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    مصطفى ابراهيم سعيد
    1. The initial approach to any poisoned patient should be the same, starting with an ABCDE assessment and ensuring airway patency, breathing support, circulation monitoring and treatment if needed, neurological examination, and exposure evaluation. 2. Risk assessment is key, considering factors like ingested agent and dose, time since ingestion, clinical features, and patient characteristics to predict prognosis and guide management. 3. Management focuses on preventing further poison absorption if possible via decontamination methods like activated charcoal or cathartics, as well as enhanced elimination using techniques like forced diuresis or dialysis and administering appropriate antidotes.

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    11 views9 pages
    1. The initial approach to any poisoned patient should be the same, starting with an ABCDE assessment and ensuring airway patency, breathing support, circulation monitoring and treatment if needed, neurological examination, and exposure evaluation. 2. Risk assessment is key, considering factors like ingested agent and dose, time since ingestion, clinical features, and patient characteristics to predict prognosis and guide management. 3. Management focuses on preventing further poison absorption if possible via decontamination methods like activated charcoal or cathartics, as well as enhanced elimination using techniques like forced diuresis or dialysis and administering appropriate antidotes.

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    1. The initial approach to any poisoned patient should be the same, starting with an ABCDE assessment and ensuring airway patency, breathing support, circulation monitoring and treatment if needed, neurological examination, and exposure evaluation. 2. Risk assessment is key, considering factors like ingested agent and dose, time since ingestion, clinical features, and patient characteristics to predict prognosis and guide management. 3. Management focuses on preventing further poison absorption if possible via decontamination methods like activated charcoal or cathartics, as well as enhanced elimination using techniques like forced diuresis or dialysis and administering appropriate antidotes.

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    11 views9 pages

    سموم نظري١

    Uploaded by

    مصطفى ابراهيم سعيد
    1. The initial approach to any poisoned patient should be the same, starting with an ABCDE assessment and ensuring airway patency, breathing support, circulation monitoring and treatment if needed, neurological examination, and exposure evaluation. 2. Risk assessment is key, considering factors like ingested agent and dose, time since ingestion, clinical features, and patient characteristics to predict prognosis and guide management. 3. Management focuses on preventing further poison absorption if possible via decontamination methods like activated charcoal or cathartics, as well as enhanced elimination using techniques like forced diuresis or dialysis and administering appropriate antidotes.

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    of 9

    Clinical Toxicology

    Important Rule
    All poisoned patients should be managed as if they have a
    potentially-life –threatening intoxication, although they
    appear normal.
    The initial approach to the poisoned patients should be
    essentially similar in every case, irrespective of the toxin
    ingested.
    This approach can be termed as (routine poison
    management).

    Introduction
    Poisoning can result from exposure to a variety of substances,
    ranging from household cleaning product to pesticides. However,
    prescription and over the counter medications account for nearly one
    half of poisoning exposures.
    Evaluation: involves recognition that poisoning has occurred,
    identification of agents involved, assessments of severity and
    prediction of toxicity.
    Management: is directed to the supportive care, prevention of
    poison absorption or enhancement of elimination, and appropriate the
    administration of antidote.
    Initial evaluation
    ABCDEs: Clinician who treat poisoned patients
    should have a systematic and consistent approach to
    evaluation and management.
    This should start with:
    The standard Airways, Breathing, Circulation,
    Disability and Exposure (ABCDE) approach:

    Airway
    Airways should be kept patent and any suspicion for obstructing
    material must be removed. The most common factor contributing to
    death from poisoning is loss of airway-protective reflexes with
    subsequent airway obstruction caused by: Flaccid tongue or
    pulmonary aspiration of gastric contents.
    Breathing:
    Evaluate respiratory rate and if available ,oxygen saturation. If there
    is no oxygen monitor available but the patient has an elevated
    respiratory rate, consider supplemental oxygen.

    Circulation:
    A prompt assessment of vital signs and hydration status is essential.
    A. Check blood pressure and pulse rate and rhythm.
    B. Begin continuous ECG monitoring.
    C. Secure venous access.
    D. Draw blood for routine studies.
    E. Begin intravenous infusion if the patients is hypotensive, normal
    saline or another isotonic solution is preferred.
    Disability(Neurological)
    A decrease level of consciousness is the most
    common serious complication of drug overdose or
    poisoning. In patients that are presented with seizures,
    it is important to check the blood sugar level.
    If the blood sugar level is <72md/dl, then administer
    50ml of 50% dextrose IV, Toxic seizures should be
    treated with IV benzodiazepine, Seizures refractory to
    benzodiazepine can be treated with barbiturates.

    Exposure(evaluation of temperature)
    Consider the possibility of toxic syndromes
    associated with hyperthermia (toxic levels of certain
    drugs can lead to significantly elevated body
    temperature).

    Definitive care with poisoning


    Try to identify the poison.
    Accurate and complete history from sources other than
    patient(family, friends, pharmacist, and pill bottle at the scene).
    Attempt to establish the time and the amount of the ingestion.
    Supportive Care and Monitoring
    Remember that acute poisoning is a dynamic illness and the patients
    condition may fluctuate over time. Therefore repeated examination
    and ongoing clinical assessment and management are required.
    Physical examination
    This may provide guide as to what the drugs ingested were:
    Important aspects of the examination include:
    Vital signs(PR,RR,BP,temp,O2 saturation if available).
    Neurological exam(pupil size, mental sate, tone, reflexes, clonus,
    focal signs).
    Skin (colour, sweating absent/present).
    Dry mouth/salvation, bowel sounds, urinary retention
    Evidence of trauma.

    Risk Assessment
    An early, accurate risk assessment is the key to managing acutely
    poisoned patients. It enables us to predict the likely clinical course,
    potential complication, and to plan the management of the patient.
    5 steps of a risk assessment:
    1. Agent(s)
    Asses whether the ingested agents are likely to cause significantly
    toxicity.
    2. Dose(s)
    Calculate the dose taken in mg/kg body weight, use this information
    to predict likelihood of significant toxicity.

    3. Time since ingestion


    This is important for determining the likely clinical progress of the
    patient, and to guide management.
    4. Clinical features and progress
    Correlate the patients clinical features and progress with the dose
    taken and time since ingestion.
    5. Patient factors(weight and co-morbidities)
    Consider individual patient factors that may put the patient at
    particular risk.
    Investigation
    1. Blood sugar level
    2. ECG_ look for:
    -Rate (Bradycardia or Tachycardia)
    -Rhythm
    Management
    The management of poisoning is directed towards
    1. The prevention of further poison absorption
    2. The increase of poison elimination
    3. Use of an antidote (if appropriate)

    Prevention of further poison


    absorption
    1-Dermal Exposure
    *Remove all clothing
    *Washing skin gently with soap and water for at least 30 minutes.
    2- Eye Exposure
    *Washing conjunctiva with running water or normal saline for 20
    minutes.
    *Solid corrosive should be removed by forceps.

    3-GIT Exposure
    *Gastrointestinal Decontamination
    *Induction of emesis
    *Gastric lavage
    *Activated Charcoal
    *Cathartics
    *Whole bowel irrigation
    INDUCTION OF EMESIS
    Ipecac syrup: the only safe method for induction of vomiting, should
    be given within 30 minutes of poison.
    Syrup of ipecac should no longer be used routinely as a poison
    treatment intervention in the home.
    Emesis Contraindication
    1.Convulsion
    2.Corrosives
    3.Hydrocarbon
    4.Coma
    5. Less than 6 months of age (not well develop gag reflex).

    GASTRIC LAVAGE
    Used in hospital when emesis was failed or there was
    contraindication for it.
    Gastric lavage is effective in the first 4-6 hrs after ingestion.
    Technique:
    1.An assistant with suction machine should be available.
    2.Dentures ,mucous,vomitus should be removed from patients mouth.
    3. Proper tube size to be selected according to the patient age.

    Activated charcoal
    Adsorption of a wide variety of drugs and chemicals. It is
    not digested; it stays inside the GIT tract and eliminated the
    toxin when the person has a bowel movement. Adult dose is
    1gm/Kg.
    Indication: (all of these must be met)
    Within one hour of time of ingestion
    Patient at risk of significant toxic effects
    Patient NOT at risk of airway compromise
    Activated charcoal
    Contraindication:
    Non-toxic ingestion
    If an oral antidote is given
    Seizures, coma
    Corrosive
    Agent not bound to activated charcoal:
    Hydrocarbons, alcohols and corrosive (acids, alkali)

    CATHARTICS(laxative)
    These are substance that enhance the passage of material through GIT
    and decrease the time of contact between the poison and the
    absorptive surfaces of the stomach and intestine.
    A)Osmotic cathartics: increase osmotic pressure in the lumen, as
    Magnesium sulfate.
    B) Irritant cathartics: act by increase motility, such as castor oil.
    Contraindication:
    GIT hemorrhage, Recent bowel surgery, Intestinal obstruction.

    WHOLE BOWEL IRRIGATION


    The goal of WBI is to clean GIT from nonabsorbed ingested toxins.
    Polyethylene glycol electrolyte solution are used and administered by
    gravity.
    Indications:
    Ingestion of a toxin that is known to be poorly adsorbed by A
    charcoal.
    Ingestion of massive amounts of drugs.
    Ingestion of sustained-release or enteric-coated preparation.
    Removal of ingested packets of illegal drugs (body packers).
    ANTIDOTE
    A therapeutic substance used to counteract the toxic actions of a
    specific xenobiotic.
    Antidote are classified according to mechanism of action into
    1-Interacts with poison to form a nontoxic complex that can be
    excreted e.g. chelators
    2.Accelerate the detoxification of the poison:N-
    acetylcyteine,thiosulfate.
    3.Decrease the rate of conversion of poison into its toxic metabolites:
    Ethanol, Fomepizole.

    4-Compete with poison for certain receptors:


    Naloxone.
    5-Block the receptors through which the toxic effects
    of the poison are mediated: atropine.
    6-Bypass the effect of the poison:O2 treatment in CO
    and cyanide toxicity.
    7-Antibodies to the poison: digiban, antivenoms.

    Antidote are classified into


    1-Physical Antidote Agents used to interfere with
    poisons through physical properties, not change their
    nature
    a) Adsorbing: the main example is activated charcoal.
    b) Coating: a mixture of egg and milk makes a coat
    over mucosa.
    c) Dissolving: 10% alcohol or glycerin for carbolic
    acid.
    2-Chemial Antidotes
    a)Oxidizing: Amyl Nitrite is used in cyanide toxicity.
    b) Reducing: Vitamin C: used for drugs causing Met-
    Hb.
    c) Precipitating: Starch, it makes blue precipitate with
    iodine.

    3-Physiological(Pharmacological)
    Antidote
    a)Antagonism
    1-Competitive Antagonists
    2-Non-Competitive Antagonism
    b)Chelating Agents
    Unite metallic poisons to form soluble, nonionizable, less toxic, and
    easily excreted chelates.e.g Dimercaprol (BAL)
    C)Antibodies (Immunolgy-based Antdotes) e.g. Digoxin Specific
    Antbody Fragment (FAB fragments, Digiband)

    ENHANCEMENT OF POISON EXCRETION


    1- Forced Diuresis
    It is a simple method for some poisons. It is effect is increased with manipulation
    of urine Ph.e.g. Fluid Diuresis, Osmotic Diuresis as mannitol 10%.
    2-Dialysis
    By allowing toxic substances to pass through semi-permeable membrane
    depending on the concentration gradient. It is beneficial when renal function is
    impaired.
    a)Peritoneal dialysis
    b)Hemodialysis
    3-Hemoperfusion
    Using equipment and vascular access similar to that for hemodialysis,the blood is
    pumped directly through a column containing an adsorbent material (either
    charcoal or resin).

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