General Antidotes

agents that counteracts the effect of poisons

1. Physiological Antidotes →produce an effects as that of the poison acting on different receptors

Ex: ▪Histamine → Epinephrine (H1 receptor)

 (B2 receptor) (bronchoconstriction) (bronchodilation)

▪INH Isonicotinichydrazide → Diazepam
▪Atropine → Physosttigmine

2. Chemical Antidotes - alter the chemical characteristics of the poison

Ex: Cyanide (CN) + NaS2O4 SCN (H2O soluble)

3. Mechanical Antidote →is reliable

→ prevent absorption of the poison (if the poison has been ingested for less than 2 hrs.
→ suitable for cooperative & noncombatative patient

a. Gastric Lavage:
Use: Not alert or diminished gag reflex Patients who are seen early following
CI:
1. If the poison is corrosive or caustic

2. Combatative Patient

3. acid, alkali, or hydrocarbons/petroleum ingestion

b. Emesis → induce vomiting

▪Systemic Emetics →stimulate the vomiting center (chemoreceptor trigger zone)

Example: Apomorphine

▪Local Emetics → cause irritation of the GIT

Example: tickling the throat, syrup of Ipecac, tepid water, saline solution

Syrup of Ipecac:

Age Dose (mL)

6–9 5

9 – 12 10

1 – 12 15

> 12 yrs 30

Intructions regarding Inducing vomiting as an initial interventions of poisoning at home:

- For adults, use 2 tablespoonfuls of Ipecac Syrup followed by a glassful of water.

-For children,less than 1 year-old but more than 6 months-old, a teaspoon of Ipecac Syrup may be used.

- Extract of Ipecac should not be used in plase of Ipecac Syrup

- If Ipecac fails, time must not be wasted on trying to induce vomiting, & the patient must be immediately brought to the
hospital

CI:

1. Children <6 months of age

2. With CNS depression or seizures

3. Strong acid, alkali, or a sharp object ingestion

4. With compromised airway protective reflexes

5. Ingestion of some types of hydrocarbons/ petroleum

→can promote lung asphylaxis

6. Ingestion of substances with an extremely rapid onset of action

7. With emesis following the ingestion

c. Cathartics → induce evacuation of vowel

Examples: Children – Castor Oil (Resinoleic Acid)

Irritant Laxatives

Containing Magnesium

Containing Sulphates

Containing Biphosphate – “Fleet Enema”

→Sodium Phosphate

→Sodium Biphospahte

d. Whole Bowel Irrigation →cleaning of the bowel by using PEG w/ Electrolyte (Golytely®, Colyte®)

→ is the most effective process for evacuating the intestinal tract in poisoned patients

Dosage: 1-2 L/hr (PO or by NGT)

Indication: Poorly adsorbed substances (Fe, Pb, Li) SR preparation Body packers of illicit drugs
Late presentation

SE: vomiting, abdominal bloating, fullness, flatulence, pruritus

CI:

 prior, current or anticipated diarrhea

 Volume Depletion
 Significant gastrointestinal pathology/ dysfunction

**ileus, perforation, coloitis, toxic megacolo, hemorrhage, & obstruction

 Uprotected or compromised airway

 Hemodynamic instability

e. Precipitants → alter the poison by forming an insoluble by forming an insoluble substance

4. Adsorbents → form physical complexes with poison preventing its absorption

Example:
 Activated Charcoal (burnt bread)
 Universal Antidote: Activated Charcoal
Tannic Acid
Magnesium Oxide

CI:

Ethanol, Iron, Lithium, Cyanide, Ethylene glycol, Lead, Mercury, Methanol, Organic
Solvents, Potassium, Strong Acid, Strong Alkali

5. Extracorporeal Methods → for life-threatening types of poisons (ex: poison in the blood)

a. Hemodialysis (filtration of blood)

 while removing the person it can correct fluid & electrolyte imbalance
▪Requirements: Vd = <1 L/kg
PB = <50%
LMW = <600 Daltons

▪Indication: Ethylene Glycol, Methanol – more effective Ethanol, Theophylline, Lithium, Salicylates, Long-acting Barbiturates –
less effective

▪Drug Groups have high volumes of distribution which makes Hemodialysis ineffective therapeutic option in cases of Poisoning:
 - Antipsychotics

- Antidepressants

–Antimalarials

b. Peritonel Dialysis →There is no need for anticoagulant

→10-15% as affective as hemodialysis

c. Hemoperfussion → Passage of anticoagulant blood through a column containing activated charcoal or resin particles.

→only use for highly protein bound drugs

▪Advantage: Faster than hemodialysis

▪Disadvantage: cannot correct fluid & electrolyte imbalance

▪More Effective: Phenobarbital, Phenytoin, Carbamazepine, Methotrexate, Theophylline

▪Less Effective: Ethanol, Methanol

6. Chelating Agent → contain electon-donating groups that react with metals to form complexes

→ used in heavy metal poisoning

→commulative poisoning

▪MOA: Coagulation of proteins (CHONS) by binding to Sulfhydryl (-SH) groups

a. Dimercaprol (BAL- British AntiLewisite) / 2,3- dimercaptopropanolol

 serves as the metal acceptor & prevents binding of the –SH groups of
enzymes to metals
 used in Hg, Pb, Au, Sb
 Intamuscular, needs an oil solvent (Peanut oil)
 CI: Fe, Cd, Se
b. EDTA (Ethylene Diamine Tetraacetic Acid/ Calcium Disodium Edetate)
 only limited metals can be used for EDTA (higher affinity than Ca2+)
 used in Fe,Zn, Mg, Cd
c. Penicillamine (Cuprimine®) / - -dimethylcysteine
 hydrolytic produc of penicillin
 PO; used in Cu, Pb, Hg
 hydrolysis product of Penicillin

d. Deferoxamine/Deferoxime

 bonds with Fe Ferroxamine Complex

 IV, IM, SC

e. DMPS (2,3-dimercapto- 1- propanesulfonic Acid)

f. DMSA (meso-2,3-dimercaptosuccinic Acid)

g. DTPA (diethylenetriaminepentaacetic Acid, Calcim Salt)

h. DTC (Dithiocarbamte)

Classification of Poisons

Based on Specific Effects:

Irritants → cause tissue necrosis on contact, caustic effects

Ex: Acid & Alkali

Neurotics → affect the CNS,

Ex: Hallucinogens
Carcinogenics → stimulate growth of cancer cells

Ex: Industrial Poisons

Asphyxiants →cause dyspnea,

Ex: Methane Gas, Carbon Monoxide

Lacrimators →stimulate flow of tears,

Ex: Organophosphates

Sternutators → cause excessive sneezing,

Ex: Veratrine

Asthetics → produce muscular weakness,

Ex: Neuromuscular Blockers

Narcotics →produce mental weakness/ depression,

Ex: Sedative- Hypnotics

Based on Origin:

▪ Natural

 Animal: also known as Zootoxin

 Plant: also known as Phytotoxins
 Microbials Minerals

▪Synthetic

Based on Properties:

▪ Chemical Composition

Inorganic

Organic

▪Volatility

Volatile

-Hydrocyanic Acid: Prussic Acid

-Carbon Monoxide: Acetylene Gas; found as a byproduct of incomplete combustion in automobile, furnace,
& in cigarettes

-alcohols/acetone/phenols/formaldehyde

Non-volatile –alkaloids

General Kinds of Poison:

A. Industrial & Household Poison

1. Ethylene Glycol → used in Antifreeze Preparation

→ excreted by Kidney

→ causes a drunken sate followed a day later by severe high anion gap metabolic acidosis & acute renal
failure

MOA:
 Ethylene glycol oxidized Glycol aldehyde

Oxidized

Glycolic acid

Oxidized

Glyoxallic acid

Formic acid Glycine Oxalic acid

(cause blindness)

▪Metabolites: Glycol Aldehyde, Glycolic acid, Glyoxylic acid

▪Toxic Metabolite: Oxalic acid, Formic Acid

▪ Signs & Symptoms:

Severe Metabolic Acidosis

CNS depression

Cardiopulmonary Depression

Acute Renal Failure

Seizure (treated w/ Diazepam)

▪Treatment:

1. Ethanol competes w/ alcohol dehydrogenase

2.Fomipazole → (-) alcohol dehydrogenase

3. Leucorin →Formic Acid CO2

4. Hemodialysis + NaHCO3 Systemic Alkalizer

5. Ca gluconate →for Hypocalcemia

2. Methanol “Wood Alcohol”

→ denaturant, paint remover, solvent

▪MOA: Methanol Formaldehyde Formic Acid (Blindness)

▪Metabolites: Formaldehyde, Formic Acid

▪Signs & Symptoms:

1. Ocular Toxicity (visual disturbances)

2. Metabolic Acidosis

3. CNS Depression

4. Seizure (treated w/ Diazepam)

▪Treatment:

1. Ethanol & Fomepizole → competes w/ alcohol dehydrogenase

2. NaHCO3 – Systemic Circulation

3.) Isopropyl Alcohol → “Crude Oil Alcohol”

→70% alcohol
→ lead to ketosis (formation of Ketone Bodies)
metabolic Acidosis
▪Treatment: Hemodialysis + Gastric Lavage

4. Aldehydes:

a. Formaldehyde
  35-50% aldehyde
 formalin, formol
 embalming fluid
 Similar in presentation to methanol toxicity

▪Signs & Symptoms:

Local: Mucosal Irritation

Systemic:

 CNS depression,
 Coma,
 Metabolic Acidosis

▪Treatment: NH3 + NaHCO3

b. Aldehyde → responsible for “Hang-Over”

→ “Ethanal”

▪Signs & Symptoms:

 CNS depression,
 Metabolic Acidosis

▪Treatment: Hemodialysis, NaHCO3

5. Ketones: Acetone (2-propanone)

→ primary ingredient in fingernail polish remover, airplane glue, varnish, & rubber cements

▪Signs & Symptoms:

 CNS depression
 Coma
 Respiratory Dep.

▪Treatment: Neutralization Milk + H2O

6. Hydrocarbon →mostly derived from petroleum distillates

▪Petroleum distillates – “Kerosene”

Signs & Symptoms: Lung Aspiration

Treatment: Mineral oil → use to increase the viscosity of toxicant

▪Benzene – can cause megaloblastic leukemia; aplastic anemia

Signs & Symptoms:

 Dyspnea
 CNS Depression →most important toxidrone of acute exposure of Benzene
 Bone Marrow Injury →most significant serious toxic effect of chronic exposure to Benzene →manifesting as
aplastic anemia, agranulocytosis, & a risk for the development of Leukemia

Treatment: Ventilatory Support + 100% O2

Mineral Oil →use to increase the viscosity of toxicant

7. Nitrates & Nitrites

a. Inorganic Nitrates – meat preservative

▪NaNO3 – “Chile Salt peter”

▪KNO3 – “Salt peter”

b. Organic Nitrates – for the treatment of Angina Pectoris

▪Isosorbide Mononitrate (Imdur)

▪Isosorbide Dinitrate (Isordil)

▪Glyceryl Nitrates –

Organic Nitrates – vasodilator; Monday’s Disease

c. Inorganic Nitrites
- Tx of Met Hgb

▪Amyl ntrite

▪NaNO2

d. Organic Nitrites → antioxidant property

MOA: Nitrates & Nitrites

Signs & Symptoms: Light headedness, headache, nausea & vomiting, diarrhea, abdominal pain

Treatment: Methylene Blue (1-2mg/kg)

*Low Dose= treatment

*High dose = can cause also MetHgb

8. Silica – “silicosis”

Signs & Symptoms: Lung fibrosis, Bronchogenic CA

Treatment: “Alumina”

9. Asbestos – “Asbestosis”

Signs & Symptoms: Lung CA

Treatment: Decontamination

10. Carbon Tetrachloride → used in non-flammable cleaning fluids & fire extinguisher

Metabolites: Epoxide, Phosgene

▪Phosgene –

 war weapon
 Poison gas
 hepatorenal toxin

Signs & Symptoms:

 Difficulty in breathing
 Nausea & Vomiting
 Pulmonary Edema
 Skin lesions

Treatment: Ventilatory support

11. Household Poisons

a. Bleaches – “NaOCl”

Signs & Symptoms: Esophageal Irritation

GI Discomfort

Treatment: Gastric Lavage

b. Oxalic Acid – metal cleaners & mat removers

Signs & Symptoms: Metabolic Acidosis, Seizure, Hypocalcemia

Treatment: Ca Gluconate → hypocalcemia

B. Cosmetics:

1. Deodorant

a. Aluminum – “Shaver’s Disease”

→ 3rd most abundant element; most abundant metal

→used for healing burns & as abrasive in industries

→has constipating & astringent effects

b. Zinc → used in the galvanizing of iron & container for battery cells

Deficiency: Parakeratosis (inflamed & scaly skin)

Toxicity: Metal Fume Fever (muscle aches & fever)

Treatment: Aspirin + Bed rest (recovery occurs after 12 days)

2. Depilatories → for hair removal contains sulfides or thioglycolates

Signs & Symptoms: Local Irritation

C. Food Additives:

1. Chloramin T → in milk products

Signs & Symptoms: Transform in CN-

Treatment: NaNO2 + NaS2O3

2. Tartrazine →FD & C no. 5 (Tartrazine)

Signs & Symptoms: Anaphylaxis in allergic reaction

3. Monosodium Glutamate (MSG)

Signs & Symptoms:

 light headedness (↑ pressure in the head)

 Tightness of the feet
 Seizure

Treatment: Lessen MSG in foods

4. Saccharin & Aspartame → Artificial Sweeteners

Signs & Symptoms: diarrhea, Abdominal pain, Nausea, Pain

▪Aspartame: Aspartic Acid

Methanol

Phenylalanine → cause Phenylketonuria (lack of Phenylalanine hydroxylase)

5. Naphthalene →Moth Balls, Coal Tar

Signs & Symptoms: Jaundice Oliguria (low urine output) Convulsion

Treatment: ASA

D. Acid & Alkali:

▪Acids → causes Coagulative Necrosis

▪Alkali (Bases) → causes Liquefaction Necrosis

Treatment: Dilutional Therapy (large amount of water + milk)

Sp. Treatment for Alkali Poisoning: Vinegar; Fruit Juice

Sp. Treatment for Acid Poisoning (Ex: HCl): Antacid -can be diluted w/ H2O except w/ H2SO4 (highly exothermic)

CI:

 Gastric Lavage
 Do not Neutralize
 Emetic
 Cathartic

E. Poisons w/ Systemic Effects:

1. Hydrogen Fluoride (HF) – source: Fluorinated Water

Signs & Symptoms: Hypocalcemia

Treatment: Ca Gluconate

2. Paraquat →agriculture: Weed Killer

→ is known to accumulate slowly in the lungs by an active process & causes lung edema, alveolitis, & progressive pulmonary
fibrosis days to weeks after an acute exposure

Signs & Symptoms: Pulmonary edema, Pulmonary Fibrosis Alveolitis

MOA: (-) inhibit superoxide dismutase

3. Permanganate →Strong Oxidizing Agent

→ can cause Met Hgb

4. Phenol → “Carbolic Acid” : Joseph Lister

MOA: Protein denaturation

Signs & Symptoms:

Local: Mucosal/ Local Irritation, Redness of Skin, Corrosive

Sytemic: Seizure, Coma, Liver damage, Kidney Damage

Diagnosis: Chemical Evidence= Phenol + FeCl2 Blue violet (+)

Treatment: Castor Oil (Resinoleic Acid: cathartic)

5. Phosphorus → Luminous vomitus

→Garlic Odor

Treatment (Tx): CuSO4 (Blue Vitriol)

Types of Phosphorus

1. Red→granular; non-toxic; matches

2. Yellow/White→toxic;can be seen in pyrotechniques & fireworks

6. Picric Acid & Tannic Acid

Signs & Symptoms: Hepatic Injury

7. Cyanide→Sources: Prunus sp.

→ Bitter Almond, Peach, Apricot,Cassava Peel, Lima Beans, wild black berry, plum, cherry laurel, mountain mahogany, Silver
Cleaner

MOA: Inhibits Cytochrome Oxidase ↓O2 Consumption

Signs & Symptoms: CNS & CV disturbances; Seizure; Respiratory Depression; Death; Odor of Bitter Almonds; Cherry Red Blood

Treatment: NaNO2 (IV) Amyl Nitrite (Inhalation) Methylene Blue Sodium thiosulfate (IV)

Alternative: Dicobalt edentate (Kelocyanor®) Hydroxocobalamin →Vitamin B12

8. Carbon Monoxide → result from incomplete combustion

→secondary to smoking

→ most common cause of air pollution

MOA: CO → Hg → Carboxyhemogloginemia → 200x nonbinding capacity than Hg

Signs & Symptoms: Cherry red Color of the Blood

*Hypoxia →anoxia → death

*Psychomotor Impairment → Headache →Confusion → Tachycardia →Coma

*The Brain & the heart are the most affected organs

*Forms Carboxyhemoglobin which ca not transport oxygen

*Smoking males have a higher Carboxyhemoglobin levels

Treatment: 100% O2; Hyperbaric O2 → revives death tissue;

Artificial Air 80% helium + 20% Oxygen

Hyperbaric Oxygen Supplementation

 may be necessary intervention if no response is seen w/ 100% Oxygen supplementation in cases of poisoning w/
Carbon Monoxide & Cyanide

9. Hydrogen Sulfide → “Rotten-egg Odor”

MOA: Binds with Hemoglobin to form another abnormal form of hemoglobin which is Sulfhemoglobinemia

Signs & Symptoms: Dyspnea (difficulty of breathing)

↓O2 COnsumption

Treatment: Hyperbaric O2

F. Insecticide & Pesticides

1. Organophosphates

→ Parathion, Malathion

MOA: Binds to Acetylcholine forming a stable phosphate-ester bond →inactivation of Ache →↑ Ach (irreversible without
treatment)

Signs & Symptoms: DUMBBELSS

Treatment: Atropine – inhibit Ach

Pralidoxime – aid for the treatment

enzyme deactivation (Acetylcholinesterase)

Edrophonium→Tensilon®

 Dx of Myasthenia Gravis (Muscle weakness)

*Delayed neurotoxicity associated w/ exposure to organophosphates characterized by polyneuropathy, paralysis, & axonal
degeneration has been attributed to Inhibition of the Neuropathy target esterase

2. Carbamate - not persistent toxicant

- the clinical approach to management is similar to organophosphate poisoning

MOA: Reversibe binding to AChe

Signs & Symptoms: DUMBBELSS

Treatment:

 Atropine
 Pralidoxime

3. Rodenticides →agents to kill mice & rats

a. Coumarin derivatives

MOA: Inhibit Gamma decarboxylation of the Vitamin K dependent factors

Signs & Symptoms: Hemmorage/ Excessive Bleeding

Parameters: INR (International Normalize Ratio)

𝐼𝑁𝑅 =𝑃𝑇 𝑝𝑎𝑡𝑖𝑒𝑛𝑡

𝑃𝑇 𝑠𝑡𝑎𝑛𝑑𝑎𝑟𝑑

Treatment: Vitamin K (Phytomendaione) Fresh Frozen Plasma

b. Heparin

MOA: Direct thrombin Inhibitor

Signs & Symptoms: Hemmorage/ Excessive Bleeding

Parameters: aPIT (activated Partial Thromboplastin Time)

Treatment: Protamine Sulfate

4. Chlorinated HC Pesticides

→ DDT; Chlordane

→ known to be Neurotoxin

MOA: Inhibit the inactivation of Na channel

Signs & Symptoms: Seizure, N/V (Nausea & Vomiting), Paresthesia, Respiratory Depression CNS Stimulation (primary
toxidrome)

5. Botanical Insecticides:

- Nicotine

- Rotenone

- Pyrethrum
G. Heavy Metals

1. Arsenic → Lewisite Metal

→ for treatment of syphilis (Arsphenamine/Salvarsan/606)

→ manufacture of insecticides, glaswares

→ result to hyperkeratosis & hyperpigmentation

→ causes “black foot disease”

→proplasmic poison

→choice of professional poisoners

MOA: Coagulation of protein by binding to -SH groups

Signs & Symptoms: “Mee’s Line” (white line in the nails) Abnormal Weigh gain, Watery Diarrhea Milky/rosy complexion, Garlic
odor of breath Luminous vomitus, Alopecia Black line on gums/ bleeding gums “Raindrop” pattern of Hyperpigmentation &
Hyperkeratosis

Treatment: BAL/ Dimercaprol (+Penicillamine if severe)

2. Cadmium - Itai-itai Disease (through consumption of cadmium contaminated rice in Japan)

Sources: Anti-dandruff Shampoos, Smoke & stink bamboos, solder(metal alloys)

Signs & Symptoms: Osteomalacia, Fractures. Renal Abnormalities, Gait disturbances

Treatment: EDTA (for acute ingestion)

3. Lead → “Plumbism” (Absorption of Lead via Respiratory Tract)

→ most ubiquitos of the toxic metals

→exposure may be through air,water or food sources

→Main target: Hematopoietic system & nervous system

→Factors predispose to increased Lead absorption:

-Decreased Dietary Calcium

- Iron deficiency

- Ingestion on an empty stomach

→Pharmacokinetics:

-Lead can cross the placenta & pose a potential hazard to the fetus

-Young children have greater degree of absorption of ingested Lead than adults

-The major route of excretion of Lead is through Urine

→ *Skeletal Muscle (Bone) –is the primary repository site of inorganic lead in the body of an adult

Sources: Canned goods, Automobile exhaust, wine glasses, Old pipes, Cables, Paints

MOA: Inhibits cytochrome, Inhibiys heme synthesis ↓O2 Consumption

Signs & Symptoms: Pb encephalopathy Hemolytic Anemia Abdomical Colic Elevated Liver Enzymes Pb palsy ( wrist/foot drop
)Milky vomitus Black stools Fanconi-like syndrome ( proteinuria- hematuria)

Treatment: Penicillamine, BAL, EDTA

4. Mercury aka. Quicksilver

→ Messenger of the Gods

→Minimata Disease (mercury poisoning)

through consumption of fish & shellfish

MOA: Coagulation of protein by binding to -SH groups

Signs & Symptoms: Acrodinia (photophobia, anorexia, restlessness, stomatitis, oliguria, severe diarrhea, pains in arms & legs,
pink palms & toes) Gingivitis (hyperplasia) Erethism (behavioral pattern characterized by change in mood)

Treatment:

 Na Formaldehyde Sulfoximate (Antidote of Choice)

 BAL (for high level of exposure)
 Penicillamine (for low level of exposure)
  Chelation w/ Unithiol may diminish nephrotoxicity thay may result from acute exposure to inorganic Mercury

*Unithiol - Dimercaptopropanesulfonic acid

Three types of Mercury:

a. Elemental Mercury: Thermometer, Sphymomanometer

b. Inorganic Mercury: Hg2Cl2 Calomel HgCl2 Corrosive Sublimate

c. Organic Mercury: Thimerosal–old(Methiolate®) Benzalkonium Chloride new(Methiolate®) Methymercury a highly toxic

form of Hg causes Minimata dis.

5. Iron → for hemoglobin & myoglobin production

→*Chronic excessive exposure to the metal can lead to deposition in various organs & tissues causing the development of
conditions such as secondary DM, restrictive cardiomyopathy, & hepatic failure; Hemachromatosis

→*Hemorrhagic gastroenteritis –is the most consistent manifestation of acute overdose of Iron in Children

→cause of toxicity: Overingestion of OTC preparations

*Lethal Dose: 200 300mg/kg

*Toxic Dose: >600mg/kg

Phases of toxicity:

I. -nausea, vomiting, diarrhea, GI bleeding, hypotension

II. -clinical improvement seen 6 24 hours postingestion
III. -metabolic acidosis, renal & hepatic failure, sepsis, pulmonary edema & death

Treatment: Deferoxamine/Deferoxime (Antidote of Choice)

6. Thallium

MOA: Binf to -SH group

Signs & Symptoms: Gastroenteritis Paresthesia (numbness) Alopecia

Treatment: Prussian blue/ Ferric Ferrocyanide

H. Drugs of Abuse

1. Opioids → from Papaver Somniferum (opium poppy)

Natural: Opium, Morphine(pure agonist)

Semi-Synthetic: Heroin (Diacetylmrphine) Codeine (Methylmorphine)

Synthetic: Methadone & Meperidine

MOA: All bind to opioid receptors - Mu, Kappa, Delta

Signs & Symptoms: Triad: Coma Miosis(pinpoint pupil) Respiratoy depression Meperidine: + Seizure

Treatment: Naloxone (pure Antagonist), Naltrexone, nalorphine, Nalmefen

→ competitive opioid antagonist but may precipitate withdrawal symptoms in an addict patient Activated Charcoal can limit
further GI absorption

2. Amphetamine

→ β-phenyllisopropylamine / α-methylphenylethylamine

→alternative for ADHD

→ Sympathomimetic agent

→ used in HPN, Arrhythmias, seizures, CNS stimulation

MOA: Increases Dopamine Activity in the brain

Treatment:

Seizures: Diazepan, Phenytoin

Psychosis/Agitation: Chlorpromazene, haloperidol, Diazepam

Hypertensive crisis: -blockers, -blockers

Arrhythmias: Propanolo, Lidocaine

3. Sedatives & Hypnotics

a. Benzodiazepines → +alcohol →fatal CNS & respiratory depression

MOA: potentiate neurotransmitters – GABA (inhibitory)

Signs & Symptoms: Drowsiness, Ataxia, Confusion

Treatment: Flumazenil (Mazicon®) →reverses benzodiazepine effect in the CNS

b. Barbiturrates → enzyme Inducer

→used in induction of anesthesia & for seizures

Signs & Symptoms: Mild: Slurred Speech

Ataxia

Altered mental status

Severe: Comatose with absence of deep tendon reflexes, Cheyne-Stokes (irregular) respiration

Treatment: Force Alkaline dieresis (NaHCO3) Hemodialysis

c. Chloral hydrate → Mickey Finn®

→invivo via alcohol dehydrogenase→ Trichloroethanol

→”Knock-out drops”, similar to barbiturates

Treatment: Supportive

4. Hallucinogens →are substances that alter sensory processing in the brain, causing depersonalization, perceptual
disturbances, & changes in thought processing

a. LSD → Lysegic Acid Diethylamide

→ergot derivatives

MOA: Stimulates serotogenic receptors, Increase levels of 5-HT5

Signs & Symptoms: Increase suicidal tendency Altered mental status

Treatment: Benzodiazepine (for seizure)

b. Mescaline → peyote cactus (Lophophora williamsii), “buttons”

→ related to Amphetamine

→ is one of the first phenylakylamine hallucinogen identifiesd

c. Amphetamine derivatives

*Ecstacy (MDMA, Methylenedioxymethamphetamine)

”E”,”adam”, “ XTC”

structurally relative to:

-MDEA (3,4-methylenedioxyethamphetamine)

– “eve” -MDA (Methyldioxyamphetamine) –“Love drug”

MOA: Acting like false neurotransmitters (act like catecholamines)

Toxic dose: 50-150 mg

Signs & Symptoms: Hypotension; Cardica arrest → Death

Treatment: Force Diurestic (NH4Cl- acidifier) Labetalol, Nitroprusside, Nifedipine for HPN

*Methamphetamine →more substantial than amphetamine

→crystal form

→”Crack”, “Speed”, “Yaba”, “Go”, “Ice”, “Siopao”, “Ubas”, “Batak”, “Bato-Bato”, “Poor Man’s Cocaine”

*Ephedrine Ma huang

*Khat →“quat”, “qat”

→from Catha edulis shrub

-Cathinone→ active ingredient in fresh leaves of Khat

→ (benzylketamphetamine)
 -Cathine →active ingredient when cathinoneis degraded as the leaves age, which explains why dried Khat is neither
popular nor widely distributed.

-Methcathinone - methyl derivatives of cathinone

→chemicall synthesized from Ephedrine

→ aka “Ephedrone”

→ Street names: “Cat”, “Jeff”

5. Phencyclidine (PCP) poisoning- aka “Angel Dust”, snort, super grass

→ similar to a dissociative anesthetic, Ketamine

Signs & Symptoms: Nystagmus (difficult to rotate your eyeballs) Decrease consciousness Acute brain syndrome (disorientation,
psychosis, coma)

Treatment: Benzodiazepine, Diazepam (for seizure) Ntroprusside (for HPN)

6. Dimethyltryptamine (DMT) →a short acting hallucinogen found in the seeds of Piptadenia peregrine.

7. Marijuana → Cannabis sativum

→ aka Mary Jane, Hash-ish, Hash-oil, Weeds

→used a antiemetic for patient undergoing chemotherapy

A.I.: -9-tetrahydrocannabinol (THC)

8. Cocaine →Erythroxylon coca, “crack” “freebase” (purified)

MOA: Increase Dopamine activity

Treatment: Seizures: Benzodiazepine

Psychosis: Neuroleptics HPN: Labetalol

9. Alcohol (Ethanol)

→ CNS depressant

→grain alcohol, neutral spirit

→responsible for major medical & socio-economic problems

Acute Alcoholism (Enzyme Inhibitor)

Chronic Alcoholism (Enzyme Inducer)

Metabolites: Acetaldehyde, Acetic Acid

Signs & Symptoms: CNS depression, Acid-base Imbalance, Metabolic Acidosis, Impaired Thermal Regulation, Hypoglycemia
Treatment: Thiamine (prevention of Wernicke-Korsakoff Syndrome) Disulfiram (Antabuse®, used to stop alcohol addiction
Fomepizole

10. Nicotine →Enzyme Inducer

→active ingredient of tobacco for the addictive effect

Lethal Dose -Child: 1.5 – 2 mg/kg

-Adult: 40 – 6- mg

Minimum fatal dose of Nicotine: 40 mg = 2 sticks ofCigar.

Acute Nicotine Toxicity: Hypertension Cardiac Arrythmia

Management: -Anticonvulsant (involves Benzodiazepine) -Epinephrine & Neostigmine are both avoided

Treatment: Activated Charcoal Gastric Lavage Mecamylamine (Inversine®)

11. Strychnine → abused by athletes before

Scientific Name: Strychnos nux vomica

Signs & Symptoms: Rigor mortis, Convulsion

Treatment: Diazepam Phenobarbital Neuromuscular Blockers Skeletal Muscle Relxant

12. Volatile Substances

a. Toluene
→Methy benzene

→ “Glue Sniffers”

b. Nitrous Oxide

→ Anesthetic

→ “laughing gas”

→ may cause diffusional hypoxia

→ Hysterical laughing

→ blue container in hospital

Treatment: Ventilation Support, 100% oxygen

Drugs can be used to treat Heroin Addicts:

1. Methadone reduce the craving of heroin

2. Naltrexone blocks the effect of heroin

3. Levo- -acetyl methodol (LAAM) synthetic opioid, block the effect of heroin for up to 72 hours w/ minimal side effects when
taken orally.

4. Buprenone also used as a treatment of heroin addiction since it does not produce the same level of physical dependence as
other opioids.

I. Clinical Toxicology

1. Salicylates

Signs & Symptoms:

Mild: Tinnitus

Severe: Lethargy, Convulsions, coma, Metabolic Acidosis

Treatment:

Urine Alkalinization with NaHCO3

Vitamin K1/ fresh frozen plasma (for bleeding)

Hemodialysis or Hemoperfusion (100mg/dL)

2. Paracetamol / Acetaminophen

*Above 150-200 mg/L - minimum serum Acetaminohen level (indicate a high risk for liver injury)

MOA: Depletion of Glutathione causing Hepatic necrosis due to its toxic metabolite, NAPQI

Phases of toxicity:

I. anorexia, diaphoresis
II. asymptomatic
III. abdominal pain, hepatic failure, coma, death

Treatment: N-Acetylcystein (NAC, mucolytic) –PO -acts as a precursor for glutathione

3. Warfarin

MOA: Inhibition of Vitmain K-related clotting factors (II, VII, IX)

Principal Manifestation: Bleeding

Treatment: Vitamin K

4. Heparin

Principal Manifestation: Bleeding

Treatment: Protamine Sulfate (acts as the base to neutralize heparin activity) *1mg Protamine = 100IU Heparin

5. Chloramphenicol

Gray Baby Syndrome: GI disturbance, vomiting, anorexia, abdominal distention, diarrhea, hypothermia, hypotension, &
cyanosis
 Treatment: Charcoal Hemoperfusion

6. Vancomycin → Red Man or Red Neck Syndrome

Prevention: Prolonging the infusion to 1-2 hours or increasing the dosing interval

7. Digoxin

Signs & Symptoms:

Mild: Nausea, vomiting, anorexia, confucion

Severe: Cardiac dysrhythmias

Treatment:

 Lidocaine or Phenytoin
 Digoxin-specific Fab antibodies (DIgibind)
 Potassium Chloride

8. Muscle Relaxants

*Succinylcholine & Tubocurarine

Malignant Hyperthermia: Succinylcholine Histamine Release (Anaphylactic shock): Tubocurarine

Treatment:

 Ephinephrine (DOC for Anaphylactic shock)

 Dantrolene (DOC for Malignant hyperthermia)
 Neostigmine/ Pyridostigmine

9. Methyxanthines

*Theophylline

Signs & Symptoms: Seizures, Cardiac Dysrhythmias

Treatment: Ipecac Syrup, Activated Charcoal, WBI, Hemoperfusion & Hemodialysis; consider blockers for manifestations

10. Lithium → DOC for mania & bipolar disorders

Signs & Symptoms:

Mild: polyuria, blurred vision, weakness, slurred speech, Ataxia, tremor & myoclonic jerks

Severe: delirium, coma, seizures & hyperthermia

Treatment: Ipecac Syrup, NA polysterene sulfonate, WBI (SR products), hemodialysis (rebound effects)

11. Tricyclic Antidepressants (TCAs)

Signs & Symptoms:

 Anticholinergic signs & symptoms

 Cardiopulmonary toxicity
 CNS manifestations

Treatment:

Physostigmine: DOC for Anticholinergic signs & symptoms

NaHCO3: DOC for Cardiopulmonary toxicity

Phenytoin &/or Benzodiazepine: DOC for CNS manifestations

12. Isoniazid (INH)

Signs & Symptoms: Peripheral Neuropathy; Hepatitis

Management:

-Pyridoxine is given at a dose of 1mg per mg of Isoniazid

-Activated Charcoal can limit further absorption of the drug form in the GIT

- Benzodiazepine are used to control seizures

Treatment: Vitamin B6
13. Beta-Blockers

Signs & Symptoms: Hypotension, Bradycardia, AV block Bronchospasm (non-cardioselective agents)

Treatment: Glucagon Epinephrine (w/ caution)

14. Calcium-Channel Blockers

Principal Manifestation: Hypotension

Treatment: Calcium Chloride IVP Glucagon

15. Potassium

Signs & Symptoms: Cardiac Irritability; Dysrhythmia; Peripheral Weakness

Treatment:

▪Calcium Chloride (antagonize the cardiac effects of hyperkalemia)

▪NaHCO3, Glucose, Insulin ( for intracellular shift of K

▪Cation exchange resin: SPS,Sodium polystyrene Sulfonate (exchange K with Na)

▪Hemodialysis: Last Measure

End ………..