APPROACH

TO
TOXICOLOGY
BY
DR. ASHOK KUMAR
 General principles
• ABCDE assessment and supportive management.
• Decontamination.
• Elimination.
• Antidotes.
• Psychiatric assessment
 Resuscitation of toxic patient
• A- Airway patency maintenance, ET intubation, recovery position
• B – O2 supplementation and ventilation.
• C- Correction of hypotension by identifying reversable cause, IV crystalloid bolus (10 to
20 mL/kg) is first-line, inotropes.
• D- decontamination
• E – elimination of toxins with antidotes.
 Decontamination.
1. Remove contaminated clothing
2. Copious water irrigation
1) Skin decontamination. 3.Contraindication- sodium, potassium
substance poisoning
2) Activated charcoal.
3) Gastric lavage
4) Whole bowel irrigation
5) Induced emesis - is no longer recommended.
1. Polyethylene glycol
solution is used
2. Indication : iron, lead,
illicit drug packers
3. Contraindication
 Activated charcoal
• MOA • Repeated doses needed in :
• DOSE
A. Aminophylline/theophylline
• NOT ADVICED FOR:
P ● Lithium. B. Barbiturates
H ● Boric acid.
A
C. Carbamazepine/concretion forming
● Iron.
I drugs (eg, salicylates)
● Petroleum distillates.
L
S ● Ethanol. D. Dapsone
● Methanol.
● Ethylene glycol. Q. Quinine
● Strong acids and alkalis.
● Cyanide.
● Organophosphates
GASTRIC LAVAGE
1. Within 1 hour of ingestion of life threatening poison which
has no antidote or cannot adsorb by activated charcoal.
2. Use 30 fr or large orogastric tube
3. Risks : aspiration, esophageal trauma
Elimination
• Urinary alkalinization,
• Haemodialysis(e.g. severe salicylate poisoning, ethylene
glycol, methanol, lithium, phenobarbital).
• Haemoperfusion (e.g. barbiturates, theophylline, choral
hydrate).
Focused History
1. Type of tablets taken
2. packets with patient
3. time of overdose
4. number of tablets
5. single or staggered ingestion of tablets
6. other drugs taken
Toxidromes
• Sympathomimetic
• Anticholinergic
• Cholinergic
• Opiate
Sympathomimetic toxidrome
1. Hyperthermic
2. Tachypnea
3. Tachycardia
4. Hypertension Agents :

5. Flushed a) Amphetamines - MDMA

6. Diaphoretic b) Cocaine
7. Mydriatic c) Cathinones
8. Agitated
9. Seizures
Anticholinergic

• Hyperthermia
• Flushed
AGENTS:
• Dry skin and mucosa
• Mydriatic a)Atropine,
• Delirium, hallucinations b)Datura spp.,
• Urinary retention, decreased c)Antihistamines
bowel sounds
d)Antipsychotics
• Tachycardia
• Seizure
 Cholinergic toxidrome
Diarrhoea,
D diaphoresis
U Urination
M Miosis
BE Bradycardia
LL Bronchorrhea
S AGENTS:
Emesis
 Organophosphates
Lacrimation
 Carbamate insecticides
Lethargic  Chemical warfare agents
Salivation (sarin, VX)
Nicotinic toxidrome
 Mydriasis

 Tachycardia

 Weakness

 Tremors
Agents :
 Fasciculations Children who ingest detritus, such
as used cigarettes or chewing
 Seizures tobacco, as well as liquids from
 Somnolent electronic cigarettes
Opiate toxidrome

1. Miosis WITHDRAWAL :
Diarrhea
2. Hypoventilation Mydriasis
Goose flesh
3. Depressed
mental Tachycardia
status/coma Lacrimation
Hypothermia Hypertension
Yawning
Bradycardia Cramps
Hallucinations
Seizures (with ethyl alcohol and
benzodiazepine withdrawal)
 Serotonin toxidrome NEUROLEPTIC MALIGNANT
SYNDROME

• Altered mental status, • Altered mental status,

• Hyperthermia
• Hyperthermia
• Agitation
• Agitation
• Hyperreflexia,

• Clonus, • HYPOREFLEXIA

• Diaphoresis • RIGIDITY
• Tremors
Psychiatric assessment
Focused history
Concurrent medication
Past medical history
Physical examination
COMA COCKTAIL
1. Supplemental O2
2. NALOXONE ( IV/ SC/ IM/ INTRANASAL) 0.1-0.4 mg start dose IV

3. DEXTROSE IV

4. THIAMINE 100mg IV
 Cardiac arrythmias

• Most toxin-induced dysrhythmias

• Sodium bicarbonate.
• overdrive pacing.
• No anti arrhythmic drugs are recommended as first line
treatment.
 Seizures – toxin induced
1.Benzodiazipines IV are 1st line drugs.
2.Propofol and barbiturates - for benzodiazepine-resistant seizures
3.If Isoniazid induced - Pyridoxine 5g IV is the first line
treatment.

Phenytoin is not recommended for toxin induced seizures, it may

worsen the toxicity.
 Toxins causing hypoglycemia
1. Salicylate poisoning
2. Paracetamol poisoning
3. Alcohol poisoning
4. Insulin overdose
5. Oral hypoglycemics
check CBG in all patients in Overdose and with altered
mental status.
Potential interventions in toxin induced
cardiac arrest
 TYPES OF POISONING
1. UNINTENTIONAL POISONING – Common in children, stuffers
and drug packers.
2. SELF POISONING – Suicidal
3. NON- ACCIDENTAL POISONING- Parents poisoning the child,
mostly chronic variant of arsenic or thallium poisoning.
4. CHEMICAL PLANT INCIDENTS AND TERRORISM
Objective examination
Examination
Examination
INVESTIGATIONS
1) CBG

2) ABG,VBG

3) CBC , U AND E

4) ECG

5) SERUM PARACETAMOL AND SALICYLATE LEVELS

6) URINE PARAQUAT LEVEL ( acc. to history)

Antidotes
POISON ANTIDOTE DOSE
PARACETAMOL N-acetylcysteine
SALICYLIC ACID,TCA Sodium bicarbonate
CARBON MONOXIDE Hyperbaric /100%O2
IRON Deferoxamine
BETA BLOCKERS Glucagon
DIGOXIN Digi Fab
CALCIUM CHANNEL Calcium, high dose insulin
ANTAGONISTS euglycemic/glucose