycemia
• Severe muscle spasm
• Withdrawal reactions with dependency
• Decrease seizure threshold
 Emergency Stabilization
• Hypokalemia vs. hyperkalemia
• Hypothermia vs. hyperthermia
• Hypoglycemia common among alcohol
intoxication and salicylates intoxication
• Hypocalcemia
• Acid-base abnormalities
 Emergency Stabilization
• Treatment of Coma
– Naloxone
– Glucose
– Thiamine
 Clinical Evaluation
• History taking:
– Time of Exposure
– Mode of exposure
– Intake of other
substances
– Circumstances prior to
poisoning
– Current medications
– Past Medical History
– Any home remedies
taken
 Physical Examinations
• Tachycardia vs. bradycardia
• Hypertension vs. hypotension
• Patients skin
• Breath odors
• Auscultation heart and lungs
• Check abdomen
• Complete neurologic examination
 Physical examinations
• Tachycardia • Bradycardia
– Iron – Propanolol
– Carbon monoxide – Clonidine
– Ethanol – Calcium blockers
– Amphethamines – Digitalis
– theophylline – antichonesterases
 Physical examinations
• Hypertension • Hypotension
– Cocaine – Clonidine
– Caffeine – Sedative hypnotics
– Amphetamine – Antidepressants
– Theophylline – Heroin
– nicotine
 Physical examination
• Skin
– Diaphoretic: organophosphate, amphetamines,
salicylates
– Jaundice : paracetamol and other hepatotoxic
drugs
– Dry/hyperpyrexia: atropine
– Flushing : alcohol and cyanides
 Physical examination
• Odor
– Bitter almond : cyanide
– Fruity odor : diabetic ketoacidosis
– Oil of wintergreen : methylsalicylates
– Rotten egg: hydrogen sulfide and sulfuric acid
– Garlic : arsenic, organophosphate
– Mothballs : camphor
 Physical Examination
• Glasgow Coma Scale (3-15)
– Verbal response
– Motor response
– Eye opening
• Check the pupils
• Trauma to the head for patients who fall after
loosing consciousness
 Pupillary reflex
• Miosis • Mydriasis
– Cholinergic / clonidine – Antihistamine
– Opiates – INH
– Organophosphates – Amphetamines
– Sedative hypnotics – Cocaine
– CVD
 Toxidromes
• Signs and symptoms when taken collectively
can characterize a suspected intoxicant
• Cholinergics (organophosphate, carbamates)
– Diarrhea, urination, miosis, muscle fasciculations,
bradycardia, bronchocostriction, lacrimation,
salivation
• Anticholinergics/antidepressants
– Hyperthermia, dry mucosa, flushed skin, dilated
pupils, confusion/delirium
 Toxidromes
• Narcotics/Opiates
– Miosis, bradycardia, hypotension, hypoventilation,
coma
• Sympathomimetics ( cocaine, amphetamines)
– Mydriasis, tachycardia, hypertension, hyper
thermia, seizures
 Toxidromes
• Sometimes may not present with the Classic
clinical findings
• Important to take them into consideration so
as to establish correct etiology
 Laboratory examinations
• Bedside toxicology
– Urine screening test
(Forrest Test)
• Specimen Collection
– Timing of specimen
collection
– Urine or blood
– CBC, FBS, BUN,
Creatinine, Electrolytes,
ABG, liver function test
– EKG, x-ray
 Elimination of the Poison
• External
Decontamination
– Discard patients
clothing/ bath patients
– Irrigate the eyes
– Use of Personal
protective equipments
 Elimination of the Poison
• Empty the stomach
– Emesis ( 1 hour)
• Contraindication:
depressed sensorium,
impaired gag reflex, late
pregnancy, cardiac
disease, ingestion of
caustics
– Gastric lavage(6-12
hours)
• Contraindication :
ingestion of caustics or
kerosene, convulsions
• Limit GI absorption
– Activated charcoal- decrease absorption of some
drugs
– Multiple Activated charcoal – drugs that undergo
enterohepatic circulation
– Demulcents : Egg albumin
– Neutralizing agents: sodium bicarbonate , starch,
diluted potassium permanganate
– cathartics
– Whole bowel irrigation
 Excretion of Absorbed substances
• Alkalinization therapy
– Ionizes weak acids
– Inhibits passive renal
reabsorption of non-
ionized molecules,
enhancing excretion
– 8.4% sodium
bicarbonate
• Acidification therapy
– Ionizes weak bases
– Ascorbic acid or
ammonium chloride
 Excretion of Absorbed Substance
• Dialysis and hemoperfusion
– Life threatening poisons , electrolytes and acid
base disturbances, dialyzable toxins with poor
body clearance and high plasma toxin
concentration with underlying kidney or liver
problems

• Forced Diuresis:
– 20% Mannitol
– Furosemide
 Antidotes

1. Inert complex formation: chelating agents

used for heavy metal poisoning
2. Accelerated detoxification: thiosulphate in
CN poisoning
3. Reduction in conversion to more toxic
compounds: ethanol in methanol and
ethylene glycol
 Antidotes
4. Competitive inhibiton at the receptor sites:
Naloxone and atropine
5. Bypass the effects of the poison: oxygen and
pyridoxine
6. Antibodies interacting with the poison:
Digoxin –specific antibodies
 Supportive therapy
• IVF given for maintainance and replacement
of fluid loss
• Monitor Blood and urine pH
• Intensive nursing care
• Treat metabolic disturbances: electrolyte
imbalances and hypoglycemia
• Monitor vital signs
• Monitor input and output
 Disposition
• Patients not admitted should be observed for
24 hours in the ER
• Psychiatric consult is important
• Poisoning in children, rule out possible child
abuse
• Family counseling and education while at the
ER until OPD follow-up
Thank you
CHEMICAL WEAPONS