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Poisoning and Overdose
• The adverse effects of plants, foods, chemicals or pharmaceutical agents on the body
• Poisoning by excessive dose
preschool age when children are exploring there environment • The second group is young adult age group.Two Peak Age Groups • The first group. when ingestion is a form or suicidal behavior .
General Assessment • Management of poisoning is primarily supportive – – – – – Basic Life Support (BLS) Level Of Consciousness (LOC) Airway Breathing Circulation • Pulse • Hemorrhage • Skin color • Skin temperature • Skin Condition – Redness .
what.History • • • • • • When. how much ? Why? Circumstances Drug history Psychiatric history Assess mental status and capacity .
Specific Medical Questions • Poisoning & Overdose History – Substance – When exposed/ingested – Amount – Time Period – Estimated weight .
Obtains SAMPLE History • • • • • • S = Signs and symptoms A = Allergies M = Medication P = Pertinent medical history L = Last oral intake E = Events .
Initial Symptoms of Poisoning • • • • • • Pain Fluid imbalance Water and electrolyte imbalance Acidosis Body temperature disregulation Malnutrition .
Signs and Symptoms of Poisoning • Central Nervous System Involvement – Convulsion – Coma – Hyperactivity. Delirium. and Mania • Hypoglycemia • Hypoxia and depressed respiration – Maintenance of Adequate Airway – Oxygen Administration – Pulmonary Edema .
Sign&Symptoms of Poisoning • Circulatory System Involvement – Circulatory failure or shock – Congestive heart failure – Cardiac arrest • Genitourinary Tract Involvement – Acute renal failure – Urine retention .
S&S of Poisoning • Gastrointestinal Tract Involvement – Vomiting – Diarrhea – Abdominal distention • Blood and Hematopoietic System Involvement – Methemoglobinemia – Agranulocytosis and other blood dyscrasias – Hemolytic reactions .
General Comments • Try and get as much history as possible including witnesses • People truly wanting to commit suicide often lie • Remember the ABCs: – Airway Clear mouth & throat. ABGs (Arterial BloodGas – Circulation Venous access. IV fluids if shocked • Examination . gag reflex – Breathing O2 saturation.
Investigations • Always check blood glucose. LFTs. bicarbonate • ECG. CXR (Chest X Ray) • Specific blood levels . • U&Es. • ALWAYS measure paracetamol & salicylate levels – Failure to diagnose & treat is negligent. glucose. • Send blood & urine for toxicology screening. clotting.
and acidosis – Control seizures • Monitor – TPR. BP. • General – Absorption – Elimination – Specific antidotes . ECG.Management • Supportive – Correct hypoxia. hypohyperthermia. Oxygenation. hypotension. dehydration.
ethanol. Absorption • Gastric lavage – Only if within 1 hour & life-threatening amount – Never for corrosives • Activated charcoal – 50 g single or repeated dose ( elimination) – Doesn’t bind heavy metals. acids .
Elimination • Multiple dose activated charcoal – Quinine. phenobarbitone • Diuresis • Urinary alkalinization – salicylates • Dialysis .
Drug Toxicology • • • • • • • Paracetamol Salicylates CNS depressants CNS stimulants Antidepressants Digitalis Organophosphates .
Paracetamol Overdose • Acetaminophen • Most common analgesic drug taken in overdose • Often found in combination with antihistamines. codeine Few symptoms or early signs • As little as 12g can be fatal • Hepatic and renal toxin – Centrolobular necrosis. jaundice • More toxic if liver enzymes induced or reduced ability to conjugate toxin .
opiates) • Volume of Distribution approx. antihistamines. anticholinergics.Pharmacokinetics • Tablets dissolve rapidly • Peak level 3-4 hours after ingestion – May be delayed in the presence of other drugs (eg. 1L/kg • Elimination half-life normally 1-3 hours – Increased to 4-6 hours or more after overdose .
Acetaminophen Metabolism ~ 45% P450 ~ 50% Glucuronidation (non toxic) ~ 5% Sulfation (non toxic) NAPQI Glutathione + NAPQI = nontoxic product N-acetylcysteine (NAC) Liver cell damage .
ADULT – (1) 150mg/kg IV infusion in 200ml 5% dextrose over 15 minutes. anaphylactoid reaction • Alternative is methionine PO (<12 hours) . then – (2) 50mg/kg IV infusion in 500ml 5% dextrose over 4 hours. wheezing.N-acetylcysteine • Supplies glutathione • Dosage for NAC infusion . then – (3) 100mg/kg IV infusion in 1000ml 5% dextrose over 16 hours • Side-effects – Flushing. hypotension.
glucose. However. clotting. Patients should be advised to return to hospital if vomiting or abdominal pain develop or recur. check creatinine and ALT before discharge. . paracetamol and salicylate levels – Activated charcoal • <8 hours – Start N-aceylcysteine if above treatment line – Patients are usually declared fit for discharge from medical care on completion of its administration. LFTs.Management • General measures including – U&Es. bicarbonate.
Management • >8 hours – Urgent action required because the efficacy of NAC declines progressively from 8 hours after the overdose – Therefore. if > 150mg/kg or > 12g (whichever is the smaller) has been ingested. without waiting for the result of the plasma paracetamol concentration • >24 hours – Still benefit from starting NAC . start NAC immediately.
aspirin toxicity remains an important clinical problem .Aspirin • Aspirin is a widely prescribed antiplatelet therapy for cardiovascular and cerebrovascular disease • When combined with the fact that aspirin is readily available.
Biochemical pathway inhibited by aspirin .
Pharmacokinetics • Rapidly absorbed in the stomach – Reach peak levels in 15-60 minutes • 90% bound to albumin in the blood at a dose of 10 mg/dL • 90% metabolized in the liver. 10% unchanged • T1/2 = 15-20 minutes • Metabolites and unchanged drug are filtered and secreted by the kidneys .
Toxicokinetics – Peak blood concentrations may be delayed 24 hours • 76% bound to albumin at a dose of 40 mg/dL – increased free drug in the blood • Hepatic enzymes become saturated and elimination follows zero-order kinetics – Functional half-life can be over 20 hours .
Diagnosis • Serum salicylate concentrations and concomitant arterial blood pH values can definitively confirm or exclude toxic salicylate levels .
correct acidosis and K+ If levels >500mg/L alkalinize urine (HCO3-) Levels > 700 mg/L before rehydration. glucose. and after 2hrs >700mg/L potentially lethal >500mg/L moderate-severe poisoning U&Es. bicarbonate • • • • Activated charcoal Rehydrate. monitor glucose.Management • General measures • Blood – – – – Salicylate level >2 hours. ABG. renal failure or pulmonary oedema consider haemodialysis .