Course Code: PHA 060L

Laboratory Activity Sheet #3

Lesson title: General Management of

Materials: Poisoning
LAS answer sheet, internet connection, Lecture SAS 3
Lesson Objectives: by the end of this activity,
you should be able to … References:
1. Determine different management of poisoning based on the different patient • Pillay,
V.V. (2013). Modern medical toxicology. New case. Delhi:Jaypee Brothers Medical Publishers.

PRE-LABORATORY INTRODUCTION

Poisoning is contact with a substance that results in toxicity. Symptoms vary, but certain common syndromes may
suggest particular classes of poisons. Diagnosis is primarily clinical, but for some poisonings, blood and urine tests can
help. Treatment is supportive for most poisonings; specific antidotes are necessary for a few. Prevention includes labeling
drug containers clearly and keeping poisons out of the reach of children.

The process in Management of Poisoning follows the following:

• Stabilization
• Evaluation
• Decontamination
• Poison Elimination
• Antidote administration
• Nursing and Psychiatric Care

Stabilization
The initial survey should always be directed at the assessment and correction of life-threatening problems, if
present. Attention must be paid to the airway, breathing, circulation, and depression of the CNS (the ABCD of resuscitation).

Airway, breathing, and circulation must be maintained in patients suspected of a systemic poisoning.

Patients without a pulse or blood pressure require emergency cardiopulmonary resuscitation.

If patients have apnea or compromised airways an endotracheal tube should be inserted. If patients have respiratory
depression or hypoxia, supplemental oxygen or mechanical ventilation should be provided as needed.

Medications such as intravenous naloxone, dextrose, and thiamine can be used to stabilized the patient.

Evaluation
If the patient is not in crisis, i.e. he is alert with normal speech and pulse, proceed to a complete, thorough, and
systematic examination. As far as treatment is concerned, the emphasis should be on basic supportive measures.

A detailed and thorough clinical examination should be made with special reference to the detection and treatment
of any of the following abnormalities:

• Hypothermia:

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Some common drugs which produce hypothermia are: Alcohol, Antidepressants, Barbiturates, Carbon monoxide,
Hypoglycemics, Opiates, Phenothiazines, and Sedative-hypnotics. It is essential to use a low reading rectal
thermometer. Electronic thermometers with flexible probes are best which can also be used to record the
esophageal and bladder temperatures.

• Hyperthermia
Oral temperature above 102°F is referred to as hyperthermia. If it exceeds 106°F (which is very rare), there is
imminent danger of encephalopathy. In a few individuals there is a genetic susceptibility to hyperthermia, especially
on exposure to skeletal muscle relaxants, inhalation anesthetics, and even local anesthetics— malignant
hyperthermia. This should be distinguished from neuroleptic malignant syndrome, which is also characterized by
high fever apart from other neurological signs, but is the result of adverse reaction to antipsychotic or neuroleptic
drugs, and has no genetic basis. Table 3.7 lists some of the important toxicological causes of hyperthermia along
with postulated mechanism. Complications include coagulopathy, rhabdomyolysis, renal failure, and
tachyarrhythmias

TABLE

• Acid-Base Disorders
Serum electrolytes to evaluate for metabolic acidosis should be obtained if there is any possibility of mixed ingestion
or uncertain history. The diagnosis of these acid-base disorders is based on arterial blood gas, pH, PaCO2,
bicarbonate, and serum electrolyte disturbances. It must be first determined as to which abnormalities are primary
and which are compensatory, based on the pH. If the pH is less than 7.40, respiratory or metabolic alkalosis is
primary. In the case of metabolic acidosis, it is necessary to calculate the anion gap. The anion gap is calculated
as follows: (Na+ + K+)–(HCO3- + Cl-)

Normally this translates as

140–(24 + 104) = 12 mmol/L (Range: 12 to 16 mmol/L) TABLE

If the anion gap is greater than 20 mmol/L, a metabolic

acidosis is present regardless of the pH or serum
bicarbonate concentration.

• Convulsions (Seizures)
There are several drugs and poisons which cause
convulsions (Table 3.10). Improper treatment or
mismanagement can lead to status epilepticus which is a
life-threatening condition.

• Agitation
Several drugs and poisons are associated with increased aggression which may sometimes progress to psychosis
and violent behavior. This is especially likely if there are other predisposing factors such as existing mental disorder,
hypoglycemia, hypoxia, head injury, and even anemia and vitamin deficiencies. Delirium is the term which is often
used to denote such acute psychotic episodes, and is characterized by disorientation, irrational fears,
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Laboratory Activity Sheet #3

hyperexcitability, hallucinations, and violence. Dementia refers to a more gradual decline in mental processes
mainly resulting in confusion and memory loss, and though it is often organic in nature due to degenerative diseases,
there are some drugs which can cause this especially on chronic exposure. Elderly patients are more vulnerable.
Dementia due to drugs is usually reversible.

• Movement Disorder
Exposure to several drugs and toxins can result in a wide variety of movement disorders ranging from full blown
Parkinson’s disease to isolated tremors. The most frequent culprits for parkinsonian manifestations are
phenothiazines and major tranquillizers, though there are several others which have also been implicated.
Most of the movement disorders induced by toxins or drugs are dose and duration related. Withdrawal of the
incriminating agent commonly results in recovery. The usual measures undertaken in the management of the
respective drug overdose (or abuse) must be instituted wherever applicable.

• Electrolyte disturbances
1. Hyperkalemia (potassium level more than 5.5 mEq/L)
The causes include digitalis, beta-2 antagonists, potassium sparing diuretics, NSAIDs, fluoride, heparin,
succinylcholine, and drugs producing acidosis.
Treatment: Glucose, insulin infusion, sodium bicarbonate, and calcium gluconate. Haemodialysis and exchange
resins may be required.

2. Hypokalemia (potassium level less than 3.5 mEq/L)

The causes include beta2 agonists, theophylline, insulin, chloroquine, caffeine, dextrose, loop diuretics, thiazide
diuretics, oral hypoglycemics, salicylates, sympathomimetics, drug-induced gastroenteritis, and metabolic
acidosis.
Treatment: Oral or IV potassium

3. Hypernatremia (sodium level more than 150 mEq/L)

The causes include colchicine, lithium, propoxyphene, rifampicin, phenytoin, alcohol, mannitol, sorbitol, sodium
salts, excessive water loss, IV saline solutions, and salt emetics.
Treatment: Water restriction with or without loop diuretics.

4. Hyponatremia (sodium level less than 130 mEq/L)

The causes include carbamazepine, chlorpropamide, NSAIDs, amitryptiline, biguanides, sulfonylureas,
captopril and other ACE inhibitors, lithium, imipramine, oxytocin, and excessive water intake. Treatment:
Hypertonic saline.

5. Hypocalcemia (calcium level less than 4 mEq/L)

The causes include hydrogen fluoride, oxalates, aminoglycosides, ethanol, phenobarbitone, phenytoin,
theophylline, and ethylene glycol.
Treatment: Calcium gluconate IV (10% solution, 10 ml at a time, slowly).

NOTE: Drug-induced hypercalcemia is uncommon.

Decontamination
This is with reference to skin/eye decontamination, gut evacuation and administration of activated charcoal. (see lecture
SAS 3 for references)

Poison Elimination
Depending on the situation, this can be accomplished by diuresis, peritoneal dialysis, haemodialysis, haemoperfusion, etc.
(see lecture SAS 5 for references)

Antidote Administration
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Unfortunately, antidotes are available for less than 5% of poisonings. (will be further discussed on topics in lecture)

Nursing And Psychiatric Care

General nursing care is especially important in comatose patients and those who have been incapacitated by the poison.
Since some cases of poisoning leave behind persisting sequelae, adequate follow-up for a period of time may be necessary.
Psychiatric intervention is frequently essential in suicidal overdose.

GUIDE QUESTIONS:
1. Give the dose and purpose of the intravenous naloxone, intravenous dextrose, Thiamine and IV fluids during the
stabilization of patients.
a. Intravenous Naloxone:
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b. Intravenous dextrose
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c. Thiamine
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d. IV fluids
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Laboratory Activity Sheet #3

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2. What first aid treatment should be done for respiratory insufficiency?

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3. What is the drug of choice for patients with metabolic acidosis?

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4. What are the two common extracorporeal techniques antidotes? When should these techniques used on patient?
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5. Your classmate was so determined to pass toxicology subject. He ingested 15 cups of coffee because he was
afraid, he will fail if he can’t finish studying the lesson and fall asleep. After your last subject today, you invited him
to go to Starbucks and study for your toxicology exam for the next day. During your review, he was consuming
chocolates. At 3am when you are about to go home, your classmate says that everything is moving very “fast.” He
also felt headache and fever so he decided to take 1 tablet of Rexidol® and another tablet after 4 hours. He has
had no vomiting or diarrhea but you decided to accompany him to the ER as he can’t tolerate the muscle rigidity
all over his body and trembling on his both hands. He had a seizure en route.

PMH: None.

Physical Examination:
T: 104 °F HR: 134 bpm RR: 18 breaths per minute BP: 142/96 mm Hg
General: Alert, but agitated male who is actively pacing around the room.
HEENT: Normocephalic, pupils dilated bilaterally.
Pulmonary: Clear to auscultation.
CV: Regular rate and rhythm.
Neurologic: No focal deficits.
Skin: Diaphoretic

• What management of Caffeine Poisoning should be applied on the above-mentioned case?

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 Course Code: PHA 060L
Laboratory Activity Sheet #3

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This document is the property of PHINMA EDUCATION