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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7

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

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

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

Toxidromes (toxicology syndromes) Salicylates Sympathomimetics

Fever

Tachypnoea

Vomiting

Lethargy

tinnitus

Hypertension

Tachycardia

Hyperpyrexia

Mydriasis

Anxiety or delirium

Toxidromes Sedative-hypnotics Extrapyramidal (TROD)

Unpredictable pupillary changes

Confusion or coma

Respiratory depression

Hypothermia

Vesicle or bullae

Tremor

Rigidity

Opistothonus, oculogyric crisis

Dysphonia, dysphagia

Laboratory Full Blood Count Toxicology Screen

Elevated total white count

Infection

Iron

Theophylline

hydrocarbon

Paracetamol

Salicylates

Cholinesterase

Iron

Lithium

Theophylline

Carbon monoxide

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

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

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

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

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

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

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

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

0,6

Disposition Internal Medicine

High Dependency unit/ICU admission

Psychiatric consultation for suicidal intention case

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