GENERAL APPROACH TO

POISONED PATIENT

Dr. Kapil Sharma

Lecture objectives
 After this lecture, and further reading as required, students
will be able to:
• describe the manifestations of toxicity
• Approach to the poisoned patient
 Toxidromes
 History, examination, Laboratory Studies and detective
work
 İnitial management including methods of supportive care,
prevention of poison absorption, enhancement of
elimination of poison
Chemical agents that cause toxicity
include

 Drugs
 Insecticides/herbicides
 Plant toxins, Animal toxins
 Chemical weapons

Radioactive elements
 Commonly observed poisonings
Insecticides like OPC, herbicide like paraquat and agrochemical like
aluminium phosphide ( Celphos)
- MOST COMMON IN INDIA
 Carbon monoxide,

 Salicylates, acetaminophen,

 Alcohol, heroin, marijuana, narcotic analgesics,

benzodiazepines, tricyclic antidepressants, amphetamines, and

cocaine
 Corrosive agents

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Pathophysiology
The Stimulated Physiologic State
The Depressed Physiologic State
The Discordant Physiologic State
The Normal Physiologic State
Stimulated…
 Increased PR, BP, RR, temperature, and neuromuscular
activity
 sympathetic,anticholinergic,hallucinogen poisoning or
drug withdrawl
 Mydriasis is characteristic
Depressed…
 Decreased PR, BP, RR , temperature, and neuromuscular
activity
 Sympatholytics, cholinergic (muscarinic and nicotinic)
agents, opioids, and sedative-hypnotic γ-aminobutyric
acid (GABA)-ergic agents
 Miosis is also common and is most pronounced in opioid
and cholinergic poisoning
The Discordant…

 mixed vital-sign and neuromuscular abnormalities

 manifestations of physiologic stimulation and physiologic
depression occur together or at different times during the
clinical course
 Asphyxiants, AGMA inducers, Membrane-active agents
The Normal…

 Nontoxic exposure, psychogenic illness, or poisoning by

“toxic time-bombs”
 ASSESSMENT

 A health care facility’s systematic approach to the assessment

of the poisoned or overdosed patient includes performing
TRIAGE,
 A) Obtaining the patient’s history,
 B) Performing a physical examination, and
 C) Conducting laboratory studies.

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 Triage
 Triage is always the first step performed in the emergency
department.
 Two essential questions to be considered in the triage

evaluation are:
1. Is the patient’s life in immediate danger?
2. Is the patient’s life in potential danger?

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 Initial management of the poisoned
patient
 If the patient’s life is in immediate danger, the goals of
immediate treatment are patient stabilization and evaluation
and management of airway, breathing, circulation and
dextrose (ABCDs).
 Stabilization;First the airway should be cleared of vomitus or
any other obstruction and an oral airway or endotracheal
intubation may be necessary to adequately maintain and
protet the patient’s airway.For many patients is sufficient to
move the flaccid tongue out of the airway.

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Breathing
Breathing should be assesed by measuring arterial blood
gases.
Mechanical ventilation may be necessary to support the
patient.
Many drugs and toxins, such as heroin, depress the
respiratory drive. Patients therefore may require
ventilator assistance until the drugs or toxins are
eliminated from the body.
Circulation

 should be assesed by continious monitoring of pulse rate,

blood pressure, urinary output and evaluation of
peripheral perfusion
 Some toxic drug ingestions impair myocardial
contractility, cause cardiac conduction delays and
arrhythmias and fluid overload may result because of the
heart’s inability to pump effectively.
 In these cases, fluid balance needs to be carefully controlled.
 Invasive monitoring (e.g., central venous pressure, pulmonary
artery catheter, Foley catheter with urometer) and drug
therapy may be necessary to prevent or minimize
complications such as pulmonary edema

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 Every patients with altered mental status should receive a
concentrated Dextrose. Adults are given 25g (50ml of 50%
dextrose solution) i.v. Children 0.5g/kg(2ml/kg of 25%
dextrose).
 Hypoglycemic patients may appear to be intoxicated , and
there is no rapid and reliable way to distinguish them
from poisoned patients.
History and Physical examination
 Once the essential initial ABCD interventions have been
instituted ,
 one can begin a more detailed evaluation to make a
specific diagnosis.This includes gathering any available
history and performing a toxicologically oriented physical
examination.
 The history of the drug(s) or toxin(s) involved may not be
reliable or even known, especially when patients are found
unconscious or have attempted suicide

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A.History

Key points include

identifying the drug(s) or toxin(s),
type of exposure,
the time and duration of the exposure,
amount or dose, empty bottles or containers, houshold
products, over the counter drug (OCD), smells or suicide
note.
B. Physical Examination

 Check clothing for objects or substances

 A quick but thorough physical examination is
essential.These include vital signs and temperature, eyes
and mouth, skin, abdomen and nervous system.
Toxidrome
 A toxidrome is a group of signs and symptoms associated
with overdose or exposure to a particular category of
drugs and toxins.
 Recognizing the presence of a toxidrome may help
identify the toxin(s) or drug(s) to which the patent was
exposed, and the crucial body systems that may be
involved.
Lungs
 Wheezing?
 Rapid respirations are typical of salicylates, CO,and other
toxines that produce metabolic acidosis or cellular
asphyxia.
CV system
 rhythm, rate, regularity
 Hypertension and tachycardia are typical with
amphetamines, cocain and anticholinergic drugs.
Hypotension and bradycardia are characteristic features
of overdose with calcium channel blockers, beta blockers,
clonidine, and sedative hypnotics.
 Hypotension with tachycardia is common with tricyclic
antidepressants, vasodilators and beta agonists.
 Hyperthermia may be associated with sympathomimetics,
anticholinergic, salicylates, and drugs producing seizures
or muscular rigidity.
 Hypothermia can be caused by any CNS depressant drug.
Eyes
 The eyes are a valuable source of toxicologic information.
 Exam eyes for pupils size, nystagmus, reactivity, increased
lacrimation
 Miosis is typical of opioids, cholinesterase inhibitors (e.g.
Organophosphate insecticides), and deep coma due to
sedative drugs.
Eyes
 Mydriasis is common with amphetamines, cocaine, LSD,
atropine and other anticholinergic drugs.
 Horizontal nystagmus is characteristic of intoxication with
alcohol and other sedative drugs. The presence of both
vertical and horizontal nystagmus is strongly suggestive of
phencyclidine poising.
Mouth
 The mouth may show signs of burns due to corrosive
substances, or soot from smoke inhalation.
 Typical odors of alcohol or ammonia may be noted.
Skin
 Exam skin for hot, and dry, flushing, bruising, cyanosis,
 Cyanosis may be caused by hypoxemia or by
methemoglobinemia.
 Icterus may suggest hepatic necrosis.
 Excessive sweating occurs with organophosphates,
nicotine and sympathomimetic drugs.
 Abdomen
 Hyperactive bowel sounds, tenderness abdominal
cramping and diarrhea are common in poisoning with
organophosphatase, iron, arsenic, theophylline, Amanita
muscaria and phalloides.
 Nervous system
 A careful neurologic examination is essantial
 Assess general appearance
 Agitation or confusion

 reflexes, muscle tone coordination, cognition

 Focal seizures or motor deficits suggest a structural
lesions.
 Extremities: fasiculations, tremor,
 muscular rigidity can be caused by anti-psychotic agents,
serotonin syndrome and by strychnine.
 Nystagmus and ataxia are typical of phenytoin, alcohol or
other sedative intoxication.
Mentation
 Many factors can affect the patient’s mental status.
 Hypoglycemia and hypoxemia; that can be life-
threatening but easily addressed by administering oxygen
and IV dextrose until laboratory results are available.
Laboratory Studies
 Relevant clinical laboratory data are vital to the
assessment of the poisoned or overdosed patient.
 Tests that provide clues to the agent(s) taken by the
patient include arterial blood gases (ABGs), electrolytes,
serum osmolality tests, urinalysis ( Urine for drug of
abuse), complete blood count, electrocardiography ,
imaging findings, hepatic & renal function.
 Electrolytes
 Acute poisoning can cause an imbalance in a patient’s
electrolyte levels, including sodium, potassium, chloride,
bicarbonate, carbon dioxide, magnesium, and calcium.
 Serum level measurements are also available for
carbamazepine, iron, ethanol, lithium, aspirin, and
valproic acid and may be obtained if these agents are
suspected in an overdose.
 The anion (A negatively charged ion) gap represents the
difference between unmeasured anions and cations (An
ion or group of ions having a positive charge ) in the
blood.
 Anion gap = (Na + K) - (HCO3 + Cl)
 The normal value for the anion gap is approximately 8 to
16 mEq/L.
 An anion gap that exceeds the upper normal value can indicate
metabolic acidosis caused by an accumulation of acids in the
blood.
 Drugs, toxins, or medical conditions that can produce an elevated
anion gap include iron, isoniazid (INH), lithium, lactate, carbon
monoxide, cyanide, methanol, ethanol, metformin, ethylene
glycol, salicylates, hydrogen sulfide, ,diabetic ketoacidosis,
uremia, seizures, and starvation.

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Diagnostic tools include the following
Electrocardiography: can provide evidence of drugs causing
arrhythmias or conduction delays (e.g., tricyclic
antidepressants).
 Radiology
Many substances are radiopaque, or can be visualized using a
contrast-enhanced computed tomography (CT) scan (e.g.,
heavy metals, button, batteries, some modified-release tablets
or capsules,aspirin concretions, cocaine or heroin containers).
Chest radiographs provide evidence of aspiration and pulmonary
edema.
7.Toxicology screens
A toxicology screen is a laboratory analysis of a body fluid or
tissue to identify drugs or toxins. Saliva, spinal fluid, and hair
may be analyzed, blood or urine samples are used more
frequently.Each screen tests for specific drugs or agents.
 The sample must also be properly collected, and there must

be a laboratory near enough to obtain results quickly.

 The test sample must be collected while the drug or toxin is in
the body fluid or tissue used for testing.

 For example, cocaine is a rapidly metabolized drug; however, its

metabolite, benzoylecgonine, can be detected in the urine for
several hours after cocaine use.

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Management
 Management of the poisoned or overdosed patient seeks
to prevent absorption of and further exposure to the
agent.
 Treatment begins with first aid at the scene and continues
in the emergency department and often the intensive
care unit (ICU).
 Advanced general management involves further steps to
prevent absorption and enhance elimination of the agent.
For instance, antidotes, antivenoms (the treatment of
venomous bites or stings) or antitoxins may be
administered.
General- management
 I.provision of supportive care
 II.prevention of poison absorption
 III.enhancement of elimination of poison
 IV.administration of antidotes
I. Supportive care

cardiac monitoring, ECG

Protect airway

Intravenous access and maintaining vitals

cervical immobilization if suspect trauma

II.Preventing absorption
 Decontamination;
 A) dermal
 B) ocular
 C) inhalation
 D) ingestion
A) DERMAL EXPOSURE
 Generally; achieved by; undressing patients and washing
them thoroughly with copious amounts of lukewarm
water for 15 to 30 minute
 All towels and clothing should be put into hazardous
waste bags
 Some toxins may require further decontamination. For
example, three separate soap and water washings or
showers are recommended to decontaminate
organophosphate pesticides (e.g., Malathion or Diazinon).
 Protective clothing should be worn to reduce the risk for
toxicity while handling contaminated clothing or assisting
with skin decontamination.

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B) Eyes
 Many substances can accidentally splash into the eyes.
 When this happens, the eyes must be flushed to remove
the agent.
 Immediate irrigation with lukewarm water or normal
saline is recommended.
 Continuous flooding of the eyes with a large glass of water
or low-pressure shower should be done for 15 minutes.
C) INHALATION EXPOSURE

 A victim of an inhalation exposure should be moved to

fresh air as quickly as possible.
 The responder must also protect himself or herself from
the airborne toxin.
D) GI Decontamination
 Three general methods involve removing toxin from
stomach via the mouth, binding it inside gut lumen, or
mechanically flushing it through GI tract
 Each method has benefits and risks
 Milk or water dilutes ingested irritants such as bleach or
caustics such as drain cleaner.
After such an ingestion, adults or children should drink milk
or water (children based on their size).
 Further evaluation is necessary after dilution if there is

mucosal irritation or burns.

Gastrointestinal Decontamination

 Induced Vomiting,
 Gastric lavage,
 Adsorbents
 Cathartics
 Whole-bowel irrigation
1. Induced Vomiting-Ipecac
 Achieved by using syrup of ipecac
 Dosing: 15 ml for 1-12 years old and 30 ml for adults;

may repeat once if no emesis in 12 hr

 Usually 3-5 episodes of emesis and resolve in two hours; if
protracted emesis occurs consider toxin as etiology
 Risk of aspiration
2.GASTRIC LAVAGE

 Fluid (usually normal saline) is introduced into the

stomach through a large-bore orogastric tube and then
drained in an attempt to reclaim part of the ingested
agent before it is absorbed.
 A small-bore nasogastric tube is ineffective for lavage

because particulate matter such as tablets or capsules are

too large to pass through the tube.
If airway protection is necessary, the patient should be
intubated before lavage begins.
Orogastric lavage con’t
 Contraindications: Not in unconscious patient unless
intubated (risk aspiration)
 caustic ingestion or hydrocarbons with a high aspiration
potential, airway integrity not secured, more toxic to lung
than GI
 Because of the associated risks and the lack of clear
evidence supporting its use, gastric lavage should be used
only if the patient has ingested a life-threatening amount
of a substance and the procedure is undertaken within an
hour of the ingestion.
3. ADSORBENTS

 An adsorbent is a solid substance that has the ability to

attract and hold another substance to its surface (“to
adsorb”).
 Activated charcoal is an effective nonspecific adsorbent of
many drugs and toxins.
 Activated charcoal adsorbs, or traps the drug or toxin to
its large surface area and prevents absorption from the GI
tract.
 ADSORBENTS

 Activated charcoal is a fine, black powder that is given as a slurry

with water, either orally or by nasogastric or orogastric tube, as
soon as possible after the ingestion.
 Commercially available activated charcoal products may be
mixed with 70% sorbitol to decrease grittiness (composed of or
covered with relatively large particles, increase palatability
(Acceptable to the taste) , and serve as a cathartic. The usual
dose that is given is one 50-g bottle.

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Activated Charcoal
• binds non-specifically
• timing - use within 1 hour
 Safety proven in adults and children
 Dose 1g/kg
Activated Charcoal
 Indications: any drug known to absorb it or after unknown
ingestions. Activated charcoal is used cautiously in
patients with diminished bowel sounds and is
contraindicated in patients with bowel obstruction.
 Should not be given if esophageal or gastric perforation
suspected or emergent endoscopy possibly needed.
 Complications rare; aspiration or impaction possible
 Drugs/Toxins Well
Adsorbed
by Activated Charcoal Drugs/Toxins Not Well
Adsorbed
■ Acetaminophen by Activated Charcoal
■ Amphetamines ■ Acids
■ Antihistamines ■ caustic alkalis
■ Aspirin ■ Alcohols
■ Barbiturates
■ Iron
■ Benzodiazepines
■ Beta blockers ■ Lithium
■ Calcium channel blockers ■ Metals cyanide
■ Cocaine mineral acids,
■ Opioids organic solvents,
■ Phenytoin
■ Theophylline
■ Valproic acid
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 4. CATHARTICS
 A cathartic is a substance that causes or promotes bowel
movements.
 In theory, cathartics decrease the absorption of drugs and toxins
by speeding their passage through the GI tract, thereby limiting
their contact with mucosal surfaces.

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Cathartics
 Osmotic cathartic usually given with activated charcoal
 70% sorbitol (1 g/kg) or 10% Mg citrate
 Shown to decrease transit time of activated charcoal
5. WHOLE-BOWEL IRRIGATION

 The goal of whole-bowel irrigation is to give large volumes

of a balanced electrolyte solution rapidly (1 to 2 L/hour)
to flush the patient’s bowel mechanically without creating
electrolyte disturbances.
 Commercial products used in whole-bowel irrigation include
GoLYTELY and Colyte.
 Both products are dispensed (To prepare and give out ) as
powders and are given after adding water.
 Whole-bowel irrigation is contraindicated in the patient with
bowel obstruction or perforation.

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III.Enhanced Elimination of the Drug or
Toxin

 The absorption rate, body distribution, metabolism, and

elimination must be considered when choosing methods
to eliminate the drug or toxin from the body.
There are six methods of enhanced elimination:
1. Multiple-dose activated charcoal
2. Alteration of urine pH
3. Chelation
4. Hemodialysis
5. Hemoperfusion
6. Hyperbaric oxygenation (HBO) therapy