Basic Principles

poison: 1- Definition of poison:

The poison is any substance when introduced into the body, produces toxicity, deleterious effects, ill health up to death.

poisons 2- Classification of poisons:

According to site of action: Poisons have local action only: Examples: Corrosive Poisons Poisons have remote action only: Examples: Plant Poisons Poisons have both local and remote action: Examples: Irritant Poisons According to target organ affected: Neurotoxic poisons: Examples: alcohol & lead. Cardiotoxic poisons: Examples: digitalis. Hepatotoxic poisons: Examples: ethanol, acetaminophen, phosphorus, carbon tetrachloride and arsenic. Nephrotoxic poisons: Examples: metals e.g., mercury. Ohpthalmotoxic poisons: Examples: UV light (sunlight) Dermatotoxic poisons: Examples: UV light, gold & nickel. Immunotoxic poisons: Examples: isocyanates. Poisons affect respiratory tract: Examples: tobacco smoke, asbestos & ozone. Poisons affect reproductive System: Examples: dibromochloropropane. According to the chemical nature: Acidic poisons: Examples: sulphuric, nitric and hydrochloric acid. Alkaline poisons: Examples: caustic soda & caustic potash and ammonium hydroxides : According to the source: Animal poisons: Examples: snake bite and scorpion sting Plant Poisons: Examples: opium, cannabis, atropine. According to mode of Poisoning: Deliberate Overdose as self-harm or suicide attempt. Child abuse Munchausen's syndrome by proxy. Third party (attempted homicide, terrorist, warfare). Accidental Most episodes of pediatric poisoning. Dosage error. latrogenic. Patient error. Recreational use. Environmental: Plants. Food. Venomous stings/bites. Industrial exposures. effect: According to toxic effect: Death: cyanide. Organ Damage: ozone & lead. Mutagenesis: UV light. Carcinogenesis: benzene & asbestos. Teratogenesis: thalidomide.

Basic Principles

poisons 3- Factors affecting the action of poisons:

- Factors related to the poison: State of the Poison: Gas form: Gases or vapour poisons are the most rapid action. Liquid form: Liquid are rapid absorption than solid form. Solid form: Fine powders are rapid than big crystals or lumps. Dose of the Poison: The Bigger The Dose The Greater The Toxicity. Route of the Poison: Method of administration IV injection: is the Rapidest Route Then Inhalation Then IM & SC injection Then Ingestion Absorption from m.m. of vagina & rectum is more Then Intact skin absorption: is the Slowest Route. - Factor related to the person: - Gastric condition: Amount of Food: On Empty Stomach: Poisons have faster action. On Full Stomach: Poisons have slower action. Type of Food: Fatty Food may: Absorption of some poisons e.g. Arsenic due to: Coating the gastric mucosa. Delaying the gastric emptying Absorption of other poisons e.g. Phosphorous & DDT due to: their solubility fat soluble compounds. - Genetic Condition: Glaucose 6 phosphate dehydrogenase enzymes Haemolytic effect of some drug Even in therapeutic doses. Antimalarial Sulphonamides Vitamin K Naphthalene & Benzene. 3- General condition of the patient: Generally: Liver, Kidney, Heart diseases

Toxicity of most of poisons.

4- Age of the patient: Generally: Extremes of age Children & Old age peoples are more susceptible to toxicity. Example: Children are more susceptible to i action of morphine. 5- Hypersensitivity: Penicillin:In hypersensitive persons may produce severe symptoms even fatal anaphylaxis by Therapeutic Dose. 6- Idiosyncrasy: Morphine: In abnormal response, it may produce CNS excitation. 7- Tolerance, Habituation and Addiction. Morphine, Alcohol and Cocaine. Persons who Tolerated, Habituated or Addicted To some drugs Can stand big doses of these drugs without toxicity. 8- Cummulation: Reach to the effect of single large dose after repeated small doses. AE: Poor metabolism of the drug e.g.: Digitalis Lead.

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Cases: 4- General Diagnosis of Poisoning Cases:

Diagnosis of Poisoning: i- History and circumstantial evidences. ii- Clinical manifestations. iii- Investigations.

i- History and circumstantial evidences:

Successful treatment of acute toxicity mainly depends on Early Rapid & Correct Diagnosis as i following: a- Sudden appearance of toxic manifestations in a healthy person or a group of persons after taking certain food or drink (as food poisoning, methanol and carbon monoxide toxicity). b- History of intake a poison, financial problems, psychiatric troubles, previous attempts at suicide or threatening by somebody. c- Presence of bottle of tablets or insecticide near the victim. d- Patients rescued from fire (CO, cyanide). History It should include: Type of toxin. Time of exposure (acute versus chronic). Amount taken. Route of administration (i.e. ingestion, intravenous, inhalation). Reason for the ingestion or exposure. It is also important to understand why the exposure occurred (accidental, suicide attempt, euphoria, therapeutic misadventure) Presence of history of psychiatric illness or previous suicide attempts. Patient must be asked, about all drugs taken, including: Prescription, over-the-counter medications, vitamins, and herbal preparations. Patients may incorrectly name the drugs they have ingested; For example, they may refer to ibuprofen as acetaminophen or vice versa. Patients can be unreliable historians, particularly if: Suicidal, psychotic, presenting with altered mental status, or under the influence of recreational drugs. Patient with unreliable history, information taken from family and friends may also prove helpful.

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iiii- Clinical Examination:

To detect the symptoms and signs Clinical toxicology Clinical toxicology Symptoms: Symptoms CNS: CNS CNS stimulation: Agitation, Anxiety, Insomnia, Irritability, Convulsion & Coma. AAIICC AAIICC AAIICC CNS inhibition: Dizziness, Drowsiness, Stuprous, Confusion & Coma. DDSCC DDSCC DDSCC CVS: Tachycardia, Bradycardia, Palpitation, Arrhythmias & Arrest. TBPAA CVS TBPAA TBPAA RT: CCDWP RT Cough, Crepitations, Dyspnea, Wheeze, & Pul. oedema. CCDWP CCDWP GIT: Diarrhea. ANVAC&D ANVAC&D GIT Anorexia, Nausea, Vomiting, Abdominal Colic & Diarrhea ANVAC&D UT: OPRAH UT Oliguria, Proteinuria, Renal failure, Anuria & Haematuria OPRAH OPRAH

Signs: Examination: General Examination: a) Directed cardiovascular, respiratory, abdominal and neurological examination "When patient stabilized". b) Vital signs, Pulse, Blood Pressure, Respiratory rate, Temp, Pupil, Breath odour, Skin. Recorded in initial evaluation & repeated regularly. c) Temperature: Hypothermia (phenothiazines, barbiturates, or tricyclics) or hyperthermia (amphetamines, Ecstasy, MAOls, cocaine, antimuscarinics, theophylline, serotonin syndrome). d) Muscle rigidity: (Ecstasy, amphetamines). e) Skin: Cyanosis (methaemoalobinaemiay ) very Pink (carboxyhaemoglobinaemia, cyanide, hydrogen sulphide) Blisters (barbiturates, TCAs, benzodiazepines) Needle tracks; hot/flushed (anticholinergics). f) Breath: ketones (diabetic/alcoholic ketoacidosis) Bitter almonds (cyanide) Garlic-like (organophosphates, arsenic) Rotten eggs (hydrogen sulphide) organic solvents. g) Mouth: Perioral acneiform lesions (solvent abuse) Dry mouth (anticholinergics) Hypersalivation (parasympathomimetics). Respiratory system, color: Respiratory system, abdomen, CNS, urine color: see later

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iii- Investigations: iii- Investigations:

They are done to assess base line of the patient and follow up target organs. Treat the patient and not the poison is fact still present up till now . History & clinical examination are the main step in the diagnosis of toxicological cases . a- Routine investigations: ECG U+E, lab glucose, anion gap /lactate & osmolal gap. LFT & Clotting (Paracetamol, anticoagulants). Arterial Blood Gases. Urinalysis - ? Rhabdomyolysis, save sample for possible Toxicological analysis. CXR if pulmonary oedema/aspiration suspected.

Common radiopague medications: (BETA CHIP) Barium Enteric coated tablets Tricyclic antidepressants Antihistamines. Chloral hydrate, cocaine, calcium, condoms (contains tablets). Heavy metals Iodides Phenothiazines, potassium films: Chest films: Drugs causing pneumonitis or pulmonary edema (MOPS MOPS) MOPS Meprpbamate Methadone Opioids Phenobarbital Propoxyphene Paraquat Phosgene Salicylates Chemical b- Chemical detection: (Analytical toxicology) The most important evidence of poisoning is by chemical analysis. Samples are taken from vomitus, gastric lavage, blood, urine and stool. Toxicological laboratory screen is important in Delirium (Come , Convulsion , Acute Delirium , Metabolic Acidosis & Hypoxia) Toxicological Laboratory serum level is important in :anti(Alcohol Aspirin Paracetamol Digoxin Iron Theophyline salicylates - lithium anti-epileptics ) Toxicological Laboratory urine drug screen (is the sample of choice for the most of the drugs and metabolites) (Athletes Brain Death Pregnancy suspect abuse TTT Abuse Program Work Place) Carboxyhaemoglobin levels if carbon monoxide poisoning is suspected. Comprehensive toxicology screens are not normally indicated in the emergency treatment.

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5- General Treatment of Poisoning Cases:

General lines of treatment of poisoned patient Good supportive care is the backbone of any successful therapy of poisoned patients. 1. Stop exposure and Emergency treatment. 2. Decontamination. 3. Excretion Enhancement. 4. Antidote Administration. 5. Symptomatic treatment.

I- Stop Exposure and Emergency Treatment:

i- Stop Exposure:
Aim to prevent further exposure or administration of poisons: In Medical Treated Patient. If toxic S & S of any drug appear stop i drug immediately. In Industrial or Agricultural workers: Removed from the polluted area. In Homicidal or Suicidal Cases: Hospitalization and observation to prevent further exposure. In Children: Any drugs must be kept away from children to avoid accidental intake.

iiii- Emergency treatment:

The clinical approach to the poisoned patient starts with recognition & treatment of life threatening condition A, B, C & D.

Airway:
Airway Opening & Clearance; The greatest contributor to death from drug overdose or poisoning is respiratory failure. Airway opening: Triple airway maneuver: (Head tilt, jaw thrust, Mouth opening) If there is any suspicion of neck injury: Place the patient in left lateral position with the head downwards which allows the tongue to fail forwards and vomitus or secretions to drain out of the mouth. Airway clearance: Finger sweep technique to remove any F.B. or denture. Suctioning of the mouth and oropharynx to remove secretions. Toxic causes of respiratory failure; I- Central causes: Such as opiates, barbiturates, alcohols ..... II- Peripheral causes: 1- Airway obstruction 2- Neuromyscular block 3- Paralysis of respiratory muscles (1) Airway Obstruction: Falling back of the tongue or vomitus in a patient with altered mental status such as in: Toxic comatose patient. Excessive secretions as in: Organophosphate or carbamate toxicity. Edema of the airway: Irritant fumes or gas such as chlorine inhalation. Laryngeal spasm as in: Cyanide poisoning. Bronchospasm as in: Organophosphorus compounds. Pneumonia as in: Aspiration of gastric contents, or aspiration of hydrocarbons such as kerosene. Pulmonary edema as in: Organophosphate. (2) NeuromuscuIar block: Neostigmine and physostigmine. (3) Paralysis of respiratory muscles: BOSB Botulinum toxins. " Organophosphates. Snake bites. Post convulsive muscle exhaustion.

Basic Principles

Breathing support:
(I) Airway devices: Oropharyngeal or nasopharyngeal airway devices: Placed in the mouth or nose to lift the tongue and push it forward. Endotracheal intubation (ETT): In comatose patient. . Advantages: : It protects the airway & prevents aspiration and obstruction. It allows for mechanically-assisted ventilation. It allows some emergency drugs to be be given through it e.g. naloxone, atropine and epinephrine Cricothyrodotomy or tracheostomy: In upper airway obstruction (ETT can not be inserted). (II) Assist ventilation: (oxygen) Indication Indication: PO2 < 60 mmHg & PCO2 > 60 mmHg. Don't wait until the patient is apneic Methods: Mouth-to-mouth ventilation. Mouth-to-mask ventilation (this method is more hygienic). Bag and mask ventilation. Bag and tube ventilation. Mechanical ventilation (used when resuscitative efforts are prolonged). (III) (III) Active treatment: Bronchospasm: Administer bronchodilators if there is wheezing or ronchi. B2-agonists e.g. sulbutamol inhalation. Aminophylline slowly IV if the above is not effective. Pneumonia: Antibiotics if there is evidence of infection. Corticosteroids (if it is a chemical-induced pneumonia). Pulmonary edema: Avoid excessive fluid administration. Administer supplemental oxygen. Diuretics. Specific antidote: Consider specific antidotes: e.g. Naloxone can reverse respiratory depression in a patient with opiate overdose.

Circulatory support :( 5)
(I) Check blood pressure, pulse rate and rhythm: - Perform cardiopulmonary resuscitation if there is no pulse. - Treat shock and arrhythmia if present. (II) Begin continuous ECG monitoring: - This is essential for comatose patients and cardiotoxicity. (III) Establish an intravenous line. (IV) Draw blood for routine studies. (V) Insert Foley's catheter - It is placed in the bladder if the patient is seriously ill (shocked, convulsing or comatose). - Obtain urine for routine and toxicological testing and measure hourly urine output.

Basic Principles

Disability:
Once ABC are addressed, the neurological status should be assessed, mainly level of consciousness & convulsions.

consciousness: I- level of consciousness

Stupor or coma Stupor: it is a grade of unconsciousness in which the patient can be aroused (awakened) only by painful stimuli. Coma: it is a state of prolonged unconsciousness in which the patient can not be aroused by painful stimuli. Coma: i- Definition: It is a state of unconsciousness. ii- Aetiology and types: 1) Toxic causes: Generalized CNS depression (e.g. ethanol, opiates, sedative-hypnotic) As a post-ictal phenomenon (after a drug-induced seizure) (e.g. anticholinergics). Hypoglycemia (e.g. insulin, oral hypoglycemic drugs). Cellular hypoxia (e.g. CO, cyanide). 2) Traumatic causes: Head injures. 3) Pathologic causes: Liver & renal failure. Infections as encephalitis or meningitis . 4) Environmental causes: Hypothermia or hyperthermia. 5) Hysterical: Normal vital signs: Pulse, B/P, Temperature & Respiratory Rate. No apparent organic lesion. No characteristic odour. No positive finding investigation "Negative Analysis". Not complete coma. iii- Complications of coma: Loss of protective airway reflexes, resulting in airway compromise which is a major cause of death. Hypotension. Hypothermia. Rhabdomyolysis. iv- Grades: Level of consciousness is evaluated roughly by: Scale: AVPU Scale A= Alert. V= Drowsy but Verbal command responsive. P= Comatose but response to Pain responsive. U= Comatose and totally Unresponsive. Scale: Reed's Scale: G0: Asleep. GI: Response to verbal command & Drowsy. GII: Unresponsive to verbal command but minimal responsive to pain. GIII: Unresponsive to verbal command & to pain with absent reflex. GIV: Completely unresponsive with cyanosis and shock. Stage 0 I II III IV Conscious level Asleep Comatose Comatose Comatose Comatose Pain response Arousable Withdrawal Non Non Non Reflexes Intact Intact Intact Absent Absent Respiration Normal Normal Normal Normal Cyanosed Circulation Normal Normal Normal Normal Shock

Glass Gaw Coma Scale: Depend on Eye signs Response to painful stimuli Response to verbal command. The best score "15" The worst score "3" Frank coma "<8" v- Treatment o coma (5): i- Emergency treatment: Airways: Maintain airway and assist ventilation if necessary Breathing: Oxygen inhalation at a high flow rate 8-10L/minutes Circulation ii- Decontamination: Emesis: X is contraindicated. Gastric lavage: But: Cuffed endotracheal tube 1st before lavage.

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iii- Antidotes: Give coma Cocktail: Dextrose, Naloxone and Thiamine: Dextrose: - It is given to all patients with depressed consciousness. - It is given To treat or exclude hypoglycaemia" - Child: 25 % (2 ml/kg) I.V. - Adolescent/Adult: 50 % (1 ml/kg) I.V. Naloxone: - It is given to all "adult and children" patients with depressed respiration "Respiratory failure" - Child: 0.1 mg/kg I.V. - Adolescent/Adult: 0.4 mg I.V. - If no response give 2 mg I.V. - If no response, repeat the dose every 2 min. till a total dose of 10 mg Thiamine: - It is given to malnourished and chronic alcoholic patients. - It is not given routinely to children. - 100 mg l.V. or I.M. Specific Antidote is given according to the type of toxicity. iv- Elimination Enhancement: According to the type of toxicity. v- Symptomatic treatment: Buccal care: Frequent wash the mouth. Breathing care: Oxygen inhalation and frequent suctioning, antibiotics Bladder care: Catheterization under aseptic condition. Bowel care: Frequent enema, antacid and lactulose. Bed sores: Frequent changing of the patient position in bed to avoid bedsores. Control convulsions if they are present. Correct acid-base disturbance. Care of the eyes: Antibiotic eye drops & ointment and covering. Consider specific antidotes e.g. flumazenil for benzodiazepines CT scan and treat accordingly if suspecting a brain lesion .&.. Antibiotic: to avoid the infection Prophylactic Blanket: to treat hypothermia. Continuous monitoring: of pulse, B/P, temperature & respiratory rate. Dehydration: treated by IV fluids. Electrolytes correction & fluid balance Feeding: Ryles tube for nutritional support.

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2- Convulsions:
1- Causes: 1) Toxic causes: Poisons acting on the cerebrum "muscular hyperactivity": e.g. Amphetamine, cocaine, caffeine & atropine. Poisons acting on the brain stem "clonic convulsions" i.e. contraction and relaxation of the muscles: e.g. Picrotoxin & Pb. Poisons acting on the spinal cord "tonic convulsions" i.e. sustained hypertonia of the muscles.: e.g. Strychnine Poisons cerebral anoxia: e.g. Cyanide 2) Metabolic causes: Hypoglycemia, hyponatremia, hypocalcemia, or hypoxia. 3) Traumatic causes: Head trauma with intracraniaLmjury. 4) Idiopathic epilepsy. 5) Exertional or environmental hyperthermia. 6) Pathologic causes: - CNS infection: meningitis or encephalitis, febrile seizures in children. 2- Complications: Any seizures can cause: Airway compromise, resulting in apnea or pulmonary aspiration. Multiple or prolonged seizures: May cause severe metabolic acidosis, hyperthermia, rhabdpmyolysis, and brain damage. 3- Treatment of convulsions: i- Emergency treatment: Maintain an open airway and assist ventilation Put the patient in Dark Quite Room to avoid any stimulation ii- Decontamination: Emesis: X is contraindicated to avoid precipitating the convulsion Gastric lavage: X is contraindicated to avoid precipitating the convulsion iii- Antidotes: According to the toxicity type. iv- Enhancement of Elimination: According to the toxicity type. v- Symptomatic treatment: Convulsion control BY: Use one or more of the following anticonvulsants Anticonvulsant Drugs: Benzodiazepines: Djazepam: 0.1- 0.2mg/kg IV "10 mg for Adult .2mg/kg for Children" Midazolam: 0.1- 0.2mg/kg IM when IV access is difficult Barbiturates: Ultrashort acting as pentothal sodium: 0.5 -1 gm, slowly IV Short acting barbiturates: 0.5 -1 gm, slowly IV Phenobarbital: 10-15mg/kg slowly IV infusion over 15-20 minutes. Phenytoin: the anticonvulsant of last choice for most drug-induced seizures. Dehydration: Fluids. Exhaustion: Bed rest. Fever: Cold sponges. Glaucose: in cases of hypoglycaemia

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IIII- Decontamination:
i- Skin Decontamination: Indications: Indications: i- Cases of Corrosives to prevent skin injury. ii- Toxins that are readily absorbed through the skin (e.g. organophosphorous insecticides, paraquat, phenol, oxalic acid, etc) to prevent systemic absorption. Steps of decontamination: Wear protective clothes & gloves. Remove the patient's contaminated clothing. Flush exposed areas with copious quantities of tepid water or saline for at least 30 minutes. Use soap for oily substances. iiii- Eye decontamination: Indications: i- Corrosive agents and hydrocarbon solvents that can rapidly damage the cornea. ii- Toxins that are readily absorbed through the skin can also be absorbed through the conjunctiva. Steps of decontamination: Steps Remove the contact lens. Flush exposed eyes with copious quantities of tepid water or saline for up to 20 minutes. Consult ophthalmologist after irrigation. iiiiii- Lungs (inhalation) Indications: 1. Irritating gases and fumes e.g. chlorine gas. 2. Toxins that are absorbed through the respiratory tract e.g. CO, cyanide, hydrogen sulphide, organophorous insecticides. Steps of decontamination: Ensure adequate respiratory protection for yourself and other care providers (wear protective mask). Remove the victim from exposure to fresh air. Care of respiration is started after cleaning the mouth: Administer humidified O2 (if available) and assist ventilation (if necessary), Tracheostomy or ETT may be needed. Observe for evidence of upper respiratory edema: (Early manifested by stridor and hoarse voice) (Later manifested by non-cardiogenic pulmonary edema "dyspnea, tachypnea and hypoxemia").

Basic Principles
iviv- Gastric Decontamination: iviv- GIT decontamination: 1. Emesis. 2. Gastric lavage. 3. Local antidotes e.g. activated charcoal. 4. Cathartics. 5. Whole bowel irrigation.

a- Emesis: i- Definition: A very rapid and safe method of decontamination. This is one of the most convenient methods used to get rid of the poison from the stomach. ii- Types: Systemic: apomorphine is unsafe and should not be used. Mechanical: By: Tongue depressor. Chemical: By: Syrup of Ipecac. 1- Definition: Most safest Method for induction of emesis Ipecac is the dried root of Cephalus ipecaquanha plant that contains the active alkaloids emetine & cephaline. Syrup of ipecac is the emetic of choice in both children over the age of 6 months and in adults. 2 -Indications: Large Amount of Poisons Ingested Within 1 Hour, after 60 minutes it is not effective. 3- Contraindication: Poison: Poison: Convulsants Corossives (inorganic). Carbon (Hydrocarbons) Sharp objects (needle, pin) Patients: Patients: Comatose patient or Unconscious Come late. >1 hour. Children <6 months (gag reflex not well developed). Convulsion. Decreased gag reflex. Severe CVS disease or emphysema or respiratory distress. Recent surgical intervention. Hemorrhagic tendencies. Previous significant vomiting before this moment. Pregnancy to avoid potential mechanical effect on i uterus. 4- Mechanism: It causes vomiting through 2 phases: Early vomiting (within 30 minutes): due to the direct local irritant action of ipecac on gastric mucosa. Late vomiting (after another 30 minutes): Due to central stimulation of the chemoreceptor trigger zone. 5- Route: Oral. 6- Dose: 30 ml for adults. 15 ml for children 5-10 ml for children between 6 months and 2 years. If vomiting does not occur after 30 minutes, the dose is repeated. If still no vomiting, gastric lavage should be carried out to remove ipecac from the stomach (as it is toxic). 7- Advantages: : Emesis is generally less traumatic than gastric lavage which is unpleasant to most people and must be done by qualified trained physician. Emesis can recover particles that are too large to pass through the openings of gastric lavage tube. 7- Side Effects: Delay administration of Activated charcoal or oral antidote Damage to gastric mucosa Drowsiness 20% Diarrhea 25%

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2- Gastric Lavage: Stomach Wash i- Definition: It is the most satisfactory method to remove the poison from the stomach: ii- Indications: It is usually used for extremely toxic substances. In cases of unknown ingestions or when loss of consciousness is present Recently, the gastric lavage is only indicated if: Large Amount Life threatening of Poisons Ingested Within 1 Hour. iii- Contraindications: Absolute contraindications: Corrosives: Mineral Acids & Alkalies: to Avoid Gastric Perforation. Relative contraindications: G.L. can be done with some precautions Convulsions: Gastric Lavage is contraindicated EXCEPT: After general anesthesia To avoid induction of another fit. Coma: Gastric Lavage is contraindicated EXCEPT: After endotracheal intubation To avoid aspiration pneumonia. Carbon Hydrocarbon Kerosene & other Petroleum Distillate Gastric Lavage is contraindicated EXCEPT: After cuffed endotracheal intubation In Large Ingestion - To avoid aspiration pneumonia. Come late after lapse of 1 hours from ingestion. Except in poisoning delayed gastric Emptying tendency: Cases of oesophageal varices & bleeding tendency Must be take good history v- Technique: 1- Positioning: Place the patient on one side: "Better the left side" Put the head at a level lower than the feet "Avoid regurgitation" Remove any denture. 2- Introduction of the stomach tube: Apply liquid paraffin to i lower end of Place large bore OG/NG tube (16-36 Fr) as a lubricant Then, introduce the tube over the tongue. Ask the patient to swallow if conscious this make the passage more easily Until the mark reaches the level of the lip. Assure that the tube in the stomach by: In conscious patient: If the tube passes into the air passage. Sudden spasmodic attack of Cough, Cyanosis, Chest Pain & Dyspnoea In unconscious patient: Semiconscious or Comatose Cough reflex is lost and so the tube may pass into the trachea without cough reflex so: Ensure by the Following Tests: If the tube passes into the STOMACH Aspirated gastric content: See: gastric content by aspiration Bubbling sounds heared sound stethoscope on the epigastrium when little air injected via the tube. 3- Suction: Aspirate as much as possible - Put a sample in a clean jar- Send it to laboratory 4- Lavage: Instillate: 200 ml of tap water and aspirate it until withdrawal fluid clear & odourless or 2 liters used Inject: Activated charcoal & cathartic 60 gm is given. 5- Extraction After tight closure of the proximal end of the tube to avoid escape of the fluid from the distal end to the trachea during withdrawal . vi- Complication: Laryngeal spasm (Procedure very irritant to ptn.) may produce cyanosis. Aspirated pneumonia. Vigorous maneuvers Epistaxis. Arrhythmia & Electrolytes Imbalance. GIT injury & Giddiness & other CNS manifestations due to hyponatriaemia. Enhancement the passage of the poison to the intestine . N.B. Emesis is better in (Sustained release tablets) & (large masses of tablets). Gastric lavage is better in (coma) & (Hydrocarbon).

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3- Activated Charcoal: i- Definition: It is a substance that almost irreversibility adsorbs drugs and chemicals, preventing absorption. ii- Mechanism: Activated charcoal adsorbs most of the toxins. iii- Indications: indication: Single dose indication: Agents responsive to multiple dose activated charcoal Substance adsorbable by activated charcoal (ABCD) Aminophylline (teophyllin), Antimalarials (quinine), Barbiturates (Phenobarbital) Carbamazepine Dapsone Substance not adsorbable by activated charcoal (PHAILS) (PHA Pesticides, Potassium Hydrocarbons Acids & Alkali "Corrosives" - "Poor bind and Difficult Endoscopy" Alcohols Iron, Insecticides Lithium Solvents: "Petroleum Distillates" & Multiple doses: 1- Drug Excreted in The Bile (Phenobarbital Phenytoin Cabamezapine Salicylates & Theophyline) 2- Drug Excreted in The Intestine: (Digoxin Morphine) 3- Drugs form Concretion : (Salicylate & Barbiturates) 4- Drugs Inhibit GIT motility: (Morphine & Anticholinergic) 5- Drugs of Sustained Release Tablets: (Theophyline & NSAI) The activated charcoal is the best method to decrease amount of the drug absorption in the patient which may reach to 50 % if given in the 1st hour in ratio (10:1) (charcoal : toxins) amount. The main goal is to have a charcoal to toxin ratio > 10:1 iii- Route: Oral iv- Dose: Single Dose Activated Charcoal: For children: 30-60 gm I gm/kg of body weight For Adult: 60-100 gm in adult Shaken in 200 ml of water or prepared as slurry with a ratio 1:4 charcoal to water. Multiple Doses Activated Charcoal: MDAC 50 gm every 4-6 hrs & not exceed 300 gm. Given orally or by Ryles followed by cathartic. Cathartic Dose: Cathartics such as sorbitol ( 5ml/kg) can be used with first dose of charcoal to prevent constipation. Cathartics should not be used repetitively as they will cause fluid and electrolytes disturbances.

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4- Cathartics: 1- Definition: It is a substance stimulates the Gastro intestinal tract motility. 2- Mechanism: The cathartics substances enhance the passage of materials through the GIT thus decrease the time of contact between the poison and the absorptive surface of the stomach and intestine If given with charcoal, it will speed of charcoal in the intestine with more substance adsorbed by it. So it decreases the transient time (charcoaltoxins) complex before desorption occur 3- Indication: Single Dose Cathartic is not harmful . 4- Contraindication: Haemorrhage. Acid & Alkalie, Renal Failure "For Risk of Mg Over Load" - Recent Bowel Surgery Intestinal obstruction and Ileus Diarrhea Extreme of Ages It should be avoided in fat soluble poisons as organophosphates or carbon tetrachloride. 5- Complication: Dehydration particularly in children and elderly Electrolyte imbalance e.g. magnesium sulphate at a dose of 15-30 gm in a glass of water 6- Types: Osmotic: (Sorbitol) These are substances that increase the osmotic pressure in the intestinal lumen, thus causing fluid to be drawn into the lumen causing evacuation. Bulk Forming: (cellulose) Irritant (Castor Oil) They act by stimulation of motility such as castor oil at a dose 60-100ml Coating (Olive Oil) 5- Whole bowel irrigation: 1- Definition: : It is a procedure stimulate or hurry the passage of Gastro-intestinal content. 2- Mechanism: It is Using a gastric tube, give a surgical bowel-cleansing solution containing a non-absorbable polyethylene glycol in a balanced electrolyte solution, (formulated to pats through the intestinal tract without being absorbed) 3- Dose: Dose: 2L/h (children: 500 mi/h), until rectal effluent is clear. Activated charcoal 25-50 g /2-3 h may be administered while; whole bowel irrigation is proceeding, if the ingested drug is adsorbed by charcoal. Stop administration after 8-10 L (children: 150-200 mi/kg) if no rectal effluent has appeared. 4- Indications: : Large ingestion of the dose of iron or lithium or other drugs poorly adsorbed to activated charcoal. Large ingestion of sustained release or enteric coated tablets. Body Baker "Drugs filled packets or condoms" Body Stuffer Foreign body ingestion 5- Contraindications: Ileus Intestinal obstruction. Comatose patient the airway is protected Convulsing patient unless the airway is protected. 6- Adverse effects: Nausea Vomiting Bloating Pulmonary aspiration & Less effective activated charcoal when given with whole bowel irrigation

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Therapy: Later" III- Antidote Therapy: "See Later" IVIV- Enhanced Elimination:
Toxic substances and metabolites are excreted from the body by different ways: Lung, Liver, Intestine & Kidney. The aim of this process is: Increase The effectiveness of the excretory routes that lead to: Decrease the half-life of the toxic substances. Decrease the duration and severity of the toxic substances. It is used in drug intoxication when the renal route is a significant contributor to its total clearance. Forced diuresis may increase glomerular filtration rate. Urinary pH manipulation may produce ion trapping by may induce elimination of polar drugs. Via Lung: Rate of excretion in Expired Air: By inhalation of oxygen 95% O2 Rate & Depth of Respiration. Via Liver: Rate of excretion in Bile: By Hepatotonic drugs e.g. vit. C & amino acids Rate of Hepatic Metabolism i.e. Detoxification Power. Via Intestine: Rate of excretion in stool: By Purgatives Rate of peristaltic movement Via Kidney: Rate of excretion in urine: MAIN ROUTE ROUTE The elimination enhancement via kidney through urine will depend on: The kidney functions are Normal or Impaired.

i- Fluid Diuresis: iiii- Diuretics: iiidiuresis: iii- Urinary manipulation and forced diuresis:
I- Definition: It is the simplest method to excretion of some poisons By Renal Excretion G.F.R. of these poisons Renal Clearance of the poison By alternating the urine pH according to acidity or alkalinity of the drugs More Renal Clearance of the poison. II- Types: A- Forced alkaline diuresis: pH 7-8 Alkalinisation of the urine Alkalinization is commonly used for: Salicylate overdose Isoniazid Phenobarbitone Methanol Methotrexate Forced diuresis (producing urine volumes up to 1L/h) is generally not used because of the risk of fluid overload. Alkalinization with sodium bicarbonate: 1-2 mEq/kg in 15 ml/kg of 5% dextrose every one to two hours aiming to maintain pH of urine at 7.45and 7.55. B- Forced acidic diuresis: pH < 5 Acidification of Urine Urinary acidification using ammonium chloride has previously been used to enhance excretion of weakly alkaline drugs (amphetamine, strychnine, quinine and phencyclidine) but danger of acidosis & hyperammonaemia outweigh the benefits of this technique. Obsolete nowadays

iv. iv. Haemodialysis:

i- Principle: Diffusion of particles across a semipermeable membrane from the higher concentration To a lower concentration.

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ii- Technique: Patient blood circulates through a semipermeable membrane tubing system which is surrounded by a dialysate solution. Haemodialysis with a flow rate of up to 300-500 ml/min can be achieved and clearance rate may reach 200-300 ml/min. iii- Precautions: For dialysis to be effective toxin must be: Small size (molecular weight < 500 daltons) Highly water soluble. Low protein binding Small volume of distribution (< 2 L/kg) As salicylate, methadone, vancomycin and Lithium). iv- Indications of heamodialysis (Unstable Unstable): Unstable Uraemia No response to conventional therapy Salicylates Theophylline Alcohols (isopropanol, methanol) Boric acid, barbiturates Lithium Ethylene glycol N.B. Smaller, portable dialysis units that utilize a resin or filter to recycle a smaller volume dialysate do not efficiently remove drugs and poisons and should not be used

Haemoperfusion: v. Haemoperfusion:
i- Principle: Using equipment and vascular access similar to that for haemodialysis. ii- Technique: Pateint blood is pumped directly through a column containing an adsorbent material (either charcoal or amberlite resin). iii- Indications of haemoperfusion: Examples: carbamazepine, barbiturates and theophylline. iv- Advantages: Because the drug or toxin is in direct contact with the adsorbent material, drugs size, water solubility and protein binding are not important limiting factors. For most drugs, haemoperfusion can achieve greater clearance rates than haemodialysis. For example, the haemodialysis clearance for Phenobarbital is 60-80 ml/min, whereas the heamoperfusion clearance is 200-300 ml/min v- Disadvantages: Systemic anticoagulation is required, often in higher doses than for haemodialysis and thrombocytopenia is a common complication Vi. Vi. Haemofiltration: i- Principle: It can remove compounds with high molecular weight (>500 40000 daltons). ii- Indications: It is used in aminoglycoside, theophylline, iron and lithium overdoses. N.B. Substances not amenable to significant extracorporeal removal include Benzodiazepines, tricyclic compounds, phenqthiazines, chlordiazepoxide and dextropropoxyphene.

Peritoneal 5. Peritoneal dialysis:

i- Advantages: It is easier to perform than haemodialysis or haemoperfusion and does not require anticoagulant. ii- Disadvantages: It is only about 10-15 % as effective owing to poor extraction ratios and slower flow rates (clearance rates: 10-15 ml/min). However, it can be performed continuously, 24 hours a day, 24 hour peritoneal dialysis with dialysate exchange every 1-2 hours is approximately equal to four hours of haemodialysis.

Repeatedactivated 6. Repeated-dose activated charcoal:

i- Principle: Repeated doses of activated charcoal: (0.5 -1 gm/kg every 2-3 hours) are given orally or via gastric tube. ii- Technique: Constant slurry of activated charcoal in the intestinal lumen extracts drug or toxin from the gut wall in a kind of gut dialysis c) Quite distinct from simple adsorption of ingested unabsorbed tablets. iii- Advantages: It is easy, non-invasive and shortens the half-life of many toxins. iv- Indications: Phenobarbital, theophylline, carbamazepine, dapson, digitoxin, phenytoin, phenylbutazone and salicylates.

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V- Symptomatic Treatment:
Rest In Bed: At least 2 weeks is necessary as exhaustion may Heart Failure. Diets Deficiency: Care of nutrition especially in cases of coma or corrosives where the swallowing is not possible. Dehydration: Fluids by all routes. IV Glaucose , Saline and Ringer. Respiratory Tract Irritation: Asphyxia: Due to acute oedema of epiglottis Tracheostomy. Pulmonary Oedema: Due to direct irritation of the poison Semisitting position Atropine: 1mg IV To Bronchial Secretion. Aminophyline: 500mg slowly IV : To Bronchial Spasm. Antibiotic: Prophylactic Measure :To avoid Bronchopneuomonia. Corticosteroids: In cases of hydrocarbons: To avoid Inflammation Respiratory embarrassment: Oxygen inhalation. Ventilation. Gastro-Intestinal Tract Irritation: Demulcent Milk - Olive Oil Pain: Analgesic. Urine Retention: Catheterization. Infection: Antibiotic as prophylactic measure. Metabolic Acidosis: Na Bicarbonate Na HCO3 1.26% 1-2 mq/kg/hr Repeated until: Blood pH return normal or Urine pH become alkaline. Renal Impairment: Compact The Renal Failure: Adjust water and electrolyte intake & Maintain good urine output Peritoneal Dialysis Haemodiaysis Hepatic Impairment: Hepatic Extracts and Vitamins. Hypotension: Saline 0.9% 10-20ml/kgIV. If no response Dopamine in 7-9 ug/kg/hour If no response Norepinephrine 0.1-0.2ug/kg/min At as vasopressor agent. Hypertension: Benzodiazepine To sympathetic over activity & stress If no response Phentolamine Acts as Blockers & stress If no response Na Nitroprusside Acts as a peripheral vasodilator Hypoglycaemia: Glaucose 10% I.V. infusion Hyperglycemia: Insulin therapy Hypothermia: Blankets and Warm I.V. Fluid. Hyperthermia: Cold Fomentation & Ice Bags Tachycardia: B-Blockers. Bradycardia: Atropine Under observation & Follow up: Patient must be put under observation especially in homicidal or suicidal cases. Psychiatric consultation: in suicidal cases.

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6- ADMISSION POLICY IN CASES OF TOXICITY:

Decision about the need for hospitalization of poisoned patient presenting with possible accidental poisoning is sometimes difficult. Most patients will be asymptomatic and a short, period of observation, in an emergency department of admission ward, is often required. admission: I- General Indicating criteria for admission: Anyone taking an overdose, however apparently trivial in amount. Any one with self-harm. II- Special Indicating criteria for admission: II Patient with delayed complications from slow absorption of medications: complications e.g. from tablet concretion, sustained release or enteric coated preparations. If specific drug levels are determined, obtain repeated serum levels to be certain that they are decreasing as expected. Patient with delayed toxic time bombs bombs: e.g. acetaminophen, carbon tetrachloride, ethylene glycol, mercury, methanol and toxic mushrooms. IIIIII- Special Indicating criteria for ICU admission: The decision to admit the patient to an intensive care setting should be individualized based on the initial presentation. Patients who would require an ICU or monitored bed must have at least one of the following criteria: Intubation in the emergency room. Hypercarpia. QRS complex greater than or equal to 0.12 second. Cardiac dysrhythmias other than sinus tachycardia. Hypotension (systolic BP of less than 80). Unresponsiveness to verbal stimuli. Seizures. Patients with tricyclic antidepressant overdose as they may develop sudden cardiac dysrhythmias and probably warrant cardiac monitoring. - DSCHARGE POLICY IN CASES OF TOXICITY: When patients are fit to be discharged? Patients are fit for discharge from inpatient care when: They no longer require the specialist skills They no longer require the continous monitoring available in the ward. This generally means they are: Alert Awake Oriented Have no life-threatening organ failure Have been passed psychiatrically safe for discharge. Patients mental state is the most important discharging criteria. ALL Patients who have taken an overdose prior to discharge should be assessed by psychiatric doctor. SOME Patients, especially if family support is good, may be fit enough to return home after an overdose. Others Patient , with less family relationship may require psychiatric observation and nursing care.

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7- Psychiatric assessment IN CASES OF TOXICITY

Be sympathetic despite the hour Interview relatives and friends if possible. state: Factors determine the present suicidal toxic condition state:

Planned act or not Precautions against being found. Patient seek help after suicidal act or not Problems led to the act: do they still exist? Presence of psychiatric disorder (depression, alcoholism, personality disorder, schizophrenia, and dementia) Patient resources (friends, family, work, personality)?
Factors increase the chance of future suicide:

Present intention is to die. Presence of psychiatric disorder. Poor resources. Previous suicide attempts. Patient, Male, Socially isolated, Unemployed and Over 50 yrs old.

patient: Factors prevent the acute toxicity in psychiatric patient:

Patient:
Adult education

Health professionals:
Vigilance by health professionals to recognize the early signs of abuse and potential suicide.

Medicine:
Double-check dosage before administration. Put all medicines and household chemicals in a locked child-proof cupboard >1.5 m off the ground. Safely dispose of medicines, chemicals which are not needed or out of date. Keep all medicines and chemicals in their original containers with clear label.

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Medico8- Medico-legal issues IN Cases of toxicity:

A mentally competent adult has every right to withhold consent to examination, investigation or medical treatment, even if such a decision may result in his or her death. It is therefore important to asses the capacity for competence. It is often best that a third person, such as a nurse, witness such assessment and it is vital that adequate documentation is made.

Assessing - Assessing capacity for competence: To show that patients are competent to refuse medical treatment. - Patients must be able to: Understand and retain, information on the treatment proposed Its indications, its main benefits, as well as possible risks and the consequences of non-treatment. that information. Believe that information Weighing up the information in order arrive at a conclusion. - Valid Consent: - If a patient is capable of all three of these elements refusal of treatment must be judged as valid and respected elements, respected. - Family and Friend Support: - It is essential to maintain a supportive approach and the support of family and friends can be invaluable at the stage. Support: - Second Opinion Support: - If there is any doubt on the assessment of capacity, get a second opinion, ideally from a psychiatrist. - A particularly difficult situation arises if a patient who has capacity but later on becomes unconscious - in such cases treatment cannot be given in the absence of prior consent. - Treatment can be only given to a patient against her/his will in the following circumstances: circumstances: - Mental Illness: If the patient is detainable under the Mental Health Act 1983. However, the MENTAL Health Act allows for treatment for mental disorders to be given without the patient's consent, but dose not allow for medical treatment to be given without THE patient's consent. Under common law if a patient lacks. Mental to capacity, a doctor may administer any medical treatment essential to preserve life and considered to be in the patient's best interests. This also applies to the patient who is brought to the hospital unconscious requiring emergency treatment. Children: - Children: In patients under the age of 16 years, assessment of the individual child's understanding will determine whether he or she can give consent to medical treatment. Children over 16 are treated as adults.