Download - Poisoning; General Principles
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Poison Vs. Toxin Poison:
is a substance that cause disturbances to organisms, usually by chemical reaction or other activity on the molecular scale, when a sufficient quantity is absorbed by an organism.
Poisoning: the action of poison in organism body.
Toxin: is a poisonous substance produced within living cells or organisms
Intoxication: The action of toxin in organism body
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Introduction 2.5 million ER visits drug abuse or misuse (51%).
(Drug Abuse Warning Network, US, 2011)
Recreational drug use is common worldwide 6.1 % of the worlds population (aged 15-64 years). (J. Med. Toxicol, 2012)
Asia Pacific region over half of the worlds opioid using population lives in Asia. (WHO, 2002)
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Introduction Toxic overdose can present with various clinical
findings the only clue to a diagnosis.
In patients who have unknown overdoses, a toxidrome can assist in making a diagnosis.
Toxidrome = collections of physical findings that occur with specific class of substances.
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Important! Drug overdose (OD) is often unreliable!
Have a high index of suspicion & assume the possibility of mixed overdose, incl. alcohol intake!
Do proper physical examination to get clues about the types of DO!
Altered mental state (AMS) with a suspicion of DO should have ECG and bed-side capillary glucose done!
Pay attention to emotional/psychiatric state of your pt!
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History D.O.?
What? How much? How long ago? How? Where? Why?
Any suicidal risk? Any previous suicide attempts?
Psychiatric and past medical history?
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Vital Signs are IMPORTANT!
1. Temperature
2. Pulse
3. Blood Pressure
4. Respiratory
5. Rhythm
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Vital Signs TEMPERATURE PULSE RATE/RHYTHM BLOOD PESSURE RESPIRATORY
HYPOTHERMIA (COOLS)
C Carbon monoxide
O Opioid
O Oral Hypoglycaemics, insulin
L Liquor
S Sedative hypnotics
BRADICARDIA (PACED)
P Propanolol (beta blockers)
A Anticholinesterase drugs
C Clonidine, Calcium channel
E Ethanol/alcohol
D Digoxin
HYPOTENSION (CRASH)
C Clonidine (or any
antihypertensive)
R Reserpine
A Antidepressant
S Sedative hypnotics
H Heroin (opiates)
HYPOVENTILATION
Opioids
HYPERTHERMIA (NASA)
N Neuroleptic malignant syndrome,
nicotine
A Antihistamines
S Salicylat, sympathomimetics
A Anticholinergic, antidepressant
TACHYCARDIA (FAST)
F Free base (cocaine)
A Anticholinergic, antihistamine,
amphetamine
S Sympathomimetic (cocaine, PCP)
T Theophylline
HYPERTENSION (CT SCAN)
C Cocaine
T Theophylline
S Sympathomimetic
C Caffeine
A Anticholinergic, amphetamine
N Nicotine
HYPERVENTILATION
Salicylates
CNS stimulant
Cyanide
DISRITMIA
Digoxin
Cyclic antidepressant
Sympathomimetic
Phenothiazine
Chloral hydrate
Anticonvulsant
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A Case 23-years-old male came to Emergency Department
unconscious with history of consuming some unknown
yellow pills, alcoholism, and drug abuse. On presentation, he
was shock, respiratory distress, hypothermia, pinpoint
pupils, hypoglycemia , cyanotic, full rales on both lungs, and
tattoo on his lower left arm. ECG was unremarkable. Lab
result showed type II respiratory failure. Toxicology test were
unavailable.
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Vital Signs TEMPERATURE PULSE RATE/RHYTHM BLOOD PESSURE RESPIRATORY
HYPOTHERMIA (COOLS)
C Carbon monoxide
O Opioid
O Oral Hypoglycaemics, insulin
L Liquor
S Sedative hypnotics
BRADICARDIA (PACED)
P Propanolol (beta blockers)
A Anticholinesterase drugs
C Clonidine, Calcium channel
E Ethanol/alcohol
D Digoxin
HYPOTENSION (CRASH)
C Clonidine (or any
antihypertensive)
R Reserpine
A Antidepressant
S Sedative hypnotics
H Heroin (opioids)
HYPOVENTILATION
Opioids
HYPERTHERMIA (NASA)
N Neuroleptic malignant syndrome,
nicotine
A Antihistamines
S Salicylat, sympathomimetics
A Anticholinergic, antidepressant
TACHYCARDIA (FAST)
F Free base (cocaine)
A Anticholinergic, antihistamine,
amphetamine
S Sympathomimetic (cocaine, PCP)
T Theophylline
HYPERTENSION (CT SCAN)
C Cocaine
T Theophylline
S Sympathomimetic
C Caffeine
A Anticholinergic, amphetamine
N Nicotine
HYPERVENTILATION
Salicylates
CNS stimulant
Cyanide
DISRITMIA
Digoxin
Cyclic antidepressant
Sympathomimetic
Phenothiazine
Chloral hydrate
Anticonvulsant
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Odours Odours Probable poisons
Fruity Mothballs Bitter almonds Silver polish Stove gas* Rotten eggs Garlic Wintergreen
Ethanol Camphor/nophtalene Cyanide Cyanide Carbon monoxide Hydrogen sulphide Arsenic/parathion Methylsalicylate
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Neurologic Examination Level of consciousness
CNS antidepressant Anticholinergics
Antihistamins
Barbiturates
Cyclic antidepressant
Ethanol & other alcohols
Phenotiazines
Sedative-hypnotic agents
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Sympatholytic agents Clonidins
Methyldopa
Opiates
Cellular hypoxia Carbon monoxide
Cyanide
Hydrogen sulphide
Methaemoglobinemia
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Neurologic Examination Pupils
Miosis (COPS) C Cholinergics, clonidine
Opiates, organophosphate
Phenothiazines, pilocarpins, pontin bleed
S sedative-hypnoyics
Mydriasis (AAAS) A Antihistamins
A Antidepressants
A Anticholinergics, atropines
S Sympathomimetics cocaine, amphetamines)
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Neurologic Examination Fits (OTIS CAMPBELL)
O Organophosphate
T Tri-cyclic antidepressant
I Insulin, isoniazid
S Sympathomimetic
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C Camphor, cocaine
A Amphetamines
M Methylxanthines
P Phencyclidine
B Beta-blockers
E Ethanol
L Lithium
L Lead
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Skin Diaphoretic (SOAP)
S Sympathomimetics
O Organophosphates
A ASA (salicylates)
P Phencyclidine
Blistering
Carbon monoxide
Barbiturates
Poison ivy
Sulphur mustard
Lewisite
Dry
Antocholinergic
Colour
Red
Anticholinergic
Cyanides
Carbon monoxide
Blue
Methaemoglobinemia
Needle tracks
opioids
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Toxidromes (toxicology syndromes) Opioids Cholinergics (SLUDGE)
Coma
Respiratory depressions
Pinpoint pupils
Hypotension
Bradycardia
S Salivation
L Lacrimation
U Urination
D Defecation
G Gastric emptying
E Emesis
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Toxidromes (toxicology syndromes) Anticholinergics
(antihistamines, cyclic antidepressant, homatropine, scopolamine)
Hot: hyperthermia
Red: cutaneous vasodilatation
Dry: decreased salivation
Blind: cycloplegia and mydriasis
Mad: delirium and hallucinations
Tachycardia
Urine retention
Decreased GIT motility
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Toxidromes (toxicology syndromes) Salicylates Sympathomimetics
Fever
Tachypnoea
Vomiting
Lethargy
tinnitus
Hypertension
Tachycardia
Hyperpyrexia
Mydriasis
Anxiety or delirium
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Toxidromes Sedative-hypnotics Extrapyramidal (TROD)
Unpredictable pupillary changes
Confusion or coma
Respiratory depression
Hypothermia
Vesicle or bullae
Tremor
Rigidity
Opistothonus, oculogyric crisis
Dysphonia, dysphagia
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Laboratory Full Blood Count Toxicology Screen
Elevated total white count
Infection
Iron
Theophylline
hydrocarbon
Paracetamol
Salicylates
Cholinesterase
Iron
Lithium
Theophylline
Carbon monoxide
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Laboratory Elevated Anion Gap
Anion Gap: Na HCO3 Cl
Normal AG: 8-16 mEq/l
Metabolic acidosis
C: Carbon monoxide, cyanide
A: Alcoholic ketoacidosis
T: Toluene
M: Methanol
U: Uraemia
D: Diabetic ketoacidosis
P: Paraldehyde
I: INH, iron
L: Lactic acidosis
E: Ethylene glycol
S: Salicylates, solvent
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X-rays Chest Abdominal
Pulmonary toxic agents
Hydrocarbons
Toxic gases
Paraquat
Non-cardiogenic ALO
Opiates
Phenobarbitone
Salicylates
Carbon monoxide
Toxins radioopaque on X-rays (CHIPES)
C Chloral hydrate
H Heavy metals
I Irons
P Phenothiazines
E Enteric-coated salicylates
S Sustained-release theophyllines
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ECG Prolonged PR & QRS Intervals
Cyclic antidepressant
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Treat Patient, Not Poison! At your clinic: Attend to
the ABC of drug overdose patient first before sending the patient to the ED
At ED: Attend to the ABC of drug overdose patient first before seeking for antidotes
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Patient is NEVER just drunk until all other possibilities are excluded
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Critical Care Area Airway management
Resuscitation drugs
Supplemental oxygen
Monitoring ECG, VS, pulse oxymetry
Peripheral IV lines
Labs
Urinary catheter
Control fits
Control dysrhytmias
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Unknown Case Coma Cocktail
D40% 40ml if the pt hypoglycemia, followed by D10% over 3-4hours
Naloxon (Nokoba) 0,8 - 2,0 mg iv bolus
Thiamine 100mg iv bolus in alcoholic or malnourished pt
Flumazenil (Anexate) 0,5mg iv bolus
C-spine X-ray if trauma cannot be excluded
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Decontamination Procedure
Remove from contaminated area
Remove cloth
Brush off all powder contaminants from skin
Wash all areas with water/soap
Areas to concentrate are head, axille, groin, back
Brush under nail
Irrigate the eyes
All open wounds must be additionally decontaminated with water
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Gastric Decontamination Dilution: water
Indications: ingested within 1-3 hours of ingestion
Contraindications:
Corrosive
Petroleum
On-going fits
Non-toxic ingestion
Ingestion of sharp material
Significant haemorrhage
Procedure: large bore NG tube
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Activated Charcoal Indication:
poison absorbed by charcoal (if known)
Within 1-3 hours of ingestion
Drugs absorbed by charcoal:
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Activated Charcoal Dosis
1 gm/kg
Dosis dewasa : 25 to 50 gms
Dosis anak : 12.5 to 25 gms
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Enhancement of Elimination Forced alkaline diuresis
Haemoperfusion
Haemodialysis
Specific antidotes
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Specific antidotes Toxin Antidotes Dosage
Paracetamol N-acetylcysteine
IV 150mg/kg iv in 200ml D5 x 15 min, then IV
50mg/kg in 500ml D5 x 4 hours, then IV 100mg/kg
in 1000ml D5 x 16 hours
Arsenic, Mercury BAL (Dimercaprol) 5mg/kg body weight IM
Atropine Physostigmine 0,5-2mg IV
Benzodiazepine Flumazenil (anexate) 0,5mg IV bolus
Carbon monoxide Oxygen O2 100%
Cyanide
Amyl nitrite pearls Inhalation of contents of 1-2 pearls
Sodium nitrite (3% sol) Adults: IV 300 mg (10 ml) over 2-5 min
Children: IV 0,2-0,33ml/kg (6-10mg)
Sodium thiosulfate (25% sol)
Adults: 50 ml IV (12,5g) over 10 min; can repeat
half dose x 1 prn
Children: 1,65 ml/kg IV over 10 menit
Ethylene glycol, methanol Ethanol (10%) mixed in D5 Loading dose : 800mg/kg
Maintenance : 1-1,5ml/kg/hour
Ion Desferoxamine 1,5mg/kg/hour IV
Lead EDTA: calsium disodium edetate 1000-1500mg/m2/day IV continuous infusion
Nitrites Methylene blue (1% sol) 1-2mg/kg IV x 5 min
Organophosphate Atropine
2-4mg IV every 5-10 min prn (adults)
0,5 mg/kg IV every 5 min prn (children)
Pralidoxime (2-PAM) 25-50mg/kg IV (up to 1 g)
Opioids Naloxone 0,8 - 2,0 mg iv bolus
Phenothiazine Benztropine (Cogentin) 2mg IV/IM
Diphenhydramine 50mg IV/IM/PO
Isoniazid (INH) Pyridoxine 5 g IV (can be repeated if fits persist)
Digoxin Digibind
Digoxin level unknown: 5-10 vial IV (40g vial):
can repeat
Digoxin level known: # vial digibind =
(serum digoksin) x 5,6L/kg x wt in kg
1000
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Disposition Internal Medicine
High Dependency unit/ICU admission
Psychiatric consultation for suicidal intention case
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Further reading: Hack JB, Hoffman RS. General Management of Poisoned Patients. In: Tintinalli JE,
editor. Emergency Medicine; A Comprehensive Study Guide. 6th ed. USA: McGraw-Hill;
2004. p. 1015-21.
Travers J, Manning P, Ibrahim I. Poisoning: General Poisoning. In: Ooi S, Manning P,
editors. Guide to the Essentials in Emergency Medicine. Singapore: McGraw-Hill; 2004.
p. 75-80.
Goldfrank LR, Hoffman RS, Nelson LS, Howland MA, Lewin NA, Flomenbaum NE.
Principles of Managing the Poisoned or Overdosed Patient. In: Goldfrank LR, Hoffman
RS, Nelson LS, Howland MA, Lewin NA, Flomenbaum NE, editors. Goldfranks
Toxicologic Emergencies; 2007. p. 24-28.
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Thank You