POISONING

Broad objective
• Be able to acquire knowledge and skills on
handling patients with poisonings and drug
overdose in emergency department effectively.
 Specific objectives
• Introduction and definition of terms
• Epidemiology of poisoning
• Classification
• Etiology of poisoning
• Routes of Poisoning
• General approach to Treatment of poisoning
• Specific toxicological emergencies &
management in accident and emergency
department.
 Definition of terms
• Poisoning
refers to the development of dose-related adverse effects
following exposure to chemicals, drugs, or other
xenobiotics.
• Xenobiotics
is a chemical which is found in an organism but which is
not normally produced or expected to be present in it.
• Acetylcholine
activates muscles, and is a major neurotransmitter in the
autonomic nervous system
 Cont…
• Acetyl cholinesterase; AChE is an enzyme that degrades
the neurotransmitter acetylcholine (ACh) into choline and
acetic acid
• Toxicity : The ability of a chemical to do systemic damage
to an organism.
• Acute Toxicity : The ability of a chemical to harm an
organism as a result of a relatively short one-time exposure.
• Chronic Toxicity : The ability of a chemical to cause harm
to an organism as a result of repeated exposures for long
periods of time – perhaps even a lifetime.
 Introduction
• Poisoning refers to the development of dose-
related adverse effects following exposure to
chemicals, drugs, or other xenobiotics. The
dose makes the poison
• Conversely, in small doses, substances
commonly regarded as poisons, such as
arsenic and cyanide, can be consumed without
ill effect.
 Cont…
• Poisoning may be local (e.g., skin, eyes, or
lungs) or systemic depending on the chemical
and physical properties of the poison, its
mechanism of action, and the route of
exposure.
• The severity and reversibility of poisoning
may be influenced by age and preexisting
disease
 Epidemiology cont,
• In Kenya,Out of the 1564 cases studied, 18.1 %
was organophosphate poisoning and it was the
highest prevalence compared to other poisonings.
• Organophosphate poisoning prevalence was
17.9% at Kenyatta National Hospital, 12.9% at
Nyeri Provincial General Hospital and 35.1 % at
Kiambu District Hospital.
 Cont…
• Suicide contributed 68.2% of
organophosphate poisoning while accidental
poisoning accounted for 12% and homicide
the lowest at 7.4%.
 Cont…
• Unintentional exposures can result from the
improper use of chemicals at work or play;
product mislabeling; label misreading;
mistaken identification of unlabeled
chemicals; uninformed self-medication; and
dosing errors by nurses, parents, pharmacists,
physicians, and the elderly
 Cont…
• Overall, carbon monoxide and
organophosphates are the leading cause of
death from poisoning, but this is not reflected
in hospital or poison center statistics because
patients with such poisoning are typically dead
when discovered and are referred directly to
medical examiners
 POISON
• Any substance( solid/ liquid or gaseous ) that
is harmful to the body, when ingested, inhaled,
injected, or absorbed.
• Does not include adverse reactions to
medications taken correctly
 Etiology of poisoning
• Can be categorised into three groups;
 Accidental/ Unintentional poisoning ; includes playful
exploration in young children,ingestion from
mislabelling or not following direction and
environmental exposure.
 Intentional poisoning; includes recreational drug abuse
and suicide attempts.
 Iatrogenic poisoning; results from unanticipated drug
interactions or overdosing in patients with renal or
hepatic insufficiency.
 Routes of Poisoning
Inhalational Ingestion
 Poisons that are breathed  Poisons that are
in: swallowed:
 Gases: ammonia, chlorine  Household and industrial
 Vapors: carbon monoxide chemicals
 Sprays: insecticides  Medications
 Volatile liquid chemicals:  Improperly prepared food
change easily from liquid to
gas  Plant materials
 Petroleum products
 Routes of Poisoning
Injection Absorption
o Intra venous – Poisons taken in through
Benzodiazepines, unbroken skin:
barbiturates, tricyclic oCorrosives or irritants
antidepressants etc. oThrough bloodstream
o Intramuscular – oInsecticides and
Benzodiazepines, chemicals
opioids etc.
o Subcutaneous –
Botulinum toxin
o Intra- dermal – Local
anesthetics,
o organophosphates
General approach to
Treatment of
poisoning
 General- evaluation
• Recognition of poisoning
• Identification of agents involved
• Assessment of severity
• Prediction of toxicity
 General Evaluation of Poisoning in
Patients
• There are several general guidelines for the
evaluation and treatment of a patient with a
potential ingestion or toxic exposure.
Diagnosis of poisoning
• History
• Physical examination
• Signs and symptoms
• Laboratory studies
 History
Obtaining history from a patient with a potential ingestion
or toxic exposure may be difficult if:
• Patient is too young to communicate
• Is obtunded
• Is reluctant to cooperate
So in these case it may be helpful to question the patient’s
relatives, friends, or co works.
Correlate history with physical examination and ancillary
test results.
Critical questions in the interview of
the patient with poisoning
• What was ingested?
• How much was taken?
• What was the time of ingestion?
• What is the route of poisoning?
• Does the patient have a history of
depression/drug abuse or alcoholism?
• What is the patient’s medical history?
 Physical examination (PE)

• Provide a wealth of information, in patients

unable to provide a useful history
• PE should include vital signs , a brief neurologic
examination emphasizing level of consciousness
and pupillary and motor responses, palpation of
the skin for moisture and inspection for cyanosis
and rashes, auscultation and percussion of the
lungs and auscultation of bowel sounds
 Cont…
• Focus on physical finings observed in patients
exposed to a particular types of poisons and
offers rapid assessment and guides testing and
treatment
 Signs and symptoms
• Symptoms obtained by history and signs by physical
examination may be used to establish and confirm
diagnosis of poisoning.
• A group of signs and symptoms that are often
associated with a particular poison or type of poison is
referred to as a toxidrome
• Familiarity with common toxidromes is important to
the practicing Emergency nurse and allows for clinical
recognition of toxin patterns
 Laboratory studies
• A rapid RBS should be checked in all patients with altered
mental status if found to be low administer intravenous glucose.
• Serum electrolyte-U/E, Serum osmolality
• BUN-blood urea nitrogen
• Serum creatinine
• Arterial blood gas
• Urinalysis-crystals, myoglobinuria or hemoglobinuria
• Toxicology screen- drug levels, carboxyhemoglobin level
• ECG- heart rate, evidence of dysrrhythmia
• Abdominal x-ray-helpful in patients who ingest radiopaque
medications, visualizing drug packets in “body packers”
individuals who ingest packets of illicit drugs to transport them.
 General measures
• Management strategies are dictated by the
poison involved, presenting and predicted
severity of illness and time of presentation in
relation to time of exposure
 General measures
• The first priority in treating any patient with a toxic
exposure is resuscitation and stabilization
• Assessing the patient’s ABCD are the initial goals
• Establish an airway, ventilating and oxygenating the
patient, and supporting circulation by normalizing and
maintaining an adequate heart rate and blood pressure
• Place on a cardiac monitor
• Intravenous access should be established
 General- management
1. Provision of supportive care
2. Prevention of poison absorption
3. Enhancement of elimination of poison
4. Administration of antidotes
 1. Supportive care
• The goal of supportive therapy is to maintain
physiologic homeostasis until detoxification is
accomplished and to prevent and treat
secondary complications such as aspiration,
cerebral and pulmonary edema, pneumonia,
renal failure, sepsis, coagulopathy, and
generalized organ dysfunction due to hypoxia
or shock
 Cont…
• ABC
• Vital signs, mental status, and pupil size
• Pulse oximetry, cardiac monitoring, ECG
• Protect airway
• Intravenous access
• cervical immobilization if suspect trauma
• Rule out hypoglycaemia
 Cont…
Admission to an intensive care unit is indicated for the
following:
• Patients with severe poisoning (coma, respiratory
depression, hypotension, cardiac conduction abnormalities,
cardiac arrhythmias, hypothermia or hyperthermia, seizures)
• Those needing close monitoring, antidotes, or enhanced
elimination therapy;
• Those showing progressive clinical deterioration
• Those with significant underlying medical problems
 2.Prevention of poison absorption
Copious flushing with water or saline of the
body including skin folds, hair
Inhalational exposure
 Fresh air or oxygen inhalation
 Cont…
Gastric lavage
• In unconscious patient unless intubated (risk aspiration)
• Flexible tube is inserted through the nose into the stomach
• Stomach contents are then suctioned via the tube
• A solution of saline is injected into the tube
Induced Vomiting
• Ipecac(drug used as a rapid acting emetic) - Not routinely
recommended
• Risk of aspiration
 Cont…
Activated charcoal
• Adsorbs toxic substances or irritants, thus inhibiting GI
absorption
• Not effective for cyanide, mineral acids, caustic alkalis,
organic solvents, iron, ethanol, methanol poisoning, lithium
 Cont…
Substances that are not absorbed by activated charcoal
• Mnemonic: CHARCOAL
• Caustics & corrosive
• Heavy metals
• Alcohol & glycols
• Rapidly absorbed substances
• Cyanide
• Other insoluble drugs
• Laxatives
 3. Elimination of poisons
Renal elimination
• Medication to stimulate urination is given to try to flush the
excess drug out of the body faster.
Forced alkaline diuresis
• Infusion of large amount of NS+NAHCO3
• Used to eliminate acidic drug that mainly excreted by the kidney
eg salicylates
• Serious fluid and electrolytes disturbance may occur
• Need close monitoring
Hemodialysis
• Reserved for severe poisoning
• Used temporarily or as long term if the kidneys are damaged due
to the overdose.
 Cont…
• Dialysis is considered in cases of severe
poisoning due to acetone, barbiturates,
carbamazepine, ethanol, ethylene glycol,
alcohol, lithium, methanol, theophylline, and
salicylates.
 4. Administration of Antidotes
• Does an antidote exist?
• Does actual or predicted severity of poisoning
warrant its use?
• Do expected benefits of therapy outweigh its
associated risk?
• Are there contraindications?
 Cont…
• Antidotes counteract the effects of poisons by
neutralizing them.
• Antidotes can significantly reduce morbidity
and mortality but are potentially toxic if used
for inappropriate reasons.
 Cont…
• Not all poisons have antidotes
SPECIFIC
TOXICOLOGICA
L EMERGENCIES
 SPECIFIC TOXICOLOGICAL
EMERGENCIES
• Opiate Use • Salicylate Poisoning
• Cocaine • Acetaminophen
• Amphetamines Poisoning
• Inhalants • Acid and Alkali Burns
• Carbon Monoxide
Poisoning
SPECIFIC TOXICOLOGICAL
EMERGENCIES: Opiate use
Symptoms
•Drowsiness, apathy, seizures,
apnea/respiratory arrest, hypotension,
bradycardia, and miosis.
Treatment
•Maintain A,B,C, D,E
•Provide supplemental oxygen
•Establish IV access
•Administer Naloxone (short acting narcotic
antagonist)- may need to repeat doses
•Activated charcoal if indicated
 SPECIFIC TOXICOLOGICAL
EMERGENCIES: Cocaine use
Symptoms
• Irritability, anxiety, hallucinations such as “bugs” crawling
under skin, tachycardia, hypertension,. You may also find
perforated nasal septum from snorting.
Treatment
• Maintain A,B,Cs
• Provide supplemental oxygen
• Establish IV access
• Haloperidol for delirium/psychosis
• NGT and Whole bowel irrigation
• ECG and Continuous cardiac monitoring
 SPECIFIC TOXICOLOGICAL
EMERGENCIES: Amphetamines
Symptoms
•Changed level of consciousness and bizarre behavior,
paranoia, delusions, seizure activity, hypertension, mydriasis,
tachycardia, tremors. Thin, appears emaciated and unkempt
Treatment
•Maintain A,B,Cs and provide supplemental oxygen
•Establish IV access for medications and/or crystalloids
•Activated charcoal (if indicated) prevents systemic absorption
•Benzodiazepines provides sedation; Haldol for psychotic symptoms
SPECIFIC TOXICOLOGICAL
EMERGENCIES: Inhalant
Symptoms
•Behavior ranges from euphoria to
depression, suicidal ideas ataxia , bloodshot
eyes. Respiratory wheezing, circumoral red
spots on mouth and nose if using spray paint,
decreased peripheral reflexes.
Treatment
•Maintain A,B,Cs and provide supplemental
oxygen
•Establish IV access
•Sodium bicarbonate for metabolic acidosis
•Electrolyte replacements (especially
potassium)
 SPECIFIC TOXICOLOGICAL
EMERGENCIES: Carbon monoxide
poisoning
Symptoms
• Headache (most common),
dizziness, weakness, nausea,
vomiting, confusion. “Cherry
red” skin and mucus membranes.
Treatment
• Maintain A,B,Cs
• High flow100% oxygen
(decreases half-life of COHb)
• Establish IV access
• Hyperbaric oxygen therapy for
severe cases
SPECIFIC TOXICOLOGICAL
EMERGENCIES: Salicylate
(aspirin) poisoning
Symptoms
• Respiratory alkalosis, electrolyte imbalances,
nausea, vomiting, tinnitus, tachypnea, tachycardia,
diaphoresis, respiratory crackles.
Treatment
• Maintain A,B,Cs and provide supplemental oxygen
• Establish IV access for meds and fluids
• activated charcoal indicated
• IV crystalloids for renal clearance and hydration
• Sodium bicarbonate to correct acidosis or alkalinize
urine
• Replace electrolytes
 SPECIFIC TOXICOLOGICAL
EMERGENCIES: Acetaminophen
poisoning
Symptoms
• 3 stages: Initial (0-24 hrs), Dormant (24-48 hrs
after), Hepatic (48-96 hrs).
• Malaise, nausea/vomiting, Palpitations,
syncope, bradycardia, hypotension, metabolic
acidosis, hepatic failure, Jaundice and
electrolyte imbalances
Treatment
• Maintain A,B,Cs and provide supplemental
oxygen
• Establish IV access
• Activated charcoal within one hour of ingestion,
IV Fluids (NS)
• N-acetylcysteine (Mucomyst) orally, by NGT or
intravenous)
• IV Calcium Gluconate, Glucagon or
vasopressors,
 SPECIFIC TOXICOLOGICAL
EMERGENCIES: acid and alkali
Symptoms
burns
•Stridor, drooling, burn blister in oral cavity or skin, corneal erosion, pale
conjunctiva, respiratory crackles
Treatment
•Maintain A,B,Cs and provide supplemental oxygen as indicated
•Establish IV access
•Alkali exposure: diluted with small amounts of water if ingested. For Ocular
injuries, Irrigate with NS for one hour
•Acid exposure: Do not use water for ingestions as it will create heat. For
ocular injuries, irrigate with NS for 15 minutes.
•Pain medications/analgesics
•Steroids for alkali burns
•Activated charcoal if indicated
•Calcium Chloride for hydrofluoric acid burns
Everything is poison,
there is poison
in everything.
Only the dose makes a
thing not a poison.
--Paracelsus, Father of Toxicology