Poisoning & Overdose

By
Dr Rephaim T. Mpofu

Department of Family Medicine

 Presentation Roadmap
●
Introduction
●
Definitions
●
Epidemiology
●
How to approach the Poisoned Patient
– History & Examination
– Investigation
– Management
●
Specific poisons
●
Complications
●
Call a friend
 Introduction
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Acute poisoning is a cause of both morbidity and mortality
in many parts of the world
●
The toxic agents associated vary from place to place, and
over time, due to the availability and use of various
chemicals and other poisoning agents.
●
Multiple drug ingestion is common
●
The majority of patients will have taken a non life
threatening dose and will only require supportive care and
a psychosocial assessment,
●
However there is the potential for significant morbidity and
mortality to occur. It is important to perform a full risk
assessment of all poisoned patients.
 Definitions
●
Parasuicide - any non-fatal, self-injurious behaviour
with a clear intent to cause bodily harm or death.
– Thus parasuicide includes both lethal suicide
attempts and more habitual or low-lethality
behaviours such as cutting or other self-mutilation
●
Suicide – fatal, wilful, self inflicted life threatening act
without apparent desire to live.
– Lethality and intent must both be present
●
Poisoning - occurs when any substance interferes
with normal body functions after it is swallowed,
inhaled, injected, or absorbed.
 Epidemiology
●
In many parts of the world, acute Poisoning is
one of the most common reasons for acute
admission to a medical ward
●
In South Africa, reports suggest that acute
poisoning is responsible for up to 17% of total
ward admissions in children
●
Children under 10 years of age statistically
account for 80% of all victims of poisoning, and
the large majority of these are accidental
 Epidemiology
●
In other developing nations with poor
resources, acute poisoning is also a cause for
concern
●
A study conducted in Bangladesh demonstrated
that 14% of deaths among 10-50 year old
females were due to poisoning, the majority
being intentional
Sub-Saharan Africa Statistics
 Epidemiology
●
A systematic review of recent studies of
poisoning and overdose in developing countries
found that:
– Poisoning is a common form of self harm in developing
countries
– In rural areas, pesticide use is more common, however
medicine or household product use (corrosives included) are
more common in urban areas
– Whilst anti-TB medication overdose was largely reported, it
did not have a high mortality rate
– Traditional medicines accounted for 16% of admissions, and
had a mortality rate of 15%, however none of them were due
to deliberate self-harm (50% of these cases were children
under 10 years of age)
 Epidemiology
– Household products were found to play a large role
in the epidemiology of poisoning, and mortality was
largely related to respiratory complications such as
aspiration. Kerosene products were the most
prevalent, followed by rodenticides
– CNS-acting medication were found to be the most
common drug to use for self harm, e.g.
benzodiazepines, barbiturates, antidepressants
– Other medication used commonly include
analgesics (paracetamol, salicylates), chloroquine
(especially malaria prevalent regions), and
anticonvulsants
 Epidemiology in South Africa
●
A profile of acute poisoning at Selected
Hospitals in SA (2005) by N Malangu & GA
Ogunbanjo found:
– Median age of admitted patients: 17.6 years
– Gender: 58% females, 42% males
– 90% black Africans (?sample collection bias)
– 59% of admissions were accidental
 Epidemiology in South Africa
– Order of involved agents in descending order:
●
Household chemicals: (46%)
●
Modern medicines (18%)
●
Animal/insect bites (16%)
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Agrochemicals (10%)
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Food poisoning (5.4%)
●
Drugs of abuse (3.3%)
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Traditional Medicines (2.4%)
●
Plants (0.2%)
 How to approach the poisoned
patient?
●
Don’t panic!
●
History:
– Take as good a History as you can – Most patient's will
still be able to give a decent history. Collateral history
can also be obtained
– Look for circumstantial evidence, e.g. open bottles,
missing medication, suicide letter, etc.
– If present, attempt to identify the medication, ask for
assistance if necessary
– Risk of adverse effect is determined by lethality and
dose of the drug. Important questions: Agent, dose,
Time since ingestion, Current clinical features, Patient
factors
 History
●
Previous psychiatric History – Including
previous attempts of self-harm
●
Concomitant medical conditions
●
Family history – Gives a clue of other
medication lying around in the house
●
Social/Individual History – Glean as much
information as possible without impacting
negatively on management
 Examination
●
ABCD – Fast, primary survey to assess whether intervention is
necessary
●
Observe patient and personal safety: Remove patient from the
source of poison if applicable
– Wash skin with running water for at least 20 minutes if skin contact
occurred
●
Level of consciousness – Glasgow Coma Scale or AVPU scale
can be used to assess consciousness
●
Vital signs: Pulse, Respiratory rate, Temperature, Blood
pressure, HGT
●
Pupil size and reaction to light
●
Exclude a possible head injury that might complicate
presentation
●
Use all your senses available to you, e.g. smell of alcohol
Toxidromes - Anticholinergic
Toxidromes – Cholinergic
 Management
●
Primary, “Emergency” Management – Support
vital functions
●
Maintenance Management – Long term
management
 Primary Management - Airway
●
A – Establish and maintain a clear airway
– Severe toxicity usually involves loss of protective
reflexes
– Anticipate vomiting: Have equipment
available/protect airway/position patient
appropriately
 Primary Management - Breathing
●
B – Ensure adequate ventilation and oxygenation
– Oxygenation and ventilation may need to be maintained
artificially if ventilatory failure occurs
– Possible causes of respiratory failure:
●
Muscle paralysis - botulinism, tetanus, neuromuscular
blockers, organophosphates, etc.
●
Central nervous depression – organophosphates,
alcohol, benzodiazepines, opioids, TCA
●
Mechanical obstruction – Vomitus, other foreign bodies
●
Pulmonary oedema – salicylates, opiates,
organophosphates, ethylene glycol, organ failure
●
Hypoxia – methyl alcohol, carbon monoxide, V/Q
mismatch
 Primary Management - Circulation
●
C – Support the circulation
– Arrhythmias may be present and require treatment
– Tachycardias – sympathomimetics, amphetamines,
antidepressants, Fever, Anaemia, hypovolaemia,
Cardiogenic insufficiency
– Hypotension – antihypertensives, fluid loss or vasodilation
(caffeine, B2-agonists, nitrites)
– Hypertension – sympathomimetics, amphetamines,
hyperthermia (endogenous or exogenous)
– Temperature abnormalities – altered BMR, amphetamines,
environment
–
 Primary Management – Glucose
●
Don’t Ever Forget Glucose!
– Hyperglycaemia - salbutamol, salicylates, theophylline, infection
– Hypoglycaemia - Alcohol, anti-DM, insulin, Liver failure
 How to get rid of the toxin?
1) Reduction of poison absorption
2) Increasing poison elimination
3) Antidotes
 Reduction of Poison absorption
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Remove patient from toxin exposure
●
Decontaminate skin with soap and running
water
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Gut decontamination
– Gastric lavage
– Ipecachuanha
– Single dose activated charcoal
– Cathartics – emesis inducing drug
– Whole bowel irrigation
 Gastric Lavage
●
Technique:
1. Prepare equipment, including measuring tube length
2. Position patient in Left decubitus position, head 20º
downwards
3. Lubricate tube and pass it down the oesophagus
4. Confirm tube position
5. Administer 200ml of tap water into the stomach, aspirate,
decant, and repeat
●
Contraindications: a) Lack of airway protection, b) Small
children, c) Corrosive ingestion
●
Not routinely recommended according to recent
guidelines
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Beware of electrolyte disturbances
 Activated Charcoal
●
Definition: a form of carbon processed to have small,
low-volume pores that increase the surface area
available for adsorption or chemical reactions
●
Can be used as a Single or multi dose
●
Dose: 1g/kg body weight (usually 50g given)
– Note: no maximum dosage, although larger doses may
increase risk of vomiting & aspiration
 Activated Charcoal
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Good drugs: aspirin, carbamazepine, digoxin,
barbiturates, phenytoin, paracetamol
●
Bad drugs: petroleum products, strong acids, alkalis,
ethanol, ethylene glycol, iron, lithium, mercury,
methanol,
●
Greatest effect of single dose administration is within 1
hour. Should not be routine
●
Absolute contraindication: Corrosive substances
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Do not give if airway is not protected
McDonald’s Activated
Charcoal burger

Look good?
 Decreased Drug absorption
●
Cathartics – Sole administration of a cathartic,
e.g. sorbitol, magnesium citrate, has no role in
Mx of the poisoned patient
– May be used in conjunction with activated charcoal,
but evidence is lacking
●
Whole bowel irrigation – Introduce 1500-
2000ml/h PGE in an adult
– Not recommended for routine use as there is poor
evidence
 Increasing poison elimination
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Urine alkalinazation
– Increase drug elimination by alkalinizing urine
– Practically used in the event of salicylate or chlorophenoxy
poisoning
– Urine PH is increased to approx. 7.5 with IV HCO3 to
achieve effect
●
Multiple dose activated charcoal
– Studies demonstrate that it increases elimination
significantly, however it has not been shown to reduce M&M
significantly
– Regimen: 50-100g initially, followed by 50g 4 hourly or 25g 2
hourly until charcoal appears in faeces or recovery occurs
 Increasing Poison elimination
●
Dialysis
– Used in acute renal failure, or in the presence of life
threatening amounts of toxin
– Not used routinely
– Not useful in drugs with a large volume of distribution, e.g.
TCA
 Antidotes
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Anticoagulants – Vitamin K
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Benzodiazepines – Flumazenil
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B-blockers – Atropine
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Carbon Monoxide – Oxygen
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Digoxin – Digoxin-specific antibody fragments
●
Ethylene glycol – Ethanol/fomepizole
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Iron Salts – Desferrioxamine
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Opioids – Naloxone
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Organophosphates – Atropine
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Paracetamol – N-acetylcysteine
 Investigation
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Full blood Count
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Renal Function tests
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Liver function Tests
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Urine Toxicology
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Arterial blood gas
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Electrocardiogram
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Chest X-ray
 Toxicology Level testing
●
Agents where emergency measurement of
blood concentrations is appropriate:
– Aspirin (salicylate)
– Digoxin
– Ethanol
– Ethylene glycol
– Iron
– Lithium
– Methanol
– Paracetamol
– Theophylline
– Antiepileptic agents (carbamazepine, epilim, phenytoin)
Urine Toxicology Testing
Arterial Blood Gas
 Anion Gap
●
The anion gap is the difference between primary
measured cations (sodium Na+ and potassium K+)
and the primary measured anions (chloride Cl- and
bicarbonate HCO3-) in serum.
●
This test is most commonly performed in patients who
present with altered mental status, unknown
exposures, acute renal failure, and acute illnesses.
●
Ag. Gap = ([Na+] + [K+]) − ([Cl-] + [HCO3−])
●
Reference range – 3-11 mEq/l
●
Poisoning with most medications will have an
increased anion gap
 Electrocardiogram
●
ECG is a rapidly available clinical tool that can
help clinicians manage poisoned patients.
●
Specific myocardial effects of cardiotoxic drugs
have well-described ECG manifestations that
can aid in the diagnosis and management of
such patients (an understanding of ECG
interpretation and characteristics of
cardiotoxicity will guide you greatly)
 Electrocardiogram
●
Common ECG findings:
– Tachycardia/Bradycardia
– Right axis deviation
– Prolonged PR/QT intervals
– Widened QRS intervals
– Heart block due to AV node conduction delays
– ST Elevation/depression
– T wave abnormalities
 Specific Poisons
●
Too many for this presentation!
●
Specific mention:
– Aspirin
– Paracetamol
– Paraffin
– Rodenticides
 Aspirin
●
Mortality risk increases significantly after 10g salicylate
●
Aspirin metabolism stimulates the respiratory centre →
respiratory alkalosis → compensation → metabolic
acidosis
●
They also affect Krebs cycle and increase acidosis
●
Management:
– Glucose
– Activated charcoal
– Vitamin K – overdose has a similar effect to warfarin
– Increase pH to 7.4 with sodium bicarbonate
– Urine alkalinization
– Haemodialysis if initial management fails
 Paracetamol
●
Most common form of
overdose in UK
●
NAPQI - metabolite
that accumulates
once glutathione
stores are depleted
Paracetamol Normogram
 Petroleum Products (Paraffin)
●
Poor systemic absorption but high risk of chemical
pneumonitis in the event of aspiration
●
Features usually appear within hours but may take
days to develop:
– Dyspnoea and Tachypnoea
– Fever
– Crepitations
– Rhonchi
– Signs of pulmonary oedema
●
N.B. Milk and activated charcoal are contraindicated
Chemical Pneumonitis
Rodenticides
 Rodenticides
●
Three common mechanisms of action:
– Anticoagulation – vitamin K epoxide inhibition
– Metal phosphides – toxic phosphine gas
– Hypercalcaemia –
hypervitaminosis/hyperphosphataemia
●
Management:
– CMP, Clotting profile, Vitamin K levels
– Give Vitamin K (may require extended Rx if on
superwarfarin)
– Activated Charcoal
 Maintenance Management
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Inpatient vs. Outpatient Management
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Continued supportive care
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Suicide Risk assessment
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Psychological Intervention
Suicide Risk Assessment
 How to Call a friend
●
Poison Information Centre
– Tygerberg Hospital – (021) 931-6129
– Red Cross Children's Hospital – (021) 689-5227
– Universitas Hospital – (082) 491-0160
– Www.sun.ac.za/poisoncentre
●
Afritox
 References
●
Available upon request