GENERAL PRINCPLES

INVOLVED IN THE
MANAGEMENT OF POISON
Sirisha Koppula
Assistant Professor
Department of pharmacy practice
KVSR SCOPS
INTRODUCTION
• Clinical Toxicology: It is the branch of science deals with study of poison.
• The study includes :Properties of poison
Action of poison
Toxicity of poison
Lethal dose
Estimation
Treatment of poison
Poison: Any substance introduced into the living body or brought into contact with any part will
produce ill effects or death, by its local or systemic action or both.
The word poison comes from the Latin word—potare— meaning to drink. But poisons can also enter
the body in other ways: By breathing, Through the skin, By IV injection From exposure to radiation
Action :
Local effect: On the part they come in contact with e.g. Aconite cause tingling effect 
Systemic effect: On one or more organ systems after absorption into the systemic circulation e.g.
Opiates – CNS, Digitalis- Heart
Combined effect: Both local and systemic effects e.g. Oxalic acid
Toxicity: Describes the degree to which a substance poisonous or can cause injury. The toxicity depends on variety of
factors include: dose , duration, route of exposure, shape and structure of the chemical itself and individual human
factors.
Toxin: A natural substance of toxic material. A toxin is any poisonous substance of microbial, vegetable or synthetic
chemical origin that reacts with specific cellular components to kill cells, after growth or development or kill the organism.
Toxic effects: Health effects that occur due to exposure to toxic substance; also known as a poisonous effects on the body.
Types of Poisoning
Fulminant: Produced by a massive dose of a poison. Death occur very rapidly, without symptoms i.e. collapse suddenly
Acute: A single large dose or several small doses taken in a short period
Chronic: Produced by small doses taken over a long period
Subacute: Characterized by a mixture of features of acute and chronic poisoning.
Majority of poisoned patients presenting to the casualty department with acute exposures.
In most cases , the poisoned patients comes with one or more of the non specific features:
Impairment of consciousness
Respiratory /cardiovascular depression
Dehydration due to vomiting / diarrhea
Hypothermia
Convulsions
Cardiac arrhythmias
• EPIDEMIOLOGY OF POISONING:It has been estimated that some form of poison directly or
indirectly is responsible for more than 1 million illnesses worldwide annually.
• The incidence of poisoning in India is among the highest in the world; it is estimated that more
than 50,000 people die every year from toxic exposure.
• Poisoning causes:The causes of poisoning are many—civilian and industrial, accidental and
deliberate. The problem is getting worse with time as newer drugs and chemicals are developed
invast numbers.
The commonest agents in India appear to be
• pesticides (organophosphates, carbamates, chlorinated hydrocarbons,pyrethroids and
aluminium/zinc phosphide),
• Sedative drugs, chemicals (corrosive acids and copper sulfate ),
• alcohol, plant toxins (datura, oleander, strychnos, and gastrointestinal irritants such as castor,
croton, calotropis, etc.), and
• household poisons (mostly cleaning agents).
• Among children the common culprits include kerosene, household chemicals, drugs, pesticides,
and garden plants.
POISON CONTROL CENTRES:
Poison Information Centers are arise due to increase the incidence of poison and lack of public awareness and its
seriousness.
• Poisons Information Services made their first appearance in the Netherlands in 1949.
• In1961, a telephone answering service was introduced in Leeds,England, which gave information to medical
practitioners and others about the poisonous properties of a variety of household,agricultural, and therapeutic
substances
• 1963, a National Poisons Information Service was established London and same year Chicago, USA.
• All around the world similar Centers have sprung up, performing the invaluable functions of generating public
awareness on poisoning, and imparting much needed toxicological diagnostic and therapeutic assistance to
doctors.
• India made a belated foray with the establishment of the National Poisons Information Centre at the All India
Institute of Medical Sciences, New Delhi in December, 1994.
• A second Centre was subsequently opened at the National Institute of Occupational Health, Ahmedabad. Some
more Regional Centers have come up in cities such as Chennai, and efforts are under way to establish similar
Centers in other parts of the country.
• A full-fledged Poison Control Centre with poison information service and analytical laboratory was started at
Amrita Institute of Medical Sciences and Research, Cochin, Kerala in July 2003. The Centre was converted into a
separate department of Toxicology shortly thereafter, and today offers extensive facilities pertaining to poisons and
poisoning to all hospitals, government doctors, private practitioners, as well as the lay public of Kerala State (and
neighbouring regions). It is for the first time that such a department exclusively devoted to toxicology has been
started in a hospital in the entire country.
• The Department has state-of-the-art software packages (POISINDEX from Micromedex, USA
and INTOX from the WHO) that have detailed information on more than 1 million poisons and
drugs encountered worldwide.
Facilities offered:
• Toxicological analysis of blood, urine, or stomach contents (vomitus, aspirate, or washing) for
evidence of any poisonous substance or drug.
• Screening of urine for substances of abuse.
• Toxicological analysis of water samples for pesticides and chemicals.
• Toxicological analysis of medicinal and other commercial products for toxic adulterants or
contaminants.
• Toxicological screening for common chemicals and poisons in chronic, undiagnosed ailments
(skin disease, respiratory illnesses, gastrointestinal disorders, neurological disorders).
• Advanced treatment facility at AIMS for all kinds of cases of poisoning (due to chemicals,
drugs, plant products, animal bites or stings, food poisons, etc.).
• Instant access to detailed information (free of charge) on poisons and poisoning through
telephone, email, postal mail, personalcontact, etc.
• Free expert guidance on diagnosis and treatment of all kinds of poisoning.
General principles of poisoning management: It includes:
Stabilization & evaluation
 Gut decontamination
 Poison elimination
 Antidote administration
 Nursing care
 Psychiatric care
STABILIZATION AND EVALUATION:The initial survey should always be directed at the assessment and correction of life-
threatening problems,if present is the primary focus
• Life threatening problems include Airway, Breathing ,Circulation, and Depression of the CNS (the ABCD ofresuscitation).
ASSESSMENT
• 1.Airway & Breathing:
Causes of death from airway block: 1. air obstruction
2. pulmonary aspiration of gastric contents
3. Respiratory arrest
• Symptoms of airway obstruction include dyspnoea, airhunger, and hoarseness.
• Signs comprise stridor, intercostal and substernal retractions, cyanosis, sweating, and tachypnea
• Normal oxygen delivery requires adequate haemoglobin oxygen saturation, adequate haemoglobin levels, normal
• oxygen unloading mechanisms, and an adequate cardiac output.
• Increasing metabolic acidosis in the presence of a normal PaO2 suggests a toxin or condition that
either decreases oxygen carrying capacity or reduces tissue oxygen
• The immediate need for assisted ventilation has to be assessed clinically, but the efficiency of
ventilation can only be gauged by measuring the blood gases
MANAGEMENT:
Remove dentures
Use chin lift & jaw thirst to clear airway
Remove saliva ,vomitus, blood from oral cavity by suction or finger sweeping methods.
Place the patient in lateral position
If required insert an endotracheal tube
If required keep artificial ventilation
Oxygen therapy: to raise the PaO2 to 45-55 mmHg
Begin oxygen mask if PaO2 is 28% given up to progress 35%
BREATHING :Breathing difficulties contribute morbidity and mortality in patient with poisoning
Issues are ventilator failure
Hypoxia
Bronchospasm
• Causes of ventilator failures: snake , nicotin, botulin toxins causes paralysis of ventilatory muscles .
Circulation
• Several drugs produce changes in pulse rate and blood pressure. while others induce cardiac arrhythmias and heartblock
• Eg: Amphetamines beta- blockers
Clonidine Theophyline
Levodopa Amphetamines
Cocaine Cardiac glycosides
MANAGEMENT:
CIRCULATORY FAILURE
Correct acidemia
Elevate foot end of the bed
Given 200 ml of iv saline and monitor the bp up to 2 liters
If no response give
Vasopressors; Dopamine 200 mg in 250 ml Dextrose
Nor adrenaline 8 mg in 500 ml Dextrose
Monitor ECG
CARDIAC ARRYTHMIAS:
Obtain ECG
Evaluate conditions like Hypoxia, Acidosis
Treat with 1st line drugs Lignocaine , sotalol, Amiodarone
If severe Bradycardia - Atropine
Depression Of CNS:
Depression of CNS is defined as lack of awareness with rating of less than 8 on the Glasgow Coma Scale.
There are numerous causes for coma of which one of the most important is acute poisoning.
Perform a quick physical examination with particular attention to the breathing, vital signs , gag reflex
How to check real or fake coma by:
Pinching nipples / genitals or any other part of the body
Slapping on face hard, repeatedly,
Cotton soaked ammonia solution being inserted into nostrils.
Lift the patient hand directly about face and drop it
If it lands on face – true coma
on side – psychogenic coma
MANAGEMENT:Till recently , it was recommended that in every case ehre the identify of the poison was
not known, the following antidotes must be administred.
Dextrose -100 ml OF 50% SOLUTION
Thiamine (vit B1) –100 mg
Naloxone 2 mg
All patient with decreased mental status should receive 100% oxygen mask.
EVALUATION: In all those patient with poisoning need through clinical examination should determine the following abnormalities
HYPOTHERMIA:
Caused by : Alcohol, Barbiturates , Opiates, Benzodiazepines, hypoglycemiba, carbon monoxide
It is essential to se a low reading rectal thermometer
Electronic thermometer with flexible probes are best which can also be used to record the oesophagela and bladder temperatures.
Treatment:
Rewarming – warm water bath for mild cases
Gastric lavage with warm fluids
HYPERTHERMIA:
Oral temperature above 102ₒ F
If it exceeds 106ₒ F there is a risk of encephalopathy
Caused by: Amphetamines, Cocaine, Anti- psychotics, MAOinhibitors, Anti histaminics, Anti cholinergics
TREATMENT:
Remove clothes
Pack the neck with ice
Cold water bath
Dantrolene – muscle relaxtant is given
ACID- BASE DISORDERS:Serum electrolytes to evaluate for me1tabolic acidosis .
The diagnosis of acid base disorders is based on arterial bold gas, ph , paco2 ,bicarbonate and serum electrolyte disturbances.
It must be first determined as to which abnormalities are primary, which are compensatory, based on the ph. If ph is lesss than 7.40 respiratory or metabolic
acidosis is primary.
In case of metabolic acidosis it is necessary to caliculate anion gap
The anion gap = (Na+ +K+ ) – HCO3- +Cl-
Normally the range is 12- 16 ( 140-(24+104) =12 )
If anion gap is greater than 20 mmol/L, a metabolic acidosis is present regardess of the ph or serum bicarbonate concentration.
Several poisons are associated with increased anion gap
• TREATMENT:
Drug of choice is sodium bicarbonate. It is widely consider as best antidote for acidosis
Add 2 to 3 ampules of 8.4% of NAHCO3 to 1 litre of 5%dextrose in water, infused IV over 3 to 4 hrs.
In paediatrics patients, add 1 to 2 mEq NAHCO3 in15 ml/Kg 5% dextrose on 0.45% NS over 3to 4 hrs
CONVULSIONS:
Several drugs and poisons which can cause convulsions
Eg: Antidepressants, antihistamics, cyanide, isoniazid, cocaine
Improper or misleading treatment can cause status epilepticus which is a life threatening condition
TREATMENT:
Administer oxygen mask
Position patient head for optimal airway potency
Establish iv line
Benzodiazepines:
lorazepam – 0.1 /kg @ 2 mg/min
diazepam – 0.2 mg/kg @ 5 mg/min
If persists
Phenytoin 15-20 mg/kg @ 50 mg/min
If still persists
Phenobarbitone 20 mg/kg @ 100 mg/min
Monitor ECG, hydration and electrolyte balance , hypoglycemia , cerebral odema
AGITATION:
Several drugs and poisons are associated with increased aggression which sometimes progress to psychosis and violent behavior. This is especially if there are
other predisposing factors like existing mental disorder, hypoglycemia, hypoxia, head injury and anemia and vitamin deficiency.
Delirium - acute psychotic episodes characterized by disorientation, irrational fears, hyper excitability, hallucinations and violence.
Dementia- more gradual decline in mental process mainly confusion, memory loss
• TREATMENT:
• Chlorpromazine, diazepam, haloperidol.
MOVEMENT DISORDERS:
Exposure to several drugs and toxins can result in wide variety of movement disorders ranging from full blown Parkinson's disease to isolated tremors.
Eg: phenothiazines and major tranquillizers
Drugs associated with agitation and psychosis during the withdrawal of amphetamines, corticosteroids, barbiturates, digitalis, opiates, benzodiazepines
Akathisia, dystonia( facial grimacing), chorea( involuntary writhing movements of limbs), myasthenia crisi( sudden onset of muscular weakness)
TREATMENT:
Movement disorders are due to induced toxins or drugs are due to dose and duration related. Withdrawl of the incriminating agent results in recovery
Eg: Parkinson's: carbon monoxide, amoxapine
ELECTROLYTE DISTUBANCES:
1.HYPERKALEMIA: > 5.5 mEq/L
Causes: digitalis, beta 2 antagonists, potassium sparing diuretics, NSAIDS, heparin etc
Manifestations include abdominal pain, diarrhea, myalgia, weakness
Ecg : tall t waves, STseg depression, prolonged PR intervals, QRS prolongation in severe ventricular fibrillation
Treatment: Glucose, insulin infusion, sodium bicarbonate, calcium gluconate, hemodialysis
2.HYPOKALEMIA:< 3.5
Causes: beta 2 agonist, theophylline, insulin, etc
Ecg- flat or inverted T waves, ST seg depression, prominent U wave
In severe cases AV block, ventricular fibrillation
TREATMENT:
Oral \ iv potassium
3.HYPERNATREMIA: >150 mEq/l
Causes: phenytoin,alcohol, sorbitol, mannitol, excess water loss etc
Treatment: water restrictions with or with out diuretics
4.HYPONATREMIA: <130
Causes: NSAIDS, carbamazepine, ACE Inhibitors, Captopril, Lithium, Imipramine
Excess water intake
TREATMENT: hypertonic saline
5.HYPOCALCEMIA: < 4
Causes: phenytoin, phenobarbitone, ethanol,oxalates, aminoglycosides
TRWATMENT: Calcium gluconate IV ( 10% soln , 10 ml at a time, slowly)