Toxicology L1 (General Toxicology) PDF

Prof Dr Heba Youssef Vice Dean for Postgraduates studies Head of Forensic Medicine and Clinical Toxicology Faculty of Medicine PSU Clinical Toxicology round 2021-2022 Prof Dr Heba Youssef Vice Dean for Postgraduate studies affairs Head of Fo...

Prof Dr Heba Youssef Vice Dean for Postgraduates studies Head of Forensic Medicine and Clinical Toxicology Faculty of Medicine PSU Clinical Toxicology round 2021-2022 Prof Dr Heba Youssef Vice Dean for Postgraduate studies affairs Head of Forensic Medicine & Clinical Toxicology Department  GENERAL TOX HOW TO MANAGE ACUTE INTOXICATED PATIENT BY Prof. HEBA YOUSSEF  Clinical Toxicology In Glance  Medical Toxicology is a branch of medicine or medical subspecialty focusing on the diagnosis, management and prevention of poisoning and other adverse health effects due to medications, occupational , environmental toxins, and biological agents. Medical Toxicology also can be further subdivided into  Part I: General Toxicology: which include general principals and guidelines needed to be applied for acute intoxicated patients including common toxicological emergencies and role of investigations in aiding the diagnosis and management  Part II: Systemic Toxicology : include full analysis of each drug or toxin in terms of pathophysiology or mechanism of action , clinical presentation, investigation , complications and management.  Part III : Environmental Toxicology : include toxins that victims could exposed to them due to hazardous unsafe environment they include home environment by exposure to household toxins, occupational environment by exposure to industrial toxins and agricultural pesticides poisoning and natural toxins which include toxic animals , plants , food poisoning , and marine poisoning. Recently toxicological disasters caused by CBNRE are added to this part demanding special considerations in management.  Part IV: Medicolegal Responsibilities of Medical Toxicologists: this include the medicolegal responsibilities of toxicologists and emergency physicians in managing with acute intoxicated patients  6 WHY COMPETENCE BASED DIAGNOSIS????? To proceed from undifferentiated signs and symptoms in an intoxicated patient to a clear diagnosis....... in order to initiate appropriate therapy. STEEEP Safe Timed Effective Efficient Equitable Patient centered Prof Dr Heba Youssef 21/2/2016  Part I: General Toxicology  What Is Poison Or Toxin?  The term "poison" is used to describe any substance or agents that when enter the human body in sufficient amount or dose can cause harmful effects or death  Paracelsus (1493–1541), the father of toxicology, once wrote: "Everything is poison, there is poison in everything. Only the dose makes a thing not a poison"  What is poisoning or intoxication? It is the process of exposure of individuals to any substance or agent that when human body exposed to it either due to single large dose (acute toxicity); or due to repeated smaller dose (chronic toxicity) can be life threatening. -Mode of poisoning ? - Route of intake ? - Delay time ? Routes of intake Factors affecting action of poison: Factors related to Factors related to poison patient Dose Stomach Route Age Form Disease Cumulation Tolerance Time of contact Hypersensitivity Who are the risk groups? When to suspect poisoning ??? A. If sudden deterioration of vital functions of body systems neurological, respiratory and cardiovascular functions in otherwise healthy individuals. B. History of neuro-psychiatric diseases or psychological problems that may suggest self-inflicted poisoning. C. Group poisoning :group of individuals manifesting with panic attacks and sharing the same symptoms and signs after consuming the same meal which may suggest food poisoning or toxic gases exposure. D. Road traffic accidents with multiple injuries among drivers and passengers E. Suspect poisoning in any crime especially in absence of trace evidence in the scene of crime F. Teenagers found comatose with or without injuries in street or party or club or lonely in home or bathroom. General Guidelines for Management of Acute Intoxicated Patients The management of any toxicological emergency follows regular steps best described by monomeric ABCDEFG  Initial management of intoxicated patient Airway with cervical spine control Breathing100% O2 , ventilation Circulation : Insert IV cannula – Draw bloods with IV start – Bolus 1-2L NS – Cardiac monitor Drugs (coma cocktail), Decontamination Elimination  Find an antidote General management(supportive management)  A. Airway: Clearance of airway through the following steps: 1. The patient is placed on his back with the head extended and chin lifted (to establish an aligned airway passage).  2. Suction of accumulated upper airway secretions, regurgitated food, and stomach contents.  3. Removal of any foreign bodies, loose removable dentures, or mucous from the mouth.  4. Prevent falling back of the tongue in comatose patients by using oropharyngeal tube.  5. Endotracheal intubation and mechanical ventilation, better used with inflatable cuff, if patient cannot breathe spontaneously.  6. Tracheostomy may be needed in laryngeal obstruction.  B. Breathing (to deliver oxygen to respiratory passages): 1. Artificial respiration is done by mouth to mouth breathing before arrival to hospital. 2. The rescuer places the patient on his back with head tilt chin lift maneuver 3. The rescuer rapidly takes a deep breath and breaths into the mouth of the patient after good sealing between their lips (****Toxicological secrets: it is more safe for the rescuer to use face mask to avoid infection). 4. After arrival to the hospital, oxygen mask is used if the patient breathe spontaneously, or endotracheal intubation with the use of mechanical ventilation if apnea occurs.  C. Circulation 1. Place the patient on ECG monitor 2. Correction of hypotension by IV fluids. Inotropic drugs may be used if no response occurs. 3. Treatment of dysrhythmias  D. Drugs Any patient with undiagnosed coma should empirically receive the following drugs (coma cocktail) for immediate treatment of rapidly reversible causes of coma: 1.100 ml glucose 50% Dextrose : to correct hypoglycemia 2. 0.4-2 mg Naloxone ( Narcan ®): to revert coma of opiate overdose 3.100 mg Thiamine (vitamin B1) : to correct Wernicke's encephalopathy in alcohol toxicity  “Coma Cocktail” Current – DON’T Dextrose Oxygen Naloxone Thiamine  D. Decontamination: The aim of these procedures is to reduce the absorption of poisons before approaching the systemic circulation. Early intervention is recommended for these methods to be efficient. The choice of the procedure depends on the route of entry of the toxic substance to the body  DECONTAMINATION *DERMAL: OPC, Carbolic acid. ( remove clothes ,wash with soap & water for 15 min ,NO forceful rubbing) *EYE: wash conj. With running water or saline for 20 min. *Inhalation: CO ,CN. 1.Remove to fresh air 2.Care of resp. *GIT Never Never Never (Use Salty H2O) ????  GIT DECONTAMINATION 1. Ipecac 2. Lavage 3. A.C. 4. Cathartics 5. Whole bowel irrigation  Gastric Lavage Indications Recent ingestion (