Management of the poisoned or

overdosed patient

Delelegn G. ( B.Pharm, MSc.)

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 Introduction
• Poisoning: Exposure to a substance that is toxic in any amount.
• Overdose: Exposure to substance in excess amount resulting in
toxic effects.
• Indicators include:
 Sudden onset of CNS signs: Seizures, Coma,
 Decreased level of consciousness, Bizarre behavior
 Sudden onset of Abdominal pain, N, V etc…
 Sudden onset of unexplained illness

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Clinical management of toxicologic emergencies

• Poisoning is a medical emergency and requires rapid treatment

• Whether in hospital emergency room or in the field

• Management has five basic elements:

1. Stabilization of the patient (supportive care)

2. Clinical evaluation (history, physical examination, and laboratory

and/or radiological tests)-Identification of a poison

3. Prevention of further absorption (decontaminations)

4. Promotion of poison removal (enhancement of elimination of

toxicants)

5. Use of specific antidotes

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 1. Supportive care (stabilization of the patient)

• Is the most important element in managing acute poisoning

• Support is based on the clinical status of the patient
• It is the first step in the t/t of a potential poisoning
• Requires no knowledge specific to the poison involved
• Maintenance of respiration and circulation are primary concern:
airway, breathing, circulation (ABC)

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 Supportive care …..

• Most common cause of poisoning death is loss of airway/aspiration

 Insertion of an airway, administration of humidified oxygen, and
mechanical ventilation
• Volume depletion results from vomiting, diarrhea, sweating
 restored by administration of normal saline or ringer solution

• Levels of blood glucose should be monitored

 IV dextrose should be given immediately even if information
about glucose level is not known.

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 Supportive care …..
• Acid-base disturbance may occur
• Determination of arterial blood pressure and its management
• If convulsion develops, IV diazepam is the treatment of choice
• Supportive care may also include psychiatric assessment in case of
deliberate ingestion or exposure

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2. Identification of a poison (Clinical evaluation)
 history of the event

Determination of substance ingested and time of exposure

By inspection of the area adjacent to the victim and questioning

of any potential witnesses

 Fact finding mission – patient, family, friends, empty packets

 Physical examination:

Identification of clinical signs and symptoms that, together, are

likely associated with exposure from certain classes of toxic

agents.
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The identification of the toxic syndrome or “toxidrome,”
 Identification of a poison…….
Common Toxidromes and Their Clinical Features
Anticholinergics Dry mucous membranes, flush skin, urinary retention, decreased
bowel sounds, altered mental status, dilated pupils, cycloplegia

Sympathomimetcs Psychomotor and physical agitation, hypertension, tachycardia,

hyperpyrexia, diaphoresis, dilated pupils, tremors; seizures (if
severe)
Cholinergics SLUDGE (sialorrhea, lacrimation, urination, diaphoresis, gastric
emptying), BBB (bradycardia, bronchorrhea, bronchospasm),
muscle weakness, intractable seizures
Opioids CNS depression, miosis, respiratory depression, bradycardia,
hypotension, coma
Benzodiazepine Mild sedation, unresponsive or comatose with stable vital signs;
transient hypotension, respiratory depression

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 Identification of a poison…….

Laboratory Procedures
• Initializing emergency measures should not depend on obtaining

laboratory results

• Qualitative and quantitative analysis

• Arterial blood gases

• Electrolytes

• Renal function tests

• Serum osmolality

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Electrocardiogram 9
 3. Prevention of further absorption of exposure
 Helps to minimize the blood level of the poison and thereby
significantly decrease morbidity and mortality
 Initially involves removing the patient from the environment
 When poison exposure is topical, surface decontamination is done
 For ingested poison, the four primary methods currently available for
reducing absorption are:
1. Giving activated charcoal
2. Induction of emesis with syrup of ipecac
3. Gastric lavage
4. Whole bowel irrigation
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Prevention of further absorption…..
Activated charcoal

• Is an inert substance that adsorbs drugs and other chemicals

and thus prevents their absorption from GI tract

• Charcoal selectively adsorbs large molecules that contain a

carbon atom/high molecular weight organics

• not effective for metals such as lead or iron, acids, and alkalis

• Is preferred method for removing poisons from the GIT

• It should be administered no later than 60 minutes.

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Prevention of further absorption…..
• Dose: 1-2 g/kg as a slurry
 is given orally or can be given via lavage tube, NG tube

• Advantages: Inexpensive, safe, nontoxic, effective modality with

wide indications
• Limitations: inability to bind small, ionized molecules
 Drugs: ferrous sulfate, lithium
 Pesticides: malathion, DDT, N-methyl carbamate
 Industrial chemicals: cyanide, lead, mercury, alkalis, acids

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 Prevention of further absorption…..
2. Syrup of ipecac
• It induces vomiting and thereby remove ingested poison from
the stomach
• Vomiting usually occurs 20-30 minutes after ipecac
administration.
• Rarely used anymore

• MOA: Stimulating the CTZ of the medulla, and irritating the

stomach→ emesis

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 Prevention of further absorption…..

• Dose: 15 ml if 12 months to 12 years old, 30 ml if >12 yrs old

 Dose may be repeated if emesis dose not occur in 20-30 min.

• Most common side effects are sedation and diarrhea

• Ipecac should not be administered after ingestion of:

 Corrosive acids or bases
 Hydrocarbons with a high potential for aspiration
 Substances that can cause a rapid loss of consciousness
 Substances that could cause seizure

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 Prevention of further absorption…..
3. Gastric lavage
• Rinsing the patient’s stomach with water or saline lavage solution by
means of a tube inserted
• Potential complication of mechanical injury to the throat, esophagus,
and stomach may occur
• Will not remove large tablets, sustained release tablets
• Used when charcoal is not effective enough
 Lithium, iron, massive aspirin

• Contraindications
 Convulsions, Petroleum distillates
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 Unconscious patients unless airway is protected
 Prevention of further absorption…..
4. Whole Bowel Irrigation
• performed by administering a bowel cleansing solution
 sodium sulfate and polyethylene glycol electrolyte solution

 orally or by gastric tube at a rate of 0.5 L/hr in children and 2L/hr

in adults until rectal effluent is clear
• This method decreases absorption of salicylates, lithium, and
ampicillin
• It has also been used in overdoses of iron and zinc sulfate and in
removing ingestion of cocaine packets

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4. Promotion of poison removal/ elimination

A) Drugs that enhance renal excretion of poisons

 forced diuresis, eg, mannitol or furosemide or
 changing the pH of the urine

Alkalinization or acidification of urine

• Changing the pH of the urine can accelerate the excretion of
organic acids and bases.
• The mechanism underlying these effects is called ion trapping.

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Promotion of poison removal……

• Ascorbic acid or ammonium chloride is used to acidify the urine

(pH 5-6).
• Sodium bicarbonate alone or with acetazolamide is used for
alkalinization (pH 7-8).
• By alkaline diuresis:
 Salicylates, barbiturates, isoniazid
 ethylene glycol, alcohol

• By acid diuresis:
 Amphetamine, quinidine, strychnine
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 Promotion of poison removal……
B) Non-drug methods of poison removal
• Peritoneal dialysis, hemodialysis, exchange transfusions
• It is costly and requires specially trained personnel
• Non-drug procedures are most effective when:
 Binding of toxicants to plasma proteins is low
 Blood level of toxicants is high

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 Promotion of poison removal……

Peritoneal dialysis
• Works based on the laws of diffusion.
• Chemical diffuses from blood/mesenteric capillaries through the
peritoneum into the dialyzing fluid introduced into the peritoneal
cavity
• Solution of 1-2 L is introduced over a period of 15-20 min and left
for 45-60 min and then removed.

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Promotion of poison removal……
• The procedure is simple and with lowest risk for causing
complications; but it is less effective.
• Limited use in poisoning (clears drugs with low Mwt., Small
Vd, minimal protein binding & those that are water soluble)
 Alcohols, NaCl intoxications, salicylates

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 Promotion of poison removal……

Hemodialysis
• Two catheters are inserted in patient’s femoral vein about 2 inches
apart
• Blood is pumped from the catheter through the dialysis unit and
returned through the other catheter; continue for 6-8 h.
• Hemodialysis machine pumps the patient’s blood through a
dialysis membrane.
• Although more difficult than peritoneal dialysis, it is about 20
times more effective.
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 Promotion of poison removal……
• May also be used temporarily or as long term if the kidneys are
damaged due to the overdose
• Optimal drug characteristics for removal:
 relative molecular mass (< 500 D)
 water soluble
 small Vd
 minimal plasma protein binding

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 Promotion of poison removal……
Exchange transfusion
• Exchange transfusion is the technique of removing blood from a
patient, followed by transfusions of the similar quantity of blood
from a donor
• The process is usually repeated several times, in order to remove a
sufficient quantity of the toxin.
• helpful in situations of hemoglobin toxicity or in cases of severe
hemolysis
• This technique is rarely used except in neonates.

• The complications are those associated with the risk of transfusions

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 5. Use of specific antidotes

• An antidote is an agent administered to counteract the effects of a

poison
• Once the agent responsible is suspected or identified,
administration of an antidote may be necessary.
 Antidotes are associated with their own adverse reactions and
toxicity
 Their effectiveness also compromised in the presence of
overdose from multiple agents

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 Use of specific antidotes …..
Mechanisms of action of antidotes
 The formation of inert complexes between the poison and the

antidote
 Activated charcoal, chelating agents, Immunoglobulins/antitoxins

 Influence on the metabolism of the poison by the antidote in such a

way that the toxicity is eliminated or modified
 Acetylcysteine vs paracetamol

 The action of the poison is antagonized by the antidote at receptor

sites
 Flumazenil vs benzodiazepines
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 Use of specific antidotes …..

 The chemical injury is healed or counteracted by the antidote

 Amyl nitrite: In cyanide poisoning, improvement of
microcirculation and tissue oxygenation
 Antidotes act on different targets
 enzymes, receptors
 displacement of tissue binding sites
 replenishing the essential substances
 binding to poison

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