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Module 4
Clinical Toxicology
Specific discipline of the broader
TOXICOLOGY field of toxicology concerned
with the toxic effects of agents
whose intent is to treat,
Rowel P. Catchillar, MS ameliorate, modify or prevent
disease states, or, the effect of
drugs which, at one time, were
6 April 2019
intended to be used as such.
BREX Pharmacy Review

Basic Definitions Basic Definitions

Toxicology Intoxication
⌂Study of ⌂Toxicity associated with any
⌂Involves
Poison Poisoning Overdose
⌂Any agent which may cause

⌂Corpus delicti 

Risk vs Hazard Factors Affecting Poisoning Effects

POISON -RELATED FACTORS
Hazard Risk
⌂Route of administration

⌂Concentration

⌂Solubility

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Factors Affecting Poisoning Effects Factors Affecting Poisoning Effects

POISON -RELATED FACTORS PATIENT-RELATED
FACTORS
⌂Solubility
⌂Age ⌂Habit

⌂Physical state or form of poison

⌂Association with other substances

Factors Affecting Poisoning Effects Factors Affecting Poisoning Effects

PATIENT-RELATED
FACTORS Patient-related factors
⌂Idiosyncrasy ⌂Mental or ⌂Tolerance
physical state

Poisoning Effects Types of Poisoning

Local effects
⌂The impression is made directly upon that part According to medical viewpoint
of the body with which the poison comes in
contact
⌂eg: corrosives
Acute
Remote effects
⌂The effect is produced or developed in an area
other than that of the site of application Chronic
⌂Eg: oral intake of atropine causing blurred vision
Combined effects
⌂Local + remote effects Cumulative
⌂cantharidin

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Types of Poisoning Evidences of Poisoning

According to legal point of view Circumstantial or moral
 Deduced from various occurrences and facts
accidental  Not a strong evidence
Suicidal Symptomatic
Homicidal  Based on
undetermined Post-mortem
 Autopsy

Evidences of Poisoning Kinds of Poison

Chemical Corrosive Poison

⌂Detection of suspected substances via ⌂Causes
analysis of samples of body fluids True poison
collected
Experimental
Cumulative poison
⌂Use of biological animals and noting the
effect or symptom of the suspected
substance

CLASSIFICATION OF POISONS Zootoxin

Based on origin
⌂Natural
⌂Synthetic
Based on properties
⌂Chemical composition
⌂Volatility
Based on effects
Based on vitality or strength

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Zootoxin Zootoxin

Zootoxin Zootoxin

Zootoxin Zootoxin

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Zootoxin Zootoxin

Zootoxin Phytotoxin

Phytotoxin Phytotoxin

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Phytotoxin Based on Origin: Natural

Phytotoxin
Poison Source/s
Deadly nightshade
(Belladona)
Foxglove
Tobacco
Prunus species

Based on Origin: Natural Based on Origin: Natural

(1) castor bean Phytotoxin
(2) Convallarin Lily-of-the-valley
(3) Coniine Poison hemlock
(4) Podophyllotoxin American mandrake/mayapple
Pacific yew tree Calabar bean
Phalloidine Death angel
Betel nut
Nux vomica
Fish berries
Nutmeg
Autumn crocus

Based on Origin: Natural Based on Origin: Natural

Microbial Mineral
POISON SOURCE/S POISON OTHER NAME NOTES
Dinoflagellates Muriatic acid _______ burns
Aspergillus flavus
Oil of vitriol Brown-black burns
Ptomaine Bacterial decay
Tyrotoxicon Ground coffee vomitus
Clostridium botulinum Aqua fortis _______ burns
Clostridium tetani Carbolic acid __________ burns
Cytotoxin Clostridium perfringens
NaOH Lye Forms _____ soaps
Staph. aureus
Mostly Gram (+)
Sosa Found in detergents
Mostly Gram (-) Caustic potash Forms _____ soaps
Ergot Clavicep purpurea Found in detergents
Daikin’s solution Bleaching agent

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Synthetic Based on origin: Synthetic

Picric acid Colorant in textile industries
Aniline Nitrobenzene Chloramine-T Use:
Converted to:
Tx:

⌂Aka essence of Carbon disulfide Used in textile industry

mirbane
Causes RBC hemolysis
Hydrogen sulfide Sewer gas, stink damp; “gas eye” tunnel workers

Asbestos Use:
Causes
Eosin Found in
Aluminum Found in
chlorohydrate

Based on properties: chemical Based on properties: chemical

composition composition
Inorganic Poisons Organic
⌂Gold ⌂Ice tea?
⌂Silver ⌂Artificial sweetener?
⌂Copper ⌂Food colorant?
⌂Zirconium ⌂Ajinomoto
⌂Chromium ⌂BHA/BHT
⌂Aluminum

Based on properties: volatility BASED ON EFFECT

Volatile Irritants
⌂CO Neurotics
⌂CN Carcinogenics
⌂Alcohols Asphyxiants
Non-volatile Lacrimators
⌂Alkaloids Sternutators
Asthenics
Narcotics

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General Management of Poisoned

Based on vitality or strength Patients
Numeric Toxicity Rating Probable Oral Initial assessment
al Value Lethal Dose ⌂Evaluate and assess vital functions
6 Super toxic <5mg/kg ⌂A-irway
5 Extremely toxic 5-50 mg/kg ⌂B-reathing
4 Very toxic 50-500 mg/kg ⌂C-irculation
3 Moderately toxic 0.5 – 5 g/kg ⌂D-isability
⌂E-xposure
2 Slightly toxic 5 – 15 g/kg
1 Practically Above 15 g/kg
nontoxic

General Management of Poisoned General Management of Poisoned

Patients Patients
Treating a patient w/ depressed Decontamination
⌂Inhalational exposure
mental status (1)
⌂Dextrose (2)
(3)
⌂Thiamine ⌂Dermal exposure
⌂Naloxone Mx:
⌂Ocular exposure
!!!
NSS
⌂Gastric exposure

General Management of Poisoned

Patients Antidotes
Antidotes Pharmacologic antidotes
⌂Competitive
Chelators (1)
Whole Bowel Irrigation (2)
(3)
Forced diuresis & urinary pH ⌂Non-competitive
manipulation (1)  Bond: _______
Extracorporeal methods (2)
(3)
⌂Example: Pilocarpine & Atropine

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Antidotes Antidotes
Physiologic antidotes Chemical antidotes
⌂(+) of ⌂CN  SCN
⌂Effect:

Antidotes The Universal Antidote

Mechanical Antidotes (1)
⌂Prevent the absorption of the (2)
poison (3)
G
A
C
E
P

Forced Diuresis & Urinary pH

Chelating Agents Manipulation
Chelator Use Others For drugs
BAL ___, Hg, Pb, Sb, Au ⌂(1)
CaNa2EDTA ___, Mn, Zn ⌂(2)
Deferoxamine ___, Al ⌂(3)
Penicillamine ___, Pb, Hg ⌂Approach: ________
Succimer ___, As, Hg ⌂(1) _____ (or bases)
⌂(2) _____ (or acids)

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Clinical Correlation Hemodialysis vs Hemoperfusion

Aspirin

Cisplatin

Alcohols Alcohols
Poison Manifestation Mx Poison Manifestation Mx
Ethylene 1st stage: CNS (1)H
Methanol (1) glycol 2nd: cardiopulmonary (2) T
(2) 3rd: kidney failure P
(3) Severe metabolic (3) L
acidosis (4) F
seizure (5) Ca
(6) D

Alcohols Ethanol

Poison Manifestation Mx __CNS = ___________

⌂P
Isopropyl - Supportive care
⌂A
alcohol Gastric lavage ⌂C
- __CVS
__GIT = __ Pancreatitis,
- malabsorption
Liver
Endocrine:

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Acute Intoxication In chronic Intoxication, which is not given?

Prevent severe respiratory A. Disulfiram

depression and pulmonary aspiration B. Naltrexone
(1) C. Thiamine
(2) D. Electrolytes
E. Fomepizole
F. Disulfiram + Naltrexone

Others Volatile Substances

Poison Manifestation Mx Cyanide
Formaldehyde Mucosal irritation ⌂ __ cytochrome oxidase
CNS depression
Metabolic acidosis
⌂ __ oxidative phosphorylation
Acetone CNS depression ⌂ __ cellular respiration
Respiratory ⌂central respiratory depression
depression
HCs Respiratory tract
injury

Cyanide Carbon Monoxide

 Cyanide Antidote Package MOA
⌂(1) ⌂CO + Hgb  carboxyhemoglobin
⌂hypoxia
⌂(2)
⌂(3)
___ greater affinity to haemoglobin
than oxygen
Treatment
Others ⌂Artificial air
⌂(1) ⌂Hyperbaric oxygen
⌂(2) ⌂100% oxygen

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Acids and Bases Phenol

Base: _________ necrosis Carbolic acid
Acid: _________ necrosis Derivative: Lysol
Treatment: dilutional therapy Protein denaturant
Treatment:
⌂Dermal exposure:
⌂Inhalational:
⌂Ingestion:

Heavy metals Heavy metals

Metal Toxicity Antidote Metal Toxicity Antidote

Lead Manganese

Zinc Cadmium

Heavy metals Heavy metals

Metal Toxicity Antidote Metal Toxicity Antidote

Mercury (1) Iron
(2)
(3)
Arsenic

Aluminum

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Organophosphates Strychnine
Parathion/ Malathione MOA: __Glycine =
⌂MOA: ___ AChE = ___ACh S/Sx:
⌂S/Sx: DUMBELS ⌂Same as _____ but faster
⌂Treatment: development
(1) ⌂Sardonic smile
(2) ⌂Spinal convulsion
Treatment:

Phosphorus Carbon Tetrachloride

Forms: aka
⌂Red Component of fire
⌂Yellow extinguishers
S/Sx: Metabolites:
⌂Vomitus: ⌂Epoxides
⌂Breath odor: ⌂phosgene  (1)
⌂Loose teeth (2)
⌂Seizure
⌂Hypocalcemia

Substances of Abuse CNS Stimulants

Caffeine
⌂1-2 cups (100-200mg) 
⌂12-15 cups (1.5g) 
⌂MOA: __PDE = __cAMP = __ adrenergic
action
Nicotine
Amphetamine
⌂Shabu
⌂Methylphenidate
⌂Ecstasy
Cocaine

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CNS Depressants Board Exam

Opium: Opioid addiction
⌂Natural:
⌂Semisynthetic Which of the following is NOT
(1) used in opioid poisoning?
(2) ⌂Naloxone
⌂Synthetic ⌂Naltrexone
⌂Nalmefen
(1)
⌂Nalorphine
(2)
⌂Nalbuphine
S/Sx: miosis, coma, respiratory
depression, seizures (meperidine)

CNS Depressants BDZ vs Phenobarb

Comparison Benzodiazepine Barbiturates
MOA (1) (1)
(2) (2)
GABA-mimetic
effect
Binding to BDZ
receptor
Margin of safety
Antidote

CNS Depressants Hallucinogens / Psychotomimetics

Chloral hydrate Phencyclidine (PCP)
⌂(1) ⌂(1)
⌂(2)
⌂Metabolite:
Lysergic acid diethylamide (LSD)
Ethanol ⌂Aka “acid”
Anti-histamines ⌂Source:
Mescaline
⌂Peyote cactus

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Hallucinogens / Psychotomimetics “TOT” Toxicity

Marijuana (Hashish, pot) Aspirin
⌂Source:
⌂Most Paracetamol
⌂∆9-THC Iron
⌂Dronabinol
⌂S/E:
Sedation
Euphoria
HTN
Eyes:
___appetite

Warfarin vs Heparin Selected Drugs

Comparison Heparin Warfarin Drug Use Toxicity Antidote
Atropine
MOA
Monitor
Toxicity

Vancomycin

Antidote

Selected Drugs Selected Drugs

Drug Use Toxicity Antidote Drug Use Toxicity Antidote
Digoxin
Succinylcholine
Theophylline
Sulfonylureas
Isoniazid
Cyclophosphami
de
Beta-blockers
CCBs
Methotrexate

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End
Mag-aral ka!

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