General principles and management of

poisons.
By. Dr.Eze Chidi Eze
In management of patient with poison, ABC's always come first followed by the
confirmation of a toxic ingestion and specific management. The majority of poisoned
patients only require supportive therapy while others may require hospital admission
and the use of antidotes or specific measures.

The physical finding identifies "toxidrome"or toxic syndrome. The term

Toxidrome"or toxic syndrome is simply means a pattern of signs and symptoms that
suggests a specific class of poisoning and allows specific diagnosis. Toxicology
screening provides direct evidence of ingestion but rarely impacts upon initial
management. Initial management should never await results of such analysis. The
following drugs with their toxidrome includes

Opioids

Triad of respiratory depression, pinpoint pupils, decreased LOC , bradycardia,

hypotension, hypothermia

Sedative / Hypnotics

- benzodiazepines, alcohol, barbituates

altered mental status, stupor, coma, slurred speech, respiratory depression

variable pupil changes, hypotension, hypothermia, barbiturate blisters

Sympathemimetics / Withdrawal

- Cocaine, amphetamines, Phencyclidine(Phenylcyclohexyl piperidne PCP,

pseudoephedrine

HTN, tachycardia, Mydriasis, Anxiety, delirium, paranoid delusions, Diaphoresis,

Increased temperature,Seizures

Anticholinergics
TCA, antihistamines, antipsychotics

Hyperpyrexia, cutaneous vasodilation, decreased saliva, mydriasis, hallucinations

Tachycardia, Urinary retention, Decreased bowel sounds, Seizures, dysrhythmias

Cholinergics

insecticides,carbamate, organophosphates, nerve gas, physostigmine

Salivation, Lacrimation, Urination, Defecation, Gastric cramping, Emesis SLUDGE

Drowning in secretions, profuse sweating, AMS, seizures, coma, Muscle

fasciculations, Miotic pupils

Salicylates

Fever, tachypnea, tinnitus, lethargy, altered mental status,respiratory alkalosis

metabolic acidosis, ketosis, vomiting

Serotonin Syndrome

fluoxetine, trazadone, meperidine

irritability, agitation, hyperreflexia, tremor, myoclonus, trismus

ataxia, incoordination, flushing,diaphoresis, diarrhea,fever

Extrapyramidal

haloperidol, phenothiazines

rigidity, tremor, opisthotonus, trismus, choreoathetosis, hyperreflexia

Hallucinogenic

amphetamines, cannabinoids, cocaine, Lysergic acid diethylamide(LSD),

Phencyclidine(Phenylcyclohexyl piperidne)PCP

hallucinations, psychosis, panic, fever, mydriasis

Bradycardia
Beta- blockers, calcium-channel blockers, Digoxin

Clonidine, Phenylpropanolamine, Carbamates, organophosphates, physostigmine

TCA's,

Opioids

Hypoxemia, MI, hyperkalemia, hypothermia, hypothyroidism, ICP

Agitation/ Seizures

Temperature alterations

Toxicology laboratory
Toxicology laboratory screening provides direct evidence of poison ingestion. The
toxicology laboratory investigation "Tox screen" becomes important in initial
management and involves analysis of various metabolic products and large number of
substances including antihypertensives and cardiac drugs, hallucino

gens, MAOI's, the newer antidepressants, plants, mushrooms, fentanyl, cyanide,

metals, and household products. This may be done by screening the initial urine soon
after ingestion, the concentration in the urine may be too low for detection.

However some substances like Cocaine metabolites are detected for days and
marijuana metabolites for weeks post-exposure.

The following readily obtainable laboratory tests should also be obtained in specific
circumstances:

Arterial Blood Gas with Co-oximetry

CO, MetHgb, CN-

Oxygen saturation gap

Respiratory or metabolic acidosis

Urinalysis

FeCl3 test for salicylates

Ketones ( salicylates, ketoacidosis )

Calcium oxalate crystals ( ethylene glycol )

Woods lamp ( ethylene glycol )

Electrolytes, BUN, Cr, CPK

Lactate

Serum ketones

Serum osmolarity- Calculated osmolality = 2[Na+] + [BUN] + [glucose] + [ ethanol]

Anion gap metabolic acidosis AG = [Na+] - [Cl-] -

[HCO3-] Methanol Uremia Diabetic Ketoacidosiss ( AKA, SKA ) Phenformin,
Paraldehyde Iron, INH Lactic acidosis Ethylene Glycol Salicylates

Abdominal X-Ray

Choral hydrate, heavy metals, iron, phenothiazines, enteric coated are all radio-opaque

ECG - important to search for signs of TCA's or other cardiotoxic drugs

Beta-HCG in all women of child-bearing age

Toxicology Screening - Knowledge of the quantitative serum levels of the following

drugs may impact on therapy: Acetaminophen, ASA, Digoxin, Theophylline,
Phenobarb, Iron, Lithium. Methanol, Ethylene glycol

Treatment with Antidotes

- As many antidotes have the potential for causing harm, they should not be given as a
reflex

Antidote Toxin used for

Naloxone Opiates
Flumazenil Benzodiazepines
Bicarbonate TCA, ASA(Acetylsalicyclic acid)
Calcium CCB(Calcium channel blockers)
Glucagon Beta-blockers, CCB
Physostigmine Anticholinergics
Atropine Organophosphates, Carbamates
Protopam Organophosphates
Ethanol Methanol, ethylene glycol
Pyridoxine INH
Digibind Digoxin
N-acetylcysteine Acetaminophen
EDTA Lead
DMSA Lead
BAL Arsenic, mercury,lead
D-penicillamine Ar,lead,Mercury
Cyproheptadine Serotonin syndrome
Sodium nitrite, sodium thiosulfate Cyanide
Desferoxamine Iron
Methylene blue Met-hemogloninemia

Gastric emptying/ decontaimination

This involves the use of Activated Charcoal especially within hours of ingestion of
poison. This is highly selective and not routine as Risk/ Benefit ratio of gastric
emptying is unfavorable for the majority of poisonings and should not be used for
non-toxic doses or non-toxic substances, or when the toxin is no longer likely to be in
the stomach or have involved other systems of the body.

Gastric lavage

Whole Bowel Irrigation

Hemodialysis - Indicated when intoxications cause severe end-organ compromise like

renal failure, metabolic acidosis or electrolyte disturbances not easily correctable by
medical methods or use of antidotes.

The five most commonly dialyzed drugs are methanol, ethylene glycol, ASA, lithium,
and theophylline

ICU admission