INTRODUCTION
Poisoning is injury or death due to swallowing, inhaling, touching or
injecting various drugs, chemicals, venoms or gases. Accidental or
intentional poisoning from both licit and illicit substances can produce a
wide range of symptoms and clinical findings. Hence, history and physical
examination are of great importance in recognizing the poisoned patient.
Initial management should be focused on acute stabilization and
supportive care till the correct substance is identified. The plan of
management is to provide supportive care, prevention of poison
absorption, use of antidote wherever is indicated, and enhancement of
elimination techniques.
Whole-Bowel Irrigation is a decontamination technique that cleanses the
entire bowel. It aims to physically flush ingested toxins out of the
gastrointestinal tract before absorption.
PROCEDURES
WHOLE BOWEL IRRIGATION
A nasogastric (NG) tube should be placed, especially in children, to
ensure that an adequate amount of polyethylene glycol electrolyte solution
(PEG-ES) has been administered. Once placement of the NG tube is
confirmed, the PEG-ES can be administered. A commode should be
positioned by the patient's bedside, and the patient should be seated on it.
The entire procedure usually takes 4-6 hours.
TARGET TOXIN AND TOXICANTS
TOXINS AND OVERDOSE SUBSTANCES CLEARED BY WHOLE-
BOWEL IRRIGATION
 Iron
 Lithium
 Inorganic salts (K+)
 Metals (mercury, arsenic)
When is whole-bowel irrigation necessary?
Whole-bowel irrigation is uncommonly performed because it carries
significant risks in patients. This procedure is performed for the below
conditions:
 Prior to an intestinal surgery
 Ingestion or overdose of a significant or life-threatening amount
of sustained-release medications or drugs (sustained-release
potassium chloride)
 Ingestion of a significant or life-threatening amount of
medications that are not adsorbed by activated charcoal (AC),
or a situation in which no other intestine cleaning methods are
appropriate
Toxins Poorly Absorbed by Activated Charcoal
 Iron
 Lithium
 Inorganic salts (K+)
 Metals (mercury, arsenic)
 Fluoride
 Alcohols
 Glycoles (ethylene glycol)
 Alkali or acids
 Hydrocarbons
Ingestion of sustained-release or enteric-coated drug preparations
(theophylline, calcium channel antagonists, aspirin, etc.)
Removal of ingested packets of illicit drugs (body packers, drug “mules”)
- Mule: In the drug trade, a person who transports a drug by
internally concealing it. Also called a body packer.
Ingestion of large amount of drugs that tend to form concretions or
bezoars
-(kən-krē′shən) n. Medicine A solid mass, usually composed of
inorganic material, formed in a cavity or tissue of the body

Drugs that Commonly Form Concretions
 Salicylates
 Barbiturates
 Carbamazepine
 Enteric - coated tablets
 Sustained - release tablets
 Meprobamate
Treatment of suspected drug concretion (i.e. continual rise in
measurable toxin concentrations despite charcoal administration)
ADVANTAGES
WHOLE BOWEL-IRRIGATION
 Decontaminate the GI tract.
 Prevent absorption of ingested matter.
 Prevent faecal incontinence and chronic constipation.
Decontamination means the removal of dangerous substances. And so,
when executing whole bowel irrigation, GI decontamination happens
wherein there’s a removal of ingested toxin or drug from the GI tract in
order to: (a) decrease or prevent their absorption and (b) increase their
clearance or elimination. And since because we remove those dangerous
substances, of course, fecal are also being removed, thus, perhaps,
treating or giving relief to those people who are experiencing chronic
constipation. Additionally, according from the study of enenbein et al.
(1987), it is a safe decontamination procedure for acute drug ingestion.
DISADVANTAGE (LIMITATION/SIDE EFFECT) OF WHOLE BOWEL
IRRIGATION
SIDE EFFECT
 Nausea and vomiting
o The entire procedure takes 4-6 hours, Patients often
experience nausea and may vomit, in which case it
may be necessary to slow the infusion rate.
Alternatively, an antiemetic may be administered. The
procedure is stopped once clear rectal effluent is
seen or all drug packets have emerged.
CONTRAINDICATION
 To patients with compromised or unprotected airway
 Whole bowel irrigation could result in pulmonary aspiration.
 It should not be performed in the hypotensive or
hemodynamically unstable patient.
 Hemodynamic instability occurs when there's abnormal or
unstable blood pressure, which can cause inadequate blood
flow to your child's organs. Hemodynamic instability symptoms
may include. Abnormal heart rate (arrhythmias) Chest pain.
 It cannot also be performed to patient who has illues
 Ileus is a temporary lack of the normal muscle contractions of
the intestines.
 Ingestion of toxic substances that markedly slow
gastrointestinal motility (e.g., anticholinergics or opioids) may
cause an ileus, diminishing the ability to perform whole bowel
irrigation effectively.
CONTRAINDICATION

 Polyethylene glycol should not be used in patients with an

actual or suspected perforated bowel.
 Whole bowel irrigation is the infusion of polyethylene glycol
electrolyte lavage solution into the stomach at flow rates higher
than are otherwise commonly used. This technique can be used
to decontaminate the gastrointestinal tract after an acute toxic
ingestion or overdose.
 The administration of polyethylene glycol in a patient with a
bowel obstruction will result in vomiting with the potential for
aspiration.
 Intestinal perforation, defined as a loss of continuity of the
bowel wall, is a potentially devastating complication that may
result from a variety of disease processes. Common causes of
perforation include trauma, instrumentation, inflammation,
infection, malignancy, ischemia, and obstruction.
 The risk of whole bowel irrigation is quite small but the
procedure is not without effort, expense, and risk of
complications. In this light, the risk–benefit ratio would be high if
whole bowel irrigation were used to treat a nontoxic ingestion.
Hemodialysis is the process wherein a drug or toxin is removed through II. Specific (Mnemonic: "I STUMBLED")
a dialysis membrane from the bloodstream. It is used to remove  I = INH, Isopropyl alcohol, Isopropanol
accumulated uremic toxins, excess ions and water from the patient via the  S = Salicyclates
dialysate, and to supply (deficit) insufficient ions from the dialysate.  T = Theophylline, Tenormin (atenolol)
 U = Uremia
PROCEDURE  M = Methanol
HEMODIALYSIS  B = Barbiturates (e.g. Phenobarbital)
 L = Lithium
Hemodialysis is a procedure where a dialysis machine and a special filter  E = Ethylene glycol
called an artificial kidney, or a dialyzer, are used to clean the blood. To get  D = Dabigatran, Depakote (esp. if level >500)
the blood into the dialyzer, the doctor needs to make an access, or
entrance, into the blood vessels (arteries). This is done with minor The most common toxins removed by hemodialysis were lithium and
surgery, usually to the arm. The dialyzer, or filter, has two parts, one for ethylene glycol.
the blood and one for a washing fluid called dialysate.
LITHIUM
Hemodialysis is usually done 3 times per week for about 4 hours at a time
Lithium salts, particularly lithium carbonate, are frequently used to treat
TOXINS AND OVERDOSE SUBSTANCES CLEARED BY bipolar disorder and mania. Lithium poisoning, whether due to reduced
HEMODIALYSIS excretion by the kidneys or overdose, can cause permanent injury to the
nervous system.
I. General
 Low Protein binding (<80%) Hemodialysis is a process in which a person's blood is filtered outside of
 Small volumes of distribution (<1 L/kg) their body, by a machine, and then returned to the person's body.
 High water solubility Hemodialysis effectively removes lithium from the body, and has been
used to treat lithium poisoning for at least 40 years. However, it is not
 Low Molecular weight (<100 daltons)
known whether hemodialysis, performed in addition to standard therapy
 Non-ionized
with intravenous fluids, reduces or eliminates damage to the nervous
 Unstable Overdose patient of Unknown Ingestion
system.

Although the use of hemodialysis to remove lithium from patients with

lithium poisoning is logical, no randomized clinical trials support or
disprove a benefit from this therapy.
ETHYLENE GLYCOL

Ethylene glycol, like the rest of the alcohols (e.g, ethanol, methanol, and ADVANTAGES OF HEMODIALYSIS
isopropyl alcohol), has characteristics that allow for rapid removal with
hemodialysis. They all have low molecular weights, are hydrophilic, have HEMODIALYSIS
small Vd and rapidly equilibrate with the intravascular space. The drug
characteristics of these compounds are listed in Figure 8. Ethanol toxicity  Remove toxins from the body.
usually does not require hemodialysis because most patients will recover  Can be done at home.
with supportive measures alone.  Helps in balancing important minerals.

An advantage of hemodialysis is that it remove the toxins residing inside

the body with the use of dialyzer by cleaning or filtering the blood.
Hemodialysis remove excess water and metabolic wastes from the body,
and it balance important minerals such as sodium, potassium etc. by
preventing them from reaching hazardous levels. Also, according to the
National Kidney Foundation, hemodialysis can be done at home which is
very convenient to the patient.

DISADVANTAGE (LIMITATION/SIDE EFFECT) OF HEMODIALYSIS

CONTRAINDICATION

 Travel to a dialysis center may be required three times a week

 Patients may not be able to set their own treatment schedule
 Permanent access required; usually in the arm for adults and
the neck/chest area for children
 Needles are required to access a fistula
 Three different types of access can be placed for hemodialysis.
They are called a fistula, a graft, and a catheter.
Hemodialysis is very effective at clearing ethylene glycol and its
 A fistula usually allows you to have better, more efficient
metabolites. The clearance rate of ethylene glycol ranges between 200 –
dialysis than a line, because the blood can flow out quicker, so
250 ml/min depending on the filter and blood flow. Glycolate, which is the
you get more dialysis in your session. This is important for long
major toxic metabolite, has a half-life of up to 18 hours without
term health and survival.
hemodialysis but the half-life is reduced by a factor of 6 with hemodialysis.
 Access sites run the risk for infection
Patients with acidosis may therefore still benefit from hemodialysis even in
the face of a low serum ethylene glycol level if they have an anion gap
acidosis suggesting high glycolate levels.
CONTRAINDICATION HEMODIALYSIS
 Hemodialysis patients are at a high risk for infection because
the process of hemodialysis requires frequent use of catheters
or insertion of needles to access the bloodstream.
 Access site complications. Potentially dangerous complications
― such as infection, narrowing or ballooning of the blood vessel
wall (aneurysm), or blockage ― can impact the quality of your
hemodialysis. Follow your dialysis team's instructions on how to
check for changes in your access site that may indicate a
problem.
 Strict renal diet and fluid restrictions are required
 When you are on dialysis, your kidneys are no longer able to
keep the right balance of fluid in your body. They cannot
remove enough. That's why it's so important to limit how much
sodium (salt) and fluid you have between dialysis treatments.
SIDE EFFECT/ADVERSE EFFECT OF HEMODIALYSIS
 Low blood pressure (hypotension) - A drop in blood pressure is
a common side effect of hemodialysis. Low blood pressure may
be accompanied by shortness of breath, abdominal cramps,
muscle cramps, nausea or vomiting.
 Muscle cramps - Although the cause is not clear, muscle
cramps during hemodialysis are common. Sometimes the
cramps can be eased by adjusting the hemodialysis
prescription. Adjusting fluid and sodium intake between
hemodialysis treatments also may help prevent symptoms
during treatments.
 Itching - Many people who undergo hemodialysis have itchy
skin, which is often worse during or just after the procedure.
 Sleep problems - People receiving hemodialysis often have
trouble sleeping, sometimes because of breaks in breathing
during sleep (sleep apnea) or because of aching, uncomfortable
or restless legs.
SIDE EFFECT/ADVERSE EFFECT OF HEMODIALYSIS
 Anemia - Not having enough red blood cells in your blood
(anemia) is a common complication of kidney failure and
hemodialysis. Failing kidneys reduce production of a hormone
called erythropoietin (uh-rith-roe-POI-uh-tin), which stimulates
formation of red blood cells. Diet restrictions, poor absorption of
iron, frequent blood tests, or removal of iron and vitamins by
hemodialysis also can contribute to anemia.
 Bone diseases - If your damaged kidneys are no longer able to
process vitamin D, which helps you absorb calcium, your bones
may weaken. In addition, overproduction of parathyroid
hormone — a common complication of kidney failure — can
release calcium from your bones. Hemodialysis may make
these conditions worse by removing too much or too little
calcium.
 High blood pressure (hypertension) - If you consume too much
salt or drink too much fluid, your high blood pressure is likely to
get worse and lead to heart problems or strokes.
 Fluid overload - Since fluid is removed from your body during
hemodialysis, drinking more fluids than recommended between
hemodialysis treatments may cause life-threatening
complications, such as heart failure or fluid accumulation in your
lungs (pulmonary edema).
 Inflammation of the membrane surrounding the heart
(pericarditis).
 Insufficient hemodialysis can lead to inflammation of the
membrane surrounding your heart, which can interfere with your
heart's ability to pump blood to the rest of your body.
 High potassium levels (hyperkalemia) or low potassium levels
(hypokalemia)
 Hemodialysis removes extra potassium, which is a mineral
that is normally removed from your body by your kidneys. If
too much or too little potassium is removed during dialysis,
your heart may beat irregularly or stop.
 Amyloidosis.
 Dialysis-related amyloidosis (am-uh-loi-DO-sis) develops
when proteins in blood are deposited on joints and tendons,
causing pain, stiffness and fluid in the joints. The condition is
more common in people who have undergone hemodialysis
for several years.
 Depression - Changes in mood are common in people with
kidney failure. If you experience depression or anxiety after
starting, hemodialysis, talk with your health care team about
effective treatment options.