GENERAL TOXICOLOGY

?What is a Toxin
A toxin is any poisonous substance of microbial
(bacteria) , plants or animals, vegetable, or
synthetic chemical in origin that reacts with
specific cellular components to kill cells, alter
growth or development, or kill the organism.
Toxicology is the study of how natural or man-
made poisons cause undesirable effects in living
organisms which may be damage to the normal
.function of the individual up to death
All substances are poisons; there is none that is“
not a poison. The right dose differentiates a”
Paracelsus
Fate of poisons:
Absorption
The process, by which, a toxin crosses body
membranes and enters the blood stream.
Distribution-
Metabolism
It is usually the primary mechanism of detoxification.
Excretion
The poison or its metabolites are excreted mainly by
kidneys in urine; or through other body secretions,
e.g. saliva, sweat, milk or bile.
 
Diagnosis of poisoning
,.History and Circumstantial evidences: e.g )1
Sudden illness of previously healthy person or persons after
ingestion of food or drink or exposure to some chemical,
gas, insect or snake bite.
History of recent purchase of a poison or the presence of
syringe or empty bottle nearby the patient.
 
2) Clinical picture:
Vital signs (B.P, pulse, respiration, temperature).
complete general and local examinations:
Neurological examination and the state of pupils.
Chest and abdomen examination.
.Skin and smell of breath
 :Suspect toxicity with

 Acute onset of symptoms

 History of Addiction
 History of psychiatric illness
 First time seizures
 Metabolic Acidosis
 More than one patient in the same place
TOXIDROMES: They are the groups of signs and
symptoms that consistently result from a
.particular toxin (group)
 Cholinergic toxidrome
 Miosis
 Diarrhea
 Urination
 Emesis
 Lacrimation
 Salivation
 OP, carbamates
Anticholinergic
toxidrome CP

 Blind as a bat
mad as a hatter 
beet red as a
hot as a desert
dry as a bone
 and The bowel
bladder
lose their tone 
and the heart
runs alone
anxiety 
 Sedative hypnotic Toxidrome
 Decreased all VS
 Slurred speech
 Variable pupil size
 Benzo& barbiturates
 With benzo, stable vital signs.
 NON TOXIC INGESTION
 The following substances are generally non toxic if
accidentally ingested in small amounts.
 All non toxic may be toxic if in large amount.
 NO NEED FOR GASTRIC LAVAGE
Many children have nontoxic ingestion and un
needed treatment is given to them .
 Non toxic substances

 Candles. Calamine lotion

Fire ashes crayons
Silica Cold pack
Clay Charcoal
Plaster of Paris
 Ink pen indelible
marker
Matches putty
Potting soil lip balm
Newspapers Latex paint
Potting soil lip balm
 Non toxic substances
 Deodorant
 Glycerin
 Gums
 Oral contraceptive pills except iron containing.
 Steroids: oral or topical (single acute exposure).
 Baby products except inhaled powder.
 Body conditioners and moistening lotions
 Non toxic substances
 Pencils
 Vaseline
 Shampoo ( liquid non medicated)
 Suntan preparation except in large amount
Remember
All non toxic substances may be toxic if they are ingested
in large amount.
 Substances with low toxicity
 Soaps cause vomiting & bubble soap
 Detergent cause GE
 Antibiotic except ciprofloxacin, sulfadiazine &
chloramphenicol
 Antacid
 Vitamins except if with iron
General Lines of Poisoning-Treatment
I. Supportive therapy (1st Aid)
II. Gastro-intestinal (GIT) Decontamination
III. Elimination of the poison from the blood
IV. Antidotes
Supportive therapy: “Treat the patient not the .
]poison”.ABCs recently CABC
* Airway [keep it patent] by:
1. Optimize the airway position to force the
flaccid tongue forward and to maximize the
airway opening.
2. Apply the “jaw thrust” to create forward
movement of the tongue without flexing or
extending the neck. Pull the jaw forward by
placing the fingers of each hand on the angle
of the mandible just below the ears.
==. Place the patient in a head-down, left-sided
position that allows the tongue to fall forward
and secretions or vomitus to drain out of the
mouth.
2. If the airway is still not patent, examine the
oropharynx and remove any obstruction or
secretions by suction or by a sweep with the
finger.
3. The airway can also be maintained with
artificial airway devices
Breathing

Simple face mask

or
Nasal cannula
or
Mechanical ventilation
Circulation:
Check blood pressure and pulse rate and rhythm.
Secure venous access.
Hypotensive patients: intravenous infusion of
normal saline.
Hypertension treated with antihypertensive agents
as diuretic, ACE, CCB…
Begin continuous electrocardiographic (ECG)
monitoring. Arrhythmia must be treated by
antiarrhythmic drugs (lidocaine, phenytoin, etc.).
In seriously ill patients (e.g., those who are severely
hypotensive, convulsing, or comatose), place a Foley
catheter in the bladder
*C.N.S: (Coma or Convulsions)
Coma:
A coma is a prolonged state of unconsciousness
, .The person cannot be awakened by any
stimulation, including pain.
Causes of coma:
Toxic: CNS depressants, anticholinergics and
toxin causing cellular hypoxia e.g. HCN & CO.
Treatment of Coma:
Coma cocktail should be used as diagnostic
and/or therapeutic purpose.
Dextrose: All comatose patients should receive
dextrose unless hyperglycemia is diagnosed by an
immediate bedside test.
Thiamine: 100mg I.V. for possible Wernicke’s
encephalopathy in alcoholics.
Naloxone (Narcan): All patients with respiratory
depression should receive naloxone.
II) Decontamination
Avoid further exposure: ex , get fresh air in CO .
I) Local
Remove clothes
Wash skin and eyes
II) Gastro-intestinal (GIT) Decontamination:-
Emesis :OBSOLUTE
Gastric lavage
Activated charcoal
Gastric lavage
Gastric lavage is a medical procedure only used in
.hospital Emergency Rooms (ER)
for recently ingested liquid substances (less than
.3-4 h)
.
:Technique
 Place the patient on his left side with lowered
head (to prevent ingested material from being
pushed into the duodenum during lavage).
 Introduce gastric tube through the mouth or
nose into the stomach .
 Check tube position with air insufflation while
listening with a stethoscope positioned on the
patient’s stomach.
 Withdraw as much of the stomach contents as
possible.
 Give activated charcoal (1 g/kg) down the tube
before lavage to begin adsorption of material
that may enter the intestine during the lavage
procedure
 Instill tepid (slightly warm) water or saline, 200
to 300 mL and remove by gravity or active
suction.
 Repeat for a total of 2 L or until the return are
clear.
 The tube is firmly nipped (by an artery forceps)
to avoid spilling of fluids during withdrawal.
 No Breath sounds can be heard form the end of
the tube.
Contraindications of gastric lavage:
1) Coma  Lavage is allowable after inserting a
cuffed endotracheal tube to prevent aspiration
pneumonia.
2) Convulsions Lavage can be performed under
general anesthesia
3) Cardiac dysrhythmias must be controlled before
gastric lavage is initiated, as insertion of the tube
may create vagal response cardiac arrest.
4) Corrosives.
5) volatile hydrocarbons
 
Activated Charcoal (AC)
This is considered the most useful agent for the
.prevention of absorption of toxins
:Action
The charcoal particles have many pores & holes
which adsorb (binds) poisons in GIT and hence
.decrease their absorption
Dose:
.g/kg in adults [orally, mixed with H2O] 1
.15gm – 30gm in children
Only a few toxins are poorly adsorbed to
.charcoal e.g., iron,metal , lithium and alcohols
Contraindications:
 Ileus (Intestinal obstruction) should not be
used.
 Charcoal should not be given to a drowsy
patient unless the airway is adequately
protected or endotracheal intubations should
be inserted.
 Corrosive.
 Hydrocarbons.
Gastrointestinal Dialysis
Multiple-Dose Activated Charcoal (MDAC)
:Indications for poisoning that
 show enterohepatic circulation (TCA, digitalis and
barbiturates)
 Stick to the stomach (salicylate).
 Slow gut motility (barbiturates & morphine)
:Dose
gm/kg every 4 hours 1 – 0.5
:Mechanism
MDAC facilitates the passage of toxin from plasma
into intestine by creation of concentration gradient
between blood & intestinal lumen bowel fluid so it is
.called gut dialysis
III) Enhanced elimination
Alkaline diuresis: alcohol, aspirin.
dialysis: alcohols, aspirin, hyperkalemia.
 IV) Antidotes
local antidote

Adsorbents Used to adsorb the toxic agents e.g. Activated charcoal

Delmulcents Protect the stomach mucosa by coating it e.g. Milk & egg
white in corrosive

Entanglers Catch the sharp solid objects e.g. cotton for pins
Physiological [systemic] antidotes
1) Antagonistic antidotes:
 Antagonise the pharmacological effect of
physiological mechanism
 e.g.,: Atropine in organophosphorus
poisoning till dryness of chest scretions.
2) Competitive Antidotes:
 Naloxone in morphine poisoning
  The Chelators for metallic poisoning
= The Oximes in organophosphorus poisoning.