APPROACH TO

POISONING
&TOXIDROME IN
EMERGENCY
DEPARTMENT
 GENERAL APPROACH TO THE
POISONED PATIENT

1. RESUSCITATION OF UNSTABLE PATIENT WITH ADEQUATE

SELF-PROTECTION
2. RECOGNITION OF POISONING AND ITS MODE
3. DIAGNOSE THE POISONING AGENT AND LOOKING OUT
FOR ANY TOXIDROMES
4. ASSESS THE SEVERITY OF POISONING
5. PROVIDE APPROPIATE AND TIMELY MANAGEMENT
 ABC’s

Disposition GENERAL History

APPROACH

Antidote and
Physical
supportive
examination
care

Labs and
Diagnosis
imaging
 ABC’S- AIRWAY
Airway obstruction Evaluate mental
can cause death after status and gag/cough Airway interventions Intubation
poisoning reflex

• Flaccid tongue • Opening the • Consider naloxone

• Aspiration airway first in case of
• Respiratory arrest • Examine the opiods &
oropharynx for any benzodiazepine
foreign body intoxication
• Clear secretions
• Airway devices:
OPA, NPA
Determine if respirations Give supplemental Assist with bag-valve-
are adequate
BREATHING
oxygen mask

Auscultate lung fields

• Bronchospasm: Albuterol
nebulizer
Check oxygen
• Stridor: Determine need for saturation, ABG
immediate intubation
 Hypotension treatment:

IV access CIRCULATION
Measure blood pressure,
pulse
• Normal saline fluid challenge,
20 mL/kg
• Vasopressors if still
hypotensive

Hypertension treatment: Continuous ECG

• Nitroprusside, beta blocker, or monitoring
nitroglycerin • Assess for arrhythmias, treat
accordingly
What, when, how
Rx, medications,
herbals,
HISTORY
History from
Pill bottles, Allergies,
needles, beer medical problems
much, why supplements, family, friends
cans, suicide note
vitamins
 HISTORY
• BE AWARE THAT PATIENTS MAY NOT PROVIDE A
COMPLETELY ACCURATE HISTORY DUE TO ALTERED
MENTAL STATUS, PERSONAL REASON
• ALWAYS OBTAIN A CORROBORATIVE HISTORY FROM ALL
AVAILABLE SOURCE SUCH AS RELATIVE,FAMILY, FRIENDS
AND PARAMEDIC THAT ATTENDED THE PATIENT
• ASK ‘WHAT, WHEN, HOW MUCH, WHERE, WHY’ ANY
SYMPTOMPS FROM EXPOSURE
• ANY SUICIDAL RISK AND PREVIOUS SUCIDAL ATTEMPT
• PSYCHIATRIC AND PAST MEDICAL HISTORY
PHYSICAL EXAMINATION

• VITAL SIGNS: BP, HR, RR, T, O2 SAT

• MOUTH: ODORS, MUCOUS MEMBRANES
• PUPILS
• BREATH SOUNDS
• BOWEL SOUNDS
• SKIN
• URINATION/DEFECATION
• NEUROLOGIC EXAM
DDX OF VARIOUS VITAL SIGN IN
DRUG OVERDOSE
HYPOTHERMIA (‘COOLS’) HYPERTHERMIA (‘NASA’)
• CARBON MONOXIDE • NICOTINE
• OPIATES
• ANTIHISTAMINE
• ORAL HYPOGLYCAEMICS,
• SALICYLATES
INSULIN
• LIQUOR • ANTICHOLINERGICS,ANTIDE
• SEDATIVE HYPNOTICS PRESSENTS

HYPOVENTILATION HYPERVENTILATION
• OPIODS • SALICYLATES
• BENZODIAZEPINES • CYANIDE
BRADYCARDIA (‘PACED’)
• PROPANOLOL (BETA BLOCKER)
• ANTICHOLINESTERASE DRUGS
DYSARYTHMIAS
• CLONIDINE, CALCIUM
CHANNEL BLOCKER
• DIGOXIN
• ETHANOL/ALCHOHOL • CYCLIC
• DIGOXIN ANTIDEPRESSANTS
• SYMPATHOMIMETICS
TACHYCARDIA (‘FAST’) • PHENOTHIAZINES
• FREE BASE (COCAINE)
• CHLORAL HYDRATES
• ANTICHOLINERGICS,ANTIHISTA
MINES,AMPHETAMINES • ANTICONVULSANTS
• SYMPATHOMIMETICS(COCAINE ,
PHENCYCLIDINE
• THEOPYLLINE
 BLOOD PRESSURE

HYPOTENSION (‘CRASH’) HYPERTENSION (‘CT SCAN’)

• CLONIDINE OR ANY • COCAINE
ANTIHTN DRUGS • THEOPHYLLINE
• RESERPINE • SYMPATHOMIMETICS

• ANTIDEPRESSANTS • CAFFEINE
• ANTICHOLINERGIC,AMPHETA
• SEDATIVE AGENT
MINE
• HEROIN (OPIATES)
• NICOTINE
 Odours Probable poisons

Fruity Ethanol PUPILS

Bitter almonds / Cyanide

MIOSIS (COPS)
Silver polish C Cholinergic
O Opiates, organophospate
Rotten Eggs Hydrogen sulphide P Phenothiazine,pilocarpine
S Sedatives-hypnotics
Garlic Arsenic / Parathion
MYDRIASIS ( AAAS)
Wintergreen Methylsalicylate A Antihistamine
A Antidepressants
Stove gas Carbon monoxide
A Anti-cholinergic, atropine
S Sympathomimetics,
( cocaine, amphetamines)
Obvious odours
 Kerosene
 Bleaching agents
 Insecticides
 DIAPHORETIC SKIN (SOAP) &
HYPOGLYCEMIA
• S SYMPATHOMIMETICS
• O ORGANOPHOSPHATE
• A ASA ( SALICYLATES)
• P PCP & HYPOGLYCEMIA
DRY : ANTICHOLINERGIC
BLISTERING
• CARBON MONOXIDE
• BARBITURATES
• SULPHUR
COLOUR
• RED – ANTICHOLINERGIC,
CYANIDE, CARBON MONOXIDE
• BLUE- METHAEMOGLOBINEMIA
• NEEDLE TRACK – OPIOIDS
FITS (OTIS CAMPBELL)
• ORGANOPHOSPHATES
• TRICYCLIC ANTI
DEPRESSANTS
• INSULIN,ISONIAZID
• SYMPATHOMIMETICS
• CAMPHOR, COCAINE
• AMPHETAMINES
• METHYLXANTHINES
• PCP
• BETA BLOCKERS
• ETHANOL
• LITHIUM
• LEAD
 LAB INVESTIGATION

• FBC
• SERUM ELECTROLYTES
• VBG
• RP
• TOXICOLOGY SCREENS
• CHEST XRAY
• ECG
 TOXIDROME

GROUP OF SYMPTOMS AND SIGNS THAT ARE KNOWN TO

OCCUR WITH SPECIFIC CLASSES OF SUBSTANCES AND
TYPICALLY ARE HELPFUL IN ESTABLISHING A DIAGNOSIS
WHEN THE EXPOSURE IS NOT WELL DEFINED

Paraquat
Opiate
Anti cholinergic
Cholinergic
Sedative Hypnotic
Salicylates
Paracetamol
Barbiturate
 PARAQUAT
Agents Most common Additional signs Potential
presentation and symptoms intervention

Plant killer Nausea and Mouth & Removed

(herbicide) vomiting, esophageal ulcers, contaminated
Diarrhea, Pulmonary fibrosis clothes, washed
Epistaxis, skin with soap and
Acute renal failure water.
Activated charcoal
Insert NG tube
Fuller’s Earth(15%
suspension) 300ml
via NG tube, then
20ml every hour
Haemodialysis
 NARCOTIC/ OPIOIDS
Agents Most common Additional signs Potential
presentations and symptoms intervention

Heroin, morphine, Coma Hypothermia Airway protection

methadone, Respiratory convulsion and oxygen
pethidine depression Gastric lavage and
Hypotension Death usually activated charcoal
Miosis(pin point result from Naloxone: IV 0.4-
pupils) respiratory arrest 2.0mg every 3-5
Bradycardia minutes
(maximum 10mg)
or IV infusion 2mg
in 500cc NS,
100ml/H
 ANTICHOLINERGIC

Agents Most common Additional signs Potential

presentations and symptoms intervention

Antihistamines, • Hyperthermia • Tachycardia Physostigmine-IV

Cyclic • Cuteneous • Urinary 0.5-2mg
antidepressants, Vasodilatation retention cooling, supportive
scopolamine and • Decreased • Decreased GI Mx
homatropine Salivation motility/ absent
• Cyclopegia and bowel sound
mydriasis
• Delirium and
hallucination
 CHOLINERGIC
Agents Most common Additional signs Pontential
presentations and symptoms intervention
Organophosphate • Salivation • Bradycardia, Removed
Carbamate • Lacrimation AMS contaminated clothes,
• Urination • Respiratory wash skin with water.
Example:malathio • Defecation failure, Gastric lavage and
n, parathion, sarin • Gastric • Muscle activated charcoal
emptying weakness & Airway protection &
• Emesis paralysis ventilation ,
• Odour of
garlic Atropine, IV 0.5-2mg
every 5-10minutes
Paralidoxime,IV 1-2g
Death may result in 100ml NS over 30
from respiratory minutes
arrest from Diazepam may be
paralysis , used to treat seizures
bronchorrhea , or
seizure
 Cholinergic excess due to organophosphate

SLUDGE DUMBELS
Salivation Diaphoresis
Lacrimation Urination
Urination Miosis
Defecation Bradycardia,
Gastric cramping Bronchospasm
Emesis Emesis,Excess
lacrimation
Salivation
 SEDATIVE/ HYPNOTICS
Agents Most common Pontential
presentations intervention

SSRI- Sertraline, Anticholinergic manifestation- Gastric lavage and

fluxetine mydrias, dry skin and mouth,urinary activated charcoal.
TCA- retentation and hyperthemia Alkalinization-IV
Amitriptyline,amoxe Cardiovascular toxicity- sodium
pin SVT,hypotension,hypoperfusion,pul bicarbonate 1-
MAOI- monary edema 2mEq/kg
Phenelzine,Isocarb CNS manifestation-Agitation,
oxazid, phenelzine stupor,coma, seizure, respiratory
depression
 SALICYLATE

Agent Most common Additional Potential

findings signs & intervention
symptoms

Aspirin, oil of • Fever Low grade fever, alkalinization of

wintergreen • Tachypnea ketonuria urine, potassium
• Vomiting supplement,
Death may hemodialysis,
• Tinnitus
result from Bicarbonate,
• Lethargy
acute lung injury hydration ,gastric
lavage and activated
charcoal
 PARACETAMOL
Most common findings
First 24 hours-anorexia,
vomiting and diphoresis,.
24-79 hours- right upper
quadrant pain, jaundice,
coagulopathy, confusion, coma
Potential intervention
Gastric lavage and activated
charcoal.
N- acetylcysteine : iv 150 mg/kg
in 200 ml D5 in 15 min,
Then iv 50 mg/kg in 500 ml D5 in
4 hrs
Then iv 100 mg/kg in 1000 ml D5
in 16 hrs
 BENZODIAZEPINE
Agents Most common Pontential
presentations intervention
Diazepam, • Activated
Lorazepam,alprazol • lethargy charcoal
am,clonazepam • drowsiness, • IV flumazenile
• slurred speech, 0.2 mg given
over 30 sec can
• stupor,
repeat until a
• coma, dose of 0.5mg
• respiratory depression is given
 Specific therapy –ANTIDOTES
Antidotes for Common Poisons

Organophosphate Atropine : 2-4 mg iv q 5-10 min PRN / 0.05 mg/kg iv q 5m

PRN
Pralidoxime : 25-50 mg/kg iv (up to 1 g)

Carbon monoxide 100% Oxygen

Narcotics Naloxone: As much as is needed.

Typical starting dose 0.4 mg–10 mg IV

Acetaminophen N- acetylcysteine : iv 150 mg/kg in 200 ml D5 in 15 min,

Then iv 50 mg/kg in 500 ml D5 in 4 hrs
Then iv 100 mg/kg in 1000 ml D5 in 16 hrs

Anticholinergic Physostigmine : 0.5 – 2 mg iv

Methanol Ethanol (10%) mixed in D5: loading 800 mg /kg

maintenance 1-1.5 ml/kg/hr
METHANOL/ETHYLENE GLYCOL POISONING
THANK YOU