PhChem 421

CLINICAL
TOXICOLOGY
(A COMPILATION OF LABORATORY ACTIVITY)

CENTRAL PHILIPPINE UNIVERSITY

COLLEGE OF PHARMACY

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ACTIVITY TITLE PAGE

1 POISONING 3
2 MANAGEMENT OF POISONING 7
3 ANTIDOTE 12
4 FIRST AID 19
5 CARDIOVASCULAR DRUGS 25
6 RESPIRATORY DRUGS 30
7 ANALGESICS 36
8 FOOD POISONING 42
9 HOUSEHOLD POISONING 48
10 POISONOUS PLANTS 54
11 POISONOUS ANIMALS 60
12 JOURNAL READING 66

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 ACTIVITY 1
ASSESSMENT OF POISONING

OBJECTIVES:
1. To identify the purpose of assessing.
2. To demonstrate the proper way of obtaining vital signs.
3. To identify the essential physical properties/characteristics of substances that may be
associated with poisoning.

MATERIALS:
Sphygmomanometer
Stethoscope
Clinical thermometer

DISCUSSION:

All poisoned patients should be treated as if they have a potentially life-threatening

intoxication, even though they may not appear acutely ill. Assessing is an essential part in the process
of treating poisoned patients. It is the process of collecting, organizing, validating, and recording data
about a client’s health status.

The vital or cardinal signs play an important role in the assessment of the patient’s status.
These will provide important information and physiologic clues on how to assess and provide
treatment for the patient’s illness. These includes the body temperature, pulse, respirations, blood
pressure and oxygen saturation with pulse oximeter.

In case of emergency, a physical assessment should be performed in all patients to determine

the effects of toxins and other conditions that might be present. Stabilization of the patient is the first
priority simultaneous with the initial physical assessment.

PROCEDURE:
1. Assessment of Vital Signs
Check the vital signs of your groupmates, record the results and interpret.

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 Groupmates BP PR HR BT RR INTERPRETATION
1. ______________
2. ______________
3. ______________
4. ______________

2. An 18-year-old male was brought to ED comatose, incoherent and having symptoms of

delirium. His blood pressure was 168/95 mmHg, pulse 47 beats/min, and body temperature
37.5⁰C. His skin was hot and dry and displayed episodes of myoclonic jerks. He was suspected
of anticholinergic poisoning. After an hour his vital signs began to decrease and within 15min he
began to respond to the medication.

Assess the information and identify the following Interpretation

1. Blood pressure ________ ____________
2. Pulse ________ ____________
3. Body temperature _______ ____________
4. Symptoms of toxicity:
a. e.
b. f.
c. g.
d. h.

5. History of the patient:

3. PROVIDE THE FOLLOWING NORMAL VALUES

VITAL SIGNS NORMAL VALUES

A. Blood Pressure ________
B. Pulse Rate ________
C. Heart Rate ________
D. Body Temperature ________
E. Respiratory Rate ________

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4. CLINICAL SIGNS AND SYMPTOMS THAT MANIFESTS TOXICITY

Drugs/Toxin Signs and Symptoms

1. Aspirin

2. Acetaminophen

3. Ibuprofen

4. Cicutoxin

5. Muscarine

6. Datura

7. Vitamin C

8. Celecoxib

9. Metoprolol

10. Ranitidine

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GUIDE QUESTIONS

1. What are the importance of getting the vital signs of the patient?

2. Differentiate poisoning from overdose?

3. What is the significance of getting the patient’s history in the evaluation of the patient?

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 ACTIVITY 2
MANAGEMENT OF POISONING

OBJECTIVES
1. To familiarize the students on the proper management on general cases of poisoning.
2. To determine the scope of appropriate interventions on emergency evaluation and
treatment of poisoning.
3. To know the different functions of pharmacists in the management of poisons.

DISCUSSION

In 2004 (WHO data) an estimated 346,000 people died worldwide from unintentional
poisoning. Of these deaths, 91% occurred in low and middle –income countries. In the same year,
unintentional poisoning caused the loss of over 7.4 million years of healthy life.
Exposure of humans and other organisms to toxicants may result from activities: intentional
ingestion, occupational exposure, environmental exposure as well as accidental and intentional
(suicidal or homicidal) poisoning. The toxicity of the particular compound may vary with portal of entry
into the body, whether through the alimentary canal, the lungs, or the skin.
A brief physical assessment should be performed in all patients to determine the effects of
toxins and other conditions that might be present. Stabilization of the patient is the first priority
simultaneous with initial physical assessment. The treatment should address the ABC’s which is also
applicable to all clinical emergencies.

Management of Poisoned Patient should include:

1. Accurate history
2. Stabilization of patients condition
3. Physical exam-to determine the extent of poisoning
4. Laboratory exam
5. Decontamination
6. Poison-specific treatment – antidote
7. Disposition

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Taking Patient’s History: 5 ‘W’s
1. Who – patients age, weight, name
2. What – name and dosage (in cases of substances of abuse ingestion)
3. When – time and date of ingestion
4. Where – route of ingestion and the geographic location
5. Why – intentional or accidental

Note: information obtained from the patient may be inaccurate or incomplete that’s why
additional history obtained from friends or family member is important.

EMERGENCY EVALUATION AND TREATMENT

Assessment Treatment

A – AIRWAYS patients who are awake:

Intact airway reflexes
Voice, breath sounds

Lethargic patients:
Check gag/cough reflex head tilt and chin left
Position patient Oxygen suction
Clear suction airway endotracheal intubation

B – BREATHING respiratory rate (12-20bpm) seat comfortably

Chest wall movements obtain ABG
Chest percussion assist with bag/mask device
Lung auscultation give supplemental oxygen

C – CIRCULATION skin color, sweating stop bleeding

Capillary refill time elevate legs
BP infuse saline solution
PR
ECG monitoring
Heart auscultation
Start IV lines

D – DISABILITY monitor LOC (alertness, voice responsive, recognize/treat hypoglycemia

Pain responsive, unresponsive) monitor rectal temp.
Limb movements treat seizures
Papillary light reflexes control agitation
Blood glucose treat airway breathing & circulation
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E – EXPOSURE expose skin treat suspected cause.
Obtain allergy history in cases of gas poisoning expose the
patient in an area where the
patient can breathe fresh air

PHYSICAL ASSESSMENT

PROCEDURE:

1. Take the vital signs of the patient.

2. Examine the following:
➢ General appearance – assess for weakness, mood state, mental status.
➢ Head – size, shape, any tenderness. Condition of hair and scalp, symmetry, masses.
➢ Eyes – visual acuity, color, symmetry, assess vision, pain, miosis or mydriasis.
➢ Ears –symmetry, discharges, tenderness, hearing impairments, tinnitus, hearing aids.
➢ Nose – symmetry, drainage or bleeding, congestion, obstruction, inflammation.
➢ Throat – lesions, exudates, erythema, breathe odor: inspect lips, gums, tongue and
teeth.
➢ Neck – symmetry, tenderness
➢ Skin – appearance, color, rashes, wounds.
➢ Respiratory – cough, breathing, mucous discharge.
➢ GIT – inspect bowel discharges, bowel movement, characteristics of vomitus,
abdominal or stomach pain, difficulty of swallowing.
➢ UT – characteristics of urine, assess for urinary incontinence, increase or pain in
urination.

ESSENTIAL LABORATORY TESTS

❖ Serum osmolality and osmolar gap
❖ Electrolytes for the determination of sodium, potassium and anion gap.
❖ Serum glucose
❖ BUN and creatinine for evaluation of renal function
❖ Hepatic transaminases and hepatic function tests
❖ Urinalysis – to check for crystalluria, hemoglobinuria, or myoglobinuria
❖ ECG
❖ Stat serum acetaminophen level and serum ethanol level
❖ Pregnancy test (for females of childbearing age)

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DECONTAMINATION
❖ Wash skin and irrigate eyes
❖ Emesis or gastric lavage
❖ Charcoal and cathartic
❖ Hemodialysis
❖ Hemoperfusion

ANTIDOTE (refer to ACTIVITY 3)

DISPOSITION
❖ Emergency department discharge or ICU admission
- All patients with potentially serious overdose should be observed for at least 6 hours
before discharge or transfer to a nonmedical facility.

- If signs or symptoms of intoxication develop during this time, admission for further
observation and treatment is required.
- Most patients admitted for poisoning or drug overdose will need observation in an
intensive care unit, although this depends on the potential for serious
cardiorespiratory complications.
- Any patient with suicidal intent must be kept under close observation.

SOME COMMON ODORS CAUSED BY TOXINS AND DRUGS:

ODOR DRUG OR TOXIN

Acetone acetone, isopropyl alcohol

Acrid or pearlike chloral hydrate, paraldehyde
Bitter almonds cyanide
Carrots cicutoxin
Garlic arsenic, organophosphates, selenium, thallium
Mothballs naphthalene, paradichlorobenzene
Pungent aromatic ethchlorvynol
Rotten eggs hydrogen sulfide, stibine, mercaptans, old sulfa
drugs
Wintergreen methyl salicylate

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GUIDE QUESTIONS:

1. What is/are the role of pharmacists in initial treatments for cases of poisoning or overdosed
patients in clinical setting?

2. What are the different methods used in preventing cases of poisoning in community
pharmacy setting? In clinical setting?

3. What is the most common factor contributing to death from drug overdose or poisoning?
Explain.

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 ACTIVITY 3
ANTIDOTES

OBJECTIVES
1. To be familiar with the different types of antidote, their mechanism of actions, dose, route
of administration, adverse effects and contraindications.
2. To identify the specific antidotes for different poisons.

DISCUSSION

Antidotes are substances that counteracts or neutralize the effects or action of a poison.
Antidotes exert their beneficial effects by a variety of mechanisms, including forming an inert complex
with the poison, accelerating detoxification of the poison, reducing the rate of conversion of the poison
to a more toxic compound, competing with the poison for essential receptor sites, blocking essential
receptors through which the toxic effects are mediated and by passing the effect of the poison.
Antidotes play an important role in the management and treatment of certain poison. There
are only a small number of poison for which there is a specific antidote. Antidotes are only one aspect
of the management of a poisoned patient.

Antidotes can be classified as:

1. Chemical antidote
One that neutralizes the poison by changing its chemical nature or oxidize the poison
into non-toxic or insoluble form. Ex. Sodium thiosulfate which changes toxic cyanide to the non-
toxic thiocyanate

2. Mechanical antidote
One that prevents absorption of the poison. Ex. Activated charcoal- absorbs the poison
prior to the absorption across the intestinal wall.

3. Physiologic antidote
One that counteracts the effects of poison by producing opposing physiologic effects.
Ex. Naloxone- for morphine
4. Chelating agents

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 Substances which are produce from chelates with cations (mostly used in heavy metals)
ex. EDTA – used in arsenic, lead & mercury poisoning
PROCEDURE
A. IDENTIFICATION

1. ANTIDOTE:

USES:

DOSE:

ROUTE OF ADMINISTRATION:

ADVERSE EFFECTS:

CONTRAINDICATIONS/PRECAUTIONS:

MECHANISM OF ACTION:
(Explain and illustrate)

2. ANTIDOTE

USES:

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 DOSE:

ROUTE OF ADMINISTRATION:

ADVERSE EFFECTS:

CONTRAINDICATIONS/PREAUTIONS:

MECHANISM OF ACTION:
(Explain and illustrate)

3. ANTIDOTE

USES:

DOSE:

ROUTE OF ADMINISTRATION:

ADVERSE EFFECTS:

CONTRAINDICATIONS/PRECAUTIONS:

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 MECHANISM OF ACTION:
(Explain/illustrate)

B. DETERMINE THE ANTIDOTE OF THE FOLLOWING POISONS:

Poisoning Antidotes

Amatoxin

Aniline & Nitrites

Acetaminophen

Beta blockers

Benzodiazepines

Cicutoxin

Coumadin

Colchicine

Cyanide

Ethyl alcohol

Formaldehyde

Hyoscamine

Iodine
Iron

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 Isoniazid

Lead

Mercury

Methane

Morphine

Organophosphates

C. MECHANISM OF ACTION

1. ATROPINE

2. ACTIVATED CHARCOAL

3. EDTA

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4. EPINEPHRINE

5. N-ACETYLCYSTEINE

6. NALOXONE

7. METHYLENE BLUE

8. VITAMIN K

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 9. SODIUM THIOSULFATE

10. DEFFEROXAMINE

GUIDE QUESTIONS:
1. What are chelating agents? Provide 3 examples and indicate its uses.

2. What is the role of pharmacists in reducing poisoning and overdose cases?

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 ACTIVITY 4
FIRST AID
OBJECTIVES
1. To be familiar with the recommended procedures for the first aid treatment of poisoning.
2. To identify the following antidotes needed for the first –aid treatment of poisoning.
3. To know the different functions of pharmacists in preventing poisoning.

DISCUSSION
The cardinal rule for first-aid treatment of poisoning is to remove the poison from contact with
the patient (unless such removal is contraindicated) and to obtain further definitive medical care at the
earliest possible moment if warranted.

FIRST AID – is the emergency care and treatment of an injured or ill person before complete
medical and surgical treatment can be secured. It includes self-help and home care if medical
assistance is not available or encouragement, evidence of willingness to help and promotion of
confidence to by demonstration of competence.

SHOCK – a sudden disturbance of mental equilibrium. A profound hemodynamic and metabolic

disturbance characterized by failure of the circulatory system to maintain adequate perfusion of vital
organs. Shock can occur in such medical emergencies like burns, drug overdose, electrical shock, heart
attack, severe heat related illness (heatstroke), low blood sugar, extreme cold, poisoning, spinal injury,
septic shock or severe allergic reaction, blood loss, vomiting, or diarrhea.

SIGNS and SYMPTOMS of shock are a combination of the following: anxiety, restlessness,
weakness, and or dizziness: decreased alertness: a rapid, weak pulse: cool, clammy skin: rapid, shallow
breathing: pale skin with bluish lips and fingernails: extreme thirst and dry mouth: fatigue: chest pain:
nausea and/or vomiting: and consciousness.

ANTIDOTE – activated charcoal is known to be effective, nonspecific adsorbent of a large

number of materials, but it should be noted that there is no true “universal antidote”. The classical
universal antidote used for a long time consisted of activated charcoal, tannic acid and magnesium
oxide. For a few poisons, there are chemical antidotes that react with the poison in the stomach either
to inactivate it or to retard its absorption. The most useful antidotes are those available for systemic
administration to counteract the effects of poisons which have already been absorbed.

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FIRST-AID TREATMENT FOR POISONING

I. Do these things before you call someone

a. Remove poisons from contact with eyes, skin or mouth.

Eyes – gently wash eyes with plenty of water for 10-15minutes with the eyelids
held open. Don’t allow the victim to rub his/her eyes.
Skin – wash poisons off the skin with large amount of water, then wash with
detergent if possible, remove contaminated clothing.
Mouth – remove all tablets, powder plants or any other material that you may find
inside the victims mouth. Examine for cuts, burns, or any unusual coloring. Wipe
out mouth with a cloth and wash thoroughly with water.

b. Remove victim from contact from poisonous fumes or gases.

- Get the victim into fresh air.
- Loosen all tight-fitting clothing.
- If the victim is not breathing, start artificial respiration immediately. Do not
stop until the victim is either breathing well or help arrives. Use oxygen if
available. Send someone else to call for help.

c. If a caustic poison has been swallowed, you should dilute it with by giving 1 or 2
glassfuls of milk or water.

II. Call for information on what to do next.

a. Call your doctor.
b. Call for information even if you are not sure. Keep calm

III. If you are instructed to induce vomiting. Never induce vomiting until you are instructed to do so.

Note: Never induce vomiting if the patient:

- Is unconscious.
- Is having convulsions.
- Has swallowed strong caustics or corrosives.

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 IV. If you go to the hospital:

- Take or send the poison container, poisonous plant, etc, with you.
- Take any vomitus you collect.
- Don’t give substances like coffee, alcohol, stimulants, or drugs, to the victim .

FIRST AID KIT

Emergencies and accidents are part of our everyday lives. Apart from prevention and
education, each of us must be prepared at all times. Always have a first aid kit. This is used for treating
minor injuries like burns, cuts, abrasions, stings, etc.

PROCEDURE

A. MAKE YOUR OWN FIRST-AID KIT. LIST DOWN THE CONTENTS OF YOUR FIRST AID KIT AND THE
PURPOSE OF EACH.

B. FIRST-AID TREATMENT

1. Your mother accidentally cut her finger while preparing other ingredients for cooking. It’s
bleeding heavily, what will you do?

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2. Your sister was helping your mother serve dinner, while serving the hot soup she
accidentally dropped the bowl and the soup scalded her hand. What will you do?

3. Your laboratory teacher assigned your group to prepare for the chemicals needed for the
experiment for that day, when one of your groupmates spill a large amount of sulfuric acid
and one of your group member’s skin was contaminated with it. What will you do?

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GUIDE QUESTIONS

1. What are other measures, aside from removal or inactivation of the poison and use of
antidotes in the treatment of poisoning? Explain.

2. What is the role of the pharmacists in the prevention of poisoning? Explain.

3. List down 10 important things to do during emergency situations.

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 SUMMARY OF LOCAL and SYSTEMIC ANTIDOTES

POISON LOCAL ANTIDOTE SYSTEMIC ANTIDOTE

Acids, corrosive dilute with water or milk

(then give non absorbable antacid)

Alkali, caustic dilute with water or milk

(then give demulcent)

Amphetamines activated charcoal chlorpromazine

Anticholinergics activated charcoal physostigmine
Anticholinesterases activated charcoal atropine
Barium salts sodium sulfate sodium or magnesium
sulfate
Carbon monoxide 100% oxygen by
inhalation
Heavy metals milk or egg whites BAL
Oxalate dilute with water or milk calcium gluconate
(then give cal.gluconate or lactate)
Phenothiazines diphenhydramine
Phosgene methenamine
Warfarin vitamin K

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 ACTIVITY 5
CARDIOVASCULAR DRUGS

I. OBJECTIVES
1. To be familiar with the different types of cardiovascular drugs.
2. To identify the different manifestations brought about by cardiovascular drug toxicity.
3. To determine the appropriate management, interventions and treatment resulting from the
intoxication of cardiovascular drugs.

II. DISCUSSION

CARDIOVASCULAR DRUGS – Any drug that affects the heart or blood vessels, directly or indirectly, is a
cardiovascular drug.

TYPES OF CARDIOVASCULAR DRUGS:

1. Antianginal Agents
Agents that are used to relieve the symptoms of angina pectoris. It includes nitrates, beta-
blockers and calcium-channel blockers.
2. Antiarrhythmic Agents
Agents that are used to suppress abnormal rhythms of the heart. It includes acebutolol,
amiodarone, flecainide, propranolol and verapamil.
3. Antihypertensive Agents
Drugs used for the treatment of hypertension. It includes the ACE- inhibitors, alpha adrenergic
blockers, beta-blockers, calcium-channel blockers, and diuretics.
4. Cardiac Glycosides
Are a class of medications used to treat heart failure and certain irregular heartbeat. It includes
deslanoside, digitoxin and digoxin.

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III. MATERIALS
BOOKS
MEDICAL JOURNALS
LABORATORY MANUALS
OTHER REFERENCE MATERIALS

IV. IDENTIFICATION
A. ANTIANGINAL AGENT
_________________:

MECHANISM OF ACTION:

PHYSICOCHEMICAL PROPERTIES:

MANIFESTATIONS OF TOXICITY:

INTERVENTIONS/TREATMENT/ANTIDOTE:

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B. ANTIARRHYTHMIC AGENTS

__________________:

MECHANISM OF ACTION:

PHYSICOCHEMICAL PROPERTIES:

MANIFESTATIONS OF TOXICITY:

INTERVENTIONS/TREATMENT/ANTIDOTE:

C. ANTIHYPERTENSIVE AGENTS
_____________________:
MECHANISM OF ACTION:

PHYSICOCHEMICAL PROPERTIES:

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 MANIFESTATIONS OF TOXICITY:

INTERVENTIONS/TREATMENT/ANTIDOTE:

D. CARDIAC GLYCOSIDES
_________________:
MECHANISM OF ACTION:

PHYSICOCHEMICAL PROPERTIES:

MANIFESTATIONS OF TOXICITY:

INTERVENTIONS/MANAGEMENT/ANTIDOTE:

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GUIDE QUESTIONS:

1. WHAT ARE THE DIFFERENT ABNORMAL RHYTHMS OF THE HEART? EXPLAIN EACH.

2. WHAT IS THE COMMON ROUTE OF EXPOSURE FOR CARDIOVASCULAR TOXICITY?

3. WHAT ARE THE OTRHER TYPES OF CARDIOVASCULAR DRUGS? EXPLAIN AND GIVE THREE EXAMPLES
OF EACH.

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 ACTIVITY 6
RESPIRATORY DRUGS

I. OBJECTIVES
1. To be familiar with the different types of respiratory drugs.
2. To identify the different manifestations brought about by respiratory drug toxicity.
3. To determine the appropriate management, interventions and treatment resulting from the
intoxication of respiratory drugs.

II. DISCUSSION
RESPIRATORY DRUGS – These are drugs or a combination of drugs used to prevent, relieve or
treat conditions and diseases relating to lungs and/or breathing.

TYPES OF RESPIRATORY DRUGS

1. ANTIHISTAMINES – Drugs that counteracts the effect of histamine.
Two types:
1. H1-RECEPTOR BLOCKERS- which inhibit the effects of histamine released from mast
cells and are used in the treatment of allergic disorders.
2. H2-RECEPTOR- which inhibit the secretion of gastric acid stimulated by histamine,
pentagastrin, food and insulin and are used in the treatment of peptic ulcer.
2. ANTITUSSIVES – Drugs that act on the cough control center in the medulla to suppress the
cough reflex. They may be categorized as opioid, non-opioid or combination preparations. Although all
opioid drugs have antitussive effects, only codeine and its derivative hydrocodone are used as
antitussives. Non-opioid antitussive drugs are less effective.
3. DECONGESTANTS – Drugs that relieve the congestion produced when nasal blood vessels are
dilated by infection, inflammation or allergy, causing transudation of fluid into the tissue spaces.
4. EXPECTORANT – Drugs that loosen bronchial secretions causing the patient to cough up and
spit out excessive mucus, breaking it down and thinning out the secretions.

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III. MATERIALS
BOOKS
MEDICAL JOURNALS
OTHER REFERENCE MATERIALS

IV. PROCEDURE
CASE ANALYSIS: Using the following case, identify the suspected poisonous/toxic substance,
describe its clinical signs and symptoms of toxicity and provide the possible management or treatment
and antidote.

Case:
M.D., a 60-year-old male brought to the ER due to nausea, vomiting, diarrhea, shaking chills,
and restlessness. Present medication includes Codeine Antitussive cough syrup which he had been
taking for more than a week without the doctor’s prescription.

Case:
L.S. a 20 year old obese, female, brought to the ER due to palpitations. Her BP was 200/160
mmHg. Present medication includes a nasal decongestant for her clogged nose and allergic rhinitis. Her
sister states that she was drinking a slimming coffee to lose weight.

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V. IDENTIFICATION
A. ANTIHISTAMINE
________________

MECHANISM OF ACTION:

PHYSICOCHEMICAL PROPERTIES:

MANIFESTATIONS OF TOXICITY:

INTERVENTION/MANAGEMENT/ANTIDOTE:

B. ANTITUSSIVES

________________

MECHANISM OF ACTION:

PHYSICOCHEMICAL PROPERTIES:

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 MANIFESTATIONS OF TOXICITY:

INTERVENTION/MANAGEMENT/ANTIDOTE

C. DECONGESTANT
_________________

MECHANISM OF ACTION:

PHYSICOCHEMICAL PROPERTIES:

MANIFESTATIONS OF TOXICITY:

INTERVENTION/MANAGEMENT/ANTIDOTE

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D. EXPECTORANT

____________________

MECHANISM OF ACTION:

PHYSICOCHEMICAL PROPERTIES:

MANIFESTATIONS OF TOXICITY:

INTERVENTION/MANAGEMENT/ANTIDOTE

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GUIDE QUESTIONS:

1. What are the other types of respiratory drugs? Give 2 examples of each.

2. What is allergic rhinitis (or hay fever)? Give the management and treatment.

3. What is the most widely used non-opioid antitussive? Give its mechanism of action.

4. Give examples of products available in the market that contains PPA.

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 ACTIVITY 7
ANALGESICS
OBJECTIVES
1. To learn and be familiar with the mechanism of toxicity of analgesics or pain killers.
2. To identify the different treatment and interventions on analgesic-related toxicity.
3. To be familiar with the different types of analgesics.

DISCUSSION
ANALGESICS relieves pain.
TYPES OF ANALGESICS:
1. NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDs) – these drugs have the ability to
relieve pain, they can reduce fever and suppress inflammation. They provide rapid relief of
symptom, but they do not prevent joint damage or deter disease progression. Ex. Aspirin,
diclofenac, etodolac, naproxen, etc.
2. CORTICOSTEROIDS – these are not exactly pain killing drugs but they are anti-inflammatory. But
due to their inflammatory process, they can reduce pain.
3. OPIOIDS (NARCOTICS) – Relieves pain by binding to opioid receptors in CNS. These drugs act as
agonists to produce the effect of analgesia. It gives relief for moderate to severe pain.
4. NEUROLOGICAL ANALGESIA – these drugs are used for neurologic and psychiatric conditions
but they can also relieve neuropathic pain, which occurs without any external pain triggers like
heat or sharp pain.
5. ANESTHETIC NERVE BLOCKADE –anesthetic dug injected into a nerve branch so that a certain
part of the body becomes desensitized to pain. Ex. Lidocaine – injected around spinal cord,
produces pain relief in areas in the lower half of the body.
6. PARACETAMOL – This drug relieves pain, discomfort and fever. It is safe effective analgesic-
antipyretic for muscular aches and pains caused by viral infection. Unlike salicylates, it does not
cause gastric distress and does not interfere with clotting time. However, it does not have anti-
inflammatory properties and is both an OTC and a prescription drug.

PAIN - A feeling of distress, suffering or agony, caused by stimulation of specialized nerve endings.
- An unpleasant sensory and emotional experience associated with actual or potential
damage to tissues.
- Mild to moderate of skeletal muscles and joints is usually relieved with the use of non-
narcotic agents like the salicylates and the NSAIDs.

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 - Moderate to severe pain is treated with opiates or narcotic analgesics.

PAIN THRESHOLD – the level at which the body first perceives a stimuli as being painful.

PAIN TOLERANCE – the amount of pain a patient can endure without interfering with normal
functions.

III. MATERIALS
BOOKS
MEDICAL JOURNALS
OTHER READING MATERIALS

IV. IDENTIFICATION

A. NSAIDs

CELECOXIB:
(BRAND NAMES):
ROUTE & DOSAGE:

MECHANISM OF ACTION:

MANIFESTATIONS OF TOXICITY:

INTERVENTIONS/MANAGEMENT/OR ANTIDOTE:

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B. CORTICOSTEROIDS
BECLOMETHASONE:
(BRAND NAMES):

ROUTE & DOSAGE:

MECHANISM OF ACTION:

MANIFESTATIONS OF TOXICITY:

INTERVENTIONS/MANAGEMENT/OR ANTIDOTE:

C. OPIOIDS (NARCOTICS)
MORPHINE
(BRAND NAMES)

ROUTE & DOSAGE:

MECHANISM OF ACTION:

MANIFESTATIONS OF TOXICITY:

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 INTERVENTIONS/MANAGEMENT/OR ANTIDOTE:

D. NEUROLOGICAL ANALGESIA
AMITRIPTYLINE
(BRAND NAMES):

ROUTE & DOSAGE:

MECHANISM OF ACTION:

MANIFESTATIONS OF TOXICITY:

INTERVENTIONS/MANAGEMENT/OR ANTIDOTE:

E. ANESTHETIC NERVE BLOCKADE

LIDOCAINE
(BRAND NAMES):

ROUTE & DOSAGE:

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 MECHANISM OF ACTION:

MANIFESTATIONS OF TOXICITY:

INTERVENTIONS/MANAGEMENT/OR ANTIDOTE:

F. PARACETAMOL
BRAND NAMES:

ROUTE & DOSAGE:

MECHANISM OF ACTION:

MANIFESTATIONS OF TOXICITY:

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 INTERVENTIONS/MANAGEMENT/OR ANTIDOTE:

V. GUIDE QUESTIONS
1. Describe the mechanism and clinical manifestations of toxicity of aspirin.

3. Identify the treatment or antidote of the following:

Acetaminophen:

Aspirin:

Opiates:

3. What is the toxic dose of acetaminophen in children?

4. What are the alternatives to analgesics? Give 5 examples.

5. Describe the mechanism of action of NSAIDs.

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 ACTIVITY 8
FOOD POISONING

OBJECTIVES
1. To be familiar with the toxic constituents found in foods.
2. To describe the clinical signs and symptoms associated with food poisoning.
3. To learn and be familiar with the treatment or management of poisoning.

DISCUSSION
Food-borne bacteria and bacterial toxins are the most common causes of epidemic food-borne
gastroenteritis. In general, the illness is relatively mild and self-limited, with recovery within 24 hours.
However, severe and even fatal poisoning may occur with listeriosis, salmonellosis, or botulism, and
with certain strains of Escherichia coli.
Viruses such as the Norwalk agent and rotaviruses can also be transmitted through food and
are the causative agent in as many as 40% of group-related diarrhea epidemics.
Other micrrobes that can cause food-borne illness include cryptosporidium and cyclospora, which can
cause serious illness in immunocompromised patients.

MECHANISM OF TOXICITY:
Gastroenteritis may be caused by invasive bacterial infectionof the intestinal mucosa or by a
toxin elaborated by bacteria. Bacterial toxins may be preform in food that is improperly prepared and
improperly stored before use, or may be produced in the gut by the bacteria after they are ingested.

42
 SUMMARY OF BACTERIAL FOOD POISONING:

Organism/Contaminants Incubation Period Foods affected & Means of Transmission

Bacillus cereus 1-6 hours Reheated fried rice

Campylobacter 1-2 days Meat & poultry: contamination occurs during
processing if animal feces contact meat surfaces.
Other sources: unpastuerized milk and contaminated
water
Clostridium perfringes 8-16 hours Meat, stews, gravies: commonly spread when serving
dishes don’t keep food hot enough or food is chilled
so slowly.
Escherichia coli 12-72 hours Water, meat, & beef: contaminated with feces during
slaughter. Spread mainly by undercooked ground
beef.
Other sources: unpasteurized milk, apple cider, alfalfa
sprouts and contaminated water.
Listeria 9-48 hours Hotdogs, milk, soft cheeses, luncheon meat,
unpasteurized milk, unwashed raw produced. Can be
spread through contaminated soil & water.
Salmonella 12-36 hours Meat, dairy products, bakery foods, poultry, milk, egg
yolks, water.
Survives inadequate cooking. Can be spread by
knives, cutting surfaces or an infected food handler.
Shigella 1-7 days Seafood, raw and ready to eat produce, water, fruits,
vegetables.
Can be spread by an infected food handler.
Staphylococcus aureus 1-6 hours Meat, dairy products, bakery foods, prepared salads,
cream sauces, & cream-filled pastries.
Can be spread by hand, contact, coughing & sneezing.
Vibrio parahemolyticus 8-30 hours Shellfish, water
Vibrio enterocolitica 3-7 days Water, meat, dairy
Vibrio vulnificus 1-7 days Raw oysters, raw or undercooked mussels, clams &
whole scallops.
Can be spread things, contaminated water.
Novoviruses (Norwalk- 12-48 hours Raw, ready to eat produce & shellfish from
like viruses) contaminated water.
Can be spread by an infected food handler.
Giardia lamblia 1-2 weeks Raw, ready to eat produce & contaminated water.
Can be spread by an infected food handler.
Hepatitis A 28 days Raw, ready to eat produce, shellfish & contaminated
water.
Can be spread by an infected food handler.

43
Clostridium botulinum 12-72 hours Home-canned foods with low acidity, improperly
canned commercial foods, smoked or salted fish,
potatoes baked in aluminium foil & other foods kept
at warm temperature for too long.

Food poisoning is caused by ingesting foods or drinks that has been contaminated with
chemicals or
gastrointestinal infections of bacteria, viruses or parasites. Understanding the cause should be the first
priority. At the farm, some vegetables were found positive for regulated pesticides. Aflatoxin
monitoring of agricultural crops and processed products. At the processor level, some violations were
recorded:
1. Misuse of food additives like sodium nitrite and nitrate in meat and meat products, caffeine
in cola drinks, sulfur dioxide in dried fruits.
2. Use of non-permissible food additives like borax in noodles & snack foods, potassium
bromate in flour, sodium cyclamate in juice drinks.
3. Use of non-permissible food color such as Rhodamine B in candies & biscuits.
4. Presence of food contaminants such as aflatoxins in peanut butter, corn-base snacks, 3-
MCPD in soy sauce, histamine in marine products.
5. Presence of heavy metals in herbal food supplements.
6. Allergens in hotcake mix, cyanide in milk powder
7. Defective canned products, expired food products
8. Presence of microorganisms

TREATMENT:
1. Replace fluid and electrolyte losses with IV saline
2. Antiemetic agents are acceptable for symptomatic treatment but strong antidiarrheal agents should
not be used in patients with suspected invasive bacterial infection (fever and bloody stools)
3. In patients with invasive bacterial infection, ciprofloxacin or trimethoprim-sulfamethoxazole is
commonly given while awaiting culture results.
4. For pregnant women who have eaten Listeria-contaminated food, the antibiotic of choice is
ampicillin, with gentamicin added for severe infection.

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III. MATERIALS
SAMPLE LABELS OF FOOD ITEMS, SNACK PRODUCTS, CANNED GOODS
BOOKS
OTHER READING MATERIALS

IV. PROCEDURE
1. Bring samples of snacks/food labels like canned goods, noodles, corn-base snacks, etc.
2. From the list of ingredients found in each label, identify one which will potentially develop
risk to human health.
3. Check/identify the substance and provide any toxicological information.

V. ANALYSIS OF SAMPLES
1. SAMPLE 1
PRODUCT NAME:

TOXIC SUBSTANCE:

MECHANISM OF TOXICITY:

CLINICAL SIGNS & SYMPTOMS OF TOXICITY:

MANAGEMENT/TREATMENT:

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2. SAMPLE 2
PRODUCT NAME:

TOXIC SUBSTANCE:

MECHANISM OF TOXICITY:

CLINICAL SIGNS & SYMPTOMS OF TOXICITY:

MANAGEMENT/TRAETMENT:

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GUIDE QUESTIONS:
1. How can food poisoning be prevented?

2. What are the clinical signs and symptoms of foodborn illness?

3. What is gastroenteritis?

4. What is stomach flu?

SOURCE: FOOD and NUTRITION RESEARCH INSTITUTE, DOST, 2008

OLSON, KENT R. POISONING AND DRUG OVERDOSAGE 2ND ed.

47
 ACTIVITY 9
POISONING FROM HOUSEHOLD PRODUCTS

I. OBJECTIVES
1. To identify the different toxic content of household products.
2. To describe the physico-chemical properties of the different toxic substances found in
household products.
3. To be familiar with the appropriate management, treatment and prevention of poisoning.

II. DISCUSSION
Household products are the products used for cleaning, gardening and other household uses
found in the home environment.
These substances contains poisonous substances that are harmful if not used properly. These
household products cause problems if swallowed, inhaled or absorbed through the skin. These
includes:
Laundry powder pesticides motor oil and fuel additives
Paint thinners garden herbicides cleaning products
Floor polish arts and crafts supplies prescription medicines
Grease and rust removers, strippers and removers

List of information every consumer should read in hazardous product labels before purchasing:
1. Common name or chemical name
2. Amount or volume of contents
3. Signal word: ex. Danger, Poison, Warning or Caution
4. Instructions for safe handling and use
5. Name and address of manufacturer, distributor, packer or seller
6. Description of hazard and precautions

48
 7. First aid instruction.
Prevention of Poisoning:
1. Keep the products in their original containers.
2. Label correctly if the product is transferred to a different container.
3. Use the product exactly as the label says.
4. Handle the product carefully to avoid spills and splashing.
5. Hazardous products should be stored on high shelves or locked in cabinets out of reach of
children.
6. Never stored in food or beverage containers.

Fifteen most dangerous household products:

1. Antifreeze 6. Insecticide 11. Toilet bowl cleaner
2. Bleach 7. Iron-containing vitamins 12. Dishwasher detergent
3. Drain cleaner 8. Medicines 13. Air freshener
4. Furniture polish 9. Nail polish remover 14. Ammonia
5. Gasoline 10. Wiper fluid 15. Mothballs

Symptoms of Toxicity:
General symptoms include, burns round mouth, general pain in the body, loss of consciousness,
trouble breathing and vomiting.

Management/ Treatment:
1. Elimination
2. Antidote- prevents the poison from working or reverse the effects of the poison.
3. Supportive/ symptomatic treatment- if there’s no specific antidote, the physician will treat
the signs and symptoms as needed.

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Toxic Chemicals Found in some Household Products:
1. Formaldehyde
2. Chlorine
3. Hydrochloric acid
4. Lye
5. Trichloroethane
6. Petroleum distillates
7. Phenol
8. Nitrobenzene
9. Perchlorethylene
9. Triclosan
10. Sodium hypochlorite

III. MATERIALS
Mothball wrapper, Racumin empty box, Baygon insecticide spray
Any label of different household chemicals ( 3)

IV. PROCEDURE
1. Bring sample label of the following: antiseptics, disinfectants, caustics
2. Read and examine carefully each label and note the different information stated in the label.

V. ANALYSIS OF THE HOUSEHOLD CHEMICALS

1. Moth balls
Active ingredients:

Trade name:

50
 Manufacturers name:
Uses:

Toxic effects:

Treatment/ Antidote:

2. Racumin
Active ingredients:
Trade name:
Manufacturers name:
Uses:

Toxic effects:

Treatment/Antidote:

3. Baygon insecticide spray

Active ingredients:
Trade name:
Manufacturers name:
Uses:

Toxic effects:

51
 Treatment/Antidote:
4. Antiseptic: _______________
Active ingredient:
Trade name:

Manufacturers name:
Uses:

Toxic effects:

Treatment/Antidote:

5. Disinfectant: ______________
Active ingredient:
Trade name:
Manufacturers name:
Uses:

Toxic effects:

Treatment/Antidote:

6. Caustic: __________________
Active ingredient:

52
 Trade name:
Manufacturers name:
Uses:

Toxic effects:
Treatment/Antidote:

GUIDE QUESTIONS:
1. What are the chemical compositions of moth balls? Describe its mechanism of toxicity?

2. What are the active chemicals found in the following? And what is its antidote/management
of poisoning?
A. Cuticle remover-
B. Lysol-

C. Liquid detergent-

3. List down 10 examples of hazardous substances found in your kitchen, laundry, or toilet.

53
 ACTIVITY 10
POISONOUS PLANTS

I. OBJECTIVES
1. To identify the different poisonous plants.
2. To determine which part and substance responsible for its toxic effects.
3. To describe the different clinical manifestations brought about by the poisoning.
4. To learn the possible treatment, interventions, management or antidote for such poisoning.

II. DICUSSION
Most plants are commonly used to beautify our environment, some are used for food
both for humans and animals. However, some are also harmful to us.

Lists of Poisonous Plants:

A. Rosary pea Japanese yew
Water hemlock Oleander
Monkshood Bloodroot
Deadly nightshade Foxglove
Castor beans Cherry
Golden chain tree Angels trumpet
B.
Stinging tree Croton
Doll’s eye Betel nut
European yew Nutmeg
English Ivy Daffodil
Giant Dumb cane Cassava
Devil’s backbone Adelfa
C.
White snakeroot European yew
Poinsettia Fish berries
Death angel Black locust
Caladium Poison ivy
Allamanda Convallaria

54
 Datura Dwarf laurel

Lists of Mushrooms:
A. Hypholoma fasciculare Boletus spp.
Death cap False morel
Destroying angels Autumn skullcap

Psilocybe Clitocybe spp.

Fly Agaric Conocybe filaris

B. Angel wing Podostroma cornu-damae

Galerina Deadly webcap
Inocybe Lactanus
Russula Paxillus involutus
Deadly Dapperling Lepiota

III. MATERIALS
BOOKS
READING MATERIALS

IV. PROCEDURE
1. Identify the parts and constituents which are considered toxic.
2. Describe the clinical signs and symptoms of toxicity of each given sample
3. Identify the antidote of each toxicity.

V. ANALYSIS OF SAMPLES
SAMPLE 1. ACONITUM
a. common name/s:
b. Scientific name:
c. toxic substance:

55
 d. poisonous part:
e. signs/symptoms of toxicity:

f. management/antidote:

SAMPLE 2. TUNG OIL TREE

a. common name/s:

b. Scientific name:

c. toxic substance:

d. poisonous part:

e. signs/symptoms of toxicity:

f. management/antidote:

SAMPLE 3. ELEPHANT’S EAR

a. common name/s:

b. Scientific name:

c. toxic substance:

d. poisonous part:

e. signs/symptoms of toxicity:

f. management/antidote:

56
SAMPLE 4. PODOPHYLLUM

a. common name/s:

b. Scientific name:

c. toxic substance:

d. poisonous part:

e. signs/symptoms of toxicity:

f. management/antidote:

SAMPLE 5. POISON HEMLOCK

a. common name/s:

b. Scientific name:

c. toxic substance

d. poisonous part:

e. signs/symptoms of toxicity:

f. management/antidote:

SAMPLE 6. IPOMOEA

a. common name/s:

b. Scientific name:

c. toxic substance:

d. poisonous part:

e. signs/symptoms of toxicity:

57
 f. management/antidote:

SAMPLE 7. PRIMROSE

a. common name/s:

b. Scientific name:

c. toxic substance:

d. poisonous part:

e. signs/symptoms of toxicity:

f. management/antidote:

SAMPLE 8. YELLOW JASMINE

a. common name/s:

b. Scientific name:

c. toxic substance:

d. poisonous part:

e. signs/symptoms of toxicity:

f. management/antidote:

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GUIDE QUESTIONS

1. Enumerate 5 poisonous herbs and indicate the toxic substance/s present.

2. Describe or define the following.

a. Teratogenecity

b. Carcinogenecity

c. Mutagenecity

59
 ACTIVITY 11
POISONOUS ANIMALS

I. OBJECTIVES
1. To identify the different poisonous animals.
2. To identify the part responsible for its toxic effects.
3. To learn the clinical manifestations of animal poisoning.
4. To be familiar with the various management and treatment and specific antidote of
poisoning.

II. DISCUSSION
Most poisonous animals possess a bright and beautiful color. However, these beautiful
appearance are not as beautiful as it looks. These animals contains venoms that can kill human beings.
They use their venom to catch the prey or for protection from the enemy.
Venom is a form poisonous substance secreted by animals such as snakes, spiders, scorpions
for the purpose of causing harm to another, injected into the victim by means of a bite, sting or other
sharp body feature.

The following are some of the most poisonous animal species:

1. BOX JELLY FISH
Common name: sea wasps, marine stingers
Class: Cubozoa
Genus species: Chironex fleckeri
Family: Chirodropidae
Toxin: nematocysts

Their venom is considered to be among the most deadly in the world, containing toxins that
attack the heart, nervous system, and skin cells. It is so overpoweringly painful, human victims have
been known to go into shock and drown or die of heart failure before even reaching shore. Survivors
can experience considerable pain for weeks and often have significant scarring where the tentacles
made contact.

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 TREATMENT/MANAGEMENT: first aid- cold packs or ice
- ABC ‘s
- Mouth to mouth resuscitation or heart massage if necessary

- Vinegar application
- CSL Chironex antivenom, if available
- Oxygen and inhaled analgesia
2. KING COBRA
Class: Reptilia
Genu species: Ophiophagus hannah
Family: Elapidae
Toxin: neurotoxin – haditoxin

TREATMENT/MANAGEMENT:
A. First aid

1. Lay or sit down with the bite below the level of the heart.
2. Wash the bite with soap and water.
3. Cover the bite with a clean, dry dressing.

B.
1. Supportive care
2. Antivenin and tetanus booster vaccine

Don’t do the following:

1. Do not pick up the snake or try to trap it.
2. Do not wait for symptoms to appear if bitten, rather seek immediate medical
attention.
3. Do not apply a tourniquet.
4. Do not slash the wound with a knife.
5. Do not suck out the venom.
6. Do not apply ice or immerse the wound in water.
7. Do not drink alcohol as a painkiller.
8. Do not drink caffeinated beverages

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3. STONEFISH
Common name: Reef Stonefish
Class: Actinopterygii
Genus species: Synanceia verrucosa
Family: Synanceiidae
Toxin: verrucotoxin

The Reef Stonefish is the most venomous fish in the world. It has thirteen stout spines in
the dorsal fin which can inject a highly toxic venom. The venom causes intense pain and is
believed to have killed many Pacific and Indian Ocean islanders.
TREATMENT/MANAGEMENT:
1. Immersion in hot water for 30-90minutes
2. Local pain blocks useful to control pain.
3. Tweezers to remove any spines in the wound.
4. Scrub the wound with soap and water, then flush the affected area with fresh water.
5. antivenom and tetanus booster vaccine

4. DEATH STALKER SCORPION

Common name: Palestine yellow scorpion, Omdurman scorpion, Naqab desert scorpion,
deathstalkers
Class: Arachnida
Genus species: Leiurus quinquestriatus
Family: Buthidae
Toxin: neurotoxins – chlorotoxin, charybdotoxin, scyllatoxin, agitoxins type I, II, III

The sting from the Deathstalker Scorpion is painful but few people die from it. Studies
show that those with allergies or heart issues though are at the greatest risk of death. It is
important to seek medical attention immediately to prevent the lungs from filling up with fluid
that can cut off the flow of air.

TREATMENT:
1. Application of ice on the area consistently
2 .Pain medications and antihistamines
3. Antivenin

5. POISON DART FROG

Common name: poison frog, poison arrow frog, dart frogs
Class: Amphibia
Genus: Phyllobates: Dendrobates: Epibpedobate
Family: Dendrobatidae
Toxin: Batrachotoxin
Treatment: symptomatic treatment

62
 Poison dart frog excrete toxins through their skins, and the brightly coloured bodies of
poison dart frogs warn potential predators not to eat them. Despite the toxins used by some
poison dart frogs,
some predators have developed the ability to withstand them. One is the snake Leimadophis
epinephelus, which has developed immunity to the poison.

For some other species of frogs which produces significant amount of potent toxins,
death can occur particularly after oral ingestion. There are no antivenoms or direct antidotes to
treat this type of poisoning. However, for some species whose toxins have a digitalis type of
activity, it is possible to use anti-digitalis medications (digibind) to neutralize circulating toxins.

III. MATERIALS
READING MATERIALS

IV. PROCEDURE
1. Identify the other poisonous animals not on the list above.
2. Identify the parts and constituents which are poisonous.
3. Provide basic management or specific treatment if there’s any and other information.

V. ANALYSIS OF SAMPLES
1. BLACK WIDOW SPIDER
a. common name:
b. Scientific name & Family name:
c. toxic substance:

d. toxic part:
e. signs/symptoms of toxicity:

f. management/antidote:

2. OYSTERS
a. common name:
b. Scientific name & Family name:
c. toxic substance:

d. toxic part:

63
 e. signs/symptoms of toxicity:

f. management/antidote:

3. MARBLED CONE SNAIL

a. common name:
b. Scientific name & Family name:
c. toxic substance:

d. toxic part:
e. signs/symptoms of toxicity:

f. management/antidote:

4. BEE
a. common name:
b. Scientific name & Family name:
c. toxic substance:

d. toxic part:
e. signs/symptoms:

f. management/antidote:

5. PUFFER FISH
a.common name:
b. Scientific name & Family name:

64
 c. toxic substance:

d. toxic part:
e. signs/symptoms of toxicity:

f. management/antidote:

GUIDE QUESTIONS:

1. How are antivenoms produced? What are its composition?

2. What is the difference between biting insects and stinging insects?

3. What is envenomization?

65
 ACTIVITY 12
JOURNAL READING

66
67
68
69
References:

Olson, Kent, Poisoning and Drug Overdose,3RD Ed.Appleton and Lange, 1999
Remington, Joseph P., The Science and Practice of Pharmacy, 2012
Lippincot-Pharmacology 5th Edition, 2012
Katzung, Bertram G., Trevor, Anthony J. Basic & Clinical Pharmacology, 2015
www.//en.wikipedia.org

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