Antidotes

 Substances which counteract the effects of

poisons.

Incomplete removal of poison.

Gastric lavage and emesis contraindicated.
Poison is absorbed.
Poison introduced by other than enteral
route.
 Antidotes-Classification

 Physical antidotes
 Chemical antidotes
 Physiological/Pharmacological antidotes
 Universal antidotes
 Chelating agents
Antidotes-Mechanical

Impede the absorption of poison by their

presence.
1. Demulcents.
2. Bulky foods.
3. Charcoal.
 Physical antidotes-Demulcents

Mechanism
In corrosives and irritants.

Contraindications
Phosphorus , organophosphates , DDT.

Bulky foods ---Banana.

Physical antidotes-Charcoal

 Making activated charcoal involves heating

carbon-rich materials, such as wood, peat,
coconut shells, or sawdust, to very high
temperatures.
 This 'activation' process strips
the charcoal of previously absorbed
molecules and frees up bonding sites again
 Activated charcoal

Prepared by destruction & distillation of wood.

Activated charcoal: 1000 M²/g surface area

Super Activated charcoal: 3500 M²/g surface area.

Adsorption

In GIT, poison diffuse through pores on its surface.

 Antidotes-Activated
charcoal
 Effectiveness:
1. Quantity (Larger doses should be used).
2. Time of ingestion.( Max. effective within 30 min)
3. Quality of charcoal.
 Administration:
 Mix with water, use immediately.
 Gritty sensation, discoloration, stick to throat.
 Antidotes-Activated
charcoal
 Dose: 50-100gm adult.
25-50 gm child.
 Complications:
GI obstruction---Multiple doses
Large doses constipation.
 Chemical antidotes
 Act by direct chemical action with poisons.
 Form nontoxic or insoluble compounds.
Dilute acids for alkalis.
Dilute alkalis for acids.
Bicarbonates--- contraindicated.
Oxalic acid absorption ____ Nephrotoxicity.
Calcium forms oxalate with it .
Passes through intestines without being absorbed.
Potassium permanganate.
Strength of solution 1:1000.
Physiological/ pharmacological
antidote

 Produces effects opposite to that of a poison.

 Anaphylactic reaction (bronchoconstrictions).
 Epinephrine reverses this effect.
 Atropine for pilocarpine.
 Naloxone for morphine.
 Diazepam for strychnine.
 Atropine and oximes for organophosphorus
compounds.
 Universal antidote

Not very effective against poisons.

Uses:
 Where nature of poison used is not known.
 Combination of 2 or more poisons used.
Composition:
 Powdered charcoal: 2 parts
 Milk of magnesia : 1 part
 Tannic acid: 1part
Chelating agents

 Gr.Chela---Claw

 Antidotes which binds directly with metal ions to

form stable compounds/ complexes.

 Chelated metal is water soluble and excreted

through kidneys.
 BAL (British antilewisite)
Dimercaprol

Uses: Arsenic , Lead, Mercury poisoning.

Dose: 3mg/kg b/w every 4 hours on the 1st few
days.
3mg per kg body wt 6 hrly
3mg per kg 12 hrly used for 10 days.
Route: i/m

Contraindication: liver damage.

Penicillamine (cuprimine)

 It is degraded product of penicillin.

 Has a stable SH radical in it.
 It help to combine with a free metal in the
circulation.
Dose: 30 mg/kg b/w per day.
Given orally in 4 divided doses for 7 days

Uses: Copper, Lead, Mercury.

Wilson’s disease (disorder of copper metabolism).
 EDTA
Ethylene Diamine Tetra Acetate:
CaNa2EDTA
Uses: Lead ,copper, iron, mercury, cobalt and
manganese.

 It also chelate Ca⁺⁺ and leads to hypocalcaemia.

 It also excrete lead from bones to blood.
Dose: 1 gm b.d (mixed with 5 % glucose saline) by
slow iv drip for 5 days.
Repeat after 1 week.
Contraindication : Renal damage.
EDTA injection
 Desferrioxamine

 Specific antidote for iron.

 Dose: 1 g i/m, followed by 500 mg 3 times daily
 Affinity for Fe+2 ,Fe+3
 Spares transferrin , cytochrome , Hb iron.
 Properties of ideal chelating agent

1. Should have greater affinity for the metal.

2. Highly water soluble.
3. Penetrate into tissue areas of metal storage.
4. Resistant to metabolism & degradation.
5. Forms tight bonds with metals.
6. Readily excreted as chelate.
7.Low affinity for calcium.
8.Possesses minimal inherent toxicity.
9.Be absorbed via oral administration.
10.Is stable, non-toxic at physiological PH.
 Cyanide antidote

 Should be started immediately to be effective.

 Convert Hb into methemoglobin by the action of
nitrites.

 Cytochrome oxidase+NaCN = Cytochrome oxidase

cyanide.
 Aim is to decrease amount of cyanide available for
tissue binding.
 Specific antidote available unlike other toxic
exposure.
Cyanide antidote
 Cyanide antidote

 Amyl nitrite inhalant.

 3 % Na nitrite solution.
 25 per cent Na thiosulphate solution.

 Amyl nitrite is administered by inhalation.

 Followed by Na nitrite i/v.

 Hb(Fe+2)+Amyl nitrite = Methemoglobin(Fe+3).

 Cyanide antidote

 Amyl nitrite only produces 5% methemoglobin.

 In practice , a methemoglobin concentration
close to 40% is desirable.
 Methemoglobin has greater affinity for
cyanide than for cytochrome oxidase.
 Combine with free cyanide.
 Also cause dissociation of CN cytochrome
oxidase complex.
 Cyanide antidote

 Cyanide cytochrome + methemoglobin

Cyanomethemoglobin + Cytochrome oxidase.

 Reactivation of enzyme is the result.

 All these reactions are reversible.

 Cyanomethemoglobin has potential to
dissociate.
 Cyanide antidote

 2nd phase of cyanide antidote package is

instituted.

 Cyanomethemoglobin + Thiosulphate---
Thiocyanate + Sulfite + Methemoglobin.

 Thiocyanate relatively nontoxic, readily

excreted.
 Snake antivenins

 Specific (Monovalent)
 Nonspecific(Polyvalent)
 Monovalent antivenins are ideal
Indications:

 Not every bite even by a poisonous species

 Hypersensitivity reactions
 Coma, neurotoxicity, hypotension, shock, bleeding ,DIC.
 Acute renal failure, rhabdomyolysis, ECG changes
 Swelling involving more than half of the limb.
Snake ant venom
 Snake antivenins-Dose

 50 ml infusion for mild manifestations

 100 ml for moderate toxicity— Bradycardia
, coagulation defects.
 150 ml for systemic toxicity.
 Test dose in one forearm, saline in other
forearm
 Erythema or wheel greater than 10mm
within 30 min is +ve.
 Best results within four hours of bite
 Organophosphate antidotes

 GL e KMnO₄ if ingestion.
 Rapidly absorbed from GIT(GL in 30 min).
 No gastric decontamination within several hours
, activated charcoal.
 Atropine 2 mg IV , repeat every 10-15 min.
 Pralidoxime (cholinesterase reactivator), 1-2 gm
IV in saline 12 hrly.
 Synergistic action of atropine , Pralidoxime.
 Preservatives for
toxicology
Saturated solution of sodium chloride:

 It is 33 % solution of sodium chloride.

 If solution not saturated, fungi and yeast of
stomach causes fermentation of carbohydrates.
 Produce ethyl alcohol.
 Decompose alkaloids and glucocides.
Preservatives for toxicology

Rectified spirit:

 Good preservative for chemical analysis.

 Effective for all viscera
 Contraindicated in poisoning by alcohol,
Phosphorus, acetic acid and carbolic acid.
Preservative for histopathology

 Formaline is the usual general purpose fixative.

 10 % formaline preparation.
 Preserves the basic architecture of tissues.
Principles in management of poisoning

 One of most important aspect is

What to do.

In what order to do.

 Quickly determine

CVS function Resp.function CNS function

(stabilize BP , (Breathing (convulsions)
Treat shock , Oxygen
heartbeat) Naloxone)

Identity of poison
Toxic Decide Nontoxic
 First thing assess patient condition.

 Attention to airway , breathing , circulation , drugs.

 Once patient stabilized , identify poison , route ,

amount , time since exposure.
 Substance toxic or nontoxic?
 Can it be easily removed , neutralized , eliminated.

 ? Specific antidote available.

 ? Removal still effective after a long time elapsed.

 If substance toxic but no features , Should be

removed?
 History of poisoning

 Accurate history should include

Identity of poison.
Amount and time of ingestion.
First aid given or not?
Clinical assessment:
 Some poisons with characteristic features.
 Cholinesterase inhibitors ………cholinergic excess.
 Tricyclic antidepressants……….. anticholinergic effect.

 Toxicokinetics for management protocol.

Treatment of poisoning

 Avoid further intake/ removal from source of poison.

 Removal of unabsorbed poison (G.I
decontamination).
1. Vomiting
2. Gastric lavage
3. Purgatives

4. Washing the area

5. Tourniquet
 Use of antidote.

 Elimination of absorbed poison.

 Maintenance of general condition of patient.

 Symptomatic treatment.
Scandinavian method of treatment

Method of intensive supportive therapy

Regimen consists of
1.Assesment of patient
2.Emergency measures
3.General care
Assessment of patient
Assess disturbance in vitals

 CNS:
Impairment of level of consciousness
Important feature of sedatives, hypnotics and
psychotropic.
Grade 1: Drowsy but responding to vocal
commands.

Grade 2: Unconscious but responding to minimal

painful stimuli.

Grade 3: Unconscious but responding only to

maximum painful stimuli.

Grade 4: Unconscious and nonresponder.

 Respiratory system :
Blood PH , pCO2 , pO2 , HCO3.

 CVS :
Systolic 90 and 80mm Hg.

 Body temperature :
A rectal temperature less than 36---
Hypothermia

Emergency measures

General care
Removal of unabsorbed poison

Route of poison intake

 Ingestion(80 %)
 Inhalation (CO , Coal gas, Hydrogen sulphide).
 Injection (Hypnotics , insulin, snake venom).
 Skin, mucous membrane, eyes.
Vomiting (Emesis):

Early emesis of greater value than energetic lavage.

Mechanical method.
House hold emetics; tepid water with 2 tsf salt,
mustard powder
Syrup ipecac
Dose :Children ---15ml , Adults---30ml
Apomorphine injection: 6mg subcutaneously
Syrup of ipecac
Injection apomorphine
 Contraindications

Convulsants.
Hydrocarbons.
Corrosives.
Sharp objects.
Comatose patient.
Severe cardiovascular disease.

 Induced only if sufficient bulk in stomach.

 Carrier for ingested poison.
Gastric lavage

Fr. laver= to wash

A process of washing out the stomach with different
solutions .
Water,saline,NaHCO3,Tannic acid,KMnO4.
Objective: To remove unabsorbed poison.
 Indication

 Ingesting large quantity of highly toxic substances.

 Cases of ingested poison.
 Within 3 …. 4 hours of ingestion.
 Where emesis is contraindicated.
 Sometimes effective even up to 12 hours.
 Intubation should precede G L in unconscious.
 Use largest diameter tube.
 A minimum of 2 litres to wash out.
 Until return solution is clear.

 Gastric concretions.
Contra-indications:

Absolute , relative.
 Corrosives
 Coma
 Convulsions

 Petroleum distillates
Apparatus:

 Stomach wash tube diameter 1-1.5cm

 Mouth gag.
 Children ___Ryle’s tube.

Position: left lateral , head down than hips.

Specific solutions:

 Opiates poisoning : Potassium permanganate.

 Salicylate poisoning : Activated charcoal.
Aspirate should be saved for analysis.
Aliquots of 50 –100 ml in children.
200---300 ml for adults.
Allow to mix.
Pre-cautions:
1. Remove foreign body.
2. Lubrication of tube.
3. Ask the pt. to swallow .
4. NG tube should not be used.
 Complications

Aspiration pneumonia.
Laryngospasm with cyanosis.
Respiratory infection.
Cardiac arrest.
Cathartics

 Substances which remove the poison from GIT, by

inducing diarrhea.

Rule of thumb:
 Contact time between the poison and intestines.

Cathartics:
 MgSO₄ 10 % (Epsom salt): Dose children 250mg/ kg.
 Sodium sulphate 10%: 250mg/kg.
 Sorbitol
 Indication , Contraindication

1. Antimony
2. Arsenic
3. Phosphorous
4. Mercury
Absolute and relative
5. Strong corrosives.
6. Electrolytes disturbances.
7. Absent bowel sounds.
8. Mg containing cathartics in renal dysfunction
9. Sodium containing cathartics in CCF.
Elimination of absorbed poison

 Accelerating excretion.
 Ample fluids for adequate diuresis.
 Forced diuresis.
 Changing urine pH.
 Chlorothiazide & mannitol.
 Peritoneal dialysis.
 Heamodialysis
 Hemoperfusion.
 Exchange transfusion
 Forced diuresis

 Useful when compounds are eliminated by kidney.

 Mannitol or furosemide were generally used.
 Its overdoses may cause pulmonary , cerebral
edema.
 This method no longer recommended.
 PH alteration

 Many toxic compounds are weak acids or bases.

 Become ionized in solutions.
 At physiologic pH , most drugs partially ionized.
 Nonionized compounds move easily across cell
membranes.
 Ionized compounds are much less diffusible.
 Goal of pH manipulation is to enhance renal
excretion of a compound by increasing ionized form
in kidney.
 Filtration , secretion , reabsorption of agents across
tubular membranes.
 Ionized form trapped in renal tubules and excreted.
 Increased elimination of weak acids when urine pH
is more alkaline.
 Enhanced elimination of weak bases in acidic urine.
 Alkaline diuresis achieved by sodium bicarbonate.
 Salicylates , phenobarbital are eliminated.
 Acid diuresis no longer
recommended(complications)
 Dialysis and hemoperfusion

Peritoneal dialysis.
Hemodialysis.
 Used only in severely intoxicated patients.
 Complications increase with length of time the
patient remains unconscious.
 Reduce this time by any means available.
 Dialysis is governed by law of osmosis.
 Peritoneal dialysis

 Warm dialyzing solution introduced into peritoneum.

 2 liters in adults 1 liter in children.
 Fluid left for 1 hour for equilibration to occur.
 Osmotic pressure of fluid is maintained above that of
extracellular fluid.
 Thus increased recovery of water soluble chemicals.
 Not the procedure of choice when rapid removal is
needed.
Peritoneal dialysis
Peritoneal dialysis
 Hemodialysis

 Law of osmosis is applied here.

 Artificial kidney forms semipermeable membrane.
 The chemical must have a low molecular weight to
diffuse .
 Chemicals having small volume of distribution are
more readily removed.
 Salicylates , phenobarbital , digoxin removed.
Hemodialysis
Principles of hemodialysis
 Hemoperfusion

 More effective than both types of dialysis.

 Particularly useful for lipid soluble and protein
bound compounds.
 Adsorbents contained in sterile columns are used.
 Barbiturates , diazepam , aspirin , paracetamol ,
amitriptyline , digoxin and DDT are removed.
Hemoperfusion
Symptomatic treatment

 i/v line.
 Pain management.
 Respiratory distress.
 Convulsions.
 Narcosis.
 Electrolytes imbalance.
 Glucose administration.
 Restoration of acid base balance.
Maintenance of general condition

 Clear airway.
 Prevention of respiratory infection.
 Good nourishing diet.
 Psychotherapy.
 Physiotherapy.
Investigation

Serum electrolytes
Blood glucose
Urea/ creatinine
Urine R/E
X-ray, ultrasound, CT Scan, ECG.