Supportive care in clinical Toxicology

Supportive Care Supportive care is provided to poisoned patient to keep the

patient alive until the physiological function is restored by further specific
treatment. Supportive care helps people meet the physical, practical, emotional
and spiritual challenges. It is done by monitoring the physiologic functions and
correct significant deviations from normal. During this course of action
anticipate and try to prevent complications. Initial resuscitation should be based
on the assessment of the patient and not the particular toxin involved and
standard advanced life support (ALS) guidelines should be followed. Specific
instances where treatment may differ are indicated below. The majority of
patients taking overdoses or with drug toxicity are young and healthy, so
cardiac and respiratory support should be continued for much longer periods of
time in patients with a toxicity-related cardiorespiratory arrest. If there is any
doubt, cardiac compression and ventilatory support should be continued until
the situation has been discussed with a clinical toxicologist. There has been
survival with normal neurological function in patients receiving
cardiopulmonary resuscitation (CPR) for hours.

Airway
Monitoring and managing airways and breathing is crucial in the treatment of
poisoning. CNS depression is a common effect of drugs, so regular and careful
assessment of airway protection and patency is important. The immediate need
for assisted ventilation has to be assessed clinically, but the efficiency of
ventilation can only be gauged by measuring the blood gases. Some drugs
stimulate the respiratory centre. Eg. Amphetamines, Atropine, Cocaine, and
Salicylates. Some drugs are associated with non- cardiogenic pulmonary
oedema, characterised by severe hypoxaemia, bilateral infiltrates on chest X-
ray, and normal pulmonary capillary wedge pressure. Eg. Calcium channel
blockers, Anticoagulants, Beta-blockers, etc. Some drugs cause or exacerbate
asthma. The most important among them include NSAIDs, antibiotics like
penicillins, cephalosporins, tetracycline, and nitrofurantoin, cholinergic drugs,
chemotherapeutic drugs, and some diuretics.
Management:
1. First establish an open airway:
 Remove dentures (if any).
 Use the chin lift and jaw thrust, to clear the airway obstructed by
the tongue falling back.
 Remove saliva, vomitus, blood, etc. from the oral cavity by suction
or finger-sweep method.
 Place the patient in a semi-prone (lateral) position. ■ If required,
insert an endotracheal tube.
 If ventilation is not adequate, begin artificial respiration with Ambu
bag.
2. Oxygen therapy:

This is done to raise the PaO2 to at least 45–55 mmHg (6.0 Kpa to 7.3
Kpa). Begin with 28% oxygen mask. Depending on the response as
assessed by periodic arterial gas analysis, either continue with 28% or
progress to 35%. If the condition is relentlessly deteriorating, consider
assisted ventilation.

Breathing

Toxicology patients rarely have hypoxia unless they develop aspiration

pneumonitis. The commonest problem is hypoventilation secondary to
respiratory depression Many people have problems with breathing and
shortness of breath. This can be a very upsetting symptom that can
significantly affect a person’s quality of life. People who are having
difficulty breathing and shortness of breath may also feel anxious.

Management:

Try different positions to find which ones help the patient breathe easier.
The patient can try sitting upright and leaning forward slightly and also
try using pillows to prop up patient’s head and upper body when they are
sleeping. Patient can try controlled breathing or pursed-lip breathing.
Breathe in slowly through nose, hold the breath for a few counts and
then breathe out through pursed lips like they are whistling. Patient can
also try relaxation exercises or meditation to help ease anxiety when you
have trouble breathing. Make patient sit near an open window or in front
of a fan to get extra air. Opening a window or lowering the room
temperature may also help because cooler air is easier to breathe.

Oxygen therapy

Oxygen therapy is a treatment that gives extra oxygen. It makes sure

patient gets enough oxygen if you have difficulty breathing. Patient
breathe the oxygen in through a mask over mouth or through tubes in
the nostrils. Oxygen therapy is usually only helpful if you have low levels
of oxygen in your blood (called hypoxemia).

Thoracentesis

Thoracentesis may be used to drain an abnormal buildup of fluid in the

space between the lungs and chest wall (called pleural effusion). The
doctor inserts a hollow needle through the skin into the space between
the lungs and the chest wall (called pleural cavity).

Paracentesis
Paracentesis may be used to drain an abnormal buildup of fluid in the
abdomen (called ascites). The doctor inserts a hollow needle or plastic
tube (called a catheter) through the skin into the abdomen. The doctor
uses the needle to drain extra fluid from the abdomen
 Circulation

Common symptoms include alterations in mental status, an inability to

stand without dizziness, and/or severe generalized weakness. Physical
findings include pallor, cold clammy skin, gooseflesh, a thin or thready
pulse, an increased respiratory rate, tachycardia, and hypotension. In
most cases of death from acute poisoning, signs of acute circulatory
failure were observed at autopsy. Histological examination of the
myocardium reveals changes such as hyperaemia and extravasations in
the stroma, and lesions of the muscle fibres with the presence of a
fuchsinophilic substance in the myoplasm. Levels of potassium in the
myocardium would be significantly lower. Although the mechanisms,
causes and clinical syndromes are different the pathogenesis is the same,
the circulatory system fails to maintain the supply of oxygen and other
nutrients to the tissues and to remove the carbon dioxide and other
metabolites from them. The failure may be hypovolemic, distributive.

Management:

1. Inotropic support
The use of intravenous fluid therapy and inotropic support should be
based on patient haemodynamics and the specific toxins ingested.
Although specific inotropes or or other drugs are suggested in
toxicology patients, the initial management of cardiogenic shock
should be the same as for any other cause unless there are specific
contraindications to particular inotropes. The initial inotrope of choice
is adrenaline unless its vasopressor actions are contraindicated, such
as in beta blocker overdose. Administration of an inotrope should only
be undertaken in consultation with a toxicologist or cardiologist.
Prolonged cardiopulmonary resuscitation is essential because unlike in
arrests due to cardiovascular disease, the majority of patients are
healthy prior to the overdose, and survival with normal neurological
function after long periods (hours) of cardiopulmonary resuscitation is
well documented.
Adult doses of other inotropes used in toxicology
1) Milrinone (phosphodiesterase inhibitor)
Milrinone 50 micrograms/kg IV, slowly over 10 minutes, followed by 0.375 to
0.75 micrograms/kg/minute IV, adjusting according to clinical and
haemodynamic response, up to a maximum of 1.13 mg/kg daily.
2) Insulin euglycaemia
Short-acting insulin 1 unit/kg IV bolus, followed by 1 unit/kg/hour. The dose can
be increased to 2 units/kg/hour or further but this should be discussed with a
clinical toxicologist PLUS glucose 10% or 50% IV infusion.
 Sedation
Sedation is the reduction of irritability or agitation by administration of sedative
drugs, generally to facilitate a medical procedure or diagnostic procedure. Drug
induced sedation is also most common occurrence which is generally
unintended effects. Drugs in toxic doses can cause fatal consequences of
sedation. Examples of drugs which that cause sedation include propofol,
etomidate, ketamine, fentanyl, lorazepam and midazolam.
Airway obstruction, apnea and hypotension are not uncommon during sedation
and require the presence of health professionals who are suitably trained to
detect and manage these problems.
Management:
 If the patient feels drowsy and he needs to be monitored very closely.
Keep the patient away from areas of potential harm.
 If the patient wants to sleep, place them on their side with their chin up.
Wake your patient every now and then and encourage them to have
something to drink in order to prevent dehydration. At first it is best to
give the patient sips of clear liquids to prevent nausea.
 If the patient vomits, help them bend over and turn their head to the
side to insure that they do not inhale the vomit.
 Establish ABCs, obtain IV access, provide oxygen, and perform aggressive
supportive care with airway protection as necessary.
 Ensure adequate airway and ventilation. Consider and reassess the need
for endotracheal intubation.
 Seizures
Seizures are a common complication of drug intoxication, and up to 9% of
status epilepticus cases are caused by a drug or poison. Basically, seizures occur
when our systems have reached this point of toxicity or overload, even if the
culprit drug is ecstasy, acid or heroin. While the specific drugs associated with
drug- induced seizures may vary by geography and change over time, common
reported causes include antidepressants, stimulants and antihistamines.
Seizures occur generally as a result of inadequate inhibitory influences (e.g.,
gamma aminobutyric acid, GABA) or excessive excitatory stimulation (e.g.
glutamate) although many other neurotransmitters play a role. Most drug-
induced seizures are self-limited. However, status epilepticus occurs in up to
10% of cases. Prolonged or recurrent seizures can lead to serious complications
and require vigorous supportive care and anticonvulsant drugs.
No characteristic clinical features differentiate drug-induced seizures from
idiopathic epileptic seizures. Use of drugs known to cause seizures should be
avoided in patients with predisposition to seizures.
Management:
 Initial treatment should include airway management with adequate
oxygenation and ventilation, stabilization of the blood pressure and heart
rate and rapid bedside testing of serum glucose concentration and core
body temperature.
 Gastric decontamination and enhanced elimination or antidote
administration may be appropriate in some patients, and consultation
with a medical toxicologist is recommended.
 Finger stick blood sugar, electrolyte imbalance and PH should be
monitored.
 Most drug-induced seizures resolve after discontinuation of the offending
drugs, but some patients require supplementary treatment, eg,
intravenous diazepam.
 Benzodiazepines are generally accepted as the first line anticonvulsant
therapy for drug-induced seizures. If benzodiazepines fail to halt seizures
promptly,
 Continuous infusion of one or more anticonvulsants may be required in
refractory status epilepticus.
 Renal dysfunction/Nephrotoxicity

Nephrotoxicity is toxicity in the kidneys. It is a poisonous effect of some

substances, both toxic chemicals and medications. There are various
forms, and some drugs may affect renal function in more than one way.
Nephrotoxins are substances displaying nephrotoxicity. Nephrotoxicity
should not be confused with the fact that some medications have a
predominantly renal excretion and need their dose adjusted for the
decreased renal function (e.g., heparin). The nephrotoxic effect of most
drugs is more profound in patients already suffering from kidney failure.
Nephrotoxicity is usually monitored through a simple blood test. A
decreased creatinine clearance indicates poor renal function. Normal
creatinine level is between 80 - 120 μmol/L. In interventional radiology, a
patient's creatinine clearance levels are all checked prior to a procedure.

Management:

Supportive care without dialysis focuses on relief from the discomfort

and pain of kidney failure symptoms, such as swelling and shortness of
breath.

 Initial assessment begins with airway, breathing, and circulation (A,

B, C’s). Vital signs should be obtained, including blood pressure.

 Patients should be placed on continuous monitoring and IV access

obtained. If acute kidney injury is suspected,evalution should be
focursed on life threatening complication of acute kidney injury or
renal failure.
References
1. ^ Schrager, TF (October 4, 2006). "What is Toxicology". Archived from the
original on March 10, 2007.
2. ^ Hodgson, Ernest (2010). A Textbook of Modern Toxicology. John Wiley
and Sons. p. 10. ISBN 978-0-470-46206-5.
3. ^ Levey, Martin (1966). Medieval Arabic Toxicology: The Book on Poisons
of ibn Wahshiyya and its Relation to Early Native American and Greek
Texts.
4. www.PharmaDost.info