Teaching plan

Topic Lecturer
Management (3 lectures) Dr. Eman Mantawy
Cadiovascular toxicity Dr. Ahmed Esmat

Neurotoxicity Dr. Ahmed Esmat

Nephrotoxicity Dr. Ahmed Esmat

Heamtotoxicity Dr. Ahmed Esmat

Drug abuse (3 lectures) Dr. Reem Abo El Naga

Heavy metals Dr. Reem Abo El Naga

’ Management of toxicity
Emergency Management (Resuscitation)
(ABCD)

Clinical evaluation
(History & Physical Examination)

Lab Investigation

Decontamination

Enhance elimination

Supportive treatment

Antidote therapy
 Emergency
Management
Emergency Management (ABCD)

Airway

Dextrose ABCD Breathing

Circulation
 Airway
Airway management is a set of medical procedures performed to
prevent airway obstruction and thus ensure an open path between a
patient’s lungs and the atmosphere.
Causes:
Comatose patient:
- Airway obstruction by flaccid tongue
- Aspiration of gastric contents into tracheobronchial tree
- Respiratory arrest

Signs & symptoms of airway obstruction:

Dyspnea, air hunger & hoarseness, stridor, cyanosis, sweating & tachypnea
 Airway
How to get open Airway
1- Remove dentures (if any) saliva, vomitus, blood, etc. from the
oral cavity or finger sweep method

2- If no spinal injury: The head-tilt, chin-lift

technique: is performed by tilting the head backwards in
unconscious patients, often by applying pressure to the forehead
and the chin.

But if there is spinal injury: Jaw thrust technique would

be the initial method of choice. This is performed by physically
pushing the posterior aspects of the mandible upwards while
their thumbs push down on the chin to open the mouth. When
the mandible is displaced forward, it pulls the tongue forward
and prevents it from obstructing the entrance to the trachea
 Airway
3- Turning the patient to the recovery
(three-quarters prone) position. This allows
oral secretions and vomitus in the oro-pharynx to
drain out of the mouth.

4- Endotracheal or nasotracheal
intubation

5- Surgical airway management:

Layrngstomy
 breathing
 Assessment of breathing should include not just
whether the patient is breathing , but also if the
breathing is slow or fast.

 Any patient with abnormal breathing should be

provided with supplemetal oxygen and assisted
ventilation, either via a bag-valve mask or
positive pressure ventilation.

 The immediate need for assessed ventilation

depend on measuring arterial blood gases
(PaCO2>45mmHg; PaO2<70mmHg)
 circulation
 Assessment of circulation should include heart rate, blood pressure, and
peripheral circulation

 To maintain the circulation: Ideally, the systolic blood pressure (BP)

should be kept
 above 90 mmHg
 Vasopressors (dopamine and norepinephrine)
 Fluid IV bolus injection repeated again if no response
 The patient may require ECG monitoring
 If in shock, the patient should be maintained in the head -
down position
 Cns depression
 Acute poisoning is one of the most important factor inducing
coma
 Should differentiate between real comatose and
psychogenic or hysterical coma
- Slapping the face hard repeatedly
- Cotton pledges or sterile applicator tips soaked with ammonia
solution being into the nostrils

 Because most of comatose patients are due to overdose from

opiates, alcohol and hypoglycemic agents
Use Coma cocktail
◦ Dextrose (Hypoglycemics)
◦ Thiamine Wernicke–Korsakoff syndrome (WKS) induced by
alcohol due to thiamine deficiency
◦ Naloxone (Opiod antagonist)
 Clinical
evaluation
(History & physical
examination)
 history
 The primary aims of taking the history are to:
• Confirm that poisoning has occurred
• Identify the substance or substances involved

 If the patient is unconscious or unable to give any form of history, This information may
be obtained from the patient, family members, friends, rescuers, or bystanders

The following are important to establish when taking the history

 Poisoning-related information
- type of drug or poison ingested
- dosage and amount
- time of ingestion
- Source of medication :Did the patient ingest their regular medication?
Did the medication belong to someone else?
 history
 Accidental or intentional poisoning
- presence of suicide intent
- depression
- suicidal thoughts
- substance abuse

 Medical history
- Chronic diseases
- past suicide attempts
- drug allergy
- Other drug use : Drug-drug interactions

 Situational history
- where the patient was found
- the circumstances under which the patient was found
- presence of pills, drugs or empty medicine/ bottles in the area
 Physical examination
Full physical examination should be carried out for all patients. This consists of
a detailed head to-toe examination. In a toxicological patient, particular
attention may should be paid to the following:

 Check clothing for objects or substances

 Odour of breath on the patient

 Assess general appearance of pt: Agitation or confusion

 Asses the temperature : Hypo or Hyperthermia

 Exam skin for cyanosis or flushing, excessive sweeting

 Exam eyes for pupils size or increased lacrimation

 Physical examination
 Oropharynx for increase salivation or excessive dryness

 CVS: rhythm, rate, regularity

 Lungs: bronchorrhea or wheezing

 Abdomen: bowel sounds, tenderness or rigidity

 Extremeties: fasciculation, tremor

 Neuro: reflexes, muscle tone coordination, cognition

 Check for evidence of drug abuse e.g. needle marks

 Check for evidence of suicidal intent, e.g. cuts on the wrists

 Physical examination
Toxidrome
A toxidrome is a group of signs and symptoms associated with
overdose or exposure to a particular category of drugs and toxins.
Recognizing the presence of a toxidrome may help identify the toxin(s) or
drug(s) to which the patent was exposed, and the crucial body systems that
may be involved.
 Physical examination
Sympathomimetic Toxidrome
 Excess of catecholamines
 “Fight or Flight” response
 Dilated pupils, tachycardia, hypertension,
agitation/seizures, diaphoresis
 Cocaine, amphetamines, caffeine,
theophylline are examples of sympathomimetic
agents
 Physical examination
Cholinergic Toxidrome
 Excess of Acetylcholine
 DUMBLES syndrome
Diarrhea Urination Miosis Bradycardia
Bronchospasm Lacrimation Emesis
Salivation, Sweating

 Seen in organophosphate and carbamate

insecticide poisoning
 Physical examination
Anticholinergic Toxidrome
 Acetylcholine activity is blocked at muscarinic receptors

 delirium , hallucinations, dry flushed skin, widely dilated pupils,

low grade fever, significant tachycardia

 Seen with many prescription and OTC agents including

antihistamines & TCAs
 Physical examination
Opioid Toxidrome

 Stimulation of opioid receptors

 Triad of miosis, CNS depression, and hypoventilation
 Agents that cause this include: heroin, morphine,
 LABORATORY
INVESTIGATION
 LABORATORY INVESTIGATION
A number of investigations that can be carried out that it contributes
to the identification of toxic gent and management of the patient
1- Arterial Blood Gases (ABGs)
Hypoventilation will result in an elevated PCO2 (hypercapnia) and a low
PO2(hypoxia). Thus PO2 may also be low with aspiration pneumonia or drug induced
pulmonary edema.

2- Electrocardiogram (ECG)

3- Kidney function tests : Creatine & BUN

4- Liver function test: ALT , AST & Albumin

 LABORATORY INVESTIGATION
5. Electrolytes
Acute poisoning can cause an imbalance in a patient’s electrolyte levels,
including sodium, potassium, chloride, bicarbonate, magnesium, and calcium
EX: Hyperkalemia in Digitalis overdose

 The anion gap represents the difference between anions and cations in the blood.
Anion gap = (Na + K) - (HCO3 + Cl)

The normal value for the anion gap is approximately 8 to 16 mEq/L.

High anion gap can indicate metabolic acidosis caused by an accumulation of acids in the blood.
Drugs, toxins, or medical conditions that can produce an elevated anion gap include salicylates,
 LABORATORY INVESTIGATION
6. Toxicology screens
A toxicology screen is a laboratory analysis of a body fluid or tissue to
identify drugs or toxins. Blood or urine samples are used more
frequently. Saliva, spinal fluid, and hair may be analyze,.Each screen
tests for specific drugs or agents.

 The sample must also be properly collected, and there must be a laboratory near enough
to obtain results quickly. The test sample must be collected while the drug or its
metabolite is in the body fluid or tissue used for testing.

 For example, cocaine is a rapidly metabolized drug; however, its metabolite,

benzoylecgonine, can be detected in the urine for several hours after cocaine use
Decontamination
 DERMAL EXPOSURE
 Transfer the pt from toxic environment
 Remove the contaminated clothes, Wash the skin with copious amounts of warm
water for 15 to 30 minute water and non-germicidal soap,
 All towels and clothing should be put into hazardous waste bags
 Protective clothing (plastic goggles, latex gloves and a surgical mask) should be worn
to reduce the risk for toxicity while assisting with skin decontamination
 Important: Chemical neutralisation should not be attempted as there is a definite
risk of further damage from the chemical reaction.
Except for some cases:
Hydrofluoric acid magnesium sulphate or calcium gluconate
Oxalic acid calcium gluconate
Phenol mineral oil or other types of oil
 eye EXPOSURE

 Remove contact lenses, if present.

 Irrigate the eyes for at least 15 minutes with sterile normal

saline or sterile water and taking care not to cross contaminate
in uniocular injuries.

 Check the pH of the tears after irrigation. If the pH remains

abnormal, continue irrigation.

 The patient should then be sent to an ophthalmologist,

preferably within hours of the injury.
 INHALATION EXPOSURE

 A victim of an inhalation exposure should be

moved to fresh air as quickly as possible.

 The responder must also protect himself or

herself from the airborne toxin.
 gut EXPOSURE
A) Emesis
 Rarely indicated in the hospital
 The most commonly used is syrup of Ipecac (derived from root of a small
shrub; Cephaelis ipecacuanha)
 Active principle is Cephaeline, emetine & traces of psychotrine
 Mode of action
- Local activation of peripheral sensory receptors in GIT
- Central stimulation of CTZ
 gut EXPOSURE
A) Emesis
 Indications
• Conscious and alert person patient who has ingested a poison not more than 4-6 hr
earlier
• Large undissolved tablets or capsules are present
(reason: these are generally too large for removal by gastric lavage)
• The ingested substances are not well adsorbed by activated charcoal e.g. enteric-
coated or sustained release tablets

 Dose:
- 6 months to 1 year - 10 ml - 1 year to 12 years - 15 ml
- Above 12 years - 30 ml)
 Can be repeated after 20 -30 min The patient should be sitting up
 gut EXPOSURE
A) Emesis
 Contraindications:
- CNS depression-patients who are lethargic or unresponsive or are otherwise unable to protect
their airway adequately are at risk of pulmonary aspiration
- Very young (less than 6 months) or very old
- Pregnancy
- Heart disease or ingestion of cardiotoxic
- Time lapse more than 6-8hr
- Caustic ingestions-osophageal and oropharyngeal mucous membranes may be further damaged
if they are re-exposed to caustic solids or liquids upon emesis
- Seizures make patient at risk of aspirating gastric contents.
-Ingestion of petroleum distillates-systemic toxicity from low viscosity agents (e.g., mineral seal
oil) is low, but the risk of aspiration is high when vomiting is induced
 gut EXPOSURE
B) Gastric lavage
Fluid (usually normal saline) is introduced into the stomach through
a large-bore orogastric tube and then drained in an attempt to
reclaim part of the ingested agent before it is absorbed.

This is most effective in cases when ingestion of the poison was less than 1 hour
before commencing treatment, although a larger time frame is allowed for slow-
release formulations or drugs which slow gastric emptying.
 gut EXPOSURE
B) Gastric lavage
 Procedure

1- In patients with impaired consciousness, it will be

necessary to protect the airway with a cuffed endotracheal
tube.

2. Place the patient in the left lateral position to permit

pooling of gastric contents and to reduce the risk of
aspiration. His head should be lower than the rest of his body
to reduce the chances of accidental aspiration.
 gut EXPOSURE
B) Gastric lavage
 Procedure

3- Mark the length of the tube to be inserted (50cm for adult & 25 for child) & Lubricate the
inserting end with vasleine or glycerin

4. Once inserted, check the position of the tube to ensure that it is in the stomach and not the
trachea. The position must be confirmed prior to commencing lavage. This can be done by the
following manoeuvres:
a) placing the outer end in a glass of water. Active bubbling on expiration suggests that the tube is
in the trachea. In such a case, the tube should be removed and another attempt made to insert it.
b) testing aspirate with litmus paper to detect acid
c) listening for gurgle sound over epigastrum on pumping air.
 gut EXPOSURE
B) Gastric lavage
 Procedure

5. Lavage is carried out using aliquots of warm saline (38˚C) or plain water Administer 100 - 300
ml of lavage fluid via the tube (in children, administer 50 - 100 ml). Then, manually agitate the
stomach. After that, withdraw the fluid.

6. Repeat this until the lavage return is clear. Generally, anywhere from 5 to 20 L are required to
thoroughly cleanse the stomach.

7. Remember to save the aspirate for toxicology screening.

8. After completion of the lavage, activated charcoal may be administered via the orogastric
lavage tube.
 gut EXPOSURE
B) Gastric lavage
 Contraindications
- Unconscious patient unless intubated (risk aspiration)

- Caustic ingestion or hydrocarbons with a high aspiration potential

 Complications
- May potentially increased gastric delivery of tablets into small bowel
- Aspiration of gastric content (3%)
- Oesophageal rupture Perforation & bleeding
- Profound bradycardia and cardiac arrest in case of propranolol, Ca ch blockers
and other drugs affecting cardiac conduction (use atropine)
 gut EXPOSURE
C) Oral adsorbent
An adsorbent is a solid substance that has the ability to attract and hold
another substance to its surface (“to adsorb”). These are used to decrease
the absorption of the poison into the system.

- One of the more commonly used oral adsorbents is activated charcoal. Activated
charcoal is an effective nonspecific adsorbent of many drugs and toxins.
Activated charcoal adsorbs, or traps the drug or toxin to its large surface area and
prevents absorption from the GI tract

- Activated charcoal is a fine, black powder that is given as a slurry with water, either
orally or by nasogastric or orogastric tube, as soon as possible after the ingestion
 gut EXPOSURE
C) Oral adsorbent
 Indications:
- When both emesis and lavage are contraindicated
- After completion of emesis or lavage
- Time since ingestion is less than 1-2 hrs

 Dosage & adminsteration

For adults is 50 - 100

For children is as follows: 1 g / kg body weightin sorbitol to increase palatability
(Acceptable to the taste) , and serve as a cathartic or water
It can be taken orally or via a nasogastric tube
 gut EXPOSURE
C) Oral adsorbent
 Drugs that Activated Charcoal is Not Effective in
Adsorbing

• Acids and caustic alkalis

• Aromatic alcohols
• Heavy metals
• Iron
• Lithium
• Malathion
• Methylcarbamat
 gut EXPOSURE
C) Oral adsorbent
 Complications:
Constipation & mechanical bowel obstruction

 Repeated dose adminsteration:

- Restricted to few drugs: clonidine, carbamazepine, digoxin, phenytoin, salicylate

- Dose:
25-50gm/4hrs 25gm/2hrs 10-15gm/hr

- Stop after improvement of the patient or decreased plasma level (usually within 12
hrs)
 gut EXPOSURE
D) Cathartics
A cathartic is a substance that causes or promotes bowel movements. In
theory, cathartics decrease the absorption of drugs and toxins by
speeding their passage through the GI tract, thereby limiting their
contact with mucosal surfaces.
- This can be used to remove unabsorbed poisons or poisons that entered the intestines.
- Osmotic cathartic : Magnesium or sodium sulfate70% sorbitol (1 g/kg) or 10% Mg
citrate

- Caution is in order if repeated doses are administered since significant electrolyte and
fluid losses can occur due to profuse diarrhea.
 gut EXPOSURE
D) Cathartics
Osmotic cathartic usually given with activated charcoal

- They can also be used to quicken the passage of the charcoal toxin complex

- To neutralise the constipating effect of activated charcoal.

- This allows more of the charcoal to be administered and come into contact with
the poison.
 gut EXPOSURE
E) whole-bowel irrigation
The goal of whole-bowel irrigation is to give large volumes of a
balanced electrolyte solution rapidly isotonic nonabsorbable solutions
(polyethylene glycol) (1 to 2 L/hour) to flush the patient’s bowel
mechanically without creating electrolyte disturbances.

 Indications: Sustained or delayed release formulations Drugs NOT absorbed by charcoal

 End point is clear rectal effluent
 Contraindications: absent bowel sounds or obstruction
 Complications: bloating, cramping, rectal irritation
 Dose: 15-25 ml/kg/hr (4-5L), Given orally or by nasogastric tube
 questions?
- Coma Coktail ????
- Cholinergic Toxidrome
- Anion gab
- Why sorbitol is used with charcoal?
- How to open an airway?
THANK
YOU