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Poison: Treatment

In order to manage or treat poisoned patient,


doctors should first:
Seek history
Ask the time and size of ingestion
Check vital signs
Physical examination
Toxicology Screening
Physical Examination
Based on knowledge of drug pharmacology &
effects on ANS
The vital signs should be monitored accurately.
Level of consciousness, pupillary size and reaction
to light.
Skin examination and breath odors
Recognizing toxidromes.
Exam should include evaluation for head trauma,
focal neurological findings, needle track marks.
Breath odors & Skin Findings
BREATH ODORS SKIN
Bitter almonds: cyanide Diaphoretic Skin:
Fruity: DKA, isopropranolol Sympathomimetics
Oil of wintergreen: Organophosphates
methylsalicylate Salicylates
Rotten eggs: sulfur dioxide, Red Skin: CO, boric acid
hydrogen sulfide Blue Skin: Cyanosis
Pears: chloral hydrate methemoglobinemia
Garlic: organophosphate,
arsenic
Mothballs: camphor
Physical Examination
Toxidrome"or toxic syndrome
pattern of signs and symptoms that suggests a specific class
of poisoning and allows one to narrow the differential
diagnosis
provides a starting point for management and may suggest
the laboratory tests that follow
head trauma
focal neurologic findings
needle track marks
chest auscultation for signs of aspiration or non-cardiogenic
pulmonary edema
unusual odors on the patients breath.
Toxidromes
Opioids
triad of respiratory depression, pinpoint pupils, decreased LOC
bradycardia, hypotension, hypothermia
needle tracks

Sedative / Hypnotics
- benzodiazepines, alcohol, barbituates
altered mental status, stupor, coma, slurred speech
respiratory depression
variable pupil changes
hypotension
hypothermia
barbiturate blisters
Sympathemimetics / Withdrawal
- Cocaine, amphetamines, PCP, pseudoephedrine
HTN, tachycardia,
Mydriasis
Anxiety, delirium, paranoid delusions
Diaphoresis
Increased temperature
Seizures

Anticholinergics
TCA, antihistamines, antipsychotics, Gravol
Hot as a hare, Red as a beet, Dry as a bone, Blind as a bat, Mad as a hatter
Hyperpyrexia, cutaneous vasodilation, decreased saliva, mydriasis, hallucinations
tachycardia
Urinary retention
Decreased bowel sounds
Seizures, dysrhythmias
Cholinergics
insecticides,carbamate, organophosphates, nerve gas, physostigmine
Salivation, Lacrimation, Urination, Defecation, Gastric cramping, Emesis
SLUDGE
Drowning in secretions, profuse sweating
AMS, seizures, coma
Muscle fasciculations
Miotic pupils

Salicylates
fever
tachypnea
tinnitus, lethargy, altered mental status
respiratory alkalosis
metabolic acidosis, ketosis
vomiting
Serotonin Syndrome
fluoxetine, trazadone, meperidine
irritability, agitation, AMS
hyperreflexia, tremor, myoclonus, trismus
ataxia, incoordination
flushing,diaphoresis
diarrhea
fever
Difficult to distinguish from NMS, MH, cocaine intoxication, thyroid storm

Extrapyramidal
haloperidol, phenothiazines
rigidity, tremor
opisthotonus, trismus
choreoathetosis
hyperreflexia
Hallucinogenic
amphetamines, cannabinoids, cocaine, LSD, PCP
hallucinations, psychosis, panic
fever
mydriasis
Bradycardia

Beta- blockers, calcium-channel blockers, Digoxin


Clonidine
Phenylpropanolamine
Carbamates, organophosphates, physostigmine
TCA's
Antidysrhythmics ( Types 1A AND 1C)
Opioids
Hypoxemia, MI, hyperkalemia, hypothermia, hypothyroidism, ICP

Agitation/ Seizures
Temperature alterations
Therapy
Initial stabilization
Maintain airway, breathing, and circulation
an endotracheal tube
mechanical ventilation IV naloxone
IV naloxone
IV dextrose and thiamine
IV fluids, sometimes vasopressors
IV naloxone
2 mg in adults; 0.1 mg/kg in children
respiratory depression

IV dextrose
50 mL of a 50% solution for adults; 2 to 4
mL/kg of a 25% solution for children
altered consciousness
CNS depression
Thiamine
100 mg IV
given with or before glucose to adults with
suspected thiamine deficiency
given routinely to all alcoholics or malnourished
patients with altered mental status.

Flumazenil
Given rarely on emergency cases
IV fluids
hypotension.
If ineffective, invasive hemodynamic
monitoring may be necessary to guide fluid
and vasopressor therapy.
The first-choice vasopressor
norepinephrine
0.5 to 1 mg/min IV
Ongoing supportive measures
For refractory hypotension
dopamine, epinephrine, other vasopressors
intra-aortic balloon pump
extracorporeal circulatory support
For refractory arrhythmias
cardiac pacing.
Torsades de pointes can be treated with Mg sulfate 2 to 4 g IV
overdrive pacing
titrated isoproterenol infusion.
Seizures
Benzodiazepines
Phenobarbital
phenytoin
Hyperthermia
aggressive sedation physical cooling measures
Organ failure may ultimately require kidney or liver
transplantation.
Antidote Toxin used for Comments
Naloxone Opiates Less to avoid withdrawal

Flumazenil Benzodiazepines Avoid if TCA's, epilepsy,


addiction
Bicarbonate TCA, ASA
Calcium CCB
Glucagon Beta-blockers, CCB Follow with infusion of same
dose/hr
Physostigmine Anticholinergics Avoid in TCA's
Atropine Organophosphates, Titrate to drying of pulmonary
Carbamates secretions

Protopam Organophosphates
Ethanol Methanol, ethylene glycol

Pyridoxine INH
Digibind Digoxin
N-acetylcysteine Acetaminophen
EDTA Lead
DMSA Lead
BAL Arsenic, mercury,lead

D-penicillamine Ar,lead,Mercury
Cyproheptadine Serotonin syndrome

Sodium nitrite, sodium cyanide


thiosulfate
Desferoxamine iron
Chelating Drug* Metal Dosage
Deferoxamine Iron
Dimercaprol, 10% in oil Antimony 34 mg/kg via deep IM injection q 4 h on day 1, 2 mg/kg IM q 4 h on
Arsenic day 2, 3 mg/kg IM q 6 h on day 3, then 3 mg/kg IM q 12 h for 710
Bismuth days until recovery
Copper salts
Gold
Lead
Mercury
Thallium*

Edetate Ca disodium (Ca Cobalt 2535 mg/kg via deep IM injection or IV slowly (over 1 h) q 12 h for
disodium edathamil) Lead 57 days, followed by 7 days without the drug; then repeated
diluted to 3% Zinc
Zinc salts

Penicillamine Arsenic 57.5 mg/kg po qid (usual starting dose is 250 mg qid) to a maximum
Copper salts adult dose of 2 g/day
Gold
Lead

Succimer Arsenic (occupational 10 mg/kg po q 8 h for 5 days, then 10 mg/kg po q 12 h for 14 days
exposure in adults)
Cadmium salts
Lead if children have
blood lead
levels > 45 g/dL
(> 2.15 mol/L)
Lead (occupational
exposure in adults)
Mercury (occupational
exposure in adults)
Hospital admission
Indications
altered consciousness
persistently abnormal vital signs
predicted delayed toxicity
Initial Medical Care
Initial attention should be on life support,
primarily on cardiorespiratory care
Shock, arrhythmias and convulsions must be
dealt with urgently and as in the case of any
critically ill
When the patients condition is stable, the
specific treatment or antidote can be given.
Indications for ICU admission
TCA overdose with signs of cardiac toxicity ( QRS > 0.10 secs )
Wide alterations in body temperature
Need for intubation/ ventilation
Hemodynamic instability, dysrhythmias
Decreased level of consciousness
Need for continuous naloxone infusions
Progressive metabolic acidosis, electrolyte abnormalities
Need for emergency dialysis
Staffing issues including the availability of a sitter for suicidal
patients
Rare or poorly understood poisoning
Rising drug levels requiring close observation / monitoring
Potential for delayed toxicity requiring prolonged monitoring
Patient with significant underlying medical conditions which may
exacerbate toxicity
Prevention
In the US, widespread use of child-resistant
containers with safety caps has greatly
reduced the number of poisoning deaths in
children < 5 yr.
Limiting the amount of OTC analgesics in a
single container and eliminating confusing and
redundant formulations reduces the severity
of poisonings, particularly
with acetaminophen, aspirin, or ibuprofen.
Other preventive measures include
Clearly labeling household products and
prescription drugs
Storing drugs and toxic substances in cabinets
that are locked and inaccessible to children
Promptly disposing of expired drugs
Use of carbon monoxide detectors
Public education
Use of imprint identifications on solid drugs