Unit

1. General principles involved in the management of

poisoning
Teacher In-Charge
Dr. A. PRAKASH, M.Pharm (Pharmacology),
PhD (NITC)
1
Introduction
What Is Toxicology?
Toxicology is the study of the adverse effects of chemical,
physical, or biological agents on living organisms.
Toxicology is an applied science with many areas of
specialization.
Toxicology involves integration of information from
many different areas of expertise.
Most toxicologists work to assess and understand how
chemicals affect living systems, and their work involves:

2
Introduction
Most toxicologists work to assess and understand
how chemicals affect living systems, and their work
involves:
Understanding the mechanism of toxic effects
Developing treatments for chemical exposures
Developing safer drugs and medicines
Ensuring safer chemical products

3
Introduction
• Toxicology is arguably the oldest scientific discipline,
as the earliest humans had to recognize which plants
were safe to eat.

• Humans are exposed to chemicals both deliberately

and inadvertently.

• Most exposure of humans to chemicals is via

naturally occurring compounds consumed in the
diet from food plants

4
Introduction
2.1 million cases of human exposures reported in 2020
92% of the exposures occurred at home
 14% occurred in a health care facility
 2% occurred at work
Children > 3 years were involved in 40% of the cases
52.7% occurred in children > 6 years
Male predominance is found among poison exposures
younger than 13 years
Children > 6 comprised 2.2% of the fatalities
59% of fatalities occur in the 20-49 year age group

5
Introduction
85.9% of poison exposure were unintentional
suicide intent was present in 7.5% of the cases
therapeutic errors comprised 7% of exposures
920 fatalities reported
94% of adolescent and 79% of adults were intentional
Automatic capital offense to poison someone
Most poisonings enter the body orally - 76.2%
More people die from suicides than from
homicides
6
Substances most frequently
involved in Human Exposures
Analgesics - 10%
Cleaning substances - 9.5%
Cosmetics and personal care products - 9.4%
Foreign bodies - 5.0%
Plants - 4.9%
Cough and cold preparations - 4.5%
Bites and envenomations - 4.2%

7
Substances most frequently
involved in Pediatric poisonings
Cosmetics and personal care products - 13.3%
Cleaning substances - 10.5%
Analgesics - 7.2%
Foreign bodies - 6.8%
Plants - 6.6%
Topicals - 6.3%
Cough and cold preparations - 5.3%

8
Substances most frequently
involved in Adult Exposures
Analgesics - 13.3%
Sedatives/hypnotics/antipsychotics - 9.8%
Cleaning substances - 9.5%
Antidepressants - 8%
Bites/envenomations - 7.9%
Alcohols - 5.4%

9
Categories with largest number of
deaths
Analgesics
involved in 30% of fatalities
acetaminophen, aspirin and other salicylates = 72%
84% of the fatalities were intentional
Antidepressants
69% involved TCA’s
Sedatives/hypnotics/antipsychotics
benzodiazepines account for 36%
Cardiovascular drugs
Alcohols
10
Categories with largest number of
deaths
Amphetamines and cocaine - account for 61% of
street drug deaths (39 in 2000)
Ecstasy - involved in 23 fatalities
all occurred in persons 17-24 years of age
Heroin - 29% of deaths

11
Definition of terms
Toxicology - the study of poisons
Toxicologist - one who studies poisons
Hazard - likelihood an event will occur based on how the
product is packaged, formulated, or its accessibility
Risk - the probability that an event will occur based on
patient vulnerability
Toxic substance - poisons
Poison - any chemical substance which can cause harm
Drug overdose - taking a harmful amount of a drug
Clinical Toxicology - deals with the pathophysiologic
aspects clinical presentation of intoxication
12
Historical perspective
Poisonings date to antiquity
Deuteronomy 14:9-10, Moses said do not eat fish
which do not have fins or scales cause it is unclean
Job 6:4 mentions poisoned arrows
1500 BC the Ebers papyrus
King of Pontus first to develop antidotes in the first
century before Christ

13
Historical perspective
Plato reported the death of Socrates by hemlock
(Conium maculatum)
13th century Peter of Abanos reviewed the literature
and divided poisons into those of plant, animal and
mineral origin
Paracelsus, 1493-1541 said that “all substances are
poisons, there is none which is not poisonous. Solely
the dose determines that which is poisonous or not.”

14
Poisoning
A poisoning occurs when exposure to a substance
adversely affects the function of any system within an
organism.
The setting of the poison exposure may be
occupational, environmental, recreational, or
medicinal.
A poisoning may result from varied portals of entry,
including inhalation, insufflation, ingestion,
cutaneous and mucous membrane exposure, and
injection
15
Poisoning
Historically most poisonings have occurred when
substances are tasted or swallowed.
Toxins may be airborne in the form of gas or vapors
or in a suspension such as dust.
Caustics, vesicants, or irritants may directly affect the
skin, or a toxin may pass transdermally and affect
internal structures.
Parenteral exposure is also common through
intravenous or subcutaneous injection of medications
or drugs of abuse.
16
Poisoning
A poison may affect the normal activity of an
organism in a variety of ways.
It may inhibit or alter cellular function, change organ
function, or may change uptake or transport of
substances into, out of, or within the organism.
Substance Abuse – The knowing misuse of any
substance to produce a desired effect
Overdose - Exposure to substance in excess amount
resulting in toxic effects

17
Poisoning

18
Poisoning Symptoms
The poisoned patient presents with the following
non-specific symptoms

19
Poisoning Symptoms
Symptoms General:
Sudden onset of CNS signs: – Seizures – Coma –
Decreased LOC – Bizarre behavior
Sudden onset of: – Abdominal pain – Nausea –
Vomiting

20
THE GENERAL APPROACH TO
POISONING
The general approach to the poisoned patient can be
divided into six phases:
(1) stabilization;
(2) laboratory assessment;
(3) decontamination of the gastrointestinal tract,
skin, or eyes;
(4) administration of an antidote;
(5) elimination enhancement of the toxin; and
(6) observation and disposition.

21
General Management
History
What?
How much?
How long?
Multiple substances?
Treatment attempted? How? Whose advice?
Psychiatric history?
History of suicide?

22
General Management
Support ABC’s
– Secure airway, intubate as needed (Airway)
– Ensure adequate oxygenation, ventilation
(Breathing)
– Maintain adequate circulation (Circulation)
Monitor ECG
Obtain vascular access
Manage hypotension initially with volume

23
General Management
Keep patient calm
Maintain normal body temperature
Evaluate nature/toxicity of poison
– Check container, package insert, poison center
information
– Treat the patient, not the poison

24
General Management
Rule out
– Trauma
– Neurological disease
– Metabolic disease
Base general management on route of poison entry
oral ingestion (PO)
inhalation
injection ( IV, SC, IM, IO)
absorption
25
General Management
Prevent absorption
 gastric evacuation
 administration of an adsorbent
 catharsis
Gastric emptying
 must be done soon after ingestion
 emesis
 emetics
 copper sulfate
 mustard water
 zinc sulfate
 tartar emetics
 apomorphine
 soapy water

26
General Management
Gastric lavage - “pumping the stomach”
done in a hospital setting
Administration of an adsorbent
any agent capable of binding to the toxic agent in the
GIT and preventing the agents absorption
once the agent is bound, the toxin-adsorbent complex
is excreted in the feces

27
Activated Charcoal
first used by Hippocrates to bond toxic agents
part of the universal antidote
 burnt toast and tea
“activated” - by micropulverizing and exposing it to
steam and acid (compare activated with a surface
binding area of 1000m2/gm verses “unactivated”
carbonaceous material at 3 m2/gm)
Use has increased since 1983

28
Available in tablets, capsules, powder and suspension
(most useful)
Substances not well adsorbed:
alcohols
hydrocarbons
heavy metals and inorganic minerals
corrosives

29
Dosing
try to achieve a 10:1 charcoal to toxin ratio, give 10 times
as much charcoal as the toxin ingested
1 gm/kg BW also works well
children must usually have a nasogastric tube instilled
because they usually will not drink the gritty black
slurry
Administered to about 7% of patients
aspiration of AC partially responsible for 8 deaths,
given to patients who ingested CNS depressants
30
31
Cathartics - purgatives, laxatives
drugs which promote evacuation of the bowel
facilitate the expulsion of the toxin
Commonly used cathartics
sorbitol 1-2 g/kg BW
mannitol 1-2 g/kg BW
magnesium sulfate 200 mg/kg (C);10-20g (A)
magnesium citrate 225mg/kg (C);17.5 g (A)

32
Mechanism of action
osmotic agents
stimulate GIT motility
Scientific efficacy is uncertain
Contraindications: do not use in patients
with absent bowel sounds
with cardiovascular or renal disease or electrolyte
imbalance

33
Thank you

34