1 DORCAS BIO ( PHYSICIAN ASSISTANT)POISONING DORCAS BIO ( PHYSICIAN ASSISTANT)
2 OUTLINE OF PRESENTATIONDEFINITION OF POISONING EPIDEMIOLOGY ROUTES OF POISON EXPOSURE GENERAL APPROACH TO A POISONED PATIENT SPECIFIC MANAGEMENT OF A POISONED PATIENT SPECIFIC DRUGS AND THEIR MANAGEMENT ENVENOMATION SUMMARY
3 DEFINITION A poison is any substance that causes harm to the body when it gets into it.
4 EPIDEMIOLOGY Over 4 million poisonings America occur annually.10% of ED visits and EMS responses involve toxic exposures. 70% of accidental poisonings occur in children under 6 years old. 80% of attempted suicides involve a drug overdose. In Ghana 1000 deaths occur annually, (Ghana Death rate - Demographics, Index Mundi).
5 ROUTES OF POISON EXPOSUREIngestion Common agents: Household products Petroleum-based agents Cleaning agents Cosmetics Drugs, plants, or foods Absorption occurs in the stomach and small intestine.
6 CONTD Inhalation Common agents Toxic gases, vapors, fumes, aerosolsCarbon monoxide, ammonia, chlorine Tear gas Carbon tetrachloride Absorption occurs via the capillary— alveolar membrane in the lungs.
7 CONTD Surface Absorption Common agents: OrganophosphatesAbsorption occurs through capillaries in the skin.
8 PRIMARY ASSESSMENT A- (Airway) B-( Breathing) C- (Circulation)D-(disability- Is The Patient Conscious Or Comatose) E-(exposure- Remove Clothing, Irrigate Eyes And Wash Skin With Copious Of Amounts Of Soap And Water)
9 GENERAL APPROACH TO POISONED PATIENTHistory Taking Physical Examination Management
10 HISTORY TAKING What When How much Any alcohol intakeAny treatment attempt Why,( under psychiatric care and what medications) What is your weight?
11 PHYSICAL EXAMINATION A (Airway) B (Breathing) C (Circulation)Respiratory effects include cough, hoarseness, stridor, dyspnea, retractions, wheezing, chest pain or tightness, rales, decreased RR C (Circulation) Cardiac effects include dysrhythmias.
12 CONTD D (Disability-AVPU/ Glasgow Coma Scale)Central nervous system effects include dizziness, headache, confusion, seizure, hallucinations, coma Glucose level
13 SPECIFIC MANAGEMENT Decreasing drug absorptionIncreasing drug elimination Antagonizing the effects ( Antidotes)
14 DECREASING DRUG ABSORPTIONIngested poisons: Gastric lavage: used when a potential amount of toxin is ingested and effective within an hour of poisoning. Contraindicated in acids, alcohol and petroleum products Activated charcoal: given within an hour of poison ingestion at a dose of 50g in adults. Inhaled poisons: give high flow oxygen 12 l/min and bronchodilators if the patient is wheezing
15 INCREASING DRUG ELIMINATIONAlkaline diuresis : for serious poisoning with salicylates and theophylline IV 1.26% sodium bicarbonate infusion is given over 3 hours for forced diuresis. Heamodialysis
16 ANTAGONIZING THE EFFECTS (ANTIDOTES)IRON……………………………..Desferrioxamine OPIATES………………………..Naloxone PARACETAMOL…………….N Acetyl cysteine HEPARIN……………… Protamine CARBON MONOXIDE Oxygen ORGANOPHOSPHATES……Atropine/ Pralidoxime BENZODIAZEPINES………….Flumazenil
17 SPECIFIC DRUGS AND THEIR MANAGEMENT .ANALGESIACS PARACETAMOL STAGE 1 12-24 HOURS Nausea, vomiting weakness, fatiguability STAGE 2 24 – 48 HOURS Abdominal pain, decreased urine, increased liver enzymes STAGE 3 72 – 96 HOURS Liver dysfunction STAGE 4 4 – 14 DAYS Liver failure
18 CONTD Give acetyl cysteine within 16 hours of ingestion . Loading dose of 140mg/kg then 70mg/kg 4 hourly for 16 doses
19 SALICYLATES Common Overdose Drug aspirintoxicity occurs due to disturbance in acid base balance Respiratory alkalosis Metabolic acidosis
20 SIGNS AND SYMPTOMS Common Features:Vomiting, Dehydration, Tinnitus, Vertigo Sweating, Bounding pulses, Hyperventilation Uncommon Features: Confusion, Disorientation, Coma, Convulsions Hematemesis, Hyperpyrexia, clotting abnormalities, renal failure
21 MANAGEMENT Activated CharcoalGiven in those who have taken more than 250mg/Kg body weight less than 1 hour ago Gastric Lavage May be considered in those who have taken more than 500mg/kg body less than 1 hour ago. Steps must be taken to protect the airway Urinary Alkalization increase urinary pH from 5 to 8 there is a fold increase in the renal salicylate clearance by giving an infusion of Sodium Bicarbonate.
22 TRICYCLIC ANTIDEPRESSANTSAmitriptyline Signs and symptoms Anticholinergic effects Dry Mouth, Dry Eyes, Dilated Pupils, Urinary Retention, Blurred Vision, Dizziness, Palpitations, Cardiac effects( Quinidine effects) Heart block, tachycardia, bradycardia
23 MANAGEMENT Activated Charcoal if more than 4 mg/Kg within 1 hour.N.B WATCH OUT FOR THE AIRWAY Correct Hypoxia with Oxygen Correct Acidosis with sodium bicarbonate when acid base imbalance is suspected
24 ANTI – DIABETICS Signs and symptomsSulphonylureas: Glibenclamide, Gliclazide Biguanides : Metformin, Phenformin Signs and symptoms Sweating Confusion hypoglycaemia
25 MANAGEMENT Activated charcoal within 1 hour of ingestionGastric lavage Correct hypoglycaemia using 10% and 20% dextrose
26 BENZODIAZEPINES Diazepam, lorazepam Signs and symptoms DrowsinessDilated pupils Respiratory depression
27 MANAGEMENT Activated charcoal Gastric lavageMonitor oxygen saturation and administer oxygen flumazenil
28 OPIOIDS Signs and symptoms Heroin, morphine , codeine, pethidineRespiratory depression Pinpoint pupils Hypotension unconciuosness
29 MANAGEMENT Monitor oxygen saturation and give oxygenGive naloxone mg IV every 2 minutes as level of consciousness and respiration increases
30 ORGANOPHOSPHATES Insecticides and weedicides Organic phosphate insecticides cause irreversible inhibition of the enzyme cholinesterase. As result acetylcholine causing excessive parasympathetic. These agents are absorbed by all routes including skin and mucosa. Signs and symptoms: headache, blurred vision, bradycardia, vomiting, lacrimation, salivation, excessive urination and diarrhea.
31 MANAGEMENT if substance came into contact with skin and eyes wash thoroughly with water. Atropine Sulphate at a dose of 0.4 – 0.4mg/kg (maximum dose is 1mg/kg in 24 hours) and repeat half the dose till signs of toxicity disappear
32 CONTD Pralidoxime is given at a dose of 25-50mg/kg IM or IV in infusion. The dose is given 1-2 hours then repeated every 6-12 hours.
33 ALKALINES ( CAUSTIC SODA)Typically occurs by ingestion or surface absorption Slower onset of symptoms allows for longer contact and more extensive tissue damage. Signs and symptoms Facial burns Pain in the lips, tongue, throat, or gums Drooling, trouble swallowing Hoarseness, stridor, or shortness of breath vomiting
34 MANAGEMENT Resuscitation : IV Antibiotics: Airway BreathingCirculation IV Antibiotics: Aspiration Pneumonia And Oesophageal Rupture
35 CARBON MONOXIDE Signs and symptomsinhalation of gas from an enclosed place. E.g : Gas Stoves, Fire Smoke, Auto Mobile Exhaust Signs and symptoms Headache Cyanosis Convulsion Coma
36 MANAGEMENT Give oxygen intra nasally 12l/min.Administer 100% oxygen if carboxy haemoglobin levels are above 40%. Hyperbaric oxygen therapy.
37 ENVENOMATION : SNAKE BITESLife threatening condition that mostly occurs in farmers, hunters and rice pickers Venom of snakes contain complex mixture of proteins with enzymatic activity Classification: Neurotoxin: respiratory arrest Cytotoxin: soft tissue destruction leading to necrosis and compartment syndrome Cardio toxins : cardiac arrest as a result of coronary vasoconstriction and AV block Haemotoxin : alteration in coagulation leading to profuse bleeding
38 MANAGEMENT Systemic support:Iv fluids Oxygen therapy Haemo transfusion Anti-venom: Give polyvalent anti-venom if in doubt but if the snake species is known give a monovalent anti-venom intravenously over 30minutes.
39 CONTD Antibiotics Tetanus prophylaxis Necrotic tissue debridement
40 PREVENTION Medicines and drugs should be placed in secured locations, e.g. locked cupboard. Drugs shouldn’t be stored in attractive bottles ,e.g. Coke and Fanta bottles. Hospital must stock anti-venom. Drugs when not in used must be clearly labelled. Adding the antidote to the toxin, e.g. combination of Methionine and Paracetamol. Hazard warning labels on chemicals. All cases of poisoning, adverse effects of drugs and overdose cases must be documented.
41 SUMMARY Get as much history as you can to identify the toxin.Mainstay of any poisoning is supportive. Don’t forget ABC. For specifics substances there may be antidotes. For specific circumstances consider decreasing the absorption or the elimination of the drug.
42 THANK YOU