Dr. Ahmed Sudan Alhusseini Lec.

1, 2 Clinical Toxicology

General management of Poisoning

Stabilization, Evaluation, Decontamination, Poison Elimination and Antidote Administration.

Stabilizations

1- The Airway and Breathing

Symptoms of airway obstruction include dyspnoea, air hunger, and hoarseness. Signs comprise
stridor, intercostal and substernal retractions, cyanosis, sweating, and tachypnoea.

Normal oxygen delivery requires adequate haemoglobin oxygen saturation, adequate haemoglobin
levels, normal oxygen unloading mechanisms, and an adequate cardiac output. Increasing
metabolic acidosis in the presence of a normal PaO2 suggests a toxin or condition that either
decreases oxygen carrying capacity (e.g. carbon monoxide, methaemoglobinaemia), or reduces
tissue oxygen (e.g. cyanide, hydrogen sulfide).

Some drugs stimulate the respiratory center: amphetamines, atropine, cocaine, and salicylates.
Some drugs are associated with non-cardiogenic pulmonary oedema, characterized by severe
hypoxaemia, bilateral infiltrates on chest X-ray, and normal pulmonary capillary wedge pressure.

Some drugs cause or exacerbate asthma. The most important among them include NSAIDs,
antibiotics like penicillins, cephalosporins, tetracycline, and nitrofurantoin, cholinergic drugs,
chemotherapeutic drugs, and some diuretics.

Toxic Respiratory Depression

Failure of Respiratory Centre Failure of Respiratory muscles
Antidepressants Neuromuscular blocking agents
Antipsychotics Nicotine
Opiates Organophosphates
Ethanol Shellfish poisoning
Sedatives Snake bite (Cobra)
2- Circulation

Several drugs produce changes in pulse rate and blood pressure, while others induce cardiac
arrhythmias and heart block.

Drugs Associated With Disturbances in Pulse Rate and Blood Pressure

Tachycardia & Tachycardia& Tachycardia & Bradycardia & Bradycardia &
Normotension Hypotension Hypertension Hypotension Hypertension
o Antihistamines, o CO o Amphetamine o Clonidine, Phenylpropanolamine
o caffeine, o cyanide, o cocaine, o levodopa,
o cannabis, o phenothiazines o phencyclidine o MAOIs,
o lomotil o theophylline o organophosphates,
(atropine & o opiates,
diphenoxylate) o tricyclic
o thyroxine antidepressants

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Dr. Ahmed Sudan Alhusseini Lec. 1, 2 Clinical Toxicology

3- Depression of the Central Nervous System

There are numerous causes for coma of which one of the most important is acute poisoning. A
number of substances can induce coma, and it will require a great deal of astuteness and expertise
to pinpoint the poison. Before proceeding to an elaborate exercise in diagnosis however, it may be
desirable to first ascertain for sure that the patient is really comatose and not just pretending
(psychogenic or hysterical coma). This is often encountered in cases of “suicide gesture” in contrast
to “attempted suicide”.

How does the doctor humanely determine whether the coma is true or fake? Several methods have
been recommended of which the following constitute barbaric acts and must never be employed:

Pinching nipples or genitals, or repeatedly pinching any part of the body.

Slapping the face hard, repeatedly.
Cotton pledgets or sterile applicator tips soaked with ammonia solution being inserted into
the nostrils.
Perform a quick physical examination with particular attention to the breathing, vital signs,
and the gag reflex. If these are normal, the coma is almost certainly psychogenic.

Management

 Respiratory insufficiency: Oxygen therapy is done to raise the PaO2 to at least 45–55 mmHg.
Begin with 28% oxygen mask. Depending on the response as assessed by periodic arterial gas
analysis, either continues with 28% or progress to 35%. If the condition is relentlessly
deteriorating, consider assisted ventilation.
 Circulatory Failure:
 Correct acidaemia, if present.
 Elevate foot end of the bed (Trendelenberg position).
 Insert a large bore peripheral IV line (16 gauge or
larger), and administer a fluid challenge of 200 ml of
saline (10 ml/kg in children). Observe for
improvement in blood pressure over minutes. Repeat
the fluid bolus if BP fails to normalize and assess for signs of fluid overload.
Haemodynamic monitoring should be considered in those adult patients who do not
respond to 2 liters of infusion and short-term low-dose vasopressors such as dopamine
and noradrenaline.
 Obtain an ECG in hypotensive patients and note rate ,rhythm, arrhythmias, and
conduction delays.
 Vasopressors of choice include dopamine and norepinephrine.
 Cardiac Arrhythmias:
 Obtain an ECG, institute continuous cardiac monitoring and administer oxygen.
 Evaluate for hypoxia, acidosis, and electrolyte disturbances )especially hypokalaemia,
hypocalcaemia, and hypomagnesaemia(.

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Dr. Ahmed Sudan Alhusseini Lec. 1, 2 Clinical Toxicology

 Lignocaine and amiodarone are generally first line agents for stable monomorphic
ventricular tachycardia, particularly in patients with underlying impaired cardiac function.
Sotalol is an alternative for stable monomorphic ventricular tachycardia. Amiodarone and
sotalol should be used with caution if a substance that prolongs the QT interval and/or
causes torsades de pointes is involved in the overdose.
 Unstable rhythms require cardioversion.
 Atropine may be used when severe bradycardia is present.

 CNS Depression:- It was recommended that in every case where the identity of the poison was
not known, the following three antidotes (called the Coma Cocktail) must be administered
intravenously:
1. Dextrose—100 ml of 50% solution
2. Thiamine (Vitamin B1)—100 mg
3. Naloxone—2 mg

Evaluation

A. Hypothermia

Some common drugs which produce hypothermia are barbiturates, benzodiazepines, opiates and
antidepressants. It is essential to use a low reading rectal thermometer. Electronic thermometers
with flexible probes are best which can also be used to record the esophageal and bladder
temperatures.

Treatment (Rewarming):

 For mild cases, a warm water bath (46o C) is sufficient until the core temperature rises to
34o C, when the patient is placed in a bed with warm blankets.
 Heating the inspired air is recommended by some as very effective in raising the core
temperature.

B. Hyperthermia

Oral temperature above 39o C is referred to as hyperthermia. If it exceeds 41o C (which is very rare),
there is imminent danger of encephalopathy. In a few individuals there is a genetic susceptibility to
hyperthermia, especially on exposure to skeletal muscle relaxants, inhalation anaesthetics, and
even local anaesthetics—malignant hyperthermia. This should be distinguished from neuroleptic
malignant syndrome, which is also characterized by high fever apart from other neurological signs,
but is the result of adverse reaction to antipsychotic or neuroleptic drugs, and has no genetic basis.

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Dr. Ahmed Sudan Alhusseini Lec. 1, 2 Clinical Toxicology

Treatment

 Remove all clothes, and pack the neck and groin with ice.
 Immersion in cold water bath (25oC) is very effective but dangerous in the elderly and in
heart patients.
 Stop cooling measures when core temperature falls below 39oC, and nurse the patient in
bed in a cool room.
 Administration of dantrolene may be beneficial in some cases.
 Do not use antipyretic drugs like paracetamol. They are ineffective.

C. Acid-Base Disorders

The diagnosis of these acid-base disorders is based on arterial blood gas, pH, and PaCO2,
bicarbonate, and serum electrolyte disturbances. It must be first determined as to which
abnormalities are primary and which are compensatory, based on the PH. If the pH is less than 7.40,
respiratory or metabolic alkalosis is primary.

In the case of metabolic acidosis, it is necessary to calculate the anion gap. The anion gap is
calculated as follows:

(Na+ + K+) – (HCO3- + Cl-)

Normally this translates as

140 - (24 + 104) = 12 mmol/L (Range: 12 to 16 mmol/L)

If the anion gap is greater than 20 mmol/L, a metabolic acidosis is present regardless of the pH or
serum bicarbonate concentration.

The drug of choice is sodium bicarbonate. It is widely considered to be the best antidote for acidosis
of almost any aetiology.

D. Agitation

Several drugs and poisons are associated with increased aggression which may sometimes progress
to psychosis and violent behavior. This is especially likely if there are other predisposing factors
such as existing mental disorder, hypoglycaemia, hypoxia, head injury, and even anaemia and
vitamin deficiencies.

Delirium is the term which is often used to denote such acute psychotic episodes, and is
characterized by disorientation, irrational fears, hyper-excitability, hallucinations, and violence.
Dementia refers to a more gradual decline in mental processes mainly resulting in confusion and
memory loss, and though it is often organic in nature due to degenerative diseases, there are some
drugs which can cause this especially on chronic exposure. Elderly patients are more vulnerable.
Dementia due to drugs is usually reversible.

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Dr. Ahmed Sudan Alhusseini Lec. 1, 2 Clinical Toxicology

Delirium is managed by chlorpromazine, diazepam, or haloperidol.

Decontamination

EYE

Irrigate copiously for at least 15 to 20 minutes with normal saline or water. Do

not use acid or alkaline irrigating solutions. As a first-aid measure at home, a
victim of chemical burns should be instructed to place his face under running
water or in a shower while holding the eyelids open. During transportation to
hospital the face should be immersed in a basin of water (while ensuring that
the patient does not inhale water).

GUT

The various methods of poison removal from the gastrointestinal tract include:

a. Emesis
b. Gastric lavage
c. Catharsis
d. Activated charcoal
e. Whole bowel irrigation.

A- Emesis: The only recommended method of inducing a poisoned patient to vomit is

administration of syrup of ipecacuanha (or ipecac). Syrup of ipecac is indicated for Conscious and
alert poisoned patient who has ingested a poison not more than 4 to 6 hours earlier. Its mode of
action include:

 Local activation of peripheral sensory receptors in the gastrointestinal tract.

 Central stimulation of the chemoreceptor trigger zone with subsequent activation of the
central vomiting center.

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Dr. Ahmed Sudan Alhusseini Lec. 1, 2 Clinical Toxicology

Contra-indications of Ipecac Syrup:

 Very young (less than 1 year), or very old patient

 Pregnancy
 Heart disease
 Bleeding diathesis
 Ingestion of cardiotoxic poison
 Time lapse of more than 6 to 8 hours
 Ingestion of petroleum distillates, or those drugs which cause altered mental status
(phenothiazines, antihistamines, opiates, ethanol, benzodiazepines, tricyclics).
 All poisons which are themselves emetic in nature

Complications of Ipecac Syrup:

 Cardiotoxicity (bradycardia, atrial fibrillation, myocarditis).

 Aspiration pneumonia.
 Oesophageal mucosal or Mallory Weiss tears (due to protracted vomiting).

B- Gastric Lavage (Stomach Wash)

Lavage should be considered only if a patient has ingested a life-threatening amount of a poison
and presents to the hospital within 1 to 2 hours of ingestion. Some authorities still recommend
lavage up to 6 to 12 hours post-ingestion in the case of salicylates, tricyclics, carbamazepine, and
barbiturates.

Contra-indications:

 Relative: Haemorrhagic diathesis, oesophageal varices, recent surgery, advanced pregnancy,

ingestion of alkali, coma.
 Absolute: Marked hypothermia, prior significant vomiting, unprotected airway in coma, and
ingestion of acid or convulsant or petroleum distillate, and sharp substances.

Complications:-

 Aspiration pneumonia.
 Laryngospasm.
 Sinus bradycardia and ST elevation on the ECG.
 Perforation of stomach or oesophagus (rare).

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Dr. Ahmed Sudan Alhusseini Lec. 1, 2 Clinical Toxicology

C- Activated (Medicinal) Charcoal:

Activated charcoal is a fine, black, odourless, tasteless powder made from burning wood, coconut
shell, bone, sucrose, or rice starch, followed by treatment with an activating agent (steam, carbon
dioxide, etc.). The resulting particles are extremely small, but have an extremely large surface area.

Mode of action: - Decreases the absorption of various poisons by adsorbing them on to its surface.
Activated charcoal is effective to varying extent, depending on the nature of substance ingested.

Disadvantages:-

 Unpleasant taste
 Provocation of vomiting
 Constipation/diarrhoea
 Pulmonary aspiration
 Intestinal obstruction (especially with multiple-dose activated charcoal).

Contraindications:-

 Absent bowel sounds or proven ileus

 Small bowel obstruction
 Caustic ingestion
 Ingestion of petroleum distillates.

D- Whole Bowel Irrigation (Whole Gut Lavage)

This is a method that is being increasingly recommended for late presenting overdoses when
several hours have elapsed since ingestion. It involves the
instillation of large volumes of a suitable solution into the
stomach in a nasogastric tube over a period of 2 to 6 hours
producing voluminous diarrhea. Previously, saline was
recommended for the procedure but it resulted in
electrolyte and fluid imbalance. Today, special solutions
are used such as PEG-ELS (i.e. polyethylene glycol and
electrolytes lavage solution combined together, which is an
isosmolar electrolyte solution), and PEG-3350 (high
molecular weight polyethylene glycol) which are safe and
efficacious, without producing any significant changes in
serum electrolytes, serum osmolality, body weight, or haematocrit.

Indications:-

 Ingestion of large amounts of toxic drugs in patients presenting late ( > 4 hours post-exposure)
 Overdose with sustained-release preparations.

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Dr. Ahmed Sudan Alhusseini Lec. 1, 2 Clinical Toxicology

 Ingestion of substances not adsorbed by activated charcoal, particularly heavy metals.

 Ingestion of foreign bodies such as miniature disc batteries (button cells), cocaine filled
packets (body packer syndrome),etc.
 Ingestion of slowly dissolving substances: iron tablets, paint chips, bezoars, concretions.

Complications—

 Vomiting
 Abdominal distension and cramps
 Anal irritation.

Contra-indications—

 Gastrointestinal pathology such as obstruction, ileus, haemorrhage, or perforation.