Approach to the Poisoned

patient
Hydrocarbons and Volatile
Substances
Presented by: Tonyan Thompson

What is it that is not a poison?

All things are poison and nothing is without poison.
It is the dose only that makes a thing not a poison.
Paracelsus (1493-1541)

Poisoning
Poisoning occurs when exposure to a substance
adversely affects the function of any system within an
organism.
Given a large enough exposure, all substances have the
potential to be poisons.
The setting of the poison exposure may be
occupational, environmental, recreational, or medicinal.

ETIOLOGY
Poisoning may be intentional or unintentional.
Intentional:

Depression
Suicide
Homicide
Recreational drug abuse

Unintentional (accidental):
Common cause in children
Therapeutic error (e.g., double dose)
Recreational drug experimentation

Portals of Entry
Poisoning may result from varied portals of entry,
including:
inhalation, insufflation, ingestion, cutaneous and
mucous membrane exposure, and injection.
Historically most poisonings have occurred when
substances are tasted or swallowed.

Epidemiology
Poisoning is a significant global public health problem.
According to WHO data, in 2004 an estimated 346,000
people died worldwide from unintentional poisoning.
Of these deaths, 91% occurred in low- and middleincome countries.
In the same year, unintentional poisoning caused the
loss of over 7.4 million years of healthy life (disability
adjusted life years, DALYs).

Diagnosis Signs and Symptoms

Neurologic:

Lethargy
Agitation
Coma
Hallucinations
Seizures

Respiratory:
Tachypnea, bradypnea, apnea
Inability to protect airway

Cardiovascular:
Dysrhythmias
Conduction blocks

Vital signs:

Varies depending on toxic substance

Hyperthermia, hypothermia
Tachycardia, bradycardia
Hypertension, hypotension

Toxidromes
Toxidromes are collections of physical findings that
occur with specific classes of substances.
The identification of a specific toxidrome is helpful in
establishing potential toxic agents when the history is
not well defined.
Odors and skin findings may also provide useful clues.

Toxidrome

Representative
Agent

Most Common Findings

Potential
intervention

Cholinergic

Organophosphate
insecticides
Carbamate Insecticides

Muscarinic effects (Salivation,

lacrimation, diaphoresis,
nausea,
vomiting, urination,
defecation,
Bronchorrhea)
Nicotinic Effects (muscle
fasiculations and weakness)

Airway protection
and ventilation,
atropine,
pralidoxime

Anticholinergic

Scopolamine, Atropine

Altered mental status,

mydriasis,
dry flushed skin, urinary
retention,
decreased bowel sounds,
hyperthermia, dry mucous
membranes

Physostigmine (if
appropriate),
sedation with
benzodiazepines,
cooling, supportive
management

Opioid

Heroin, Morphine,
oxycodone

Central nervous system

depression, miosis, respiratory
depression

Ventilation or
naloxone

Sympathomim
etic

Cocaine, Amphetamine

Psychomotor agitation,
mydriasis,
diaphoresis, tachycardia,

Cooling, sedation
with
benzodiazepines,

History
Ask about the agent or drug, estimated amount or dose,
and route of exposure, as well as whether other individuals
were exposed. If possible, the patients intent should be
determined.
Corroborating information should be obtained from the
patients physician, prior medical records, witnesses, or
emergency medical technicians.
Ask about the environment in which the patient was found,
the presence of empty pill bottles or containers nearby, any
smells or unusual materials in the home, the occupation or
hobbies of the patient, and the presence of a suicide note.

Physical Exam
An organized approach is recommended
Undress the patient completely. Check the patients
clothing for objects still retained in the pockets or
substances hidden on the patients body (waistband,
groin, or between skinfolds).
Search clothing and belongings with care to avoid being
injured by uncapped needles or sharp objects.
Note any odors on the patients clothes.

Physical Exam
General appearance - note any agitation, confusion, or obtundation.
Skin Look for cyanosis or flushing, excessive diaphoresis or dryness,
signs of injury or injection, ulcers, or bullae. Bruising may be a clue to
trauma, a prolonged duration of unconsciousness,or coagulopathy.
Eyes - for pupil size, reactivity, nystagmus, dysconjugate gaze, or
excessive lacrimation.
Oropharynx - for hypersalivation or excessive dryness.
Lungs - Auscultate the lung fields to assess for bronchorrhea or wheezing,
Heart - for its rhythm, rate, and regularity.
Abdomen - note the presence of bowel sounds, enlarged bladder, and
abdominal tenderness or rigidity.
Extremities - for muscle tone and note any tremor or fasciculation.

Work up
Laboratory
Electrolytes, BUN/creatinine, glucose
Calculate anion gap: Na + (Cl + HCO3): Normal anion gap: 812
Serum Osmolar gap: Calculated osmolality = 2(Na+) +
glucose/18 + BUN/2.8 + ethanol (in mg/dL)/4.6.
Imaging
ECG for dysrhythmias or QRS/QT changes
CT of head for altered mental status not clearly due to toxin
Chest radiograph if suspected aspiration or pneumonia

Treatment - Initial Stabilization

ABCs:
Protect the airway - Endotracheal intubation as needed
Oxygenation - Administer a high concentration of
oxygen by mask
Ventilation
IV access
Connect the patient to monitoring Device - Pulse
oximetry, Cardiac monitor, BP, core temperature

 Hypotension:
Administer 0.9% normal saline IV fluid bolus.
Trendelenburg
Vasopressors for persistent hypotension

Bradycardia:
Atropine
Cardiac pacing

If altered mental status, administer coma cocktail: Thiamine,

D50W (or Accu-Chek), naloxone
Dextrose: D50W 1 ampule of 50 mL or 25 g (peds: D25W 24 mL/kg) IV
Naloxone (Narcan): 2 mg (peds: 0.1 mg/kg) IV or IM initial dose
Thiamine (vitamin B1): 100 mg (peds: 50 mg) IV or IM
considered after the medical history, vital signs, and immediately
available laboratory data are taken into account

Treatment - General
Decontamination
Gross Decontamination
Eye Decontamination
GI Decontamination

Gross Decontamination
Surface decontamination - completely undress patients
and thoroughly wash them with copious amounts of water.
If assistance required assisted by properly gowned staff.
The towels used to dry patients, patients clothing, shoes,
socks, watches, and jewelry should be handled as
contaminated material.
If possible, surface decontamination should occur prior to
the patients entry into the ED or other areas in the
hospital.

Eye Decontamination
Ocular exposures are treated with copious irrigation
using isotonic crystalloid, (normal saline or lactated
Ringers solution)
Typically at 1 to 2 L per eye depending on the agent.
Application of an ophthalmic anesthetic, such as 0.5%
tetracaine, may be necessary to relieve blepharospasm
and facilitate irrigation.
Use of lid retractors may be required for adequate
irrigation.

GI Decontamination
Methods used to decontaminate the GI tract have
potential benefits and risks that should be considered
prior to their use.

The three general methods of decontamination involve:

1. removing the toxin from the stomach via the mouth
2. binding it inside the gut lumen, or
3. enhancing transit through the intestines.

The specific toxin ingested, the time course, and the

patients clinical status determine the choice of
method(s) used

Gastric emptying - Emesis

Ipecac Syrup - Once the preferred technique for gastric
emptying, syrup of ipecac is no longer recommended in the ED.
Only in rare circumstances, such as immediately after ingestion
of a substance not expected to compromise the airway or lead
to altered mental status, hemodynamic derangement, or
seizure, or after recent ingestion of a highly toxic pill that is
known not to fit into the holes of the appropriately sized
orogastric tube
Typical dose - 15 mL for children 1 to 12 years of age and 30 mL
for adults, usually followed by sips of water.

Contraindications
Include ingestions that have the potential to alter
mental status, active or prior vomiting, caustic
ingestion, exposure to a toxin with more pulmonary
toxicity from inhalation than toxicity from GI absorption
(e.g., hydrocarbons), and ingestions of toxins that have
the potential for inducing seizures.
Rare complications of syrup of ipecac administration
include aspiration, Boerhaave syndrome, Mallory-Weiss
tear, and intractable vomiting.

Gastric emptying - Orogastric lavage

Consider in potentially lethal ingestions without known
antidote within 1 hr of ingestion.
Protected airway essential prior to lavage

Indications
Reserved for intubated patients with a depressed level
of consciousness from unknown substances or specific
indications such as highly toxic drugs.
May be useful to remove large quantities of alcohol in
patients with acute poisoning.

Method
Tube Size - should be of adequate size to recover pill fragments:
Adults - 36F to 40F (30 English gauge or 12- to 13-mm outside diameter)
Children - 22F to 24F (8- to 9-mm outside diameter)

Depth of Insertion of tube - depth that corresponds to the length from the patients chin to the
xiphoid process.
Positioning - on the left side (left lateral decubitus), bed tilted head down 20 degrees to reduce
the risk of pulmonary aspiration.
Carefully insert a lubricated lavage tube, correct tube positioning is assessed by insufflation of
air.
Siphon the gastric contents into a bucket, checking for tablet material; gentle pressure over
the stomach may facilitate drainage
Small amounts of fluid used to avoid stimulating the propulsion of gastric contents into the
duodenum.
- 200 to 300 mL in adults and 10 mL/kg in children

Body-temperature or at least room-temperature solutions is recommended. Gastric lavage

with cool solutions can induce hypothermia, The volume returned with lavage should be
essentially equal to that administered. Lavage is continued until the effluent becomes clear.
Before the tube is removed, activated charcoal should be instilled, if indicated

Contraindications
There are not adequate facilities and skills available to protect the
airway or deal with any complications that might arise.
Ingestion of pills that are known not to fit into the holes of the
orogastric lavage hose
The substance taken is relatively safe (e.g. benzodiazepines).
The substance ingested is safer in the stomach than anywhere else.
This applies to the following:
Oily or petroleum-based substances: relatively harmless in the stomach,
but accidental spillage into the lungs during lavage will cause a life
threatening pneumonitis.
Corrosives and caustics: may cause oesophageal perforation, especially
with the help of a lavage tube.

Complications
Insertion of the tube into the trachea
Aspiration
Esophageal or gastric perforation
Hypoxemia during the procedure

TOXIN ADSORPTION IN THE GUT

Activated charcoal
Mulitidose Activated charcoal

Activated charcoal
Agent most often used to decontaminate the GI tract
after toxic ingestion
Prepared by treating heated wood pulp, which creates a
large surface area to bind toxins
Works by adsorbing substances in the gut lumen via Van
der Waals forces, which makes them less available for
absorption into the tissues.
Most organic and some inorganic substances are
adsorbed by activated charcoal.

Not adsorbed
Metals (borates, bromide, iron, lithium)
Alcohols
Potassium
Potassium cyanide (poorly absorbed)
Hydrocarbons
Pesticides
Acids, alkali
Solvents

 The benefits of this technique include:

Its ability to decontaminate the gut without requiring
invasive procedures
The rapidity of its administration
and its overall safety in both adults and children
Clinical benefit is more likely if activated charcoal is
administered within 1 hour of toxin ingestion, but
potential benefit of administration after more than 1
hour cannot be excluded

Indications
Clear indications for administration of activated
charcoal are:
recent ingestion of any drug known to adsorb to it
or ingestion of an unknown agent by a patient with a
protected airway.

 Activated charcoal should be administered in a dose

equal to 10 times that of the poison to be absorbed.
An initial dose of 50100 g (or 1 g/kg for children) will
usually ensure that this ratio is met.
Activated charcoal is typically given in a slurry of water
or juice by mouth or through a nasogastric tube.
Oral or nasogastric tube administration

 Complications : include aspiration and intraluminal

impaction in patients with abnormal gut motility.
Contraindicated if caustic ingestion, unprotected airway,
or bowel obstruction
Adverse side effects of activated charcoal
administration include aspiration pneumonitis in the
unprotected airway as well as bowel obstruction and
perforation

Multidose Activated Charcoal

Used in toxic ingestions that are well absorbed by charcoal and
undergo enterohepatic circulation
Entails the repeated use of activated charcoal to enhance
elimination of ingested toxins.
Toxins with a long half-life and small volume of distribution are most
likely to have their elimination accelerated by repetitive doses of
activated charcoal.

theophyllines
carbamazepine
phenobarbital
quinine
dapsone

Multidose Activated Charcoal

Multidose activated charcoal is usually given with a first
dose of 1gram/kg body weight (50 to 100 grams)
followed by subsequent doses of 0.25 to 0.50 gram/kg
(12.5 grams) repeated one to three times at intervals
ranging from 1 to 4 hours.

Enhancement of Bowel Transit

Cathartics
Whole bowel irrigation

Cathartics
are generally used with activated charcoal to decrease
the transit time for the passage of the activated
charcoal and presumably the adsorbed toxin through the
GI tract.
The administration of a cathartic without charcoal has
no role in the management of the poisoned patient.
The most popular cathartics are 70% sorbitol (1
gram/kg) or
a 10% solution of magnesium citrate (250 mL for adults
and 4 mL/kg for children)

 Indications same as those for the administration of activated

charcoal.
When multidose activated charcoal is used, only the first dose is
accompanied by a cathartic to limit complications.
Complications - include nausea and abdominal pain, severe
volume depletion, electrolyte imbalances and fluid shifts, and
hypermagnesemia in patients with renal compromise.
Contraindications
Ingestion of a substance that will result in diarrhea, age of <5 years,
renal failure (magnesium-containing cathartics are contraindicated),
intestinal obstruction, and ingestion of any caustic material.

Whole Bowel Irrigation

no conclusive evidence that this intervention improves
the clinical outcome of poisoned patients.
May be effective for large ingestions of iron, heavy
metals, lithium, and other drugs poorly adsorbed by
activated charcoal.
It may also be useful for sustained release or entericcoated products not well adsorbed to charcoal.
Whole bowel irrigation can remove drug-filled packets or
other potentially toxic foreign bodies.

Whole Bowel Irrigation

performed by the instillation of large volumes of polyethylene
glycol in an osmotically balanced electrolyte solution that
produces rapid catharsis by mechanically forcing ingested
substances through the bowel at an accelerated rate
accomplished by infusing the polyethylene glycol solution
through a nasogastric tube.
end point of treatment is clear rectal effluent
Typical doses
1.5 to 2.0 L/h in adults
1 L/h in children 6 to 12 years of age
0.5 L/h in children <6 years of age

 Contraindications include:
preceding diarrhea
ingestion of substances that are expected to result in
significant diarrhea (except for heavy metals, because
these substances do not adsorb well to activated
charcoal)
bowel obstruction as evidenced by lack of bowel
sounds.
Complications - bloating, cramping, and rectal
irritation from frequent bowel movements

Enhanced Elimination
Urinary Alkalinization
Forced Diuresis

Urinary Alkalinization
Alkalinization promotes excretion of weakly acidic
agents through ion trapping at the renal tubules.
(Salicylates, Phenobarbital)
typically achieved by the administration of sodium
bicarbonate as either a 1 to 2 mEq/kg IV bolus or 3 to 4
mEq/kg IV infusion over 1 hour.
Urinary alkalinization is sustained by either intermittent
bolus or continuous infusion of bicarbonate.

 Urinary pH should be monitored frequently (every 15 to 30

minutes) until the urine pH is 7.5 to 8.5
Serum pH should not be allowed to rise above 7.5 to 7.55
Pronounced hypokalemia may result from this procedure
and should be corrected to maintain treatment benefit.
Hypokalemia induces the kidneys to reabsorb potassium
and excrete hydrogen ions, which inhibits the production of
alkaline urine.
This may result in relatively acidic urine when compared
with the serum pH.

Risks and Contraindications

Risks associated with urinary alkalinization include
volume overload (heart failure and pulmonary edema),
pH shifts, and hypokalemia.
Therefore, this procedure is contraindicated in patients
who cannot tolerate the volume or sodium load, are
hypokalemic, or have renal insufficiency.

Forced Diuresis
Has never been shown to be effective for ingestion of
any toxin, with the possible exception of chlorophenoxy
herbicides when diuresis is combined with urinary
alkalinization.

 Admission Criteria

Altered mental status

Cardiopulmonary instability
Suicidal
Lab abnormalities
Potential for decompensation from delayed acting substance

Discharge Criteria
Psychiatrically clear
Detoxified
Hemodynamically stable

Issues for Referral

Patients with unintentional (accidental) poisoning require poison prevention
counseling.
Patients with intentional (e.g., suicide) poisoning require psychiatric
evaluation.
Consider substance abuse referral for patients.

Hydrocarbons and volatile

substances
Hydrocarbons are a diverse group of organic compounds consisting
primarily of carbon and hydrogen atoms.
Major classes of hydrocarbons:
Aliphatic
Include kerosene, mineral oil, seal oil, gasoline, solvents, and paint thinners

Aromatic
Benzene (gasoline .8%), toluene (acrylic paint), xylene (cleaning agent,
degreaser)

Halogenated
carbon tetrachloride (refrigerant, aerosol propellant) and trichloroethane
(Spot remover, typewriter correction fluid)

 Physical properties determine type and extent of

toxicity:
Viscosity (resistance to flow):
Higher aspiration risk from products with lower viscosity

Surface tension (ability to adhere to itself at liquids surface):

Low surface tension allows easy spread from oropharynx to trachea,
promoting aspiration (e.g., mineral oil, seal oil)

Volatility (ability of a substance to vaporize):

Aspiration risk increases as the volatility increases.
Hypoxia from aromatic hydrocarbons displacing alveolar air

Main complication from hydrocarbon exposure is aspiration:

Hydrocarbon aspiration primarily affects respiratory and central
nervous systems.

Clinical Manifestation of Hydrocarbon

Exposure

Volatile Substances
Most often occurs in teenagers and younger adults
Common solvents abused:

Typewriter correction fluid

Adhesive
Gasoline
Cigarette-lighter fluid

Sniffing: Product inhaled directly from container

Huffing: Product inhaled through a soaked rag held to face
Bagging: Product poured into bag and multiple inhalations
taken from bag

History
Route, type, quantity, and time of exposure:
Determine intentionality and coingestions

Symptoms:
Vomiting, respiratory distress, mental status change or
pain
Bystander actions or pre-hospital interventions

Physical Examination
Evaluate for airway compromise in patients with decreased
level of consciousness and vomiting
Respiratory symptoms generally occur within 30 min but
are frequently delayed several hours
Monitor for hypoxia, hypotension, and cardiac dysrhythmias
Cyanosis and hypoxia suggest respiratory failure but may
result from methemoglobinemia
Temperature may be elevated at presentation following
aspiration and indicates pneumonitis:
Fever after 48 hr suggests bacterial superinfection

Work Up
Pulse oximetry:
If abnormal, follow with arterial blood gases.

Electrolytes; BUN, creatinine, and glucose levels; and liver

function tests:
For halogenated and aromatic hydrocarbon exposure
Metabolic acidosis
Hypokalemia

Carboxyhemoglobin levels for methylene chloride exposure:

Methylene chloride metabolized to carbon monoxide in vivo

ECG indicated in symptomatic patients and patients who ingest

halogenated hydrocarbons.

Work up - Imaging
CXR:
Abnormalities visible 20 min24 hr after exposure (usually by
6 hr)
Increased bronchovascular marking and bibasilar and
perihilar infiltrates (typical)
Lobar consolidation (uncommon)
Pneumothorax, pneumomediastinum, and pleural effusion
(rare)
Pneumatoceles resolve over weeks
Repeat chest radiograph if worsening respiratory symptoms

Treatment Initial Stabilization

ABCs
IV access and fluid resuscitation if hypotensive or ongoing fluid
losses
Oxygen
Cardiac monitor
Naloxone, thiamine, D50W (or Accu-Chek) if altered mental
status
Dextrose: D50W 1 ampule of 50 mL or 25 g (peds: D25W 24 mL/kg) IV
Naloxone (Narcan): 2 mg (peds: 0.1 mg/kg) IV or IM initial dose
Thiamine (vitamin B1): 100 mg (peds: 50 mg) IV or IM

Treatment - ED
Supportive care
Treat respiratory symptoms:
Oxygen
2-agonist for bronchospasm (albuterol)
Albuterol 2.55 mg NEB (peds: 0.150.3 mg/kg) for bronchospasm

Endotracheal intubation and mechanical ventilation for

respiratory failure
Steroids not indicated for bronchospasm
Avoid using epinephrine in volatile-substance abusers as it
may precipitate dysrhythmias

ALERT
Gastric evacuation not indicated for vast majority of
hydrocarbon ingestions:
Increases risk of aspiration which can cause significant
chemical pneumonitis

Activated charcoal does not bind to hydrocarbons well,

and is not indicated except for significant lifethreatening coingestants
Cathartics not indicated:
Diarrhea common with hydrocarbon

 Admission Criteria
Symptomatic patients
Patients with potential delayed organ toxicity (carbon tetrachloride or
other toxic additives)

Discharge Criteria
Observe for 6 hr then discharge:
Asymptomatic patients with normal chest radiograph and pulse oximetry
findings
Asymptomatic patients with abnormal CXR and normal oxygenation and
respiratory rate may be discharged if reliable follow-up is ensured.
Symptomatic patients on presentation who quickly become asymptomatic
Observe volatile-substance abusers until mental status clears.

Issues for Referral

Psychiatry consultation as needed

Summary
The first priority in treating poisoned patients is
assessment and stabilization of cardiopulmonary
function
Next Decontamination
Gross Decontamination
Eye Decontamination
GI Decontamination

Gastric Emptying
Toxin adsorbtion in the gut
Enhancement of Bowel Transit
Enhanced Elimination

Hydrocarbons and volatile

substances
Aliphatic - eg kerosene, mineral oil, seal oil, gasoline,
Aromatic - Benzene (gasoline .8%), toluene (acrylic paint)
Halogenated - carbon tetrachloride (refrigerant, aerosol propellant)
Volatile substances
Most often occurs in teenagers and younger adults
Common solvents abused: Adhesive, Gasoline, Cigarette-lighter
fluid
Methods
Sniffing, Huffing, Bagging

Ingestion or aspiration of hydrocarbons mainly impairs

the pulmonary system, but CNS, PNS, GI, CVS, renal,
hepatic, dermal, and/or hematologic systems may be
affected.
Treatment
assessment and stabilization of cardiopulmonary function
Supportive care
Treat respiratory symptoms Oxygen, Beta agonist

The surest poison is time.

Ralph Waldo Emerson (1803-1882)