Toxicological Emergency

Part - 1
Dr. Shirshendu Dhar
M.D Emergency Medicine
AGMC & GBP Hospital
 Oro-gastric Lavage
• Indications:- Rarely indicated
• Consider for recent (<1h) ingestion life Complications:-
threatening amount of a toxin for which
there is no effective treatment once  Aspiration
absorbed
 Hypothermia
• C/I:- Corrosive / hydrocarbon ingestion
 Laryngospasm
• Supportive care / antidote likely to lead
recovery
 Mechanical Injury to gut
• Unprotected airway
• Unstable  Time Consuming
 Activated Charcoal
• Indications:- (Killer Cs) life threatening ingestion of <60 mins
1. Cyanide
2. Colchicine
3. Calcium Channel Blockers
4. Cyclic antidepressants
5. Cardiac Glycosides – Oleander
6. Mushroom
7. Cocaine
8. Salicylates
9. Herbicide (up to 2 hrs of intake)
 Activated Charcoal
• Contraindications:- PHAILS
1. Pesticides Complications:-
2. Heavy Metals
3. Acid/Alkalis  Vomiting
4. Iron
 Aspiration of Activated
5. Lithium
Charcoal
6. Solvents

Dose:- 0.5 – 1 gm/kg stat

 Multidose Activated Charcoal
• Indications:-
• Carbamazepine
• Phenobarbital
• Dapsone
• Quinine
• Theophylline

• Dose:- 50 gm initially, then 25 gm of every 2 hours

• C/I :- Unprotected airway / Bowel obstruction

 Dialysable Toxin
• I – INH, Isopropyl Alcohol
• S – Salicylates
• T - Theophylline
• U - Uraemia
• M - Methanol
• B - Barbiturates
• L - Lithium
• E – Ethylene Glycol
• D - Dabigatren
 Pesticide Poisoning

Organophosphates Carbamates Organochlorines

Malathion Carbofuran Chlordane

Parathion Carbaryl DDT

Diazinon Aldicarb Dieldrin

Acephate Fenobucarb Aldrin

Chlorpyrifos Propoxur Lindane

 Clinical Features
• SLUDGE DUMBELS ( Muscarinic Effect)
• S – Salivation L – Lacrimation U – Urinary Incontinence

• D – Defecation G – GI pain E – Emesis

• D – Defecation U – Urination M – Miosis

• B – Bradycardia, Bronchorrhea, Bronchospasm

• E - Emesis L – Lacrimation S - Salivation

 Clinical Features
• Nicotinic effects:-

• Mon – Mydriasis
• Tue – Tachycardia
• Wed – Weakness
• Thu – Tremor
• Fri – Fasciculation
• Sat - Somnolent
 Management
• Stabilize Primary Survey : Airway / Breathing / Circulation

• Ryles tube wash ( if within 1 hr, not useful if more than 2 hrs) with
Normal Saline

• Inj. Atropine, 2mg i.v stat f/b 4 mg f/b 8 mg f/b 16 mg and like that…..

• If patient is gasping/ desaturating with oxygen / severe crepts /

bradycardic then give in doubling dose of 10 mg

• To be given until – PR>80/min SBP >80mmHg SpO2>90% or

clear chest (all 3 should be achieved)
 Management
• Once target is achieved – Then calculate the total dose of atropine
and start 1/3rd of the dose as infusion

• Inj. Pralidoxime, 1 gm with 100 ml 5%D i.v stat f/b 500 mg i.v Q 6 –
8hrly

• Benzodiazepine if restless or seizures are happening

• Place foleys catheter to prevent sphincter constriction

 Interesting Facts

• Carbamates do not effectively penetrates CNS, so less central toxicity

and seizures not occur.

• Carbamate binding half life to cholinesterase is approximately 30

mins, so Pralidoxime is less useful.

• Atropine is the only treatment of choice

• Activated charcoal is useful in life threatening ingestion of

organochlorines, paraquet and diquet .
 Paraquet Poisoning
• Lethal Dose :- 20 ml in adult

• G.I decontamination with activated charcoal within 2 hours of

ingestion

• Dexamethasone should be given, 8 mg i.v every 8 hours for 1st 72

hours.