Poisoning Acute poisoning accounts for ~1% of hospital admissions in the UK. In developed countries, intentional self-harm using pre- scribed or ‘over-the-counter’ medicines is most common, with Paracetamol, antidepressants and drugs of misuse being the most frequently used. Poisoning is a major cause of death in young adults, usually before hospital admission. Accidental poisoning is also common in children and the elderly. In developing countries, self-harm with organophosphorus pesticides and herbicides is endemic, and frequently fatal. SSB Ne CO eee Triage obtain inormetin about item History The diagnosis of poisoning is usually apparent from the history, although occasionally patients may conceal information, or exagger- ate or deliberately mislead staff. Try to establish:ono Oe a Pm) € 4 8744691626703587... © Yarcay medical conditions? In envenomed patients, establish: + When was the patient exposed to the bite/sting? « What did the causal organism look like? * How did it happen? * Were there mul- tiple bites/stings? * What first aid was given? + What are the patient's _ MTSU babar sha = p= Puplisizo f -@ corsair signs sat cogs eenans BS Sg Ancor, lahat aithoressarin. @ exrapyramida signs aconot apes 28 Prenahazies snanetaminas atperaa, | Reaieatory rate 9 J Ray CNS ceprssant cra Rees os tenzedosepies t wereased slopes Sragen causa ‘rethaemogiotaemis (25 apuore, am mie POISONING + 4 Biood pressure oes BN No ecm mas Sar peers Seca ce) eae Baconiyhas Sum fhant Seckers, ops ‘ight upper quacrant aa | ep NOAOs sala Rhsbdomyotyie | Body temperate eg Ampbaumines, ype and evening ‘atens ‘euteny orton rene ‘bre ealojaiee petra SRYCNS copressan, 33 opoeschorpromaane Noodle racks Daag of misuse ep, Ml O <Rech nos im | € 4 _8744691626703587. eS KAAGAZ Psychiatric illness (depression, schizophrenia) Male sex Living alone Recent bereavement, divorce or separation Suicide nate written ‘Age >45 Unemployment Chronic physica i health Drug or alcohol misuse Previous attempts (violent method) symptom? Do te have ter etl conditions rule teat ments, us similar episodes or known allergies? Clinical examination (p. 34) POISONING . ary ra ins. The Glasg s. Th + wei When patients are unconscious and no history is available, other causes of coma must be excluded (especially meningitis, intracere- bral bleeds, hypoglycaemia, diabetic ketoacidosis, uraemia and encephalopathy). Certain classes of drug cause clusters of typical signs, e.g, cholinergic or anticholinergic, sedative or opioid effects, which can aid diagnosis. Investigations Drug levels are a useful to guide treatment for some specific toxins, e.g. paraceta- mol, salicylate, iron, digoxin, carboxyhaemoglobin, lithium and theoplyline. SRE aS ee eS Psychiatric assessment for suicide are shown in Box 4.1 PDF TOOLS ‘nlcnaculants (ea warfarin) Vitamin K fresh fin7an nlacma Ul oO <sRech Roa me | € 4 _8744691626703587. eS KAAGAZ ‘Anticoagulants (@.9. warfarin) Vitamin K, fresh frozen plasma Bradrenacoptor antagonists NW glucagon, adrenaline (epinephrine) (beta-blockers) Calcium channel blockers Calcium gluconate, calcium chlride, glucagon Cardiac glycosides, e.g. digoxin Digoxin-specitc antibody fragments (Fa) =) | Cyanide Oxygen, doobaltedetate, nitrites, sodium ‘hiosulphate, hyéroxocobalamin © | Ethylene glyeolmethanol Ethanol, fomepizole 2 | ‘ron sats Desterroxamine 3 Lead DDMSA, DPS, cisodium calcium edetate & | Mercury MPs S | Opioids Naloxone © | Organophosphorus ‘opine, oximes (¢.9 pralidoxime) insecticides, nerve agents Paracetamol N-acetyleysteine, methionine iole-bowel irrigation with polyethylene glycol can be used for toxic ingestions of iron, lithium and theophylline, or to flush out packets of illicit drugs. Urinary alkalinisation using IV sodium bicarbonate enhances elimination of salicylates, methotrexate and the herbicide 2,4-D. SINE sis as NL) Paracetamol (NAQ) given IV (orally in sor tries), (Fig. 4.1). A patient presenting > rs after ingestion should have immediate NAC administration, which can later be stopped if the paracetamol level is below the treatment line. If a patient presents >15 hrs after ingestion, LFTs, prothrombin PDF TOOLS Significant amol ody weight Ul oO <Rech os Core SAVE TO € 4 _8744691626703587. KAAGAZ 5 g z 3 zal 3 gs i a 4 12 Time since ingestion (hrs) 1 evel is abo diver Fig, 4.1 The management of 2 paracetamol overdose patient. ratio (or INR) and renal function tests should be performed, the antidote started, and a poisons information centr d for advice. multiple paracetamol ingestions have taken place over time (a gered overdose), plasma paracetamol concentration will be uninter- pretable. NAC may still be indicated, although treatment thresholds vary between countries. 37 PDF TOOLS Ul oO <SRech Oa me | € 4_8744691626703587... ~ GAYE TO KAAGAZ Salicylates (aspirin) ‘Symptoms of salicylate overdose include nausea, vomiting, tinnitus and deafness. Direct stimulation of the respiratory centre produces hyperventilation. Signs of serious poisoning include vasodilation with sweating, hyperpyrexia, metabolic acidosis, pulmonary oede- ma, renal failure, agitation, confusion, coma and fits. ‘Activated charcoal is useful within 1 hr of ingestion. Plasma sal cylate concentration is measured 2 hrs after ingestion in sympto- ‘matic patients, then repeated because of continued drug absorption. Concentrations >500 mg/L. are serious and those >700 mg/L. are life-threatening. Dehydration should be corrected by careful fluid replacement, and metabolic acidosis treated with sufficient IV sodium bicarbonate (8.4%) to normalise [H"]. Urinary alkalinisation is indicated for adult patients with salicylate concentrations >500 mg/L. Haemodialysis should be considered if serum salicylate is >700 mg/L, there is resistant metabolic acidosis, or severe CNS effects (coma, convulsions) are present. POISONING Non-steroidal anti-inflammatory drugs Non-steroidal anti-inflammatory drug (NSAID) overdose usually causes only minor GI upset, inciuding mild abdominal pain, vomit- ing and diarrhoea. Activated charcoal and symptomatic treatment is usually sufficient. Rarely, patients have convulsions; these are usually self-limiting and seldom need treatment beyond airway pro- tection and oxygen. Antidepressants Tricyclic antidepressants (TCAs) in overdose: Cause anti- cholinergic, sodium. channel-blocking and a-blocking effects. Life-threatening complications include coma, hypotension and arrhythmias, such as ventricular tachycardia/ fibrillation or heart block. Activated charcoal is useful within 1 hr of ingestion, ECG. monitoring is needed for at least 6 hrs. QRS or QT prolongation indicates risk of arrhythmia and should be treated with IV sodium. bicarbonate (8.4%). Selective serotonin re-uptake inhibitors in overdose: Cause nausea, tremor, insomnia and tachycardia but rarely lead to serious arrhythmia, and supportive treatment is usually sufficient. Lithium in overdose: Causes nausea, diarrhea, polyuria, weak- ness, ataxia, coma and convulsions. Charcoal is ineffective and haemodialysis is used in severe cases. Cardiovascular medications Beta-blockers: Cause bradycardia and hypotension. Overdose is treated using IV fluids, with atropine or isoprenaline to counteract, bradycardia. Calcium channel blockers: Cause hypotension and heart block in overdose. IV fluids and calcium supplements may be effective; insulin/ dextrose infusions or pacing are also used in resistant cases. aarti Digoxin poisoning: Usually accidental or due to renal failure, ECG Ul oO <sR ech oa rm | € 4_8744691626703587... ~ GAYE TO KAAGAZ Digoxin poisoning: Usually accidental or due to renal failure, ECG monitoring is needed, as bradycardia or ventricular arthythmias may occur. Digoxin-specific antibody fragments should be adminis- tered if serious arrhythmias occur. Antimalarials Chloroquine: Toxic in overdose, ti and diazepam infusions may be protective. and enor In age overdoses, ataxia, come, respiratory depression, haemoli can occur. Treatment is with Antidiabetic agents POISONING though insulin is non-toxic if ingested. The onset and duration of hypoglycaemia vary, but can last for several days with the longer-acting agents such as isophane and lente insulins. Metformin overdose can cause lactic acidosis, particu- larly in elderly patients and those with renal or hepatic impairment, or if co-ingested with ethanol, when there is a significant mortality rate. Hypoglycaemia should be corrected urgently with 50 mL. IV 50% dextrose, or with a sugary drink if the patient is conscious. This should be followed by an infusion of 10% or 20% dextrose titrated to the patient's blood glucose to prevent further hypoglycaemia. Blood glucose and U&tEs should be checked regularly. Pass Cannabis Cannabis (grass, pot, ganja, spliff, reefer) is commonly smoked with tobacco or eaten. In low doses, cannabis produces euphoria, perceptual alterations and conjunctival injection, followed by relaxation and drowsiness, hypertension, tachycardia, slurred speech and ataxia. High doses can produce hallucinations and psychosis. Ingestion or smoking, rarely results in serious poisoning, and supportive treatment is nor- mally sufficient, Benzodiazepines Taken alone, benzodiazepine overdoses are remarkably safe but benzodiazepines can enhance CNS depression when taken with other drugs, including alcohol. ‘Common symptoms are drowsiness, ataxia, dysarthria, nystag- mus and confusion. Respiratory depression and hypotension may 39 PDF TOOLS occur with severe poisoning, especially after IV use of short-acting, agents. Activated charcoal is useful within 1hr of ingestion. Conccione level rocniratory rata and OQ. eatiration chanld he Ul O <shee Oa rm | € 4 8744691626703587... “© farcas Digoxin poisoning: Usually accidental or due to renal failure, ECG monitoring is needed, as bradycardia or ventricular arthythmias may occur. Digoxin-specific antibody fragments should be adminis- tered if serious arrhythmias occur. Antimalarials Chloroquine: Toxic in overdose, causing nausea, agitation, convul- sions, hypotension and arrhythmias. ECG monitoring and correc- tion of arrhythmias are essential, and diazepam infusions may be protective. Quinine: Deaths from quinine overdose have been reported after ingestion of only 1.5 g in adults and 900 mg in children. Symptoms include visual loss, nausea, vomiting, tinnitus, deafness, headache and tremor. In large overdoses, ataxia, coma, respiratory depression, haemolysis, hypotension and arrhythmias can occur. Treatment is with activated charcoal and management of fits and arrhythmias. Antidiabetic agents Sulphonylureas, meglitinides and parenteral insulins can all cause hypoglycaemia in overdose, although insulin is non-toxic ifingested. ‘The onset and duration of hypoglycaemia vary, but can last for several days with the longer-acting agents such as isophane and lente insulins. Metformin overdose can cause lactic acidosis, particu- larly in elderly patients and those with renal or hepatic impairment, or if co-ingested with ethanol, when there is a significant mortality rate. Hypoglycaemia should be corrected urgently with 50 mL. IV 50% dextrose, or with a sugary drink if the patient is conscious. This should be followed by an infusion of 10% or 20% dextrose titrated to the patient's blood glucose to prevent further hypoglycaemia. Blood glucose and U&tEs should be checked regularly. Pass Cannabis Cannabis (grass, pot, ganja, spliff, reefer) is commonly smoked with POISONING Benzodiazey b 39 PDF TOOLS occur with severe poisoning, especially after IV use of short-acting, agents. Activated charcoal is useful within 1hr of ingestion. Conccione level rocniratory rata and OQ. eatiration chanld he Ul O <shee Oa me | € 4_8744691626703587... ~ GAYE TO KAAGAZ ; = ul within Thr of ingestion. ‘onscious level, respiratory rate and O; saturation should be observed for >6 hrs after a substantial overdose. Flumazenil is a specific benzodiazepine antagonist that increases conscious level, but it carries the risk of convulsions and is contraindicated in those who have co-ingested TCAs, o have a history of seizures. Cocaine ises at high temperature and produces a rapid intense effect when smoked, sympathomimetic effects, including tachycardia and mydriasis, are common; and serious complications, including coronary artery spasm, myocardial infarction (even with normal coronary arteries), ventricular arthyth- mias, convulsions, hypertension and stroke, may occur within 3 hrs of use. All patients should be observed with ECG monitoring for >4 hrs, ST elevation is common and troponin T is a useful marker of myocardial damage. Benzodiazepines and IV nitrates should be used to treat chest pain or hypertension but B-blockers should be avoided. Coronary angiography may be required and acidosis should be corrected. POISONING Amphetamines mine (‘crystal meth’) (MDMA, ecstasy). Tolerance is common, leading regular users to sel ively higher doses. C fe ‘ small proportion of patients who have taken ecstasy develop hyponatraemia, usually through drinking excessive amounts of water in the absence of sufficient exertion to sweat it out. Management is supportive and directed at complications. Gamma hydroxybutyrate and gamma butyrolactone Gamma hydroxybutyrate (GHB) and gamma butyrolactone (GBL) are sedative agents with psychedelic and body-building effects. Users drink GHB solution until they achieve the desired effects. Toxic features include sedation, coma, hallucinations and hypo- tension. Nausea, diarrhoea, vertigo, tremor, myoclonus, extrapy- ramidal signs, fits, metabolic acidosis and hypokalaemia may also PDF TOOLS occur. The sedative effects are potentiated by other depressants, eg. alcohol. Coma usually resolves spontaneously and abruptly within Ul oO <shee Oa me | € 4 _8744691626703587. eS KAAGAZ occur. The sedative effects are potentiated by other depressants, e.g. alcohol. Coma usually resolves spontaneously and abruptly within hours. Activated charcoal is useful within 1 hr of ingestion. All patients should be monitored and supported for 22 hrs. p-Lysergic acid diethylamide D-Lysergic acid diethylamide (LSD) is a synthetic hallucinogen. It is usually ingested as small squares of impregnated absorbent paper, which are often printed with a distinctive design. Vision is affected most often, with heightened visual awareness of objects, especially colours, image distortion and hallucinations. Patients presenting to hospital usually do so because of a “bad trip’, with panic, confusion, vivid visual hallucinations or aggression, or after self-harm due to the psychosis. Patients with psychotic reac- jons should be observed in a quiet, dim room. Diazepam is useful if sedation is needed. Opioids r POISONING longation and torsades de poi ‘Management of opioid poisoning: The airway should be cleared and breathing supported if necessary. High-flow oxygen should be administered. ABGs should be performed to check the adequacy of ventilation. Endotracheal intubation can often be avoided by prompt administration of the opioid antagonist naloxone. It should be used as a bolus dose (0.4-2 mg IV in adults, repeated if necessary) until the level of consciousness and respiratory rate increase and the pupils dilate. An infusion of naloxone may be needed because its half-life is much shorter than the half-lives of most opioids, but may precipitate withdrawal in chronic users. Opioid withdrawal: Can start within 12 hrs and causes intense craving, rhinorrhoea, lacrimation, yawning, perspiration, shivering, piloerection, vomiting, diarrhoea and abdominal cramps. Exami- nation reveals tachycardia, hypertension, mydriasis and facial flushing. Body packers an a PDF TOOLS © condoms. Body stuffers attempt to conceal illicit drugs by swallow- ing them (often poorly packaged) to avoid arrest. Both risk acute Ul oO <shee OWN me € 4_8744691626703587... ~ GAYE TO KAAGAZ Body packers smuggle large quantities of illicit cocaine, heroin or amphetamines by swallowing packages wrapped in clingfilm or at condoms Boy tlle ate ean i rugs by sallow ing them (often poorly packaged) to avoid arrest. Both risk acute severe toxicity from package rupture. Packages may be visible on X-ray, CT or USS. Passage may be accelerated by whole-bowel irrigation TMS easly Alcohol consumption, associated with social, psychological and physical problems, constitutes misuse. The criteria for alcohol dependence, a more restricted term, are shown in Box 43. Approximately one-quarter of male patients in general hospital ‘medical wards in the UK have a current or previous alcohol problem. Availability of alcohol and social patterns of use appear to be the most important factors. Genetic factors predispose to dependence. The majority of alcoholics do not have an associated psychiatric illness, but a few drink heavily in an attempt to relieve anxiety or depression. Alcohol misuse may emerge during the patient's history, although, patients may minimise their intake. Withdrawal symptoms in those admitted to hospital are a common presentation, as a high alcohol intake cannot be sustained in this setting Consequences of alcohol misuse Acute and chronic effects of alcohol are summarised in Box 4.4. Social, psychiatric and cerebral effects are particularly damaging. Social problems: Include absenteeism, unemployment, marital tensions, child abuse, financial difficulties and problems with the law, such as violence and traffic offences. Psychological problems: Alcohol has acute depressant effects and chronic depression is common. Alcohol misuse is often implicated POISONING insuicide attempts. People who are socially anxious may use alcohol to relieve anxiety and develop dependence. Alcohol withdrawal increases anxiety. Alcoholic hallucinosis is a rare condition in which patients experience auditory hallucinations in clear consciousness. Symptoms of alcohol withdrawal (see Box 4.4) usually become maximal 2-3 days after the last drink, and can include seizures. ‘Narrowing ofthe drinking repertoire (restriction to one type of alcohol, 9. spirits) * Priory of crinking over other activites (salience) * Tolerance of effects of alcohol ‘Repeated withdrawal symptoms Relief of withdrawal symptoms by further drinking ‘Subjective compulsion to drink Reinstatement of drinking behaviour after PDF TOOLS 42 —_—.$A A} Ul O <shee Oa rm | SAVE TO € 4 _8744691626703587. KAAGAZ ‘Acute intoxication Emotional and behavioural disturbance ‘Medical problems ~ hypoglycaemia, aspiration of vomit, respiratory ‘depression; accidents and injuries sustained in fights Chronic effects ‘= Symptoms of withdrawal ~ restlessness, andety, panic attacks; autonomic symptoms — tachycardia, sweating, pupil dilatation, nausea, vomiting; delirium tremens ~ agitation, hallucinations, ilusios, delusions; seizures ' Neurological ~ peripheral neuropathy; cerebral haemorthage; cerebellar ‘degeneration; dementia ‘Hepatic - fatty change and cirrhosis; iver cancer * GI oesophagtis, gastritis; Mallory-Weiss syndrome; pancreatitis; malabsorption; oesophageal cancer; oesophageal varices ‘Respiratory ~ pulmonary TB; pneumonia, aspiration Skin ~ spider naevi; Dupuytren's contractures; palmar erythema; twlangiectasis * Gardiac — cardiomyopathy; hypertension * Musculoskeletal — myopathy, fractures POISONING Endocrine and metabolic ~ pseudo-Cushing’s syndrome; gout; hypoglycaemia Reproductive ~ hypogonadism; infertility; fetal alcohol syndrome ‘Psychiatric and cerebral ~ alcoholic hallucinosts; alcoholic ‘blackouts’; ‘Wernicke's encephalopathy; Korsakofts syndrome Delirium tremens is a form of delirium associated with severe alcohol withdrawal. It has a significant mortality and morbidity. Effects on the brain: Acute effects include ataxia, slurred speech, aggression and amnesia after heavy drinking, Established alcohol- ism may cause alcoholic dementia, a global cognitive impairment resembling Alzheimer's disease but which does not progress with abstinence. Indirect effects on behaviour can result from head injury, hypoglycaemia and_ portosystemic encephalopathy. Wernicke- Korsakoff syndrome is a rare brain disorder caused by thiamine (vitamin B,) deficiency that results from damage to the mamillary bodies, dorsomedial nuclei of the thalamus and adjacent grey matter. ‘The most common cause is long-standing heavy drinking with inad- equate diet. Without prompt treatment, acute Wernicke’s encepha- lopathy (nystagmus, ophthalmoplegia, ataxia and confusion) can progress to the irreversible Korsakoff’s syndrome (severe short-term memory deficits and confabulation). Management and prognosis Advice about the harmful effects of alcohol and safe levels of con- sumption is often sufficient. Altering leisure activities or changing, jobs may help, if these are contributing, Psychological treatment at specialised centres is used for patients who have recurrent relapses. Support is also provided by voluntary organisations such as 43 a iarrres Alcoholics Anonymous (AA) in the UK. Withdrawal syndromes can be prevented or treated with benzodiazepines. Large doses may be rantiivad fam diavanam 20 mad Himos dail tailed affngtar 5-7 dane Ul oO <shee Oa rm | SAVE TO € 4 _8744691626703587. KAAGAZ Alcoholics Anonymous (AA) in the UK, Withdrawal syndromes can be prevented or treated with benzodiazepines. Large doses may be required (e.g, diazepam 20 mg 4 times daily), tailed off over 5-7 days as symptoms subside. Prevention of the Wernicke-Korsakoff complex requires immediate use of high doses of thiamine (IV Pabrinex). There is no treatment for established Korsakoff’s syn- drome. Acamprosate may help sustain abstinence by reducing craving. Disulfiram is used with psychological support to deter patients from relapsing. Antidepressants and antipsychotics may be needed to treat complications. Relapse is common after treatment. CEUs) Carbon monoxide POISONING + fi poison should be checked in all patients and ABGs in serious cases. Hyperbaric oxygen may reduce the half-life of COHb further, although the logistical difficulties of transporting sick patients to hyperbaric chambers should not be under-estimated, and improved ‘outcome has not been proven. Organophosphorus insecticides and nerve agents PDF TOOLS The fatality rate following deliberate ingestion of OP pesticides in developing countries in Asia is 5-20%. Ul oO <shee OPN ome € 4 _8744691626703587. The fatality rate following deliberate ingestion of OP pesticides in developing countries in Asia is 5-20%. lowed by paralysis of limb, respiratory and sometimes extraocular muscles. Coma, fits and arrhythmias can complicate severe cases. Management is as follows: ficient atropine (0,6-2 mg IV, repeated every 10-25 mins until secretions are controlled) is life-saving, * Oximes, such as pralidox- ime (2 g IV over 4 mins, repeated 4-6 times daily), can reactivate phosphorylated ACHE and prevent muscle weakness, convulsions or coma if given early. Cost and unavailability restrict the use of oximes in developing countries. * Intensive cardiorespiratory support is usually required for 48-72 hrs. Intermediate syndrome: Occurs in 20% of cases 1-4 days after poisoning, Progressive muscle weakness spreads from the ocular and facial muscles to involve the limbs and ultimately causes respi- ratory failure. Onset is often rapid, but complete recovery is possible with adequate ventilatory care. Organophosphate-induced delayed polyneuropathy: This rare complication occurs ~2-3 wks after acute exposure. Degeneration of long myelinated nerve fibres leads to a mixed sensory/motor polyneuropathy with paraesthesiae and progressive flaccid limb weakness, which may progress to paraplegia. Recovery is prolonged and often incomplete. Poisonine $a) In large parts of South-east Asia and wit 7 it also occurs in the Middle East, and East and West Africa. Control of drinking water content is the key intervention. 48 PDF TOOLS ee A variety of species use venom either to acquire prey or to defend Ul oO < SAVE TO KAAGAZshee Oa me | POISONING + SAVE TO € 4 _8744691626703587. KAAGAZ d as a ee comm csi however, cases may occur anywhere from exotic venomous pets. Snake and scorpion bites are numerically the most important, but even bee and wasp stings can cause lethal anaphylaxis. Details of individual venoms are available at www.toxinology.com, Clinical effects of a bite or sting vary widely, and some bites contain no venom (‘dry bites’) Local effects: oxins ~ tissue necrosis. Management id and accurate history, examination and early intiation of treat- ‘ment are vital. Multiple bites or stings are more likely to cause major saturation, blood count, U&Es, CK and coagulation screen. © In remote locations: it may be useful to check blood held in a glass container for clotting at 20 mins. + Rapid administration of the species-appropriate antivenom. + Cardiovascular, respiratory and renal support: as required. + Treatment of specific coagulopathy. PDF TOOLS Ul oO <