POISONING

Ms. Rosana James

M. Sc (N) Prev Yr
POISONING
POISONING

Presented by-
PRESENTED
Miss BY-
Punam Dungdung
Msc.(N) 1st year student
Miss Punam Dungdung
CCON,INDORE
Msc.(N) 1st year student
CCON,INDORE
 INTRODUCTION

Poisoning is when a person is exposed

to a substance that can damage their
health or endanger their life.
Most cases of poisoning happen at
home and children under five have the
highest risk of accidental poisoning.
 DEFINITION
Poison is a substance with
an inherent property that
tends to destroy life or
impair health.

Poisoning- is when cells are

injured or destroyed by the
inhalation, ingestion,
injection or absorption of a
toxic substances”.
- WHO
 INCIDENCE

According to the American Association of

Poison Control Centers, approximately 1.5
million cases of poisoning occur in children
and adolescents under the age of 20 each
year. More than 50 percent of all poisonings
occur in children under the age of 6 years.
Peak incidence of childhood poisoning
occurs between 1 and 3 years of age.
 ROUTES OF POISONING
1% 3%
5%
5%

6%

INGESTION
DERMAL
OPTHALMIC
INHALATION
PARENTRAL
79% BITS AND STINGS
 POISONING SUBSTANCES
Inorganic
• Metallic: Arsenic, Antimony, Cu, Zinc
• Non-metallic: Phosphorus, Iodine, Cl, bromine
• Mechanical: Glass, Diamond dust, Hair

Organic
• Animal: Snakes, insects
• Vegetable: Castor, Croton,
CONT….
Corrosive :
• Acid products - toilet bowl cleaner (Phenyl, herpic) pool cleaner,
metal cleaners, rust remover, and battery acids.

• Alkaline products-include dye, drain cleaners, toilet bowl

cleaners, bleach, non -phosphate detergents etc.

• Sulfas poisoning-
 CLASSIFICATION OF POISONING

I). ACCORDING TO NATURE OF POISONING

1. ACCIDENTAL
• more common among children of age group 1-5 years.

2. DELIBERATE SELF-POISONING
• Common in adults, Peak incident between ages 15-35 years .
• Women form the major group .

3. HOMICIDAL
• Acute homicidal poisoning mainly in children and chronic
homicidal poisoning in adults.
CLASSIFICATION CONT…
II). ACCORDING TO ROUTE OF ENTRY

 Inhalation
 Ingestion
 Absorption/Topical
 Injection
 Ophthalmic
 Mechanism of action of Poison
• Swallowed poisons act directly on food passages
resulting in vomiting, pain and diarrhea
• Corrosive poisons may severely burn lips, mouth, gullet
and stomach thus causing intense pain
• Fumes and gases cause choking result in difficulty of
breathing and unconsciousness
• Some poison work in blood stream, central nervous
system and prevent breathing, heart action and other
vital life process
• Some poisons act by displacing the oxygen in blood and
preventing its distribution to tissues.
 Assessment of patient with Poisoning
• Assessment depends on nature of poison and method of
entry into body
• It includes following:
– General information from patient or witness
suggesting contact with a poison
– Check the container having poison or poisonous plant
– Observe patient for signs and symptoms
• Convulsions
• Signs and symptoms of asphyxia
• Vomiting
• Burns on lips and mouth after contact with
corrosive poisons
GOALS OF EMERGENCY MANAGEMENT

1. To remove or inactivate the poison before it is

absorbed.
2. To implement treatment that accelerates the
elimination of the absorbed poison.
3. To administer a specific antidote to neutralize
a specific poison.
4. To provide supportive care in maintaining
vital organ system.
 PRINCIPLES OF MANAGEMENT
FOR POISONING

1. Stabilization & Evaluation

2. Decontamination
3. Poison elimination
4. Antidote administration
5. Nursing and Psychiatric Care
PRINCIPLES OF MANAGEMENT CONT…

1. STABILIZATION & EVALUATION

-Assessment and correction of life-threatening problems.

1. Hypoxia – Assisted ventilation

2. Coma – Coma cocktail
(Dextrose D50 + Thiamine + Naloxone)
3. Metabolic acidosis
4. CABD of resuscitation
5. Complete, thorough and systematic examination of
the patient.(after stabilization)
PRINCIPLES OF MANAGEMENT CONT…

2. DECONTAMINATION

A. Emesis
B. Gastric lavage
C. Catharsis
D. Activated charcoal
 CONT…..
2. Decontamination

A. Emesis
- Substances used‐ Ipecac

Indications
- conscious patients mainly adults.
- within few minutes of ingestion of poison.
 CONT…..
Emesis

Contraindications –
 Very young/very old
 Convulsions/unconsciousness
 Pregnancy
 corosive toxins
 Petrollium distillation products
B. Gastric lavage-
It is indicated only if the patient arrives
within one hour i.e. golden hour of ingestion,
life threatening ingestions or those substances
that don’t bind with charcoal like- cyanide,
hydrocarbons, ethanol, metals, iron, caustic,
lithium, solvents (CHEMICALS).

• Gastric lavage is done with large bore orogastric

tube.
 CONT…

Gastric lavage fluids

a) Warm water
b) Normal saline/distil water
c) KMnO4 (Kmno4 sol 1-2 drop +500mlD/W)
- lavage until gastric secretion is clear.

d) In sulfa poisoning
- Soda-bi-carb 100 ml+ coconut oil 200ml
 CONT…
Contraindications –
Gastric lavage is contraindicated:
-corosive poisons (acid, alkaline)
-petrol distillation products E.g. Petroleum,
kerosene oil, fuel oil etc.
c. Catharsis
• Cathartic is a substance which accelerates the
defecation.eg. Magnesium sulphate saline
cathartic.
 CONT…
D. Activated Charcoal

 Small particle with highly

developed internal pore system.
 Flatuna (activated charcoal)
 500ml D/W +10-20 TAB OF CHARCHOAL
composition
 Simethicon – 80 mg (reduces bloating)
 Activated charcoal – 250 mg
 3. POISON ELIMINATION
Renal excretion

Forced Diuresis -Mannitol

Whole bowel irrigation

Extracorporal removal
Dialysis
-Peritoneal dialysis
-Haemodialysis
Haemoperfusion
Exchange transfusion
 4. ANTIDOTE ADMINISTRATION

DRUGS ANTIDOTE

Acetaminophen N-Acetylcysteine

Anticholinergic Physostigmine

Heparin Protamine sulphate

Warfarin Vitamin K

Opioids Naloxone
 CONT…
DRUGS ANTIDOTE

Organophosphates Atropine, Pralidoxime

Benzodiazepines flumazenil

Beta blockers glucagon

Calcium channel block calcium
Iron Deferoxamine
5. NURSING AND PSYCHIATRIC CARE

1. Close observation
2. Vitals monitoring
3. monitors patient progress
4. psychiatric referral/ councelling.
 First Aid for Poisoning
• Inform the police
• Collect information from patient or persons
accompanying patient
• Preserve suspecting material like bottle containing
pills or liquid
• If patient vomited, preserve vomited material
• If patient is conscious and no burns on lips or mouth
then induce vomiting by giving fluid or milk and
touching the fauces (inside the mouth)
• If lips or mouth shows signs of burn, cool them by
giving water or milk
Cont....
• If patient is unconscious but breathing
normally, treat as for shock
• If breathing and heart beat stop begin
resuscitation immediately
• If convulsions present manage it
• Shift patient immediately to hospital
COMMON TYPES OF
POISONING & its
MANAGEMENT
 MOST COMMON TYPES OF
POISONING

1. Organophosphate Poisoning
2. Ingestion Poisoning
3. Skin Contamination Poisoning
4. Carbon monoxide poisoning
5. Food poisoning
Organophosphate Poisoning
 DEFINITION
Organophosphate poisoning is poisoning due to
organophosphates (OPs). Organophosphates are
used as insecticides, medications, and nerve agents.
(isulfoton, phorate, dimethoate, parathion, malathion, trichlorfon,
paraoxon etc.)

- OP poisoning mainly affect the

neurotransmission by binding
enzyme acetyl cholinesterase at
neuro-muscular junction.
 MECHANISM OF TOXICITY

videoplayback (10).mp4
SIGNS AND SYMPTOIMS
MUSCARINIC EFFECT
NICOTINIC FEATURES

• Fasciculation
• Weakness
• paralysis
• proximal neck muscle weakness leading to respiratory
distress and failure.
• Polyneuropathy

CNS EFFECTS
Restlessness, confusion, ataxia, tremor, seizure and coma.
 TREATMENT

• Gastric lavage and its content is sent to

laboratory for test.
• Atropine Injection
• PAM Injection[ Pralidoxime injection]
 ATROPINE

• MUSCARINIC ANTAGONISTS
Aim of atropine
• To improve cardiac and respiratory functions.
• Drying of pulmonary secretions
i.e.-Clear lung fields on auscultation
– Heart Rate>80 beats/min
– SBP>80mmHg
– Pupils: No Longer pinpoint
 PAM Injection
(PRALIXODIME INJECTION)

• Pralidoxime Reactivates the AChE, by binding to the OP

molecule.

• Used as an antidote to reverse muscle paralysis.

• But is not effective once the OP compound has bound AChE

irreversibly .
– 1-2 gm for 15-30 minutes infusion repeat in 1 hour if
necessary.
- The blood pressure, HR and pupil size monitored
every hour.
 INGESTED
(SWALLOWED)
POISONS
Common substances that can
cause poisoning:

•Automobile fluids

•Cosmetics and
other personal care products
•Household cleaning products

•Over-the-counter or
prescription medications
•Foreign objects

•Paints and paint thinners

•Pesticides (e.g., insecticides,

weed killers, rodenticides)
Dizziness

Drowsiness

Fatigue

Headache

Loss of appetite
•Blurred vision

•Confusion and
disorientation

•Difficulty breathing

•Fever
•Hypotension

•Rapid heart rate

•Cardiopulmonary arrest

•Convulsions

•Loss of consciousness
 GOALS:
•To remove or inactivate the poison
before it is absorbed.

•To provide supportive care in

maintaining vital organ function.

•To administer a specific antidote

neutralize a specific poison.

•To implement treatment that hasten

elimination of the absorbed poison.
•Control airway

•Ventilation

•Oxygenation
•Monitor:
ECG

Vital signs

Neurologic status
•Gastric emptying : Syrup of ipecac
to induce vomiting

•Gastric lavage (Not to be done in

corrosive and petroleum poisoning)
Activated
charcoal Cathartic
administration
•Blood specimen are obtained to
determine the concentration of
drug or poison.

•Indwelling urinary catheter

Measures are taken to remove
the ingested substance:

Administration of multiple dose

of charcoal

Diuresis

Dialysis

Hemoperforation
Hemoperforation:
detoxification of blood by
processing it through an
extracorporeal circuit and
an adsorbent cartilage
containing charcoal or
resins, after which cleansed
blood is returned to the
body.
During detoxification.
Look for
Vital signs

Fluid and electrolyte balance

CVP

Seizure

Pain
CARBON MONOXIDE
POISONING
CO poisoning
occur as a result
of industrial or
household
incidents or
attempted
suicides
Carbon monoxide exerts its toxic effect by
binding to circulating hemoglobin and
thereby reducing the oxygen- carrying
capacity of the blood. Hemoglobin absorbs
carbon monoxide 200 times more readily
than it absorb oxygen. Carbon monoxide
bound hemoglobin, called
carboxyhemoglobin does not transport
oxygen.
 CLINICAL
MANIFESTATION
MANAGEMENT
•Carry the patient to fresh air
immediately; open all doors and
windows.

•Loosen all tight clothing.

•Initiate cardiopulmonary
resuscitation, if required.
•Administer 100% oxygen

•Prevent chilling; wrap patient in

blanket.

•Do not give alcohol in any form or

permit the patient to smoke.

•Monitor patient closely.

 SKIN
CONTAMINATION
POISONING
Skin contamination
injuries occurs from
exposure to chemicals .
The severity of a
chemical burn is
determined by the
mechanism of action,
the penetrating strength
and concentration, and
the amount and duration
of exposure of the skin
to the chemical.
•The skin should be
drenched immediately with
running water
•Except in case of lye and
white phosphorous, which
should be brushed off the
skin, dry.
•Water should not be applied
to burn from lye and white
phosphorous because of the
potential for an explosion or
for deepening of the burn.
•Flush skin with a
constant stream of water
as patients clothing is
removed.

•The health care worker

should use personnel
protection equipments.

•The patient is instructed

to have the affected area
reexamined at 24 and 72
hours and in 7 days
•Antimicrobial treatment

•Debridement

•Tetanus prophylaxis
FOOD POISONING
Food poisoning
is a sudden
illness that
occurs after
ingestion of
contaminated
food or water.
Rapid pulse

Fever

Oliguria

Anuria

Hypotension

Delirium
 MANAGEMENT

•Food, gastric content, vomitus, serum and

feces are collected for examination.

•The patients respiration , blood pressure,

level of consciousness, central venous
pressure and muscular activity are closely
monitored.
•Measures are taken to support
respiratory system.

•Fluid and electrolyte balance

•Daily weight and serum electrolyte

•Antiemetics

•Clear liquid after 12- 24 hours.

 Nurses Responsibility

 Inform police

 Report MLC
 Collect information from the surrounding
persons/bystanders
 Preserve the suspending material like
bottle containing pills or liquid
 Preserve the vomited material.
 Nursing Care Plan
ASSESSMENT-
• Assess the condition of patient.
• Assess the type of poisoning
• Assess the more injured area.

GOALS-
• Early detection, early management
and prevention of complications
1. Ineffective breathing pattern related to the swelling

of the nasal mucosa wall as evidenced by: shortness of

breath, breath with the lips, there rhinitis.

2. Acute pain related to gastric irritation as evidenced

by: abdominal pain, looked grimacing while holding

stomach.

3. Impaired skin integrity related to changes in

circulation as evidenced by: swelling and itching of the

skin and the nose, there are hives, urticaria.

 LEGAL ASPECTS OF POISONING
•Poisoning is an integral part of medico legal
cases. Medico legal cases (MLC) are an integral
part of medical practice that is frequently
encountered by Medical Officers (MO).

•In emergencies, resuscitation and stabilization of

the patient will be carried out first and medico
legal formalities may be completed subsequently.
The consent for treatment is implied in all
emergencies.
•The medical officer should be informed first
about the arrival of a patient with poisoning.

•The poisoning has to be reported by the

medical officer to the nearby police station.

•The gastric sample of the patient has to be

handed over to the medical officer which will
be sent to pathology for examining the toxic
substance.
•Maintain MLC register

•In case of discharge / transfer / death of such a

case in the hospital, the police should be
informed. Medico legal documents should be
considered as confidential records and should
be stored under safe custody.
 CONCLUSION
Poisoning is the most common cause
of nonfatal accidents in the home.
The damage caused by poisoning
depends on the poison, the amount
taken, and the age and underlying
health of the person who takes it.
Some poisons are not very potent and
cause problems only with prolonged
exposure or repeated ingestion of
large amounts. Always measure must
be undertaken immediately to reduce
the effect of poison.
 BIBLIOGRAPHY
1. Brunner and Siddhartha’s (2006).textbook of MEDICAL SURGICAL
NURSING. Philadelphia; library of congress cataloging in-publication data.
10th edition, pp. 2540-2544
2. Ross &Wilson,(2006). A TEXTBOOK OF ANTOMY AND PHYSIOLOGY,
Elsevier India limited,10th edition,p.p 142-150.
3. Samant kusum.(2000)First Aid manual.vora medical publication.Mumbai.1st
edition.p.p.145-151
4. Sankar Avinash.(1994).Handbook of poisoning.Balani publishing
house.Bombay.1st edition p.p. 23-43,283-285
5. http://www.japi.org/august_2016/01_editorial.pdf
6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2700615/
7. https://
www.omicsonline.org/open-access/neurotoxic-manifestation-of-snake-bite-in
-bangladesh-2161-0495.1000-185.php?aid=25697
8. https://www.ncbi.nlm.nih.gov/pubmed/124647
9. https://
www.omicsonline.org/open-access/pathophysiological-and-pharmacological-
What are the different types
of poisoning and write down
the management of
poisoning.
 BIBLIOGRAPHY
• Smeltzer C Suzanne ,Bare G Brenda ,Hinkle L Janice ,Cheever
H Kerry ,editor ,Brunner and Suddarth’s text book of medical
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• Black .M.J, Hawks H.J .Medical surgical nursing clinical
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in www.mayoclinic.org/diseases..poisoning/basics/.../con-
2002684