Poisoning, Overdose and Antidotes

Importance of Poisoning
-

Either deliberate or accidental

Acute, Chronic or Acute on Chronic
Second leading cause of deliberate self-harm in the UK
Poisoning responsible for over 150,000 hospital attendances per annum in
England and Wales
Most people who die do so before reaching medical assistance
For those reaching hospital, mortality is very low
Most common poisons
o Paracetamol
o Tricyclic AntiDs
o Opiates (heroin, methadone)
o CO

Common Patient Groups

-

Accidental self-poisoning in children <5 years old

o Mostly daytime
Deliberate in adolescents/young adults
o Evening/night time

Initial Assessment
1) Key Information
a. Identity of substance
b. Dose
c. Time elapsed since ingestion
d. +/- alcohol
e. Vomiting since ingestion/symptoms
2) Other information
a. Reason for overdose
b. History of self-harm
c. Overdose concealed?
d. Psychiatric Illness
e. Other questions about suicidality

Examination/Common Symptoms
Resuscitation
-

Standard ABCDE
Maintain adequate oxygen
Clear airway of oropharyngeal secretions/regurgitated matter
Shock in acute poisoning usually due to expansion of the venous
capacitance bed place patient in head-down position to encourage
venous return to the heart or colloid plasma expander IV will restore BP
CPR may be required for prolonged periods on cardiac arrest, up to several
hours
o In young patients, heart is anatomically and physiologically normal
so will recover when poison eliminated

Investigations
-

ABG

Examination of plasma for certain substances that require antidote (PCM,

iron, digoxin)
Plasma conc.
Rapid urine testing
o Amphetamine
o Methamphetamine
o Cannabis
o Methadone
o Benzodiazepines
o Barbiturates
o Phencyclidine (angel dust)
o Opiates
Other basic tests
o U&E + creatinine
o Blood glucose
o ECG
Toxicology screen (rarely indicated)

The most efficient eliminating mechanisms are the patients

own physiological processes.
Preventing Further Absorption of the Poison
Gut Decontamination
Gastric Lavage
- Should not be employed routinely
- Suitable for very large and life-threatening overdoses
- Poisons not absorbed by activated charcoal
- Contraindicated for corrosive substances, hydrocarbons with high
aspiration potential and where there is risk of haemorrhage from
underlying GI condition
- Risks:
o Hypoxia
o Arrhythmias
o Laryngospasm
o Perforation of GI tract/pharynx
o Fluid and electrolyte abnormalities
o Aspiration pneumonitis
- In drowsy patient with inadequate gag reflex cuffed endotracheal tube
Oral Adsorbents Activated Charcoal
- Comes nearest to the notion of a universal antidote
- Exceptions:
o Metal salts
o Cyanide
o Petroleum distillates
o Alcohols
o Clofenotane (dicophane, DDT)
o Malathion
o Strong acids and alkalis
o Corrosive agents
- Most effective 5-10 times as much charcoal as poison, weight for weight

Adult initial dose of 50g, repeated if necessary

Use NG tube if vomiting
Airway must be patent or protected
Most effective when given soon after ingestion of poison
Complications:
o Aspiration pneumonia
o Reduced absorption of therapeutic agents (methionine)
o Briquette formation/bowel obstruction
Contraindications:
o Absent bowel sounds
o Impaired gag reflex
o Unsafe swallow

Whole Bowel Irrigation

- Should not be used routinely
- Used for removal of sustained-release or enteric-coated formulations from
patients who present more than 2hrs after ingestion (iron, theophylline,
aspirin)
- Activated charcoal preferred

Acceleration Elimination of the Poison

-

Poison present must be high in concentration in the plasma compared to

rest of the body (small Vd)
Poison should dissociate readily from any plasma protein binding sites
Effects of poison should relate to its plasma concentration

Repeated doses of activated charcoal

-

Also adsorbs drug that diffuses from the blood into the gut lumen when
conc there is lower
As binding is irreversible, conc gradient is maintained and drug is
continuously removed intestinal dialysis
May also adsorb drugs secreted into bile
Effective in:
o Carbamazepine
o Dapsone
o Phenobarbital
o Quinine
o Salicylate
o Theophylline
Increasingly preferred to alkalinisation of urine for phenobarbital and
salicylate poisoning
50 g initially 50g every 4 hrs
Treat vomiting with antiemetic
Intolerance dose reduced but frequency increased (may effect efficacy)

Alteration of Urine pH and diuresis

-

Alter pH of the glomerular filtrate such that a drug that is a weak

electrolyte will ionise, become lipid soluble, remain in the renal tubular
fluid and leave the body in the urine
Either Alkalinisation (salicylate, phenobarbital, phenoxy herbicides,
mecoprop, dichloprop) acidification (severe acute poisoning with
amphetamine, dexfenfluramine, phencyclidine)

Haemodialysis
-

Useful when the poison

o Has small Vd
o Has low clearance rate
o Sufficiently toxic
o Either small enough to cross dialysis membrane or bound to
activated charcoal
Salicylate, isopropanol, lithium, methanol, ethylene glycol, ethanol

Haemoperfusion
During hemoperfusion, the blood passes through a column with absorptive properties aiming at
removing specific toxic substances from the patients blood. It especially targets small- to mediumsized molecules that tend to be more difficult to remove by conventional hemodialysis. The
adsorbent substance most commonly used in hemoperfusion are resins and activated carbon.
Hemoperfusion is an extracorporeal form of treatment because the blood is pumped through a
device outside the patient's body.
-

Charcoal Haemoperfusion life threatening overdoses of

o Theophylline/aminophylline
o Phenytoin
o Carbamazepine
o Phenobarbitone/ amylobarbitone

Haemofiltration
Patient's blood is passed through a set of tubing (a filtration circuit) via a machine to a
semipermeable membrane (the filter) where waste products and water (collectively called
ultrafiltrate) are removed by convection. Replacement fluid is added and the blood is returned to
the patient.

Effective for:
o Phenobarbital
o Other barbiturates
o Ethchlorvynol
o Glutethimide
o Meprobamate
o Methaqualone
o Theophylline
o Trichloroethanol derivatives

Peritoneal Dialysis
The process uses the patient's peritoneum in the abdomen as a membrane across which fluids and
dissolved substances (electrolytes, urea, glucose, albumin and other small molecules) are
exchanged from the blood. Fluid is introduced through a permanent tube in the abdomen and
flushed out either every night while the patient sleeps (automatic peritoneal dialysis) or via regular
exchanges throughout the day (continuous ambulatory peritoneal dialysis).

Lithium and methanol poisoning

Antidotes
Paracetamol Overdose
Mechanism
Clinical Features
Investigations
Prognosis
Treatment

Salicylate Overdose
Mechanism
Clinical Features
Investigations
Prognosis
Treatment

Opioid Overdose
Mechanism
Clinical Features
Investigations
Prognosis
Treatment

Tricyclic and other antidepressants Overdose

Mechanism
Clinical Features
Investigations
Prognosis
Treatment

Benzodiazepine Overdose
Mechanism
Clinical Features
Investigations
Prognosis
Treatment

Iron Overdose
Mechanism
Clinical Features
Investigations
Prognosis
Treatment

Organophosphate Overdose
Mechanism
Clinical Features
Investigations
Prognosis
Treatment