Pharmacotherapy: Acid Poisoning

Contributed by: Dr. B. N. Karelia and Dr. B. R. Kanabar Dept. of Pharmacology, PDU Medical College, Rajkot, INDIA.

Caution!
STRICTLY FOR THE USE OF MEDICAL STUDENTS AND QUALIFIED MEDICAL DOCTORS IN INDIA Medicine is an ever-changing science. Contents on these pages have been compiled from the sources that the contributor(s) consider reliable and up-to-date. The write-ups are primarily meant for improving understanding of use of drugs for therapeutic purpose by the Under-graduate Medical Students. It is hoped that it would be useful for General Practitioners and Medical Officers also. Clinical features, diagnosis and nonpharmacological management are either not included or are described in very brief. Treating physicians should use the information, recommendations and opinions presented here with application their own clinical judgment and on their own risk. GENERAL PUBLIC READING THIS MATERIAL IS WARNED AGAINST SELF MEDICATION BASED ON THESE CONTENTS. The contributors or the website cannot be held responsible for any loss or damage of any kind, resulting from the use of the information on these pages.

Contents:

1. 2. 3. 4. 5. 6.

About the Disease Treatment objectives Drug options Evaluation of drugs Recommendations References

1. About the Disease

Etiology: Suicidal Homicidal Accidental Commonly used acids are Salfuric acid Hydrochloric acid Poisoning can occur by: - Inhalation - Eye or dermal exposure - Ingestion Clinical Presentation: A. Inhalation Upper respiratory tract injury Stridor Hoarseness

Wheezing Non cardiogenic pulmonary edema

B. Eye or dermal exposure Pain and redness followed by blistering Conjunctivitis Lacrimation Various degree of burns Blindness C. Ingestion Oral pain Dysphagia Drooling Pain in throat, chest or abdomen Esophageal or gastric perforation Sign of peritoneal irritation or pancreatitis Diagnosis:

History of exposure Clinical presentation Bring the container, substance can identified PH of the substance, vomitus, tears and saliva tested X-ray of chest show air in the mediastinum if there is esophageal perforation X-ray of abdomen show free air in abdomen if there is gastric perforation CBC Electrolytes measurement Blood glucose Arterial blood gases Endoscopy of GIT Top

2. Treatment objectives:
a. Maintain the vital functions b. Keep the concentration of poison in the tissue as low as possible by preventing absorption c. To combat the pharmacological and toxicological effects at the effector site Top

3. Drug options
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4. Evaluation of drugs
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5. Recommendations:
A. Inhalation:
Remove from the atmosphere Mouth to mouth breathing In the hospital: O2 is given Intubation, tracheostomy may be required for severe laryngeal or tracheal burns Observe for airway obstruction and pulmonary edema

B. Eye or dermal exposure: Eye exposure:

Eye should be irrigated with water or normal saline for at least 20 to 30 minutes In the hospital: Eye evaluated for corneal burns and foreign bodies Fluorescein staining of the eye for corneal ulcer Consultant ophthalmologist Topical anesthetic drops like tetracaine or proparacaine Cycloplegic eye drops Antibiotic eye drops Artificial tears Steroid eye drops?

Dermal exposure:

Remove all contaminated clothes Exposed skin should be irrigated copiously with water All solids should be removed from the skin

DO NOT:

Do NOT apply ointment, butter, ice, medications, cream, oil spray, or any household remedy to a severe burn. Do NOT breathe, blow, or cough on the burn. Do NOT disturb blistered or dead skin. Do NOT remove clothing that is stuck to the skin. Do NOT give the person anything by mouth, if there is a severe burn. Do NOT immerse a severe burn in cold water. This can cause shock. Do NOT place a pillow under the person's head if there is an airways burn. This can close the airways.

In the hospital Judge the degree of burns First-degree burns affect only the outer layer of the skin. They cause pain, redness, and swelling.

Second-degree (partial thickness) burns affect both the outer and underlying layer of skin. They cause pain, redness, swelling, and blistering. Third-degree (full thickness) burns extend into deeper tissues. They cause white or blackened, charred skin that may be numb. 1st degree burns treated by dry sterile gauze or bandage, silver sulfadiazine ointment, paracetamol or ibuprofen orally to relive pain and it heal automatically no further treatment is required, tetanus immunization. 2nd degree burns- if more than 2 to3 inches diameter treated by dry sterile gauze or bandage, topical silver sulfadiazine, analgesics, i.v. fluids, skin grafting if necessary, tetanus immunization. 3rd degree burns attend airway, i.v. fluids, dry sterile gauze or bandage, topical silver sulfadiazine, analgesic (opioids i.v. not i.m.), surgical debridement, skin grafting is must, tetanus immunization.

C. Ingestion:
Give water or milk to drink within 30 min of ingestion for neutralize acids (milk of magnesia, aluminum hydroxide gel, vegetable oil, egg white, starch solution can used) In the hospital: Gastric lavage in acute liquid corrosive ingestion and is required before endoscopy Patient should not feed orally until endoscopy has established the extent of injury nd rd 2 & 3 degree burns admitted in ICU Minor esophageal injury admitted in general medical ward st st 1 degree burns - when stable start oral liquid on the 1 day nd 2 degree burns - should not feed orally for 2 to 3 day-i.v. line Severe burns- surgically placed jejunostomy for feeding Antibiotic reserved for infection - cefotetan 1 to 2 g bid or amikacin 5mg/kg tid plus clindamycin 600 to 900mg qid (prophylactic antibiotics are not recommended) nd Steroids are indicated in 2 degree burns start with hydrocortisone sodium succinate 10 to 20 mg /kg/day within 48 hrs and change to oral prednisolone 2mg/kg/day for 3 weeks then taper the dose If systematic steroids are administered prophylactic antibiotics are given concurrently (i.v. steroids are not recommended) Stricture is treated with bougienage if they are unresponsive esophageal bypass by colonic interposition Tetanus prophylaxis Hospitalized patient should be followed after discharge for development of gastric obstruction (sign of obstruction are progressive anorexia, weight loss, nausea) Obtain follow up for secondary scarring or stricture formation 2 to 4 wks after ingestion

Intentional exposure cases require psychiatric evaluation before discharge.

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6. References:
1. Klaassen CD. Principles of Toxicology and Treatment of Poisoning. In: Hardman JG, Limbard LE, Gilman AG editors. Goodman & Gilmans The Pharmacological basis of Therapeutics. 10th ed: McGraw Hill, Medical Publishing division; p.67 2. Mullen WH. Caustic and Corrosive Agents. In: Oloson KR, Anderson LB, Benowitz NL et al editors. Poisoning & Drug overdose. 5th ed: Lange Medical books/ Mc Graw Hill; p.157 3. Caravati EM. Household Products. In: Dart RG, Caravati EM, Meguigan Ma et al editors. Medical Toxicology. 3rd ed: Lippincott Williams & Wlikins:p.1294 4. Latenser BA. Burn Treatment Guidelines. In: Rakel RE, Bope ET editors. Conns Current Therapy: Saunder Elsevier; p.1381 5. Beers MH, Porter RS, Jones TV et al editors. The Merck Manual. 18th ed. White house Station, Nj; Merck Research Laboratories Publishers;2006:2663-2664 6. Fulde GW. Emergency Medicine The Principles of Practice. 2nd ed. New Delhi: Jaypee Publishers;1992:264-265 7. Treatment of Acid Poisoning. Available from: http://www.medlineplus.com/Accessed March 16, 2010 8. Treatment of Second Degree Burns. Available from: http://www.hmc.edu/health info/b/Burns2 htm/ Acessed March 17, 2010 9. Treatment of Third Degree Burns. Available from: http://www.hmc.edu/health info/b/Burns3 htm/ Acessed March 17, 2010 Top For Communication: drugtherapy.pdu@gmail.com