poisoning (toxicology)
DESCRIPTION
TRANSCRIPT
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POISONING (TOXICOLOGY)
Bimel kottarathil
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A poison is any substance that causes harm if it gets into the body. . Almost any chemical can be a poison if there is enough in the body.
POISON
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The amount of a chemical substance that gets into the body at one time is called the dose.
DOSE
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Depends upon availability and culture Uk –paracetamol is a problem Srilanka –pesticides South india –copper sulphate
INCIDENCE
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Acute exposure Chronic exposure
EXPOSURE TO A POISON
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Through mouth by swallowing Through lungs by breathing Contact Through skin Injection through skin
ROUTE OF ABSORPTION
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Most common route Children are commonly involved Can be accidental or deliberate Eg. Pesticide poisoning
swallowing
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Gas, vapour, dust Fine spray or droplet Poison enters to lungs and then spread
across the whole body Eg. carbon monoxide
INHALATION
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chemical is sprayed or splashed onto the skin
if they wear clothes soaked with chemical. E.g. pesticide
THROUGH SKIN BY CONTACT
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Poisons can be injected through the skin from a syringe or a pressure gun
During tattooing The bite or sting of a poisonous animal,
insect, fish or snake.
By injection through the skin
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DRUGS ,OTHER CHEMICALS Ethylene glycol Methanol Amphetamine Anticonvulsants Corrosives Anti diabetic drugs Antimalarials Batteries Benzodiazepines
SPECIFIC POISONS
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Calcium channel blockers Insecticide Carbon monoxide Cocaine Cyanide Digoxin House hold products Nail polish Heavy metal poisoning Organophosphorous poisoning
Contd…
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Antidepressants Acetaminophen NSAID Antipsychotics Methyl xanthine Theophylline Snakes
Contd…
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Ethylene glycol is a sweet-tasting substance that is a common constituent of antifreeze.
ETHYLENE GLYCOL
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The clinical course of ethylene glycol intoxication can be divided into three phases
The first phase The first phase occurs less than 1 h after
ingestion and is characterized by mental status depression, similar to that of alcohol intoxication ,coma ,seizurs, and respiratory depression
Symptomatology
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Second phase Cardio pulmonary toxicity Acidosis ,heart failure and pulmonary
oedema Final stage Flank pain Acute tubular necrosis Hypocalcaemia Renal toxicity due to calcium oxalate
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Air way support Circulatory support Correction of metabolic abnormalities Control of seizures Bicarbonate to correct acidosis Fomepizole is the new antidote by FDA Haemodialysis
TREATMENT
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Industrial alcohol Toxic alcohol Used in antifreeze,paint,thinner rubbing
alcohol
MENTHOL
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Oxidised to formaldehyde then to formate Formate produces toxic effect and acidosis
TOXICITY
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Cns depression Head ache Lethargy Convulsions Delirium Coma
Ocular symptoms
Photophobia Central scotoma (loss of central vision ) Visual field defects Fixed pupils
SYMPTOMATOLOGY
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Difficuilty in light adaptation Optic disc oedema Optic atrophyOther symptoms Nausea ,vomiting ,diaphoresis ,abdominal
pain (due to pancreatitis)
Contd
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airway protec tion circulatory support correction of metabolic abnorm alities control of seizures. ethanol and fomepizole for specific
treatment Hemodialysis
TREATMENT
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commonly known as ecstasy drug or party drug, has been abused world-wide.
Amphetamines are CNS and cardiovascular stimulants
AMFETAMINES INCLUDING ECSTASY (MDMA)
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Euphoria, extrovert behavior, lack of desire to eat or sleep, tremor, dilated pupils, tachycardia and hypertension
Severe intoxication Agitation, paranoid delusions, hallucinations
and violent behavior. Convulsions, rhabdomyolysis, hyperthermia and cardiac arrhythmias
Intracerebral and subarachnoid Hemorrhage(rare)
Clinical features
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Base line support Agitation is controlled by diazepam 10-20
mg i.v. chlorpromazine 50-100 mg i.m. injection
Treatment
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Carbamazepine. Phenytoin. Sodium valproate. Gabapentin. Lamotrigine Topiramaie
ANTICONVULSANTS
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Drowsiness, respiratory depression,loss of consciousness, moclonic jerks, seizurs
Lethargy, ataxia, slurred speech, nystagmus Posturing, agitation ,hallucinations
MANIFESTATIONS
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charcoal 50-100 g oral Hemodialysis
Management
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Corrosive agents: Acids: hydrochloric acid, sulfuric acid,
hydrofluoric acid Alkali: sodium hydroxide, potassium
hydroxide, ammonia, sodium hypochlorite Other: zinc chloride, mercuric chloride,,
phenols, potassium permanganate, button batteries
CORROSIVES
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Do not put NGT Acid exposure is life threatening Maintain ABC Specific antidots given to nutralise acid or
alkali Sodium bi carbonate in acid poisoning Soda ,lemon juice ammonia in alkali
poisoning
MANAGEMENT
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Insulin Sulfonylurea
ANTIDIABETIC AGENTS
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drowsiness, coma, twitching, convulsion depressed limb reflexes,apnea, pulmonary oedema, tachycardia and hypoglycemia
Clinical features
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Ensure plasma glucose concentration Intra venous glucose Glucogon is also used Maintatanance with continuous glucose
infusion with kcl
Treatment
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Chloroquine. Quinine.
ANTI MALARIALS
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Hypotension acute heart failure, pulmonary oedema and
cardiac arrest. Agitation and acute psychosis, convulsions and coma Brady arrhythmias and tachyarrhythmia's are common and ECG conduction abnormalities are similar to those seen in quinine poisoning (QT prolongation)
tinnitus, deafness, vertigo, nausea, headache and diarrhea
MANIFESTATIONS
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Common suicidal agents Rarely produce severe poisoning Mostly in elderly with respiratory disease
BENZODIAZEPINES
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drowsiness, ataxia, dysarthria nystagmus. Coma respiratory depression
Clinical features
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Respiratory depression is managed by Airway support
Flumanezenil 0.5-1.0 mg iv is the drug of choice
Treatment
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act by blocking voltage-gated calcium channels, Overdose of these drugs, particularly with verapamil and diltiazem, are serious with heart block and hypotension causing a significant fatality rate.
CALCIUM CHANNEL BLOCKERS
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Hypotension Myocardial depression Conduction block Sinus bradycardia Heart block Pulmonary oedema Nausea Vomiting Seizures Lactic acidosis
Clinical features
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Activated charcoal Intravenous hypotension with intravenous
crystalloid Iv glucagon Dopamine to treat hypotension
Treatment
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Carbonate insecticides inhibit acetyl cholinesterase
this effect is comparatively short-lived,and milder
similar to Organophosphorous poisoning Atropine is the drug of choice
CARBAMATE INSECTICIDES
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The commonest source of carbon monoxide is an improperly maintained and poor, ventilated heating system. The affinity of hemoglobin for carbon monoxide is some 240 times greater than that for oxygen. Carbon monoxide combines with hemoglobin to form carboxyhaemoglobin
Carbon monoxide
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Symptoms of mild to moderate exposure to carbon monox ide may be mistaken for a viral illness
In headache and mild exertional dyspnoea Higher concentrations of COHB are
associated with coma, convulsions and cardio respiratory arrest
Clinical features
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High flow oxygen Et intubation and mechanical ventillation
Treatment
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Assess airway and breathing Intubations Primary intervention Oxygen administration Intubation Subsequent assessment History,determine, LOC ,asses complaints Vital signs , look for rales or wheezes
Nursing management
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Cocaine hydrochloride ('street' cocaine, 'coke') is a water-soluble powder or granule that can be taken orally, intrave nously or intranasally.
COCAINE
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Initial euphoria, agitation, tachycardia, hypertension, sweating, hallucinations, convulsions ,metabolic acidosis, hyperthermia, rhabdomyolysis, ventricular arrhythmias. Dissection of the aorta, Myocarditis, myocardial infarction, dilated cardiomyopathy, subarachnoid Hemorrhage, and cerebral Hemorrhage
Clinical features
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Diazepam 10 mg iv to control agitation Active cooling Phentolamine 2-5 mg iv for hypertension
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Primary assessment and interventions Subsequent assessment General interventions
Nursing management
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Cyanide reversibly inhibits cytochrome oxidase a3 so that cellular respiration ceases. Cyanide and its derivatives are used widely in industry
CYANIDE
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Chest tightness Dyspnoea Coma Convulsion Metabolic acidosis
Clinical featurs
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Support ABC Dicobalt edetate Sodium thiosulphate hydroxocobalamin
Treatment
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Toxicity occurring during chronic administration is common, though acute poisoning is infrequent
Digoxin
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nausea, vomiting, dizziness, anorexia and drowsiness. Rarely, confusion, visual disturbances and hallucinations
SVT with or without heart block VPC hyperkalemia
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Atropine Digoxin –fab –specific antibody to
neutralise Digoxin
Treatment
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bleach, cosmetics, toiletries, detergents, disinfectants and petroleum distillate
Management Symptomatic
HOUSEHOLD PRODUCTS
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Arsenic Mercury Cadmium Iron Aluminium Lead
HEAVY METAL POISONING
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Arsenic is the most common cause of acute heavy metal poisoning in adults
Arsenic
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Symptoms of acute exposure are cough, sore throat, and shortness of breath; metallic taste in the mouth, abdominal pain, nausea, vomiting and diarrhea; headaches, weakness, visual disturbances, tachycardia, and hypertension.
Mercury
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It is used in nickel-cadmium batteries chronic exposure could include alopecia,
anemia, arthritis, learning disorders, migraines, growth impairment, emphysema, osteoporosis, loss of taste and smell, poor appetite, and cardiovascular disease
Cadmium
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most of the toxic effects of iron occurs because iron is absorbed rapidly in the gastrointestinal tractMost overdoses appear to be the result of children mistaking red-coated ferrous sulfate tablets or adult multivitamin preparations for candy
Iron
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Although aluminum is not a heavy metal Symptoms of aluminum toxicity include memory loss, learning difficulty, loss of coordination, disorientation, mental confusion, colic, heartburn, flatulence, and headaches
Aluminum
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Lead accounts for most of the cases of pediatric heavy metal poisoning. It is a very soft metal and was used in pipes, drains, and soldering materials for many years. Target organs are the bones, brain, blood, kidneys, and thyroid gland exposure to lead occurs occupationally
Lead
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abdominal pain-vomiting, constipation and encephalopathy (seizures, delir ium, and coma) may develop in more severe cases.
Clinical features
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chelation therapy sodium calcium acetate 75 mg/kg/day
has been the chelating agent of choice
Treatment
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Organophosphorous insecticides are used widely throughout the world and are a common cause of poisoning, causing thousands of deaths, in the developing world
ORGANOPHOSPHORUS INSECTICIDES
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anxiety, restlessness, tired ness, headache, and muscarinic features such as nausea, vomiting, abdominal colic, diarrhoea, tenesmus, sweating, hypersalivation and chest tightness.
intermediate syndrome
Clinical features
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Support ABC Gastric lavage Activated charcol Atropine 2 mg i.v. Should be given to
reduce pulmonary oedema
Treatment
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Tricyclic antidepressants (TCAS) are potentially lethal in overdose. TCA agents act on multiple receptor sites. Their principal antidepressant action is mediated by serotonin and noradrenalin re-uptake inhibition.
ANTIDEPRESSANT TOXICITY
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Anticholinergic effects Agitation, delirium Dilated pupils Dry, warm, flushed skin Tachycardia Urinary retention Neurotoxicity Sedation Seizures Coma
Clinical featurs
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Cardiotoxicity Tachycardia Hypotension Broad complex arrhythmias Bradycardia (late) Ecg changes Prolonged pr, qrs and qt interval
Contd…
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Within a few hours of acetaminophen overdose, typical symptoms include nausea and vomiting. Tenderness and pain in the upper right abdomen may be present.
Very large doses can result in lactic acidosis (a drop in pH of the blood) and coma
ACETAMINOPHEN AND NSAID TOXICITY
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NSAID use is associated with significant adverse effects such as gastrointestinal bleeding, peptic ulcer disease, high blood pressure, edema (i.e., swelling), and kidney disease
NSAIDS
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combine with gastro protective agents H2 receptor antagonist Ppi inhibiters Nutritional Support Antioxidents
Prevention
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Dopamine receptorsSerotonin receptorsMuscarinic receptorsAlpha adrenargic receptorsHistamine receptors
Antipsychotics
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The methylxanthines theobromine and caffeine can be found in a variety of substances (e.g., chocolate, cocoaand coffee beans, over-the-countersleep prevention aids, asthma medications [theophylline, aminophylline]).
METHYL XANTHINE
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vomiting, diarrhea, polyuria, polydipsia, hyperactivity, ataxia, tachycardia,tachypnea, hypertension, weakness,cardiac arrhythmias, tremors, seizures,coma, and death
Manifestations
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Emesis Activated charcol Supportive management
Management
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Theophylline has been widely prescribed for the management of patients with chronic obstructive lung disease and asthma. Despite declining use over recent years,
THEOPHYLLINE
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Agitation, hyperventilation, headache, convulsions Arrhythmiasnausea & vomiting (may be intractable), thirst, diarrhoea
Manifestations
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Asymptomatic Charcoal 1g/kg Observe 4 hours. If no
symptoms, discharge if not slow release medication .If ingestion of slow release preparation, admit for observation and serial drug levels
Management
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Symptomatic Charcoal 1g/kg initially unless altered
conscious state (protect airway first) then 0.5g/kg 4 hourly, and whole bowel irrigation with colonic lavage solution 30ml/kg/hr.Cardiac monitoringI.V. fluid resuscitation & maintenance of adequate hydration is vital if depressed conscious state, arrhythmias or intractable vomiting may need intubation
Contd…
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Features Likely poisons
Constricted pupils(miosis) Opioids, organophosphorus insecticides, nerve agents
dilated pupils
(mydriasis)
Tricyclic antidepressants, amfetamines, cocaine, antimuscarinic drugs
Divergent strabismus Tricyclic antidepressants
Nystagmus Carbamazepine, phenytoin
Loss of vision Methanol, quinine
Papilledema Carbon monoxide, methanol
Convulsions Tricyclic antidepressants, theophylline, opioids, mefenamic acid, isoniazid, amfetamines
CLINICAL MANIFESTATIONS OF POISONING
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Features Likely poisons
Dystonic reactions Metoclopramide, phenothiazines
Delirium and hallucinations Amfetamines, antimuscarinic drugs, cannabis, recovery from tricyclic antidepressant poisoning
Hypertonia and hyper reflexia Tricyclic anti depressants
Tinitus and deafness Salicilates
Hyperthermia Salicilates ecstasy drugs
Contd…
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. POISON ABSORPTION Gut decontamination Gastric lavage.. Induce vomiting Single-dose activated charcoal Cathartics Whole bowel irrigation
GENERAL MANAGEMENT
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Muiti-dose activated charcoal (mdac) Urine alkainization. Hemodialysis
INCREASING POISON ELIMINATION
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Poison Antidote
Aluminum (aluminum) Desferrioxamine (deferoxamine)
Arsenic Dmsa,(dimercaptosuccinic acid)
Benzodiazepines Flumazenil
Beta -adrenoceptor blocking drugs Atropine, glucagon
Calcium channel blockers Atropine
Carbamate insecticides Atropine
carbon monoxide Oxygen
Copper D-penicillamine, dmps1
Specific management
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Poison Antidote
Opioids Naloxone
Organophosphorus insecticides atropine, hi-6, obidoxime,pralidoxime
paracetamol (n-acetylcysteine)
Thallium Berlin (prussian) blue
Warfarin and other anticoagulants Phytomenadione (vitamin k)
Contd…
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Thank you