Clinical Toxicology Lines

Approach to the Poisoned Patient

Unit 1:
Overview
 100-500/100.000:
Acute poisoning is a Common Emergency Medical Presentation.
Between 100 and 500 acute poisoning presentations annually / 100 000 population In ED.
 Dynamic –Hetogenous process:
Acute poisoning
is a dynamic medical illness
with a common exacerbation to life-threatening presentation in a chronic psychosocial disorder.
with a marked heterogeneous patient pattern categories:
Intentional self-poisoning (Suicidal pattern)
Substance of abuse
Occupational poisoning
Envenoming poisoning with large spectrum of variable presentations.
 Strong & Simplified Clinical Approach:
In clinical Toxioclogy Practice WE NEED……..
A strong and simple clinical approach for all the clinician who deal with a variable heterogeneous pattern of
Acute Intoxicated cases.
With Individually fit for every type of poison separately.
 Predictive outcome:
The MAIN step of Any Strong Toxicology Approach IS:
….Risk Assessment Process….
It is a pure mental Process
By which the clinician PREDICT:
The suspected CLINICAL course
The possible complications
FOR specific Individual TOXIC PRESENTATION
 Risk Assessment Process:
It should wherever possible be QUANTITATIVE process which mainly depend on:
Type of Agent
Dose of Agent
Time of ingestion
Clinical manifestation and progress pattern.
Individual patient factors (e.g. weight and co-morbidities).
 Principle of toxicity treatment plan:
It is mainly depend ON involved Agent type.
According agent type the management priorities were detected TO avoid:
Unnecessary Intervention
Unnecessary Investigations
 Risk Assessment ORDER in Management PLAN:
Risk assessment is followed the resuscitative procedure in the management of acute poisoning.
Risk assessment is preceded the subsequent management procedure (((According to Risk Assessment Decisions)))
Supportive care and monitoring
Investigations
Decontamination
Enhanced elimination techniques
Antidotes
Disposition
All previous procedures must be Order in the Well Structured
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 Medical and psychological management:
 Any poisoned patient needs both medically and psychologically support.
 If medical requirements more than the capacity of local health services resources, it is immediately early
communication with more specialised health facilities with organized planning of early disposition.
 Strategy of the current book:
In this Clinical Toxicology LINE, the author:
Organizes a systemic risk approach in the management of Acute Poisoning Cases in the ED.
Specifies a certain chapters cover the pharmaceutical, chemical and natural toxins of most importance to the
practitioner in emergency departments in Egypt.
Structurize this book also for emergency paramedic personnel and general staff in ICU.
The basic principles of this book structure mainly depend ON:
Bedside Toxicology Case Management.
Phone Toxicology Case Consultation.
The author has directly cared for many thousands of patient in the Mansoura Toxicology Unit-Egypt and offered
consultation in thousands more acute poisoning across Saudi Arabia.
This BOOK Covers
The commonest involved Agents in clinical Toxicology Practice.
The commonest involved Agents in clinical Toxicology Phone consultation Services.
The rarest involved Agents in clinical Toxicology Practice but with life-threatening poisonings effects.
The most important Antidotes & Antivenoms, in practical Toxicology Field with PRACTICAL
INFORMATION regarding:
Administration Routes, Dose & Adverse effects.
The characteristics pitfalls, handy tips, controversies and pearls about a real situations in clinical toxicoplogy
practice and not for fantasy.
 New Strange Branch of Emergency Medicine:
This branch is a new branch of Emergency Medicine.
When compare the different scientific resources in the clinical toxicology branche, I find a very surprises notes and
strange information.
I hope this book unify the note in ONE well ORGANIZED approach to improve the care deliveried to the poisoned
patient.

 Poisoning Problem on top of Other Problem:

Poisoning cases are usually situated on the top of other problem like:
Psychiatric problems
Social problems
Drug problems
Alcohol problems.
Primary care should be directed to Acute Intoxicated Conditions
Secondary care should be directed to Predisposing Conditions to obtain more Optimistic Outcome in this vulnerable
group of patients.
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Risk-assessment-based approach to poisoning

Resuscitation:
Airway
Breathing
Circulation
Detect and correct
-↓ Hypoglycaemia
-↓↑Hypo/Hyperthermia
-↑ Hyperactivity of CNS (Seizures)
Emergency antidote administration
Risk assessment
Type of suspected agent (s) identification
Total amount of ingested dose (s) detection
Time since ingestion calculation
Together administration (Single or Combined exposure)
Toxicity pattern: Reported Clinical Manifestations and Course Pattern. Discovered Patient
Predisposing Factors.
Supportive care and monitoring
Investigations
Screening
Paracetamol
ECG
Blood glucose level (BGL)
Specific:
Essential test(s)
Recommended test(s)
Non-recommended test(s)
Decontamination
Enhanced elimination
Antidotes
Disposition
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Resuscitation
Introduction
 Leading cause of death:
Poisoning is a leading cause of death in patients under the age of 40 years
Poisoning is a leading differential diagnosis when cardiac arrest occurs in a young adult.
 Prolonged resuscitation period:
Toxicity induced cardiac arrest is unlike cardiac arrest in the older population.
Toxicity Induced Cardiac Arrest has a NO limited time of performance, even extend for prolonged periods
(hours).
Toxicity induced cardiac arrest will be followed with a good neurological prognosis even after prolonged
resuscitations period (HOURS).
Suspected Toxicity induced cardiac arrest resuscitation procedure should be maintained until obtaining a
Toxicology Expert Advice.
 Bridge therapy:
It represent in Extracorporeal membrane oxygenation therapy (ECMO)
It may provide life-saving bridging therapy in selected cases of:
Severe refractory shock
Adult respiratory distress syndrome.

TABLE 1.2.1
Resuscitation DECONTAMINATION (DERMAL or GIT)
Resuscitation: Procedures
Airway Are Never Perform Before
Breathing RESUSCITATION and supportive care
Circulation
Detect and correct
-Hypoglycaemia.
Diagnosis: Check beside blood glucose level (BGL) in all patients with altered mental status.
Treatment: Treat it if BGL < 50 mg/dl
-Hypo/Hyperthermia
Diagnosis: Check core body temperature
Treatment: Urgent Intervention, if body temperature > 38.5 ͦ C or < 35.5 ͦ C
-Hyperactivity of CNS (Seizures)
Characters: Always generalized when due to toxicological causes.
Treatment: Benzodiazepines is the first line
Emergency antidote administration

Airway, Breathing and Circulation

Dynamic medical illness:
Acute poisoning is a dynamic medical illness
Acute intoxicated patients may deteriorate within a few minutes or hours of presentation.
Acute intoxicated COMMON life threatening Signs in any intoxicated patients are:
CNS Disturbances: Altered conscious state
RS Disturbances: Loss of airway protective reflexes
CVS Disturbances: Hypotension.
Priority of treatment:
As in all life-threatening emergencies, ABCare
Cornerstone of MANAGEMENT.
Applied as the basic conventional lines.
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 Responsible for the high survival rates in if applied with basic resuscitative and supportive care measures IN
MAJORITY of PATIENTS
Clinical Toxicology Lines

Coma score validity:

Glasgow Coma Scale (GCS) & Alert-Verbal-Pain-Unresponsive (AVPU) system are:
IN MOST of CLINICAL CONDITIONS: Effective system to detect clinical Score & patient’s mental
status condition.
IN MOST of Intoxicated CONDITIONS: In-Effective system (Never Been Systemically Validated) for
All types of Poisonings.
In intoxicated patients:
Ability to protect their airway is not well correlated to GCS.
JUST GCS < 15 is associated with High Risk of aspiration.
Sharpen Dynamic Changes:
Within a very short period:
A patient's ability to protect the airway and ventilate effectively may change MARKEDLY.
Standard Algorithm:
In some specific situations, standard resuscitation algorithms do not apply.
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Specific resuscitation situations in Toxicology Practice where conventional algorithms or approaches

may not apply.
Life- Mechanism Agent (s) Comments
threat
AIRWAY
Airway compromise Corrosive injury to  Alkalies  Stridor, dysphagia and dysphonia indicate:
Oropharynx  Acids Airway injury
 Glycophosphate Airway compromise.
 Paraquat  Early endotracheal intubation or surgical airway
OFTEN REQUIRED.
BREATHING
Acidosis Various  Methanol  High Respiratory Compensation Is the MAIN Characteristics:
Acidaemia  Salicylates Until The Late Stage In The Clinical Course.
 Ethylene glycol  Recommended Procedures:
Intubation, hyperventilation & sodium bicarbonate
Intubation, maintained hyperventilation and bolus IV sodium
bicarbonate 1-2 mmol/kg to prevent worsening of Acidaemia are
Mandatory Line of Treatment.
 Non-Recommended Procedures:
Intubation and normo or hypoventilation
Intubation and ventilation at standard settings (normo- or
hypoventilation) worsen Acidaemia and Precipitate Rapid Clinical
Deterioration, if not DEATH.
Hypoventilation Opioid mu receptor  Opioids  NALOXONE:
stimulation Immediate administration of naloxone may CANCEL
→ Intubation & Ventilation REQUIREMENT.
Respiratory failure Cholinergic crisis  Organophosphates  ATROPINE:
 Carbamates Rapid administration
 Nerve agents Serial doubling of the dose
UP TO Complete Dry Respirator Secretion
May replace adequate oxygenation.
Hypoxaemia Oxygen free radical-  Paraquate  SUPPLEMENTAL OXYGEN
mediated cellular injury, If no Hypoxia:
particulary Type III Avoid supplemental oxygen
If Hypoxia presents:
Give supplemental oxygen
Titrate it to maintain oxygen saturation of ̰90% or O2 60 mmHg.

CIRCULATION
Ventricular Hypocalcaemia  Hydrofluric acid  Defibrillation
fibrillation ingestion or extensive  IF alone unlikely to be efficacious.
cutaneous burns.  Calcium
 Bolus IV calcium
 60-90 mL 10 % Ca Gluconate
 Repeated as required every 2 minutes
 Until defibrillation restores perfusing rhythm.
Ventricular Fast Na+ channel Blockade  Cholorquine  Defibrillation or Cardio-version
tachycardia  Hydoxychloquine  Unlikely to be efficacious.
 Cocaine  Intubation and hyperventilation
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  Flecainide  Urgently performed.
 Local anesthetic  Sodium bicarbonate
agent  Bolus IV Clinical Toxicology Lines
 Procainamide  1-2 mmol/kg repeated every 1-2 minutes
 Propranolol  Until restoration of perfusion rhythm.
 Quinine  Lignocaine
 TCA  It is third-line therapy when pH is established at >7.5.
 Serum pH
 Do not await determination of serum pH prior to intubate & Na
bicarbonate boluses.
 Amiodarone and Procainamide (((Vaughan William type Ia antidysrythmic agnets)))
are:
 Are contraindicated.

Life- Mechanism Agent (s) Comments

threat
CIRCULATION-cont’d
Ventricular ectopy/ Toxin-induced myocardial  Hydrocarbon  Defibrillation or Cardio-version
Ventricular sensitisation to  Organochlorines  Unlikely to be efficacious.
tachycardia catecholamines.  Chloral hydrate  B-Blockers
 Administrate IV
 Titrate to ectopy response
Cardiovascular Fast Na+ channel Blockade  Local anesthetic  IV lipid emulsion:
collapse/ agent  It should be Consider.
Cardiac arrest.  Standard resuscitation protocols
 In addition to IV lipid emulsion.
Cardiogenic Various  Calcium channels  INSULIN
HYPOTENSION blockers  High-dose of INSULIN therapy.
(Refractory  Propranolol
Type)  Local anesthetic
agents
Tachycardia Central & peripheral  Amphetamines  Beta-blockers: Contraindicated.
Sympathomimetic  Cocaine  Benzodiazepines: Indicated
response. IV Administration
Titrated to gentle sedation and heart rate control.
Supra-ventricular Adenosine antagonism  Theophylline  Adenosine ineffective
tachycardia. - Beta-blockers titrate to effect.
- Urgent haemodialysis indicated.
Hypertension Central & peripheral  Amphetamines  Beta-blockers: Contraindicated.
Sympathomimetic  Cocaine  Benzodiazepines: Indicated
response. IV Administration
Titrated to gentle sedation and heart rate control.
 Glyceryl Trinitrate (GTN)- Phentolamine- Sodium Nitroprusside
They are titratable intravenous infusion.
They are use if further therapy are necessary.
Asystole + +
Na -K -ATPase pump  Digoxin  Basic Resuscitation:
Bradycardia inhibition Usual resuscitation intervention ARE Useless
Cardiac conduction  Antibodies:
defects Digoxin-specific antibodies.
pump   Atropine and Pacing:
Bradycardia + + Calcium channels
Na -K -ATPase
Hypotension inhibition blockers Unlikely to be efficacious.
Cardiac conduction  Calcium:
defects Bolus IV (e.g. 60 mL 10% calcium gluconate)
It may provide temporary haemodynamic stability, by ↑ HR and BP
While other treatments are organized.
 Insulin:
High-dose insulin therapy.
Acute coronary Central & peripheral  Amphetamines  Beta-blockers: Contraindicated.
syndrome Sympathomimetic  Cocaine  Benzodiazepines
response.  GTN
 Antiplatelet/anticoagulant therapy if no neurological deficit (other
cranial CT first).
 Reperfusion therapy: along conventional lines
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 OTHER
Hyperkalaemia + +
Na -K -ATPase pump  Digoxin  Calcium salts are contraindicated Clinical Toxicology Lines
inhibition  Digoxin-specific antibodies
Hypoglycaemia Hyperinsulinaemia  Sufonylureas  Glucose: Difficult to maintain euglycaemia with dextrose
supplementation ALONE.
 Octreotide: Its administration decrease requirement for dextrose.
Seizures Inhibition of GABA  Isonizaide  Pyridoxine: IV pyridoxine 1 g per gram of isonizaide ingested, up to 5 g.
production
Seizures Adenosine antagonism  Theophylline  Haemodialysis: Urgently indicated.

Detect and Correct SEIZURES

Aetiology:
The most common causes of seizures in poisoned patients are:
Tramadol
Amphetamines
Antidepressants: (Venlafaxine and Bupropion).
Benzodiazepine or Ethanol withdrawal
Characters:
i- Generalized seizures:
Toxic seizures are generalized.
ii- Focal seizures:
Focal or partial seizures indicates a focal neurological disorder, which may be:
a complication of toxicological cause
a result of a non-toxicological cause, and need further investigation.
Treatment:
Benzodiazepines:
IV (diazepam, midazolam or clonazepam (Usually controlled the attack)
Barbiturates:
2nd -line therapy for refractory seizures in acute poisoning.
Pyridoxine:
Indicated IN intractable seizures secondary to ISONIAZID.
Phenytoin:
CONTRAINDICATED in the management of seizures related to acute poisoning because:
Poor efficacy
Potential sodium channel blockade exacerbation, which may be a causative mechanism.

Detect and Correct HYPOGLYCAEMIA

Aetiology:
Hypoglycaemia in acute poisoning is associated with numerous agents including:
Insulin and oral hypoglycaemic (((sulfonylureas)))
Beta-blockers, salicylates and valproic acid.
Quinine and chloroquine.
Characters:
Hypoglycaemia is an easily detectable and correctable cause of significant neurological injury .
Bedside blood glucose level (BGL) estimation should be performed as soon as possible in All Patients With
Altered Mental Status.
Treatment:
If the blood glucose is < 50 mg/dl:
In children: 50 mL of 50% dextrose should be given intravenously
In children: 5 mL/ kg 10% dextrose to urgently correct hypoglycaemia.
If Confirmation of the results:
The result may be confirmed later with a formal BGL measurement.
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Detect and Correct Hyper-/ Hypothermia

 Hyperthermia:
Characters:
Hyperthermia is associated
with a number of life-threatening acute poisonings
…&…
with poor outcome.
>38.5°C: Need continuous core-temperature monitoring during the resuscitation phase of management.
>39.5°C: Need immediate Intervention in an prompt emergency management to prevent multiple organ failure and
neurological injury.
Treatment:
Neuromuscular paralysis with intubation and ventilation leads to:
↓ Muscle-generated heat production → Rapid ↓ of temperature.
 Hypothermia:
Characters:
Profound hypothermia (core temperature < 29 ° C) = Mimic Or Lead To cardiac arrest.
Clinical manifestations:
Coma
Fixed Dilated Pupils
Bradycardia (usually atrial fibrillation)
Hypotension.
Vital signs may be difficult to elicit and the cardiac rhythm may degenerate to ventricular fibrillation or
asystole.
Treatment:
Exogenous Rewarming:
In the patient with undetectable vital signs.
Aggressive exogenous rewarming is indicated
While CPR continues.
Cardiopulmonary bypass or extracorporeal membrane oxygenation (ECMO):
If available
It is the most effective means.
Pleural lavage
It is an alternative measure
Through an intercostal catheter with large volumes of fluid warmed to 40– 45 ° C
Emergency Antidote Administration
Indications:
Necessary EARLY ADMINISTRATION OF AN ANTIDOTE During The Resuscitation Phase of Management to
ensure a successful RESULTS.
Examples:
Sodium bicarbonate (IV) in TCA poisoning,
Atropine in severe Organophosphorus poisoning
Naloxone in severe Opioid poisoning
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 Digoxin-Specific antibodies for patients with suspected Digoxin poisoning with CVS compromise.
Clinical Toxicology Lines

3- Risk Assessment:
- Definition:
It is a cognitive function process by the clinician to predict the possible clinical course and potential complications
of the intoxicated individual patient at that particular situation.
- ORDER:
As soon as possible:
1st Resuscitation procedure (((a greater priority))).
2nd Risk assessment (((Should Preceded Any Line of treatment Except Resuscitation Procedure)))
- COMPONENTS:
5- Key Components:
The five key components of Risk Assessment from the history and examination are:
Type of suspected agent (s) identification
Total amount of ingested dose (s) detection
Time since ingestion calculation
Together administration (Single or Combined exposure)
Toxicity pattern: Reported Clinical Manifestations and Course Pattern. Discovered Patient Predisposing Factors.
-VALUE:
By application of Risk Assessment, Clinicians OBTAIN a Well Balanced Decision:
Between Benefits and Risks about All Subsequent Management Steps:
Supportive care and monitoring
Screening and specialized testing
Decontamination
Enhanced elimination
Antidotes
Disposition
- SOURCES:
The sources of history section in Risk Assessment Procedure:
I- Consciousness
i- Fully consciousness:
In fully consciousness, it is easily to obtain a clear history from the patient and the accurate risk assessment
can be constructed easily.
ii- Disturbed consciousness:
In disturbed consciousness, it is difficult to obtain a clear history from the patient and the inaccurate risk
assessment may be result.
2- Backup strategy
It is applied to help a more clarification of Risk Assessment Procedure which involves:
1. Asking ambulance officers circumstantial evidences.
2. Asking family members about suspected agents and agents potentially available to the patient.
3. Counting missing tablets
4. Checking medical records for previous prescriptions
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 3- Worst-case scenario:
It is a type of risk assessment. Clinical Toxicology Lines
It is applied in cases of toxicity of unwintess substances ingestion in a small child.
4- Geographical Individualized Presentation:
In unknown ingestions.
The patient's clinical status is correlated with the clinician's knowledge of the agents commonly available in that
geographical area.
For example, CNS and respiratory depression associated with miotic pupils indicates
Opioid intoxication in a young adult male in urban Area
Organophosphate intoxication in a young adult female rural Area.

- Accepted Correlation:
The agent, dose and time since ingestion should correlate with the patient's current clinical status.
If they do not, the risk assessment needs to be Reviewed and Revised.
- TIME dependent decisions:
Acute toxicity is a dynamic process that change a particular time points.
< 6 hours:
For example:
In tricyclic anti-depressant self-poisoning, life-threatening events occur within 6 hours (and usually within the
first 2 hours) of ingestion.
Any presentation after 6 hours ingestion can be presented AS Low Risk Ingestion.
> 6 hours:
For example:
In sustained-release ,calcium channel blockers, life-threatening events occur after 6 hours (1 st few hours are
Asymptomatic)
Any presentation after 6 hours ingestion can be presented AS High Risk Ingestion with highly (((Anticipation
for severe CVS effects))).
- Trivial poisonings:
In the MOST of cases, the risk assessment allows early recognition of Medically Trivial Poisonings, which has
multiple Values:
Reassure attending staff, family and patient
Avoid of unnecessary investigations, interventions and observation.
Allow early psychosocial assessment and discharge planning may start.
FROM ALL of the ABOVE ………. Shortens hospital length of stay.
- Serious poisonings:
In the LESS COMMON cases, the risk assessment allows early recognition of Potentially Serious Poisonings, which
has multiple Values:
Put a management plan strategy.
Detect the possibility decision about gastrointestinal decontamination procedure
Detect the appropriate probability decisions regarding selected investigations procedure.
FROM ALL of the ABOVE ………. Early communication and disposition planning may start……..
if a specialised procedure or antidote might be required in the next few hours.

- Roles of the Poisons Information Centre

Assess the degree of Toxicity:
Support the clinician to construct a clear opinion about the degree of toxicity for certain Agent According
TO available Information.
Record a NEW toxic Agent:
Record any new or unusual toxic agent exposures.
Individualised Risk Assessment:
PIC collect the data from all available sources like TextBOOks and DataBASES
It represent all of this information in a clear sharp Opinion for the physicians.
It is very difficult to interpretate the data directly from a textbook to individual cases.
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 PCC Call:
In cases of facing a critical poisoning emergency cases, the procedure to obtain theClinical
most effective procedure
Toxicology Lines
to OBTAIN
An Accurate Individualised Information about Risk Assessment IS PIC CALL
The Mansoura Poison Information Centre network comprises centre located in Mansoura city, that can be
accessed nation-wide by calling 0000000.
Trained poisons information toxicology specialists are familiar with accessing information from
computerized databases and other information sources.
PCC CALL can help the clinician to:
Identification of commercial products and their constituents.
Provide essential basic data about the suspected toxic agent.
Clinical Toxicologist Consultant:
Where necessary, medical callers treating an acute poisoning case are referred to an on-call clinical
toxicologist who is able to offer more detailed individualised risk assessment and management
advice.

4- Supportive Care and Monitoring

Supportive Care
 Order:
1st Resuscitation
2nd Risk assessment
3rd Supportive care and disposition planning can start after the 1st TWO step.

 Supportive Care = Support Vital Systems:

Poisoning morbidity and mortality usually result from the acute effects of the toxin on the:
CVS
CNS
RS
Support Care of these systems mainly (((beside other system)))
During a period of Intoxication will ENSURE
a good outcome for the vast majority of acute poisonings.
Monitoring
 Value:
By monitoring procedures are very valuable for detection of:
Progression pattern of intoxication.
Decision of admission
Decision of withdrawal of supportive Care.
 Characters:
Close Period of observation is USUALLY:
In the emergency department
Especially for the 1st 2 hours.
To monitor the Clinical Situations
A correlation Between Risk Assessments Results …&… Current Clinical Situations.
 Actions:
By detection of any Early Alarming Signs as:
↓ Level of Consciousness requiring intubation→ Immediate Intubate Before transferring to Any Other
part in the HOSPITAL.
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 By detection of any unexpected deterioration in clinical conditions:
1st Resuscitation Procedures are immediately performed. Clinical Toxicology Lines
2nd Risk assessment techniques are reapplied.
3rd Supportive care and monitoring are maintained
 Duration:
The duration of observation depends on:
The type of ingested agent(s)
The formulations involved (e.g. sustained-release preparations) agent(s)
The potential complications.
Short period of Observation:
For example, patients with significant Beta-Blocker and Tricyclic Antidepressant deliberate self-
poisoning
Develop symptoms and signs of major intoxication within 2– 4 hours of ingestion.
Long period of Observation:
For example, patients with sustained-release calcium channel blocker or valproic acid deliberate self-
poisoning
Develop symptoms and signs of major intoxication within 6– 12 hours of ingestion.

 ER Disposition:
Disposition from the emergency department depends on:
The current clinical status of the patient.
The expected clinical status of the patient.
If any specific deterioration in clinical status is anticipated Immediate ER disposition and Hospital
Admission.
According to anticipated complication (ICU admission or Ward admission)
 Documented Treatment Plan:
The accuracy and skill of the initial management and risk assessment are WASTED:
If the subsequent plan of management is not documented
If the subsequent plan of management is not communicated to the treating team.
Good practice in Clinical Toxicology Field includes:
The documentation of the all next mentioned ITEMS to be very clear with any individual looking after the
PATIENT
the documentation of a comprehensive management plan that informs the team looking after the patient of:
1. Expected Clinical Course
2. Excepted Complications ((( Depend On individual risk assessment)))
3. Observation and Monitoring Required Type
4. Observation and Monitoring End points Signs ((( Beyond Them must trigger notification for the treating
doctor or further consultation)))
5. Management Plans for Agitation or Delirium
6. Management Plans Changing Criteria
7. Formal Psychosocial Risk Assessment Indicating Criteria
 SITES:
The needs of the vast majority of patients can be applied in the
Emergency department
Emergency observation unit
It is the appropriate site for the management of most acute poisonings.
It is the most appropriate site for providing the general supportive measures of most acute poisonings.
Intensive care unit.
 Criteria for admission to an ICU following acute poisoning include requirements for:
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 1. A. Airway control
2. B. Ventilation Clinical Toxicology Lines
3. C. Prolonged or Invasive haemodynamic Monitoring or Support
…&…
4. Haemodialysis.

Airway
Intubation Supportive care measures
Breathing
Supplemental Oxygen
Ventilation
Circulation
Intravenous fluids
Inotropes
Control of hypertension
Extracorporeal membrane oxygenation
Sedation
Titrated IV benzodiazepines
Seizure control/prophylaxis
IV benzodiazepines
Metabolic
Ensuring normoglycaemic
Control of pH
Fluids and electrolytes
Renal function
Hydration (((Adequate)))
Haemodialysis
General:
Nutrition
Respiratory toilet
Bladder care (indwelling catheter)
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Prevention of pressure areas

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Thromboembolism prophylaxis
Mobilisation as metal status changes resolve
 Clinical Toxicology Lines

5-Investigations
Types:
In acute Poisoning are Two Types:
- Screening tests:
To detect the medical condition in Suspected Poisoned Patients
To diagnosis the poisoning conditions in Asymptomatic Poisoned Patients (((Early Diagnosis
Improve The Outcome)))
To detect occult ingestion (((Early specific treatment will applied)))
- Specific tests:
To Detect the poisoned ITSELF
The recommended screening tests for acute intentional poisoning are
ECG
- 12-lead ECG To detect HIDDEN lethal cardiac conduction abnormalities as In :
Rate
Rhythm Tricyclic Antidepressant Cardiotoxicity
R wave: Dominant R was in aVR
Interval: PR interval
Interval: QRS interval
Interval: QT interval
RBG
- a bedside blood glucose level To detect MISSED Hypoglycaemia especially with Disturbed
(BGL) Conscious Level :
Oral Hypoglycemic and Other Hypoglycemic Drugs
Intoxications
Paracetamol Level
- Serum Paracetamol Level  To detect MISSED Acetaminophen Toxicity.
 Average 15% of adult intentional ingestion is paracetamol.
 Early stage of acute paracetamol level is asymptomatic.
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  Timely administrated acetaminophen, in the asymptomatic stage
can prevent a high possibility of a complicated acute
Clinical fulminant
Toxicology Lines
hepatic failure.
 The cost of several thousand-serum paracetamol measurements
is offset by the detection of one potentially preventable
paracetamol-related death or liver transplant.
 Paracetamol, screening should be FOR:
ALL known acetaminophen poisoning.
ALL suspected acute intentional self-poisoning.
ALL known acetaminophen poisoning with altered mental status.
 If paracetamol level was not detected after 1 hour of ingestion:
 NO significant paracetamol ingestion
…&…
 NO further required paracetamol levels.
 If Suspected Paracetamol Level:
 No Initial Screening for paracetamol Level.
 Timed Paracetamol level is Required (4 hour Post-
ingestion).
Salicylates and TCA level:
- Serum Salicylates and TCA  Excluded from a routine toxicology screening tests
Levels Salicylate level:
Now becomes relatively Un-COMMON.
In severe toxicity, clinical manifestations and pH disturbances
are clearly easily diagnostic for toxicity and rarely hidden.
Never perform a screen in a completely asymptomatic patient
(No salicylism Signs and symptoms)

Salicylates and TCA level:

- Serum Salicylates and TCA  Excluded from a routine toxicology screening tests
Levels TCA level:
It is correlate with complication and prognosis.
Major TCA Complications:
Mainly occur in the 1st 2-4 hours
ECG:
It is the preferred screen diagnostic test.
It is more accurately reflect target organ TCA toxicity.

Other investigations:
 Non-Indications situations:
 Most of poisoned patients are Young and have No Associated Medical Conditions.
 SO, in young healthy patient with Fully Consciousness Level and Stable vital signs the routine screening test
are applied:
ECG
BGL
S. Paracetamol L.

 Indicating situations :
 Usuallyin a selective conditions, where it is anticipated that the results will help the risk assessment
procedure or management plan as in the following situations:
Diagnosis:
Exclude or Confirm
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 a decision result from risk assessment prognosis procedure.
an important Specific Poisoning Diagnosis. Clinical Toxicology Lines
an important Differential Diagnosis.
a complication that requires specific management.
Treatment:
Establish
an indication for antidote administration.
an indication for institution of enhanced elimination.
a follow up procedure to monitor response to therapy
a well defined end point for a therapeutic intervention.
 Types :
Non-Specific:
 SO, in poisoned patient with associated medical abnormalities , the non- routine screening test may be
indicated:
Electrolytes …&…Blood gases pH
Complete Blood Picture…&… Coagulation Studies
Liver function tests …&…Renal function tests.
Specific:
 Drug concentration:
For most patients and poisonings, the risk assessment and subsequent clinical course are the main basics to detect
management plan.
For few patients and poisonings, the drug concentration level assist in the risk assessment or management plan
decisions.
Useful drug levels that may assist risk assessment or management in specific settings:
Paracetamol Carbamazepine Ethanol Digoxin Iron
Salicylates Phenobarbitone Methanol Theophylline Lithium
Valproic Acid Ethylene Methotrexate
Phenytoin glycol

 Drug Positivity:
 There are reported in cases of substance of Abuse Detection (SOA).
 The qualitative urine screens for drugs of abuse (e.g. opioids, benzodiazepines, amphetamines,
cocaine, barbiturates and cannabinoids) rarely change the management plan of the acutely
poisoned patient.
 Patients with acute intoxication with one or more of these SOA agents are
Managed according to their CLINICAL PRESENTATION.
Not Managed according to their LABORATORY RESULTS.
Positive SOA results without S. & S. of Toxicity NO Change in the Acute Medical
Management.
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 Clinical Toxicology Lines

6-Gastrointestinal Decontamination
 NOT ROUTINE:
 Doctors have long directed great effort into attempts at gastrointestinal decontamination following ingestion of
toxic substances.
 They have employed a variety of methods (see Table 1.6.1) in the reasonable expectation that, by reducing the
dose absorbed, they will also reduce the subsequent severity and duration of clinical toxicity.
 Unfortunately, the tendency has been to overestimate the potential benefits while underestimating the potential
hazards of gastrointestinal decontamination procedures. These procedures do not provide significant benefit
when applied to unselected deliberate self-poisoned patients and are no longer considered routine.

TABLE 1.6.1 Methods of gastrointestinal decontamination

¤ Induced emesis
¤ Gastric lavage
¤ Activated charcoal
¤ Whole Bowel Irrigation

 The theoretical benefits of gastrointestinal decontamination in selected poisonings have not been evaluated.
The decision to decontaminate is one of clinical judgement in which the potential benefits are weighed against
the potential risks and the resources required to perform the procedure (see Figure 1.6.1 and Table 1.6.2).
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 TABLE 1.6.2 Clinical Toxicology Lines
Gastrointestinal decontamination: risk– benefit analysis

Potential benefits Potential risks

↑ Improved clinical outcome (morbidity and mortality) Pulmonary aspiration
↓ More benign clinical course requiring lower level of supportive Gastrointestinal complications
care - Bowel obstruction
- Perforation
↓ Reduced need for other potentially hazardous intervention or Distraction of staff from resuscitation and supportive
expensive antidotes. care priorities.
↓ Reduced hospital length stay Diversion of departmental resources for performance
of procedure.

FIGURE 1.6.1 Gastrointestinal decontamination triangle

Detection of Current Clinical Condition Status

Decontamination
Procedure

Decontamination Triangle
Detection of Current Clinical Condition Status

 Indication of, gastrointestinal decontamination is reserved for cases where:

1- The risk assessment predicts severe or life-threatening toxicity
…&…
2- The supportive care or antidote treatment alone is insufficient to ensure a
satisfactory outcome.
…&…
3- A strong indicator that there is a presence of a significant amount
of agent remains unabsorbed and is applicable to removal by the selected
Risk Assessment procedure. This requires some
knowledge of the absorption kinetics
of the agent(s) involved. For most
ingested agents, absorption is
virtually complete within 1 hour.
…&…
Potential Risks
4- Follow Potential
the application for resuscitation andBenefits
supportive care; gastrointestinal decontamination is never
performed to the detriment of basic resuscitation or supportive care. To avoid pulmonary aspiration, the
procedure is not performed without first securing the airway in a patient with a depressed level of
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 consciousness or in whom the risk assessment indicates a potential for imminent seizures or decline in
conscious state. Clinical Toxicology Lines

Induced Emesis (Syrup of Ipecac)

Traditional procedure: Emptying the stomach by inducing emesis has a long tradition in clinical toxicology but has
recently been all but abandoned. Administration of syrup of ipecac was for many years routinely recommended
for home use following accidental paediatric ingestions with the intention of reducing the time to decontamination
and the need for hospital referral.
Nature and mechanism of therapy: This preparation contains powerful plant-derived emetics and, when
administered at the recommended dose, reliably induces vomiting via central and peripheral mechanisms. The
mean time from administration to vomiting is 20 minutes. It is now clear that the amount of toxin removed is
highly variable and decreases rapidly with time to the point that it is negligible by 1 hour.
Disadvantages: Syrup of ipecac-induced vomiting renders subsequent administration of activated charcoal more
difficult.
Theoretical Indication: The potential benefits of syrup of ipecac theoretically outweigh the risks when it is
administered promptly after ingestion of an agent in a dose likely to cause significant toxicity, which does not
involve rapid onset of depressed level of consciousness or seizures and where activated charcoal is not readily
available or known not to bind to the agent.
No stock- No Advise: Such a scenario arises so infrequently that emergency departments no longer stock syrup of
ipecac and poisons information centres no longer advise it to be kept in homes with small children.
Technique
• Give 15 mL (children) or 15– 30 mL (adults) with a glass of water.
• If vomiting has not occurred within 30 minutes the dose may be repeated.
Contraindications
• Non-toxic ingestion
• Dose ingested known to be sub-toxic
• Seizures or decreased level of consciousness
• Risk assessment indicating potential for seizures or decreased level of consciousness within the next few
hours
• Activated charcoal available within 1 hour and known to bind agent
• Infants < 12 months of age
• Corrosive ingestion
• Hydrocarbon ingestion
Potential complications
• Prolonged vomiting (10-20% vomit for more than 1 hour)
• Diarrhoea (20– 30%)
• Pulmonary aspiration if decreased mental status or seizures
• Physical injuries secondary to vomiting (rare) — Mallory-Weiss tear — Pneumomediastinum — Gastric
perforation.

Gastric Lavage
Principle of technique:
This technique attempts to empty the stomach of toxic substances by the sequential administration and
aspiration of small volumes of fluid from the stomach via an orogastric tube. This previously widely
favoured method of gastrointestinal decontamination has now been all but abandoned and few emergency
department staff remain experienced in its use.
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 USELESS IN Clinical Toxicology Lines
> 1 hour: The amount of toxin removed by gastric lavage is unreliable and negligible if performed after the
first hour.
Routine application: It does not confer any clinical benefit when performed routinely on unselected patients
presenting to the emergency department following deliberate self-poisoning.
USEFUL IN
Few situation: There are few situations where the expected benefits of this procedure might be judged to
exceed the risks involved and where administration of charcoal would not be expected to provide equal or
greater efficacy of decontamination.
Technique
1.In a resuscitation bay: This procedure is performed in a resuscitation bay.
2.In a fully consciousness patient: Do not perform in any patient with an impaired level of consciousness unless
the airway is protected by a cuffed endotracheal tube.
3.In a left decubitus position: Position the patient in the left decubitus position with 20 ° head down.
4.Measure the length of tube required to reach the stomach externally before beginning the procedure.
5.Pass a large bore 36– 40 G lubricated lavage tube extremely gently down the oesophagus. Stop if any resistance
occurs.
6.Confirm tube position by aspirating gastric contents and auscultating for insufflated air at the stomach.
7.Administer a 200-mL aliquot of warm tap water or normal saline into the stomach via the funnel and lavage
tube.
8.Drain the administered fluid into a dependent bucket held adjacent to the bed.
9.Repeat administration and drainage of fluid aliquots until the effluent is clear.
10. Give, Activated charcoal 50 g may be administered via the tube once lavage is complete.

Contraindications
• Resuscitation: Initial resuscitation incomplete
• Risk assessment: indicating good outcome with supportive care and antidote therapy alone
• Risk assessment indicating potential for respiratory aspiration complication during the procedure especially
in unprotected airway where there is a decreased level of consciousness .
• Ingestion in small children
• Ingestion of Corrosive
• Ingestion Hydrocarbon
Potential complications
• Pulmonary complications:
• Pulmonary aspiration
• Hypoxia
• Laryngospasm
• Gastro-Intestinal complications:
• Mechanical injury to the gastrointestinal tract
• Others:
• Hypervolemia: Water intoxication (especially in children)
• Hypothermia
• Distraction of staff from resuscitation and supportive care priorities

Single-Dose Activated Charcoal

Characters & Indication
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 Nature: Activated charcoal (AC) is produced by the super-heating of distilled wood pulp. The resulting fine
porous particles are suspended in water or sorbitol prior to oral or nasogastric administration.
Clinical Toxicology Lines
Mechanism of Action: The enormous surface area provided by these particles reversibly adsorbs most ingested
toxins reducing further absorption from the gastrointestinal tract.
Preferred method UP TO 4 hours: Oral AC is generally the preferred method of gastrointestinal
decontamination. Human volunteer studies confirm that oral AC reduces drug absorption when given up to 4
hours after ingestion but is most effective when given immediately after ingestion.
NOT routine: However, oral AC does not improve clinical outcome when applied to unselected patients with
self-poisoning and should not be regarded as routine.
AC Benefits: Oral AC is most likely to benefit a subgroup of patients with severe poisoning in whom it may
reduce the length of hospital stay, level of supportive care required, need for administration of antidotes or
utilisation of enhanced elimination techniques.
AC indicator: Overall, oral AC is indicated where it is likely that toxin remains in the gastrointestinal tract, and
where the potential benefits outweigh the potential risks.
AC routine administration: It is reasonable to routinely administer oral AC following intubation to
unconscious patients who have ingested pharmaceutical agents as the risk– benefit analysis is almost always
in favour of administration.
AC justify administration By contrast, the potential benefits rarely justify administration of oral AC to the
uncooperative conscious patient.
NO supported DATA: There are no data to support the use of AC in sorbitol or other cathartic agents over AC
in water.

Potential complications
• Disturbances: Mess
• Delay of therapeutic absorption: Impaired absorption of subsequently administered oral antidotes or other
therapeutic agents
• Distraction of attending staff: Distraction of attending staff from resuscitation and supportive care priorities
• Injury of respiratory tract: Pulmonary aspiration of AC
• Injury of respiratory tract: Direct administration into lung via misplaced nasogastric tube (potentially fatal)
• Injury of cornea: Corneal abrasions

Contraindications
• Non-toxic ingestion
• Sub-toxic dose ingestion
• Corrosive ingestion
• Risk assessment indicating good outcome with supportive care and antidote therapy alone
• Risk assessment suggesting potential for imminent onset of seizures.
• Risk assessment suggesting potential for imminent onset of decreased level of consciousness.
• Comatose patient: Decreased level of consciousness, delirium or poor cooperation (unless airway protected by
endotracheal intubation)
• Uncooperative patient (relative contraindication)
• Resuscitation “initial” incomplete
• Agent not bound to AC (see Table 1.6.3)
TABLE 1.6.3
Agents poorly bound to activated charcoal
Hydrocarbons and alcohols Metals Corrosives
Ethanol Lithium Acids
Methanol Iron Alkalis
Isopropyl alcohol Potassium
Ethylene glycol Lead
Arsenic
Mercury

Note: Ileus is not a contraindication to single-dose AC.

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 Clinical Toxicology Lines
Technique
• Give 50 g (adults) or 1g/ kg (children) as a single oral dose placed in a cup for self-administration.
• Mixing with ice cream improves palatability for children.
• In the intubated patient, AC may be given via oro- or nasogastric tube after tube placement is confirmed on
chest X-ray.

Note: If mental status precludes self-administration, AC is withheld until the patient is intubated if and when this
becomes clinically necessary. The decision to intubate is based on standard criteria. Only in very rare
circumstances does the risk assessment justify intubation specifically for the purpose of facilitating administration
of AC.
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 Clinical Toxicology Lines

Whole Bowel Irrigation

Procedure: This labour-intensive form of gastrointestinal decontamination attempts to cleanse the entire bowel
by administering large volumes of osmotically balanced polyethylene glycol electrolyte solution (PEG-ELS).
Indication: It is rarely performed because risk– benefit analysis reserves this intervention for life-threatening
ingestions of sustained-release or enteric-coated preparations; or agents that do not bind to charcoal and
where good clinical outcome is not expected with supportive care and antidote administration and the patient
presents before established severe toxicity (see Table 1.6.4).

TABLE 1.6.4
Whole bowel irrigation potentially useful
- Iron: Iron over dose >60 mg/kg
- Lead: Lead ingestion
- Arsenic: Symptomatic arsenic trioxide ingestion
- K: Slow released potassium chloride >2.5 mmol/kg
- Life-threatening slow-released verapamil or diltiazem ingestion.
- Body Backer

In comatose patient: Whole bowel irrigation has been performed on unconscious ventilated patients but this is
hazardous as fluid may pool in the oropharynx and flow past the tube cuff to produce pulmonary aspiration.

Potential complications
• Gastro-intestinal: Nausea, vomiting and abdominal bloating
• Metabolic: Non-anion gap metabolic acidosis
• Pulmonary: Pulmonary aspiration
• Distraction from resuscitation and supportive care priorities
• Delayed retrieval to a hospital offering definitive care

Contraindications
• Risk assessment suggesting good outcome can be assured with supportive care and antidote therapy
• Risk assessment suggesting potential for decreased conscious state or seizure in the subsequent 4 hours
• Uncooperative patient
• Uncontrolled vomiting
• Inability to place a nasogastric tube
• Ileus or intestinal obstruction
• Intubated and ventilated patient (relative contraindication)
Technique
• Single nurse: Assign a single nurse to carry out the procedure (this is a full-time job for up to 6 hours).
• Sufficient supply: Obtain sufficient supplies of PEG-ELS and make up the solution as directed.
• Nasogastric tube: Place nasogastric tube and confirm position on chest X-ray.
• AC: Give activated charcoal 50 g (children 1 g/ kg) via the nasogastric tube unless agent does not bind to
AC.
• 2 L/hour: Administer PEG solution via the nasogastric tube at 2 L/ hour by continuous infusion (children
25 mL/ kg/ hour).
• Metoclopramide: Administer metoclopramide to minimise vomiting and enhance gastric emptying.
• Commode: Position patient on a commode if possible to accommodate explosive diarrhoea.
• Clear effluent: Continue irrigation until the effluent is clear. This may take up to 6 hours.
• Stop: Cease whole bowel irrigation if abdominal distension or loss of bowel sounds is noted.
• X-Ray: Abdominal X-ray is useful to assess effectiveness of decontamination of radio-opaque substances
such as iron and K salts.
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 • Packages: Expelled packages may be counted in body packers.
Clinical Toxicology Lines

7- Enhanced Elimination
Techniques of enhanced elimination (see Table 1.7.1) are employed to increase the rate of removal of an agent from
the body with the aim of reducing the severity and duration of clinical intoxication.

TABLE 1.7.1 Techniques of enhanced elimination and amenable agents

Multiple-dose activated charcoal.
Carbamazepine
Dapsone
Phenobarbitone
Quinine
Theophylline
Urinary alkalinisation
Phenobarbitone
Salicylates
Haemodialysis and haemofilteration
Carbamazepine
Lithium
Metformin lactic acidosis
Potassium
Salicylate
Theophylline
Toxic alcohols
Valproic acid
Charcoal haemoperfusion
Theophylline

Benefit of EE: These interventions are only indicated if it is thought they will reduce mortality, length of stay,
complications or the need for other more invasive interventions.
Indications: In practice, these techniques are useful in the treatment of poisoning by only a few agents that are
characterised by:
• Severe toxicity
• Sick patient with poor outcome despite good supportive care/ antidote administration
• Slow endogenous rates of elimination
• Suitable pharmacokinetic properties.
Suitable condition:
Accurate risk assessment allows early identification of those patients who may benefit from enhanced
elimination and institution of the intervention before severe life-threatening intoxication develops.
Specialised equipment and staff:
Some of these techniques require specialised equipment and staff and early identification of candidates
facilitates the timely communication, planning and transport necessary to ensure a good outcome.
Benefit-Risk balance:
The final decision as to whether to initiate a technique of enhanced elimination depends on a risk– benefit
analysis in which the expected benefits of the procedure are balanced against the resource utilisation and
risks associated with the procedure.
Interference with other technique:
Techniques of enhanced elimination are never carried out to the detriment of resuscitation, good supportive
care, decontamination and antidote treatment.
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 End-Point of therapy:
Once the decision to initiate a technique of enhanced elimination is made, it is important to establish
Clinical Toxicology pre-
Lines
defined clinical or laboratory end points for therapy.

Multiple-Dose Activated Charcoal (MDAC)

Aim of therapy:
Rationale Repeated administration of oral activated charcoal progressively fills the entire gut lumen with charcoal. This has the
potential to enhance drug elimination in two ways:
• Interruption of enterohepatic circulation
— A number of drugs are excreted in the bile and then reabsorbed from the distal ileum. Charcoal in the small
intestine binds drug and prevents reabsorption thus enhancing elimination.
— This is only significant if a drug not only undergoes entero-hepatic circulation but also has a relatively small
volume of distribution.
• Gastrointestinal dialysis
— Drug passes across the gut mucosa from a relatively high concentration in the intravascular compartment to a
low concentration in the gut lumen, which is maintained by continuing adsorption to charcoal.
— This is only effective if the drug is a relatively small molecule, lipid soluble, has a small volume of distribution
and low protein binding.

Indications
Enhanced elimination by this technique has been proposed as clinically useful in the following scenarios:
• Carbamazepine coma
— Most common indication for MDAC
— Used in the expectation that enhanced elimination will reduce duration of ventilation and length of stay in intensive
care
• Phenobarbitone coma
— Rare
— Used in the expectation that enhanced elimination will reduce duration of ventilation and length of stay in intensive
care
• Dapsone overdose with methaemoglobinaemia
— Very rare
— MDAC may enhance elimination of dapsone and reduce the duration of severe prolonged methaemoglobinaemia
• Quinine overdose
— Not 1st chicoce: Although MDAC might enhance drug elimination, good outcome can be expected with aggressive
supportive care
• Theophylline overdose
— Not 1st choiceL: Attempts at enhanced elimination with MDAC should never delay more effective elimination
techniques (haemodialysis) following life-threatening overdose.
Contraindications
• Bowel obstruction
• Anticipated decreased level of consciousness without prior airway protection
• Decreased level of consciousness without prior airway protection
Potential complications
Although rare in carefully selected patients, they may include:
• Common complication: vomiting (30%)
• Charcoal aspiration, especially if there is decreased mental status or seizures
• Constipation
• Charcoal bezoar formation, bowel obstruction, bowel perforation (rare)
• Corneal abrasion
• Care distraction: Distraction of attending staff from resuscitation and supportive care priorities.
Technique
• Give an initial dose of activated charcoal 50- g (adults) or 1-g/ kg (children) PO.
• Give repeat doses of 25-g (0.5 g/ kg in children) every 2 hours.
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 • Give via oro-nasogastric tube: In the intubated patient, activated charcoal is given via oro- or nasogastric tube
after tube placement has been confirmed on chest X-ray. Clinical Toxicology Lines
• Check for bowel sounds and high nasogastric aspirates prior to administration of each dose.
• Clinical end points
Stop further administration if bowel sounds are inaudible
Stop further administration if nasogastric aspirates of high volume.
Stop further administration if good out comes after the procedure of reassessment of the indications and
clinical end points for therapy that occur every 6 hours.
• Close remember: MDAC should rarely be required beyond 6 hours.

Urinary Alkalinisation
Rationale
The production of an alkaline urine pH promotes the ionisation of acidic drugs and prevents reabsorption
across the renal tubular epithelium, thus promoting excretion in the urine. For this method to be effective
the drug must be filtered at the glomerulus, have a small volume of distribution and be a weak acid.
Indications
Only two drugs of significance in clinical toxicology have the required pharmacokinetic properties for this method
to be of interest in management of poisoning.
• Salicylate overdose
—Absence of Urinary Excretion in Normal condition: Salicylates are normally eliminated by hepatic
metabolism and are not readily excreted in acidic urine. In overdose, metabolism is saturated and
elimination half-life greatly prolonged.
—Presence Urinary Excretion in toxic condition: Urinary alkalinisation greatly enhances elimination
and is indicated in any symptomatic patient in an effort to reduce the duration and severity of
symptoms or to avoid progression to severe poisoning and the need for haemodialysis.
— Non-indicating in severe toxicity: Severe established salicylate toxicity indicates immediate
haemodialysis rather than a trial of urinary alkalinisation.
— Non-indicating in chronic toxicity: Note: Not generally useful in chronic salicylate toxicity due to
co-morbidities.
• Phenobarbitone coma
— Aim of therapy: May be attempted in an effort to reduce duration of coma and length of stay in
intensive care.
— Priority of therapy: Not first-line as MDAC is a superior technique of enhancing elimination.
Contraindications
• Fluid overload
Complications
• ↑ Alkalaemia (usually well-tolerated)
• ↑ Fluid overload
• ↓ Hypokalaemia
• ↓ Hypocalcaemia (not usually clinically significant)
Technique
• 1st: K correction: Correct hypokalaemia if present (it is difficult to alkalinize the urine in the presence of systemic
hypokalaemia).
• 2nd Na HCO3 Bolus dose administration: Give 1-2 mmol/ kg sodium bicarbonate IV bolus.
• 3rd Na HCO3 Maintenance dose administration: Commence infusion of 150 mmol sodium bicarbonate in 850- mL 5%
dextrose at 250 mL/ hour.
• 4th K maintenance: 20 mmol of potassium chloride may be added to infusion to maintain normokalaemia.
• 5th Close Blood Monitoring: Monitor serum bicarbonate and potassium at least every 4 hours.
• 6th Close Urine Monitoring: Regularly dipstick urine and aim for urinary pH > 7.5.
• 7th End- pointof therapy: Continue until clinical and laboratory evidence of toxicity is resolving.
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Extracorporeal Techniques of Elimination

Types:
A number of such techniques have been used to enhance elimination of toxins including:
• Haemodialysis
— Intermittent
— Continuous
• Haemofiltration
• Haemoperfusion
• Plasmapheresis
• Exchange transfusion.
Final Solution:
All of the above techniques are invasive and require specialised staff, equipment and monitoring, and may be associated with significant
complications. For these reasons, they are reserved for life-threatening poisonings where a good outcome cannot be achieved by other
means, including aggressive supportive care and antidote administration.
Indications:
Criteria of haemodialysiable poisons:
Haemodialysis effectively enhances elimination of any drug that is
Small molecule
Small volume of distribution
Slow endogenous elimination.
Short stay in peripheral tissue: (Rapid redistribution from tissues and plasma).

Clinical situations of haemodialysiable poisons (that involve life-threatening poisoning with agents fulfilling these criteria include):
• Toxic alcohol poisoning (EARLY toxicity)
— Methanol
— Ethylene glycol
• Theophylline (Severe toxicity)
• Salicylate (Severe toxicity)
- Chronic intoxication with altered mental status
- Acute intoxication with Late-presentation and established manifestation of severe toxicity
• Lithium (Severe chronic intoxication)
• Phenobarbitone (Severe toxicity with phenobarbitone coma)
• Valproate (Severe toxicity with massive overdose)
• Carbamazepine (Severe toxicity with massive overdose)
• Metformin (Severe toxicity with lactic acidosis)
• Potassium salt (Severe toxicity with overdose with life-threatening hyperkalaemia).
Notes:
 Detailed Procedure: Precise clinical indications for extracorporeal elimination in each of these important poisonings are
discussed in the relevant sections of Chapter 3.
 Early Decision: The decision to institute extracorporeal elimination should be made early as soon as the risk assessment
indicates potential lethality.
 Intermittent or Continuous: In general, intermittent dialysis achieves greater clearance rates than continuous haemodialysis or
haemofiltration techniques and is preferred where available.
 Non- Available charcoal haemoperfusion: Facilities for charcoal haemoperfusion are not available in most centres.
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8- Antidotes
Definition: Antidotes are drugs that correct the effects of poisoning.
Little Real Clinical Practice Usage: Only a few antidotes exist and many are used only rarely. Specific antidotes likely to be used in clinical
practice are discussed in Chapter 4 of this book.
Like all pharmaceuticals, antidotes have specific indications, contraindications, and optimal administration methods, monitoring requirements,
appropriate therapeutic ends and adverse effect profiles.
Risk/Benefit Balance: The decision to administer an antidote to an individual patient is based upon a risk– benefit analysis. An antidote is
administered when the potential therapeutic benefit is judged to exceed the potential adverse effects, cost and resource requirements. An
accurate risk assessment combined with pharmaceutical knowledge of the antidote is essential to clinical decision making.
Rarely Prescribed: Many antidotes are rarely prescribed, expensive and not widely stocked.
Systematized Protocol for Antidote Management: Planning of stocking, storage, access, monitoring, training and protocol development are
essential components of rational antidote use. It is often appropriate for stocking to be coordinated on a regional basis in association with
regional policies concerning the treatment of poisoned patients.
Transport Antidote Not Patient: It is frequently cheaper and safer to transport an antidote to a patient rather than vice versa.
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9- Disposition:
I- Medical assessment:
A medical disposition is required for all patients who present with poisoning or potential exposure to a toxic substance.
II- Psychiatric & Social Assessment:
Those who have deliberately self-poisoned also require psychiatric and social review. A risk-assessment-based approach to the management of
acute poisoning allows early planning for appropriate medical and psychosocial disposition.
III- Medical Care:
Patients must be admitted to an environment capable of providing an adequate level of monitoring and supportive care and, if appropriate, where
staff and resources are available to undertake decontamination, enhanced elimination techniques or administration of antidotes.
IV- Pre-hospital Assessment:
Early risk assessment in the pre-hospital setting, usually by poisons information centre staff, often allows non-intentional exposures to be
observed outside of the hospital environment. For those that present to hospital, it minimises the duration and intensity of monitoring.
V- Hospital Assessment and Discharge:
Frequently, patients can be ‘cleared’ for medical discharge directly from the emergency department immediately following assessment or
following a few hours of observation. No arrangements for admission to hospital need to be made unless unexpected signs or symptoms of
toxicity develop.
VII- Hospital Admission:
At other times the risk assessment will indicate the need for ongoing observation, supportive care or the need for specific enhanced elimination
techniques or antidote administration. Under these circumstances, the patient must be admitted to an environment capable of providing a level
of care appropriate for the anticipated clinical course. In many hospitals, this is now the emergency observation unit rather than the general
medical ward. Where ongoing airway control, ventilation or advanced haemodynamic support is required, admission to an intensive care unit
is appropriate.

Emergency Observation Units

 Emergency observation units (EOUs) have been established in many emergency departments in Australasia and elsewhere. These units vary
in capacity, design and staffing. Ideally, they are located adjacent to emergency departments, staffed by emergency doctors and provide short-
term focused goal-oriented care.
 They have been remarkably successful in:
• ↑ Organizing treatment chance in suitable conditions
• ↑ Increasing patient satisfaction
• ↓ Reducing total bed days
• ↓ Reducing inappropriate discharges and litigation.

Toxicology Patients in the Emergency Observation Unit

 In most hospitals where EOUs are established, the units appear to provide an ideal environment for the management of acute poisoning
beyond the initial assessment and monitoring phase.
 Advantages of using the EOU to admit toxicology patients include the ready availability of appropriate resources, staff and training; 24-hour
availability of experienced medical staff; an open-plan environment that facilitates observation; and an emergency department ethos that is
geared towards rapid assessment and disposition.
 Adequate resources must be dedicated to the EOU, particularly medical, nursing, psychiatric and social services.
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  Ideal design features and staffing that facilitate the management of toxicology patients in the EOU include:
• Central nursing: Central nursing stations with clear vision of all areas
• Safe Environment: An environment that protects from self-harm Clinical Toxicology Lines
• Secure entrances
• Private interviews area: Dedicated areas for private interviews
• Social and communication services: Dedicated social work, drug and alcohol, plus outpatient liaison services
• Appropriate monitors ± telemetry
• Available resuscitation equipment Dedicated resuscitation equipment
• Duress alarms
• Available Staff: Appropriate staff, skills and equipment
• Available senior coverage: Appropriate 24/ 7/ 365 senior staff coverage
• Available psychiatric services: Dedicated psychiatric services
• Nurse– patient ratios:
Nurse– patient ratios appropriate for the acuity of patients (e.g. 1 : 4 for monitored ‘step-down’ patients; 1 : 8 for non-monitored general
patients).
• Required criteria: Criteria need to be developed for admission to the EOU following acute poisoning. Such criteria might include:
• No cardiac monitoring: Cardiac monitoring not required (but this can be provided in some EOUs)
• No delirium annoying: Adequate sedation in cases of delirium
• No anticipated delirium: Deterioration not anticipated (based on accurate risk assessment and initial period of observation in the
emergency department).

EOU Advantages: Admission of toxicology patients to the EOU helps counter several of the difficulties encountered when poisoned
patients are admitted to other areas of the hospital:
• Admissions scattered all over the hospital
• Less experienced nursing staff
• Poor availability of medical staff
• Frequent security incidents/ absconding patients
• Most clinicians managing patients on general medical wards are junior and have no formal or informal training in clinical
toxicology
• Longer admissions.

Transfer of the Poisoned Patient

 Usually, the initial receiving hospital is adequately resourced to provide an acceptable level of supportive care, monitoring and therapy
for the poisoned patient. If this is not the case, transfer is necessary. Risk assessment ensures that the need to transfer is recognised early
so that appropriate planning and consultation takes place in an effort to ensure as smooth a retrieval as possible (see Table 1.9.1).
Poisoning is unusual in that transfer frequently takes place during the most severe phase of the illness.
TABLE 1.9.1 Principles of retrieval of the poisoned patient:Assess manage and stablise potential resusucuatation and supportive care
priorties to transfer.
 Risk assessment is vital.
 Identify patient who may need transport to another hospital as soon as possible.
 Patients should only be transported for specific clinical indications
 Recognize that transport may be occur during the worst phase of the intoxication.
 Consider bringing expertise and resources to the patient, rather than vice versa.
 Ensure that transport does not lead to an interval of lower level of care
 Transport to a centre capable of definitive care.

Resuscitation:
The need to retrieve a patient to another centre should not distract attending staff from resuscitation and supportive care priorities.
Attention to airway, breathing and circulation ensure an optimum outcome in the majority of cases.
Whenever possible, the patient should be stabilised before retrieval begins.
Interventions such as intubation, ventilation, initial resuscitation of hypotension, cessation of seizures, assessment of blood glucose and
management of hyperthermia are completed before a patient is placed in the transport vehicle, where further assessment and detailed
management are often impossible.
If the referring team does not possess the necessary skills or resources to complete these resuscitation and stabilisation tasks adequately,
this should be communicated to the receiving and retrieval teams, so that these resources can be brought to the patient.
Transport:
As transport usually occurs during the most severe phase of the poisoning, the patient should never be subjected to an interval of a lower
level of care during the transfer. Consideration of the mode and staffing of transport takes this into account.
Planning:
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 Planning is required to ensure that any potential complications are identified and managed in a proactive fashion. Thus, if coma requiring
intubation and ventilation is anticipated in the next few hours (e.g. controlled-release carbamazepine), early intubation and ventilation
Clinicalappropriate
should occur prior to transfer. Similarly, if significant hypotension is expected (e.g. calcium channel blockers), Toxicology Lines
monitoring,
intravenous access and resuscitation resources should be ready prior to transfer.
Communication
Communication is vital. Retrieval is always to a higher level of care. Thus, transport must occur to a facility with appropriate resources to
manage the potential complications identified by the risk assessment. For example, if haemodialysis may be required (e.g. theophylline or
salicylate poisoning), the patient must be transported to a facility capable of instituting this intervention at short notice. Ideally,
communication should include the team of clinicians who will ultimately manage the patient. Consultations with other specialist teams
(e.g. paediatricians, intensivists or clinical toxicologists) may also occur to assist the process. This improves continuity of care and
decreases the inefficiencies and errors that may be associated with multiple handovers.
Antidotes
If an antidote is likely to definitively treat the patient and render them stable (e.g. N-acetylcysteine; digoxin-specific antibodies), it is
preferable to transfer the antidote to the patient, start treatment, then move the patient only if necessary.
Psychosocial assessment
Most episodes of acute poisoning represent an exacerbation of an underlying psychosocial disorder and the final disposition of the patient
is made in this context. All patients with deliberate self-poisoning should undergo psychosocial assessment prior to discharge. Ideally, this
process begins before the medical treatment of the poisoning is complete so that final disposition is facilitated.
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