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Questions and Answers
Which of the following are necessary measures in the management of poisoned patients? (Select all that apply)
What is cyanosis?
Bluish skin color due to low oxygen saturation.
What are the signs and symptoms of inadequate tissue perfusion?
Depressed consciousness, decreased blood pressure, peripheral vasoconstriction.
Doxapram can be used as a last resort in poisoning cases to stimulate respiration.
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What is the first evaluation measure for airway obstruction?
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Inhalation exposures require administration of _____ % humidified O2.
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Which of the following drugs may be used to maintain blood pressure during poisoning?
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What is required in advanced cardiac life support (ACLS) for cardiovascular emergencies?
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What management strategy should be employed first in a patient with suspected poisoning?
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What is the primary indicator of cyanosis in a patient?
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Which evaluation measure is crucial in assessing breathing function in a poisoned patient?
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When assessing circulation in a poisoned patient, which sign indicates inadequate tissue perfusion?
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Which of the following could lead to respiratory depression in a poisoned patient?
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What is a common treatment measure for a patient experiencing shock due to poisoning?
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What is the primary treatment option for generalized seizures secondary to toxins?
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In the context of emergency toxicology, what does the evaluation of 'D' or 'E' refer to?
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Which of the following is a key intervention in maintaining blood pressure during poisoning?
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What does acrocyanosis generally indicate?
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Which drug is indicated as a last resort to stimulate respiration in poisoning scenarios?
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What is the recommended oxygen treatment duration for acute CO intoxication?
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What should be avoided in the treatment of arrhythmias since it has excessive cardiac depressant effects?
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What is the role of IV sodium bicarbonate in treating arrhythmias caused by poisoning?
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Which of the following interventions is NOT typically performed for inhalation exposures?
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What is the major symptom associated with poisoning due to tricyclic antidepressants?
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What is the primary purpose of plasmapheresis?
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In cases of opioid overdose, which antidote is recommended for reversal?
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What is the mechanism of action of N-Acetyl-L-Cysteine as an antidote?
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Which antidote is used to treat hydrofluoric acid skin burns?
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What is a common antidote used for treating acetaminophen toxicity?
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Which antidote is administered for Digoxin toxicity?
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Which of the following antidotes is effective against cyanide poisoning?
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For the treatment of benzodiazepine overdose, which antidote is utilized?
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What is the minimum recommended duration for ocular irrigation after an exposure?
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Which method is NOT recommended for inducing emesis in cases of ingested poison?
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What is the primary purpose of forced diuresis in poison management?
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Which procedure uses a hemofilter to remove waste products and water from blood?
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Which of the following statements about ocular exposure treatment is correct?
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What type of laxative might be used during treatment of a poisoned patient to promote elimination?
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What is the recommended method for rinsing the skin after dermal exposure to contaminants?
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What type of compounds require proper protective equipment due to their ability to penetrate intact skin?
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Study Notes
Principles in Management of Poisoned Patients
- Stabilization of patient: Essential to prevent further deterioration
- Treatment of poisoning: Focuses on mitigating effects of ingested toxins
- Administration of antidotes: Specific antidotes or antidote cocktails used to counteract poison effects
- Diagnosis of the poison (poisons ID): Crucial for targeted treatment and prevention
- Continuing care and Prevention: Monitoring and managing long-term effects, preventing future exposures
Stabilization of the Patient (ABCDEs measures)
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Airway Obstruction:
- Causes: Mucosal swelling, secretions, tongue displacement, foreign bodies
- Signs/Symptoms: Difficulty breathing, distress, air hunger, skin discoloration, sweating, rapid breathing
- Management: Secure airway using nasopharyngeal tube or intubation
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Breathing:
- Causes: Respiratory depressant drugs, lung infections, fluid buildup in lungs, lung abscesses, blood clots in the lungs, airway spasms
- Signs/Symptoms: Rapid breathing, skin discoloration, shallow breathing, altered consciousness
- Evaluation: Blood gas analysis, chest X-ray
- Management: Mechanical ventilation and supplemental oxygen delivery through nasal tubes or cannula
-
Circulation:
- Signs/Symptoms of inadequate tissue perfusion: Shock (altered consciousness, low blood pressure, constricted blood vessels, metabolic acidosis, decreased urine output)
- Treatment: Positioning the patient, administering vasopressors (dopamine, norepinephrine), fluid management
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Depression (D) or Excitation (E):
- Depression: Assessed through pupil size, light reflex, motor responses to pain, eye movements
- Excitation: Manifests as seizures
- Treatment of Generalized Seizures: Diazepam, phenobarbital, general anesthesia, enhancing drug elimination through dialysis
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Cardiovascular:
- Key Symptoms: Arrhythmias
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Treatment:
- CPR
- IV fluid management (primary choice)
- IV Sodium bicarbonate (NaHCO3) for early arrhythmias
- Lidocaine (IV injection) as next-line treatment
- Avoid procainamide due to excessive cardiac depressant effect
Advanced Cardiac Life Support (ACLS)
- Established by: American Heart Association (AHA) and American College of Cardiology (ACC)
- Used for: All cardiovascular emergencies
- Goal: Stabilize vital signs (heart and lungs)
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Interventions:
- Electric: Defibrillation
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Mechanical:
- Cardiopulmonary Resuscitation (CPR)
- Cardiac massage
- Artificial respiration
- Drugs: Medications to support cardiac function
Toxic ACLS - Modified for Poisoning
- Resuscitation time: May extend beyond the typical 20-30 minutes
- Doxapram: Can be used as a last resort (0.5-1.5 mg/kg IV) to stimulate breathing
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100% Oxygen: Essential in acute carbon monoxide (CO) poisoning for 4-5 hours until symptoms resolve
- Mechanism: Replaces CO from hemoglobin
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95% Oxygen & 5% Carbon Dioxide: May be used for most CO poisoning patients
- Rationale: CO has 250 times greater affinity for hemoglobin than oxygen
Treatment and Prevention of Poisoning
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Non-Ingested Poisoning (Inhalation Exposures):
- Immediate Removal: From the hazardous environment
- Oxygen Therarpy: 100% humidified oxygen, assisted ventilation, bronchodilators
- Monitor for: Respiratory tract edema and non-cardiogenic pulmonary edema
- Evaluation: Arterial blood gas analysis, chest examination
Emergency Toxicology - Principles of Management
- Stabilization of the patient using ABCDEs:
- Airway: Assess for obstruction due to swelling, secretions, tongue displacement, or foreign bodies. Manage by clearing the airway and using a nasopharyngeal tube or intubation.
- Breathing: Evaluate ventilation and oxygenation. Causes of compromised breathing include respiratory depressant drugs, pneumonia, pulmonary edema, lung abscess, pulmonary emboli, and bronchospasm. Manage with assisted ventilation and supplemental oxygen delivered by nasal catheters or cannula.
- Circulation: Assess for inadequate tissue perfusion, signs of shock (decreased consciousness, low blood pressure, vasoconstriction, metabolic acidosis, and oliguria). Manage with circulatory support by positioning, vasopressors (dopamine, norepinephrine), and fluid resuscitation.
- Depression (D) or Excitation (E): Evaluate depression by observing pupillary size, light reflex, motor response to pain, and spontaneous eye movements. Excitation is manifested as seizures. Treat generalized seizures with diazepam, phenobarbital, general anesthesia, and enhance drug elimination with hemodialysis.
- Cardiovascular: A major symptom of poisoning, especially with tricyclic antidepressants. Use IV fluids to maintain blood pressure. Give IV sodium bicarbonate to reverse early arrhythmias. Lidocaine is the next agent of choice for arrhythmias. Procainamide should be avoided due to its cardiac depressant effects.
- Advanced Cardiac Life Support (ACLS): A standard protocol for cardiovascular emergencies established by the American Heart Association (AHA) and American College of Cardiology (ACC). Focus on maintaining vital signs by using electrical interventions, mechanical measures (CPR, cardiac massage, artificial respiration), and medications.
Toxic ACLS
- Resuscitation can exceed 20-30 minutes in poisonings.
- Doxapram (0.5-1.5 mg/kg IV) can be used as a last resort to stimulate respiration in patients with compromised respiratory function.
- 100% oxygen is critical for acute carbon monoxide intoxication for up to 4-5 hours until the patient is symptom-free.
- 95% oxygen and 5% carbon dioxide can be used for most poisoned patients with carbon monoxide poisoning.
- Carbon monoxide has 250 times greater affinity to hemoglobin than oxygen.
Treatment and Prevention of Poisoning
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Non-ingested poison:
- Inhalation: Immediate removal from the hazardous environment, administration of 100% humidified oxygen, assisted ventilation, and bronchodilators. Monitor for edema of the respiratory tract and pulmonary edema. Perform blood gas analysis, chest x-ray, and blood tests to identify the substance.
- Dermal: Wear protective gear. Remove contaminated clothing, lenses, and jewelry. Gently rinse and wash the skin with water for at least 30 minutes. Do not use forceful flushing. Use slightly cold water and soap for oily substances. Protect against toxic substances like organophosphorous compounds, metals, and phenol.
- Ocular: Decontaminate by irrigating eyes with saline for at least 15 minutes. Avoid alkaline or acid irrigating solutions. Continue irrigation until pH is back to normal. Seek ophthalmic consultation for alkaline corneal burns.
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Ingested poison:
- Dilution: Dilute the poison with water.
- Prevention of absorption: Induce emesis (not recommended in many countries anymore). Gastric lavage (nasogastric or orogastric tube). Adsorption by activated charcoal (exceptions: heavy metals). Cathartics.
Enhancement of Elimination of Absorbed Poison
- Forced diuresis and pH alteration: Use mannitol, furosemide, and sodium bicarbonate.
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Extracorporeal techniques:
- Peritoneal dialysis: Diffusion of toxins from capillaries into dialysate within the peritoneal cavity.
- Hemodialysis: Blood is pumped through a dialysis unit (filter with dialysate) to remove toxins.
- Hemofiltration: Similar to hemodialysis, but uses hydrostatic pressure to remove waste products and water.
- Hemoperfusion: Blood is passed over adsorbing material (charcoal or resins) to remove toxins.
- Plasmapheresis and Plasma exchange: Separation of blood cells from plasma, then cells are resuspended in fresh frozen plasma and reinfused.
- Exchange transfusion: Removal of patient's blood and replacement with fresh whole blood.
- Plasma perfusion: Combination of plasmapheresis and hemoperfusion.
Inactivation of the Absorbed Poison (Antidotes)
- Chelators: Deferoxamine, Dimercaprol, EDTA, Penicillamine.
- Cyanide antidote: Dicobalt Edetate, Cyanide antidote kit (Amyl nitrite, Na nitrite, and Na thiosulfate), and Hydroxocobalamin.
- Calcium salts: Calcium gluconate and calcium chloride (hydrofluoric acid skin burns, neuromuscular paralysis, fluoride ingestion, calcium channel blocker overdose, and beta-blocker overdose). Administer calcium gluconate slowly.
- Antivenins: Against spiders, scorpions, and snake bites.
- Ethanol: 10% ethanol for methyl alcohol poisoning.
- Fomepizole (4-methylpyrazole: 4-MP): For ethylene glycol poisoning.
Homework
- Antidotes and their mechanism of action: Consider each antidote mentioned above to understand which specific poisoning each antidote would be used for, along with a brief explanation of its mechanism of action.
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Description
This quiz covers the essential principles for managing patients who have been poisoned. Key topics include stabilization techniques, diagnosis of poisons, and the administration of antidotes. Test your knowledge on the critical care procedures and long-term management of poisoned patients.
