General Approach to Acutely Poisoned Patients PDF

By Dr/Nada Seliem Lecturer of clinical toxicology Faculty of medicine - Cairo university o Ingestion o Inhalation o Injection o Dermal Management of intoxicated patient ❖ A … airway ❖ B … breathing ❖ C … circulation ❖ D…. Diagnosis & decontamination ❖ E…. Elimination &...

By Dr/Nada Seliem Lecturer of clinical toxicology Faculty of medicine - Cairo university o Ingestion o Inhalation o Injection o Dermal Management of intoxicated patient ❖ A … airway ❖ B … breathing ❖ C … circulation ❖ D…. Diagnosis & decontamination ❖ E…. Elimination & exposure ❖ F …. Find antidote ❖ G….. General management (supportive)  General approach to acutely poisoned patients GENERAL LINES OF POISONING TREATMENT Supportive therapy (1st Aid) “Treat the patient not the poison” & Symptomatic Decontamination & diayalsis Antidotes 5  Exposure Elimination 6 keep it patent by: Head → “sniffing” (neck flexed ,head extended) , “jaw thrust forward movement of the tongue without flexing or extending the neck. Pull the jaw forward by placing the fingers of each hand on the angle of the mandible just below the ears. ” Tongue →prevent falling back against the by using oropharyngeal tube Dentures or foreign bodies → Must be removed 7  If no pulse CPR and ACLS Hypotensive→ intravenous infusion of normal saline +inotropics (dopamine ,adrinaline). Hypertension →antihypertensive agents as ACE, CCB… Arrhythmia →antiarrhythmic drugs (lidocaine, phenytoin, etc.). obtain urine for routine ,toxicological testing and to assess urine output / hour. Coma Coma or stupor is the most common serious complications in acute poisoning. Coma cocktail “DON’T” D ….dextrose Adults: 50% dextrose, 50 mL (25 g) IV (exclude hypoglycemia). ✓ O…..High- flow oxygen to treat hypoxia. ✓ N …naloxone beginning at 0.04 mg IV for an adult or child with suspected opioid-induced respiratory compromise. ✓ T Thiamine 100 mg IV for an adult to prevent or treat Wernicke`s encephalopathy. Consider excluding other causes of coma (trauma, meningitis &encephalitis … 8  Treatment of Convulsions: Seizures are treated with diazepam 0.2 mg/kg slowly IV (over 1-2 minutes) followed by Phenobarbital 15 mg/kg slowly IV if no response to diazepam. Caution: Anticonvulsants can cause hypotension, cardiac arrest, or respiratory arrest if administered too rapidly. Exposure Completely undressed (skin ) (needle track marks) Assess other complication eg anaphylaxis ,Dystonia, rigidity ,rhabdomyolysis….. 9 SECONDARY ASSESSMENT – DIAGNOSIS OF POISONING - After the primary assessment and resuscitation, the patient should undergo a secondary assessment. as follows: 1- A careful history. 2- A detailed clinical examination. 3- Clinical laboratory tests. History should be directed towards identifying the following: 1- Type of poison (chemical, drug, insect bite/sting, plant). 2- Amount / quantity. 3- Route of exposure. 4- Time since exposure. 5- Reason for exposure. 6- Time of onset of symptoms in relation to exposure. 7- Treatment received prior to arrival to hospital. Continue to assess the patient's vital signs, mental status, and pupil size repeatedly (from every 15 to 30 minutes to every hour). Check for the following: TOXIDROMES:They are characteristic clinical signs and symptoms suggesting a specific drug class. physiologic excitation (increased agitation, BP, respiratory rate, pulse, temperature, and pupil dilation) physiologic depression (coma; somnolence; diminished BP, respiratory rate, pulse, and temperature; and pupil constriction) odors (bodily or breath) acetone (fruity), caused by ethanol, isopropyl alcohol, chloroform, or salicylates bitter almond, caused by cyanide garlic, caused by arsenic, organophosphates, phosphorus, thallium, or selenium rotten eggs, caused by hydrogen sulfide wintergreen, caused by methyl salicylate. For more information about how to use assessment findings to help determine what type of poison is causing your patient's signs and symptoms, see Pinpointing poison's effects. DR: NADA SELIEM INVESTIGATIONS Routine: - Random blood glucose (RBS), electrolytes , renal function tests , liver function tests , ABGs, and CBC. - General laboratory tests are more useful than toxicology screens. Specific: - Blood tests specific drug levels : Acetaminophen, Salicylates, Digoxin, Carbamazepine, Phenobarbitone, Phenytoin, Valproate, Theophylline, Iron, and Lithium. - Additional Tests: Electrocardiogram. Chest X-ray (CXR) for aspiration pneumonia, (NCPE). Abdominal X-ray (AXR) is useful in screening for ingestions of radiopaque materials. DECONTAMINATION Skin: Indications: In poisoning with corrosives, chemical irritants, hydrocarbons and toxins rapidly absorbed through the skin e.g. organophosphates. Remove contaminated clothing and flush exposed areas with copious running water or saline (no rubbing). Eyes: 1. Flush exposed eye with copious tap water or saline. 2. If available, instill local anesthetic drops first to facilitate eye irrigation. 3. Remove the victim's contact lenses. 4. Patients with serious injures should be referred to the ophthalmologist immediately. Inhalation Decontamination: Indications: Injury to the respiratory system is often caused by irritant gases and fumes. Method: Remove the victims from the area of exposure and give supplemental O2 and assess ventilation if necessary. GI decontamination Gastric lavage A.C Cathartics Whole bowel irrigation GI decontamination Gastric lavage Never ever Never Use salty H2O Recent ingestion of toxins (usually within one to two hours). Ingestion of a poison and an amount suspected to cause Toxicity , agents not absorbed by AC Substances likely to form concretions Contraindication Corrosive & froth forming Coma ,convulsion Single dose of activated charcoal (AC): A) Action: Reduces the systemic absorption of many drugs by adsorption of drugs to the surface of charcoal. It also acts to enhance elimination by disrupting substantial enterohepatic recirculation. B) Dose: 1-2 gm/kg in adults and 0.5–1 gm/kg in children. D) Contraindications: Coma or convulsions Caustics..Perforation or Intestinal obstruction – Need for endoscopy Colon …Absence of bowel sounds  Agents for which activated charcoal is not effective (fails to adsorb the poison): PHAILS o Pestisides?????? o Hydrocarbons o Acids , Alkalis & Alcohols o Iron &Heavy metals o Lithium & Inorganic ions eg. Fluoride and Iodide o solvents ENHANCEMENT OF ELIMINATION MDAC Diuresis Manipulation of urine PH Hemodialysis Hemoperfusion Recent Indications for enhanced elimination: o Patients who fail to respond adequately to full supportive care. o Patients in whom the normal route of elimination of the drug is impaired. o Patients with concurrent disease o Patients with concomitant electrolyte imbalances Surgery & Endoscopy: Surgery and endoscopy are occasionally indicated for decontamination of poisoned patients if the other methods failed. Generally, this method is used for body packers (cocaine, heroin) and bezoars formation in drugs like, salicylate, iron, and barium. Find Antidote Treat patient not poison Supportive care is the mainstay of management.. Never ever Never Use salty H2O  One Pill Can Kill Antidepressants and Antipsychotics Antimalarial Medications BB &Heart Medications Products (topical ) Lindane ,Benzocaine ,Camphor & Methyl salicylate Theophylline Diabetic Medications Diphenoxylate (Lomotil®) Narcotic Medications