POISONING

 These include:
a) Inhaled poisons – carbon monoxide
poisoning
b) Ingested poisons
- kerosine
- acids & alkalis (household chemical)
- disinfectants (household chemical)
-Aspirin poisoning
-Barbiturate poisoning
-Paracetamol
-Iron poisoning
-Ethyl alcohol
-Methyl alcohol
-Chlorinated hydrocarbons
– Cassava poisoning (plant)
– Mushroom poisoning (plant)
– Organophosphate insecticide poisoning
NB: THE ABOVE ARE DRUGS
C) Bites and stings
-snake bite
-spitting cobras
-spider bite
-fish sting
-cone cell sting
-bee & hornet sting
Introduction
 Poisons are defined as substances that can
cause injury, illness or death, usually by
chemical reactions when a sufficient quantity
is absorbed.
 Acute poisoning is one of the common reasons
for admission (Emergency)
 Poisoning may be suicidal or accidental.
PRINCIPLES OF MANAGING POISONING
 These include:
a) Removal of poison by
-Gastric larvage—this is commonly referred to as a
stomach pump. It is the insertion of a tube through the
mouth down into the stomach, followed by
administration of water or saline down the tube. The
liquid is then removed again, having the overall effect
of removing the contents of the stomach.
 - washing exposed skin if the cloth is
contaminated
b) Antidotes for specific poisons
c) Increasing poison elimination by
-Forced diuresis
-Dialysis
 INHALED POISONS

CARBON MONOXIDE
 Carbon monoxide (CO) poisoning is a danger.
 Whenever something burns in insufficient
oxygen, it produces carbon dioxide, water, heat &
deadly carbon monoxide.
 The commonest source is a charcoal fire burning
in an insufficiently ventilated room.
 Motor vehicle exhausts are another source of
carbon monoxide
Clinical presentation
 The patient is likely to be brought with a history of having
gone to sleep in a room with a charcoal stove burning and
the windows & doors shut.
 Clinical features include;
a) Mild cases-headache
-sweating
-limb pains
-vomiting
-patient may look pale
b) Moderate case-Also mental confusion &
- Incordination
c) Severe cases -Also ~convulsions
~coma
~hypotension
~arrhythmias
~patient may be cyanosed
 If such a patient survives, there may be
permanent neurological effects,such as
parkinsonism.
 MANAGEMENT

1) Remove the patient from the poisonous atmosphere, if

this has not been done already.
2) Give artificial respiration & oxygen if necessary.
3) Ensure adequate circulation
4) Treat complications if present
5) It is important to keep carbon monoxide poisoning
patients under observation for 72 hours, as those who
look quite well after first aid treatment may suddenly
develop cardiac failure or convulsions in the next day
or two.
 INGESTED POISONS

General management
a) Removal of poison by
-gastric lavage
-washing
b) Administration of antidotes e.g.
-atropine for organophosphate poisoning
-N-acetylcysteine for paracetamol poisoning
-ethanol for methanol
-Desferrioxamine for iron salts
c) Increasing poison elimination from the body
e.g. by
-Forced diuresis
-Haemodialysis
 Only a few poisons actually have specific
antidotes.
 In most cases the first and most important
thing is to remove as much of the poison as
possible by making the patient vomit or by
washing out his stomach, except in the
following circumstances;
1) If the poison was swallowed more than 6 hours
before except in Aspirin poisoning ( salicylates
cause pylorospasm and stay in the stomach for up to
24 hours).
2) If the patient is deeply unconscious
3) If the poison is either kerosene, a corrosive acid or
alkali
NB: NEVER TRY TO EMPTY THE STOMACH IN
KEROSENE OR ACID/ALKALI POSONING OR IN A
PATIENT WHO IS DEEPLY UNCONSCIOUS
Making the patient vomit
 Make the patient vomit as a first aid measure, at
home, or in hospital while waiting for stomach wash
out equipment to arrive.
 Put the patient on his left side on bed
 Raise the foot of the bed about 0.5 m on blockss or
chair, to reduce risk of inhalation of vomit.
 Push your finger or spatula down the back of his
throat.
Carrying out gastric lavage ( washing out the stomach)
 Put the patient on a tilted bed as above
 Pass a 30-gauge nasogastric tube
 Aspirate any fluid present before starting to wash out, so as
not to push poison into the duodenum when you give the wash
out water
 Fit a funnel and the tube and run in 300mls of warm water
 Lower the funnel and tube and let the water run back into a
bucket.
 Repeat several times, until the remaining fluid is clear.
 KEROSENE

 this is sometimes mistaken for water and

drunk, especially by children in hot weather.
 It does no harm in the intestines, but even
small amounts in the lungs may cause
chemical pneumonitis
Signs & symptoms
a) There are almost none except a history of
ingesting kerosene or smell of kerosene in the
patient`s breath.
b) Young children may be a little drowsy.
c) If kerosene is inhaled, pneumonitis is likely
within a few hours. They may present with
cough and breathlessness.
Management
1. DO NOT carry out gastric lavage
2. Observe for 48 hours
3. Give penicillin if pneumonitis develops
Prevention
I. Educate the community about the danger of putting
kerosene in containers that are accessible to children
II. Ensure children have enough drinking water,
particularly in hot weather, and that they know
where to get it.
 CORROSIVE ACIDS & ALKALIS

 Acids, such as battery acid (sulphuric acid), or

alkalis, such as caustic soda, are sometimes
swallowed by mistake, or occasionally on
purpose.
 There are usually signs of burning around the
mouth
Management
1. DO NOT carry out gastric lavage
2. If acid has been swallowed, give magnesium
trisilicate 60mls orally. If this is not available give
fresh milk or plenty of drinking water.
3. For swallowed alkali, give a weak acid, such as
vinegar (diluted 1:3), sour milk or fruit juice.
 CORROSIVE DISINFECTANTS

 These include lysol, cresol, phenol and drain

cleaners
 Apart from their direct corrosive action on the
mouth, oesophagus and stomach, if these
poisons are absorbed they may cause
convulsions, coma and renal failure.
Management
i. Do not attempt to induce vomiting (danger of
rupture of oesophagus)
ii. Gastric lavage although dangerous, is necessary in
these cases because of the systemic effects.
iii. These poisons can be absorbed through the skin, so
remove any contaminated clothing and wash the
skin thoroughly.
 ASPIRIN POISONING

 Aspirin is metabolised by the liver to salicylic acid and

subsequently to salicyuric acid.
 Salicylates stimulates respiration to induce respiratory
alkalosis.
 Compensatory mechanism results in metabolic acidosis
 Salicylates also interfere with the body metabolism
which may lead to accumulation of acids
 As mentioned above, aspirin or other salicylates cause
spasms of the pylorus, so absorption may be delayed
and no effects seen for some hours.
Signs and symptoms
I. Deafness
II. Tinnitis (ringing in the ears)
III. Epigastric pain
IV. Deep breathing due to acidosis
V. Hypotension
VI. Convulsions
VII.coma
Management
1) Carry out gastric lavage
2) Give activated charcoal to minimise salicylate
absorption
3) Give sodium bicarbonate intravenously to
correct acidosis
4) Administer I.V fluids to correct dehydration
and electrolyte imbalance
5) Give 50mls of 50% dextrose I.V to correct
hypoglycaemia
6) In moderate poisoning alkalinasation of urine
can be performed to increase excretion
7) Refer if no improvement
 BARBITURATE POISONING

 The most dangerous effect of barbiturates is that they

depress the respiration and cough reflex.
 Patients who cannot cough are in particular danger of
inhaling vomit and then developing aspiration
pneumonia.
 The short-acting barbiturates used as sleeping pills are
particularly dangerous, though recovery from them is
more rapid than with long-acting phenobarbitone itself.
 In phenobarbitone overdose patients stay in coma
longer but at a safer level.
Signs & symptoms
a) Profound respiratory depression
b) Severe myocardial depresson
c) Severe hypotension
d) Anuria
e) Coma
f) Death, if no intervention is carried out
Management
 This is an emergency
i. Try to resuscitate an unconscious patient (ABCD-of
coma-clear the airway, help the patient breathe, check
the patient`s circulation and cardiac condition, and
insert a drip)
ii. Do gastric lavage if poisoning is recent
iii. Give analeptics (CNS stimulants) e.g. Nikethamide 2-
4ml intramuscular, S.C. or intravenous
iv. Give plenty of intravenous fluids
PREVENTION
1. Do not give out large supplies of phenobarbitone to
patients as sleeping pills. Patients who complain of
insomnia may become suicidal.
2. Do not prescribe more than 3 day`s supply of short-
acting barbiturates at a time, except patients
suffering from epilepsy
 PARACETAMOL POISONING

 This is a very common analgesic.

 After absorption it is metabolised mainly by two enzyme
systems in the liver.
 One of the products of this metabolism is very toxic.
 The toxin intermediate is usually destroyed by a product
known as glutathione.
 If the dose of paracetamol is very high this will lead to
depletion of glutathione and hence increase in the level
of the toxic metabolite.
 Severe liver necrosis then occurs
Signs & symptoms
1) Shortly after ingestion the patient may have nausea
or vomiting but there are no signs of toxicity until
24-48 hours when hepatotoxicity occurs.
2) With severe necrosis there will be jaundice, hepatic
encephalopathy and renal failure
Management
1. Give stomach wash out if the drug was taken in the
last 3-4 hours
2. Give I.V. fluids if dehydrated
3. If the patient is in liver failure-refer
NB: SIGNS OF PARACETAMOL TOXICITY OCCUR
24-48 HRS AFTER INGESTION.
 CHLOROQUINE POISONING

 Children are quite often given too much

chloroquine by mistake
 It may also be taken by people attempting
suicide or women who are trying to procure an
abortion
 Poisoning causes severe hypotension,
convulsions and danger of sudden death from
cardiac arrest.
Management
a) Empty the stomach
b) Give I.V. fluids if there is hypotension
c) Use diazepam I.V. if there are convulsions
d) Watch out for cardiac arrest. Thump the chest &
give closed chest cardiac massage if arrest occurs
 IRON POISONING

 Ordinary ferrous sulphate tabs are not attractive

to children.
 However some iron tabs have a sugary coating
and children may easily swallow them
 Overdose may cause haematemesis or even
stomach perforation
 After afew days delay there may be liver failure.
 Iron tablets are visible on x-rays.
Management
1. Do gastric lavage
2. Administer desferrioxamine. This binds to
excess iron in the body and is excreted in the
urine and faeces, thereby reducing iron levels
in the body.
 ETHYL ALCOHOL POISONING

 Alcohol increases the effects of barbiturates &

some other drugs.
 A patient who is “dead drunk” has acute
alcohol poisoning ( though do not forget that
he may also have fallen & suffered a head
injury or could be hypoglycaemic).
Management
a) Empty the stomach
b) Give 50ml of 50% dextrose I.V. bolus. If this
is not available give a solution of 50%
dextrose or sugar solution 50% and continue
with this until the patient is able to eat
c) Put unconscious patients on a dextrose drip
d) Monitor vital signs every 15-30 minutes
 METHYL ALCOHOL POISONING

 This is common among people who ingest local

distilled brews which have been fortified by this
additive.
 The general effects are the same as those of ethyl
alcohol.
 However, methyl alcohol is much more slowly
metabolized and produces very toxic metabolites,
formaldehyde and formate, with danger of blindness
and severe acidosis.
 Effects may be delayed for hours or even days.
Signs & symptoms
a) Shortly after ingestion, the patient usually appears
drunk. This is followed by drowsiness,
hyperventilation due to metabolic acidosis,
confusion, convulsions and coma.
b) Methanol poisoning is frequently associated with
visual disturbance which may present as blurred
vision and blindness.
c) Unreactive pupils mean permanent blindness.
Management
i. Do stomach washout
ii. Give ethanol orally e.g. vodka
iii. Start a bicarbonate or lactate drip to correct acidosis
iv. Refer to a facility which can offer dialysis &
intensive care
NB: HEALTH EDUCATION AGAINST ILLICIT
BREWS
 CHRORINATED HYDROCARBONS (GAMMEXANE)
POISONING

 These insecticides may be taken by accident or

suicidally.
Signs & symptoms
i. Excitement and tremors, followed by
ii. Paralysis &
iii. convulsions
Management
1. Empty the stomach
2. Control convulsions with diazepam 10mg I.V.,
repeated if necessary
 CASSAVA POISONING

 Cassava is a valuable food & quite safe as

traditionally prepared.
 However strangers to an area may not know
how to prepare the local variety safely.
 They are then liable to poisoning from the
hydrocyanic acid that some varieties contain .
(usually the more bitter tasting)’
 In times of famine, cassava may be stored for
a shorter time & used carelessly.
 Bruished tubers are known to be particularly
toxic.
Signs & symptoms of acute poisoning
A. Continuous and prolonged vomiting
B. Abdominal pain
C. Mental confusion
Chronic poisoning
D. Neurological conditions may occur, including
blindness, deafness & peripheral neuropathy
Management
a) Empty the stomach if the patient has not
already vomited a lot
b) Set up a drip if there is dehydration
c) Monitor vital signs
 MUSHROOM POISONING

 There are several different species involved and

they may be difficult to identify.
Signs & symptoms
 There are 3 common types:
1. Early onset of diarrhoea & vomiting (under 4
hrs after eating the mushroom); may be fever
and colic as well. The pupil may be contracted.
The patient gets better within 2 days.
2. Psychological symptoms-hallucinations,
delusions and brightly coloured vision; the
prognosis is also good
3. Delayed onset of diarrhoea & vomiting (>4hrs
after eating), which improves after a short time.
In 2-3 days, however, oliguria, tender
enlargement of the liver, and jaundice develop
and get progressively worse. The patient often
dies.
Management
a) Empty the stomach as with other poisonings, if seen
early
b) Start I.V. drip if there is dehydration
c) If colic and vomiting are severe and the pupils are very
contracted, then give atropine as for organophosphate
poisoning but do not use it for mild cases
d) If symptoms develop more than 4 hours after eating the
mushroom, the prognosis is likely to be bad, so refer if
in small facility
ORGANOPHOSPHOROUS INSECTICIDE
POISONING
 These are compounds like parathion, diazinon,
dimethoate, fenitrothion, malathion etc.
 The effects of poisoning are due to inactivation
of the enzyme cholinesterase, allowing
acetylcholine to accumulate at nerve endings
instead of being destroyed. This causes
paralysis, most importantly of the respiratory
nerves, and overreaction of parasympathetic
nerves.
 As well as being swallowed, the poison can be
absorbed through the skin. This can happen
when crops are being sprayed, or if one of
these compounds is mistakenly used as a skin
application for, say, lice.
Signs & symptoms
 The effects may be delayed and include:
i. Nausea, anorexia, and mental confusion, followed by
vomiting, abdominal cramps, sweating, salivation,
dizziness, with constricted pupils
ii. Late effects include diarrhoea, incontinence, respiratory
difficulty with pulmonary oedema and
bronchoconstriction, tremor, ataxia, drowsiness and coma
NB: THE MAIN DANGER TO LIFE COMES FROM
RESPIRATORY PARALYSIS & PULMONARY OEDEMA
Management
i. Remove all clothing and wash the patient completely
and thoroughly
ii. Empty the stomach if the poison has been swallowed
iii. Give atropine 1mg I.V. every 15 minutes until the
pupils dilate or symptoms improve. Up to 20mg may
be needed. If no veins can be found, give it IM. The
treatment with atropine should be continued for a few
days since the body has to regenerate new enzyme.
iv. Give pralidoxime (PAM) which is a special
antidote if available
v. Counsel if the poisoning was due to suicidal
attempt.
Prevention
 These insecticides are far too easily available to
people who may not be able to read and
understand the instructions and how dangerous
they are. Many users have no idea they are
meant to wear full protective clothing when
using them
 Proper control of sales and proper education of
the farming community are needed.
Chronic poisoning
 sometimes agricultural workers who use these
compounds regularly may be using them more
or less correctly but may be repeatedly
absorbing small quantities. They then develop
chronic sub-acute poisoning.
 The signs & symptoms include nausea,
dizziness, visual disturbances and diarrhoea.
 In management:
a) Proper precautions to be taken and to stop
using contaminated clothing without washing
 BITES AND STINGS

1. SNAKE BITE
 There are 2 main groups of venomous snakes:
a) Vipers, such as the puff adder, and
b) Elapid snakes, such as cobras or mambas
 The effects of snake bites are variable.
 Non-venomous snakes sometimes bite and venomous
snakes inject little or no venom
Signs & symptoms
a) If venom is injected, there will usually be local
swelling, and sometimes necrosis of subcutaneous
tissue, though not usually of muscle
b) There may also be systemic effects
c) The venom of viperine snakes makes blood vessels
of the bitten part leak into the tissues and may also
cause generalized bleeding. This can lead to shock
similar to that caused by other kinds of bleeding.
d) In poisoning by elapid snakes the main effects
are on the CNS
e) The earliest effect is likely to be drooping of
the eyelids (ptosis), which may be mistaken for
sleep.
f) Later there may be difficulty in swallowing,
generalized weakness and mental changes.
g) Death is usually due to respiratory failure
Diagnosis
1) Poisonous snake bites are usually identified
by two fang marks
2) It is important to decide whether venom has
been injected or not and, if it has as shown by
local swelling, whether there are also any
systemic effects
3) Quite often there is no local swelling; if this is
still so after 2 hours, then it is unlikely that
venom was injected
4) Usually the snake is not brought with the
patient, even if it has been killed, and it is
necessary to rely on a description
5) A long black snake is likely to be a cobra, and
a short fat one a viper
Management
I. Reassurance is very important ( patients have been
known to die of fright after being bitten by a non-
venomous snake)
II. Give anxiolytics like diazepam 10mg if necessary.
When there is no evidence of venom having been
injected, reassurance is all that is needed.
111. If there are signs of systemic poisoning,
give Antivenom in adequate dosage of at least
40ml. Read the instructions on the antivenom
carefully. Give it I.V. very slowly for about 15
minutes. The response is usually good. If it is
not, give another larger dose. Repeat the dose if
symptoms recur after first improving
1V. If reaction occurs, stop the injection and give
adrenaline 1/1000 0.5ml S.C or hydrocortison
100mg I.V. Start the antivenom again very
slowly when the patient recovers.
V. If there is shock or anaemia, give blood
transfusion in the same way as for any other
form of bleeding
V1. If necrosis develops around the bite, then
ATS (or tetanus toxoid if the patient has been
immunized against tetanus previously) should be
given. This is not necessary for non-necrotic
bites.
V11. Avoid using a tourniquet in case of a snake
bite. The limb should not be moved actively
 SPITTING COBRAS

 This type of cobra can spit venom several

meters at a person`s face.
 It usually goes into the eyes which becomes
very red & painful, with swelling of the
conjunctiva.
 The cornea may be affected, leading to later
scaring & sometimes blindness.
 There are no systemic effects
Management
a) The eye should be washed out immediately &
repeatedly, preferably with copious amounts of clean
water.
b) After thorough washing, apply tetracycline antibiotic
eye ointment 8 hrly, to prevent secondary infection.
c) If the pain is still severe, surface anaesthetic drops
(e.g. amethocaine) may be given and then cover the
eye.
 SCORPION STING

 Stings from scorpions are common in the

warmer areas.
 The only effect, usually is severe local pain;
systemic poisoning is very rare.
Management
a) Relieve pain by injecting a local anaesthetic
around the bite & repeat if necessary.
b) Hydrocortison
 SPIDER BITE

 The effects of spider bites, if any, are local,

just like those of a scopion bite.
 FISH STING

 Two fish are important in this respect

a) Scorpion fish and
b) Stone fish
 Both have spines on their backs which sting on contact
 The scorpion fish swims about near coral reefs, and is fairly
easily avoided but the stone fish is very difficult to see as it lies
on the sea bed & is easily trodded on.
 Stings from these fish cause severe pain, which may last
several days, and there may also be systemic symptoms &
collapse.
 Secondary infection is common
Management
1. Remove the venomous spine
2. Putting the limb in water as hot as can be borne
(not more than 45 degrees Celsius) is sometimes
helpful.
3. Vomiting, bradycardia & hypotension imply
parasympathetic stimulation. Try atropine 0.6mg
s.c
4. Treat local secondary infection
 CONE SHELL STING

 These sea shells can give a dangerous sting if

handled
 There is local pain and swelling, and there
may even be generalized paralysis.
 There is no specific treatment
 BEE & HORNET STINGS

 These normally produce only local pain, but if the patient

is hypersensitive to the sting, or if he is stung by a large
number of bees, there may be serious or even fatal results
Management
a) For a mild reaction, give an antihistamine, e.g.
chlorpheniramine 4mg 8 hourly
b) For seriously affected patients, give adrenaline 1/1000
0.5ml IM; and then 100mg hydrocortison I.V if
necessary.
c) If there is circulatory collapse, give I.V fluids
NB: Bees leave their stings in the skin, with the
venom sacs attached to it; it is therefore
important to pull the stings out with the fingers.
Scrape off any sting still present with a razor
blade, or brush them off.
 FIN

END

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