Principles Of Management In A Poisoned Patient

The most important step in the management of a poisoned patient is,

a. what to do?
b. In what order to do?

What to do?
It is much more important step to think, than to provide an agent to reduce
absorption of poison or to counteract its effects. The fact is Patient must be treated
first and then the Poison.
In other words most important first step is to save the life of the patient. It will be of
no value to remove the chemical from the patients stomach if he has stopped
breathing or his heart is fibrillating. So always asses the patient first, then what
must be done and in what order.

Once the victim is stabilised, only then try to identify the poison, its quantity
involved and how much time has passed.

SO THE FLOW CHART OF MANAGEMENT WILL BE,

After clinical evaluation of the patient and after saving the life of the patient, the
next aim should be,

1) Removal of unabsorbed poison

2) Elimination of absorbed poison from the body
3) Treatment of general condition and symptoms

Steps of management will be,

1) Clinical evaluation

2) Non- Specific Anti-doting

3) Dilution of poison

4) Emesis

5) Adsorbents

6) Cathartics

7) Lavage
 8) Forced Diuresis

9) Demulcents

10) Dialysis & Haemo-perfusion

11) Specific Anti-doting

1.CLINICAL EVALUATION

It should be done regarding specific signs and symptoms of various poisons.

2. Non-Specific Anti-doting:
Generalised procedures exist for anti-doting symptoms of most of the
poisons. Most ingested poisons are removed by emesis, Inhaled poisons are treated
with oxygen and skin contaminations are managed by washing with soap & water.
So anti-doting is by and large always non-specific and is not an unapproachable
activity.

Specific anti-dotes are only used when these are appropriate. When a poison
ingestion is suspected, whether the victim is actually a candidate for anti-dote
therapy? This question has no absolute answer.

When poisoning is suspected and the suspected poison is extremely toxic, and then
anti-dote therapy should be initiated without any delay. Because many poisons do
not cause symptoms until many hours have passed after exposure. Also when the
ingested quantity of a poison is unknown, it should be assumed that it is sufficient
to cause serious problems.

Sometimes people are reluctant to administer an emetic, hours after poison is

swallowed, thinking it is too late. But it has been seen effective even after 8-12
hours after ingestion and victim vomit large of clumps of poison. All patients of
poisoning event, confirmed or suspected, should not be brushed aside as
unimportant.

3. Dilution of the Poison:

The initial procedure recommended, whenever ingestion of poison is
suspected, is to dilute it. Water is the best fluid that should be used. The quantity
which can be comfortably swallowed, should be given.

Excessive fluid may distend the stomach, which may cause premature relaxation of
pyloric sphincter. And once this occurs it becomes much more difficult to remove
the poison before it is absorbed. Water causes two functions, First it reduces gastric
irritation, Second it adds bulk to the stomach which may be needed for later emesis.

Carbonated beverages on one hand causes distension of stomach, and if the

ingested poison is corrosive, the gas may potentiate perforation.
Milk contains fat, and if substance is fat soluble, it may lead to serious toxicity. Milk
also delays emesis.

Under no circumstances weak acids or alkalis be induced to neutralise the

substance because heat released by exothermic reaction cause irreversible tissue
damage

Whether ingested poison should be diluted or not, is still a debateable issue.

1) The chemicals are more readily absorbed into blood when they are diluted.

2) Dilution of strong acids or bases may cause serious problems than

benefits.

3) Dilution followed by emesis when appropriate offer certain advantages.

4.Emesis:
It means to induce vomiting. For many years emesis has been mainstay for
the treatment of ingested poisons. Emetics have been used for this purpose and
some of them are still in use, eg; Syp. Of Ipecac

Chemically induced vomiting is accepted as first line procedure for anti-doting

poisons. However many common techniques and drugs used for emesis have been
shown ineffective and even dangerous. But they still occupy important position in
anti-doting many poisons.

Certain precautions are to be observed for all emetics,

1. If the victim is unconscious, the danger of vomitus of being

aspirated into the lungs still exists, and cause chemical
pneumonia.

2. If the poison is convulsant, forced emesis may precipitate

convulsions.

3. For petroleum distillates special care is needed, because of low

surface tension & viscosity they may aspirated into lungs
during emesis.

4. If poison is a corrosive acid or alkali, emesis should be avoided

because it may cause further damage to the oesophagus.
Tissue damage in corrosives is related to the contact time between
poison and tissue.

5. If children under 6 months of age, then emetics should not be

given, because gag reflex is poorly developed, may cause
choking with aspiration.

6. In persons with severe cardio-vascular problems, emetics should

not be given.

5. Adsorbents: The absorption of ingested poisons can be reduced by use of

adsorbents. Several substances, Kaolin, Pectin, Attapulgite are used.
Activated charcoal is very useful and should be used for adsorption of
ingested poisons.

Another preparation known as Universal Antidote is used. It contains,

Tannic acid ________ 1 part

Magnesium Oxide___ 1 part
Activated Charcoal ___ 2 parts

The activated charcoal for many years remained first choice antidote. But
experimentally it is proved that charcoal component of Universal Antidote adsorbs
part of MgO and Tannic acid. This results in reducing the adsorptive capability and
hence reducing anti-dotal capacity.

Tannic acid may be absorbed into circulation and is hepatotoxic. Thus Universal
Anti-dote is no longer recommended as an emergency anti-dote.

Only Activated Charcoal is regarded today as one of the most important for
removing ingested chemicals from GIT.
In the stomach and intestine poison diffuse onto the charcoal surface and form tight
Charcoal-Chemical complex and passes out of body.

Activated charcoal is not contra-indicated in any poison even when it is not

regarded as useful. Its only restriction is in the absence of bowel sounds.

Time interval:
It should be administered within 30 minutes, but even later administration is
beneficial.
Multiple small doses in 6 hours is more beneficial.
Burnt toasts or crushed coal are not accepted as substitutes.

Dose:
50-60 Grams in adults
15-30 Grams in children
Usually a ratio of 10 : 1, Charcoal to Drug is given, But on one hand it will become
too large amount to be swallow and secondly at multiple occasions we do not know
the nature and amount of poison taken.

In the presence of food the adsorptive property of charcoal is reduced, so it is

recommended that higher dose should used in the presence of food.
It should not be given within 30 minutes of syp of ipecac and emesis will not occur.

6.Cathartics:
These are the substances which induce diarrhoea and toxic substances are
removed from GIT. It reduces the contact time between poison and the absorption
site, reduces potential for toxicity, however requires several hours.

Cathartics can be recommended for most of the poisons but it should not be
attempted,
1) When poison is strongly corrosive, as it may increase chemical
injury.
2) In patients with electrolyte disturbances or in absence of bowel
movements.

7. Lavage:
Lavor ; To wash
Lavage is a process of washing out the stomach with water, saline, etc;
It is indicated when the poison must be quickly removed from stomach before
emesis or where emesis is contra-indicated.

Significance:
It may be life saving if it is done early i.e. within 4-6 hours after
ingestion of poison.
If excessive vomiting has occurred, then the benefits from stomach wash are less,
but even then it should be done because poison might be adherent to stomach wall.

Precautions & Contra-indications

It is absolutely contra-indicated in corrosive poisoning, coma, and
strychnine poisoning but can be performed with precaution in petroleum distillates
poisoning.

Procedure:
1) The patient should lie prone or semi-prone on the side
preferably left lateral position. With this position the
pyloric end of the stomach is upside and contents do
not enter intestine. And if the patient vomits, this position
prevents the regurgitated material from entering respiratory passages.
2) Dentures if any should be removed.
3) Airways should be cleared.

A wooden mouth gag with central hole is used which

prevents the rubber tube from being bitten off by
the teeth.

4) The stomach wash tube is made up of flexible rubber

about 1.5 meter long and external diameter of 12.7
mm, sufficiently stiff to avoid kinking.
5) A funnel is provided at the top of the upper end.

6) A suction bulb is provided in the middle of the tube, which

sucks out fluids when siphon action fails or to push air
into the tube to force out any obstruction.
7) The lower end is blunt and rounded to avoid any injury and is
perforated with many holes.

8) The distance between lips and cardiac end the stomach is

about 45 cms in adults. It is marked at distance of 50
cms which means that at this mark at lips the lower
end is into the stomach.

Technique:
The lower end of the tube is lubricated with liquid paraffin or
glycerine, pass it through the hole in the wooden mouth gag, over the tongue down
the oesophagus. When the mark reaches the lips, then the lower end is in the
stomach.

To confirm that, the tube is in the stomach, a little air is forced down
the tube simultaneously placing the stethoscope at the epigastrium. You will hear a
bubbling sound if it is in the stomach, or a hissing sound if in the trachea. If the
patient is conscious, reflex coughing will start.

After confirming tube is in the stomach, half a litter plain water is run into the
funnel, which is held above the level of head. The fluid enters the stomach by
gravity. The funnel is then lowered, below the level of stomach over a receptacle
and gastric contents will start coming out by siphon action.
 Sometimes an appropriate anti-dote can be used for washing. If KMnO 4 is
used & the returning fluid is pink, it indicates poison has been neutralised. Some
anti-dote may be left in the stomach.
Magnesium sulphate or Sodium sulphate is given to ensure purgation, Activated
charcoal to adsorb and liquid paraffin as demulcent.

Too much fluid may force the contents into the duodenum. The first washing
should be preserved for analysis. Keep repeating this process, each time using half
a litre, till the returning fluid is clear. A total of 10 litres is generally necessary for
complete lavage.

Before the with-drawl of tube, it should be pinched to prevent aspiration of

material into air passages.
In children stomach wash should be done with soft Ryles tube, 8-12 French size.
About 25 cms length is sufficient to reach stomach.