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Toxicology

Management of a case of

Acute Poisoning

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Poison is a substance which when taken in to the body in a single dose of 1gm / per kg body wt. or less is dangerous to life or injurious to health

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Definitions

Toxin-

Toxic substances directly produced by living organisms like plants, animals, fungi, bacteria or virus.

Toxicant-

Poisonous Chemical derivatives Ex. MIC. Similarly Arsenic both naturally as well as due to industrial activity may contaminate shallow wells. Polyaromatic hydrocarbons toxicants are produced during forest fire and also by burning of coal or smoking cigarettes

The derivative forms "toxic" or "poisonous" are synonymous.
Venom-

Is a toxin secreted by animals like snake, or scorpion or some spiders that is injected to cause its toxic effect

poisons are substances that can cause injury, illness, or death to organisms, usually by chemical reaction or other activity on the molecular scale, when a sufficient quantity is absorbed by an organism. Paracelsus, the father of toxicology states-- "Everything is poison, there is poison in everything. Only the dose makes a thing not a poison".

a poison is often distinguished from a venom. Venoms are usually defined as biologic toxins that are injected to cause their effect, while poisons are generally defined as substances which are absorbed through epithelial linings such as the skin or gut.

Some poisons are also toxins, usually referring to naturally produced substances, such as the bacterial proteins that cause tetanus and botulism. A distinction between the two terms is not always observed, even among scientists.

Animal toxins that are delivered subcutaneously (e.g. by sting or bite) are also called venom. In normal usage, a poisonous organism is one that is harmful to consume, but a venomous organism uses poison to defend itself while still alive. A single organism can be both venomous and poisonous.

Within chemistry and physics, a poison is a substance that obstructs or inhibits a reaction, for example by binding to a catalyst.

The derivative forms "toxic" and "poisonous" are synonymous.

Toxicant- Dioxin(2.3.7,8-tetrachlorodibenzo-p-dioxin[TCDD]) produced during combustion of some chlorinated organic chemical is a toxicant. Similarly Arsenic both naturally as well as due to industrial activity may contaminate shallow wells. Polyaromatic hydrocarbons toxicants are produced during forest fire and also by burning of coal or smoking cigarettes

Venomous organisms deliver or inject venom into other organisms, using a specialized apparatus of some kind (usually fangs or a stinger). The venom is produced in a gland attached to this apparatus. Venomous insects occur in three groups: the true bugs (order Hemiptera), the butterflies and moths (orderLepidoptera), and the ants, bees, and wasps (order Hymenoptera). Spiders, centipedes, and scorpions may also be venomous. Venomous arthropods may inject their venom into prey to immobilize it, or use it defensively against potential predators - like people

Poisonous organisms, on the other hand, do not deliver their toxins directly. The entire body, or large parts of it, may contain the poisonous substance. These organisms may be harmful when eaten or touched. Poisonous insects include members of quite a few groups: butterflies and moths (orderLepidoptera), true bugs (orderHemiptera), beetles (order Coleoptera), and grasshoppers (order Orthoptera), and possibly others. The defensive chemicals produced by these poisonous insects may cause vomiting or blistering, or have cardiac impacts on predators that try to eat or handle them

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Acute Versus Chronic Exposure

Poison delivered in single exposure or repeatedly in less than 24 hours causing poisoning manifested within 14 days appearing suddenly and developing quickly is called ‘acute poisoning’
A dose inadequate for acute poisoning if given repeatedly for longer period usually months or years may cause subacute or chronic poisoning depending on dose and cumulative toxic effects in body which appears insidiously
Effect of acute exposure to a poison often differs significantly from subacute or chronic poisoning

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Acute Poisoning

About 5-10 % of cases in emergency
More than 1 million annually
Children under 6 yrs-accidental
In older age it is intentional or occupational
90% of cases occur at home
In 10% of cases more than one poison involved
60% of poisoning not due to drugs
75% of cases taken orally, 8% through skin, inhalation 6%
About half of suicide deaths (49% among men, and 44% among women) were due to poisoning, mainly ingesting of pesticides.

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Statistics From A Hospital

1% of total admissions in emergency
20 % mortality among poisoning cases
No. of cases Male : Female = 2:1
Mortality in Males higher than in females by 2:1
50% cases by celphos + organophosphates followed by adulterated alcoholic drinks (Methyl alcohol)
More than 50% of cases of Celphos died
10% of total poisoning was by snakebite

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Patients on arrival in Emergency

Pre-toxic phase:- Decontamination is the most important part of management
Toxic phase- Treatment
Phase of resolution- Supportive care & monitoring should continue until clinical, laboratory, and ECG abnormalities have resolved completely

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Some Imporatnt Points

If initial Contact on phone then ask for caller’s number & address & condition.
Large number of cases can be treated at home
But maximum toxicity based on the greatest possible exposure should be assumed
Initial history taking and examination should be focused & brief if in toxic phase
Remember patients often give wrong information
Establish I.V. line and monitoring of vital functions in all serious cases or with uncertain history

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It may be fatal to delay treatment for identification of Poison in laboratory, and estimation of its level in Blood.

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And hence Emergency treatment of poisoning should be started based on clinical assessment of severity and identity

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Clinical Identification of Poison

Vomiting, Depressed resp. Pinpoint pupils

Widely dilated pupil, Bladder distension, Absent bowel sound, Cardiac arrhythmia, Upper motor neurone sign, dry hot skin
Sweating, Tinnitus, Deafness, Hyperventilation

Opiates& related, Cholinesterase inhibitors, Dextropropoxyphene
Tricyclic antidepressants, Dhatura

Salicylates

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Cont.

Buccal corrosive burns

Characteristic smell

Hypothermia

Skin blisters

Strong acids, alkalies, phenols, cresols, paraquat

Alcohols, volatile hydrocarbons, solvents
Chlorpromazine, Barbiturates
Barbiturates,Tricyclic antidepressants Carbon monoxide

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Cont.

Methaemoglobinaemia recognised by cyanosis, bluish coloration of skin, lips, tongue

Nitrites, aniline dyes, nitrobenzene present in shoe polish , ink , paints , varnishes and cleaning products. Azocompounds present in paints, dyes and colouring agents

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Poisons causing Pupillary Changes

Miosis	Mydriasis	Nystagmus
Barbiturates	Cocaine	Alcohol
Benzodiazepins	Dhatura	Barbiturates
Caffeine	Carbonmonoxide	Carbamazepine
Carbamates	Alcohol	Phencyclidine
Carbolic acid	Amphetamine	Phenytoin
Opiates	Belladona
Organophosphates	Hyosine

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Poisons Requiring Immediate Antidote

Pot. Cyanide & hydrocyanic acid gas
Carbon monoxide poisoning
Methanol & Ethylene Glycol
Opiates
Nitrites, azocompounds, aniline dyes, nitrobenzene
Organophosphates & Carbamates
Acetaminophen(Calpol, Crocin)

Pot.Cyanide & hydrocyanic acid gas If Patient Conscious Amyl nitrite inhalation Solution A 158g of ferrous sulphate plus 3g of citric acid made up to 1 litre in cold distilled water; Solution B 60g of anhydrous sodium carbonate made up to 1 litre in cold distilled water. Solutions are stored separately and equal volumes are mixed when required for use. If Patient Unconscious Amyl nitrite inhalation Sodium nitrite 3% maximum 10 ml Sod.thiosulphate 25% 2 ml / kg Or Hydroxocobalamin-thiosulphate mixture 4- 10 gm Cobalt EDTA (trade name Kelocyanor) ampoules of 20ml, each containing 300mg of should be available for I.V. Injection

Carbon monoxide: 100% O₂ Or hyperbaric oxygen Methanol & Ethylene glycol: Ethanol

Opiates: Naloxone- 2 mg I.V to be repeated as necessary

Methaemoglobinaemia: (Nitrites, azocompounds, aniline dyes, nitrobenzene) Methylene blue 1-2 mg / kg in 1 % soln.Exchange transfusion if 2 doses fail

Cholinergic agents: Organophosphates & Carbamates Start atropine 2-5 mg Decontaminate with soap & water Pralidoxime 25to 50 mg/ kg I.v.in 30 mts every 8 hrly

Acetaminophen

N-acetyl cysteine(NAC)

The key for diagnosing methemoglobinemia is cyanosis ( bluish discoloration of skin and lips ) with a normal oxygen blood saturation . �1. Exposure to aniline dyes , nitrobenzene , azo compounds and nitrites can produce methemoglobinemia . �Aniline and nitrobenzene are found in many common household products , such as shoe polish , ink , paints , varnishes and cleaning products . �Nitrites are strong oxidizing agents . They are commonly used for treating cyanide poisoning . �Infants who have ingested nitrate-contaminated well water , or have had repeated applications of large quantities of silver nitrate-containing creams have developed met-hgb by converting nitrate to nitrite in skin or gut. �2. There are rare hemoglobin variants one can be born with , with decreased oxygen carrying capacity such as Hgb M that can produce cyanosis since birth . �3. There are also rare hereditary methemoglobinemias due to enzyme deficiencies which are essential for normal oxygen - transportation by the blood . Only in such individuals , certain drugs can induce met-hgb , and that depends on the extent of the enzyme deficiency . Examples are antimalarials , certain anticonvulsants , certain sulfa containing drugs . �Methemoglobinemia usually presents with minor or vague symptoms of a viral syndrome and unless the cyanosis is apparent , it is rarely suspected . Met-Hgb levels have to be >30% to produce any symptoms except for cyanosis. If the causative agent is removed , met-hgb will gradually disappear with the appropriate treatment facilitating its decline . If hereditary , methemoglobin levels will remain constant

Azocompounds are chemicals used as colouring dyes..

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Poisons Urgently Needing Antidote

Pot.Cyanide & hydrocyanic acid gas

If Patient Conscious

Amyl nitrite inhalation,
Solution A 158g of ferrous sulphate plus 3g of citric acid made up to 1 litre in cold distilled water;
Solution B 60g of anhydrous sodium carbonate made up to 1 litre in cold distilled water.

Solutions are stored separately and equal volumes are mixed when required for use and given oraly

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Pot. Cyanide, HCN Poisoning

If Patient Unconscious

Amyl nitrite inhalation

Sodium nitrite 3% maximum 10 ml I.V slowly- in 5 minutes
Sod.thiosulphate 25% 2 ml / kg Or
Hydroxocobalamin-thiosulphate mixture 4- 10 gm I.V. as infusion- in 10 minutes.
Cobalt EDTA (trade name Kelocyanor) ampoules of 20ml, each containing 300mg of should be available for I.V. Injection

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Poisons With Antidote Urgency

Carbon monoxide

100% O₂ Or hyperbaric oxygen

Methanol & Ethylene glycol

Ethanol

Opiates

Naloxone- 2 mg I.V to be repeated as necessary

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Cont.

Methaemoglobinaemia- Cyanosis

Nitrites, azocompounds, aniline dyes, nitrobenzene

Methylene blue 1-2 mg / kg in 1 % soln.
Exchange transfusion if 2 doses fail

Cholinergic agents

Organophosphates & Carbamates

Start atropine 2-5 mg
Decontaminate with soap & water
Pralidoxime 25to 50 mg/ kg I.v.in 30 mts every 8 hrly

Acetaminophen

N-acetylcysteine(NAC)

Acetylcysteine rINN /əˌsɛtəlˈsɪstiːn, also known as N-acetylcysteine or N-acetyl-L-cysteine (abbreviated NAC), is a pharmaceutical drug and nutritional supplement used primarily as a mucolytic agent and in the management of paracetamol (acetaminophen) overdose

Sold in India as mucinac 600 mg Tab by Cipla

For acetaminophen (Tylenol) overdose: at the beginning of treatment, a first high dose of 140 mg/kg of a 5% solution of N-acetyl cysteine is given. The commercially available 10% and 20% solutions may be diluted with water, carbonated, or non-carbonated beverages, and given through a straw to lessen the unpleasant odor of N-acetyl cysteine. Seventeen additional doses of 70 mg/kg as a 5% solution are given every 4 hours, for a total dose of 1330 mg/kg over 72 hours.

For chest pain that is not relieved by rest (unstable angina): 600 mg of N-acetyl cysteine three times daily with a nitroglycerin patch.

For preventing sudden worsening of chronic bronchitis: doses of 200 mg twice daily, 200 mg three times daily, 300 mg slow-release twice daily, and 600 mg controlled-release twice daily have been used.

For treating chronic obstructive pulmonary disease (COPD): 600 mg of N-acetyl cysteine once daily, in addition to standard care, has been used for up to 6 months.

For treating a lung condition called fibrosing alveolitis that makes breathing difficult: 600 mg of N-acetyl cysteine 3 times daily.

For preventing damage to the bladder due to treatment with a cancer drug called ifosfamide: 1 to 2 grams of N-acetyl cysteine every 6 hours.

For reducing levels of homocysteine in the blood: 1.2 grams of N-acetyl cysteine daily.

For myoclonus epilepsy: 4-6 grams daily.

For reducing flu symptoms: 600 mg twice daily.

For reducing the risk of heart attacks and strokes in patients with end-stage kidney disease: 600 mg twice daily.

For skin wounds due to hemodialysis treatment: 200 mg four times daily or 600 mg twice daily.

For preventing kidney damage associated with the use of iopromide (Ultravist-300) for diagnostic tests: 400 to 600 mg of N-acetyl cysteine twice daily on the day before and on the day of iopromide administration, with IV saline (0.45%) 1 mL/kg body weight per hour for 12 hours before and 12 hours after iopromide administration.

For trichotillomania (hair-pulling): N-acetyl cysteine 1200 mg to 2400 mg daily has been used.

INTRAVENOUS:Healthcare providers give N-acetyl cysteine intravenously (by IV) for acetaminophen poisoning.

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Assessment of Seriousness of the Case

Judged on the basis of

Breathing difficulty,
Seizures,
Unconsciousness,
Agitation
Disorientation,
Low BP
And very high or low temperature

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Assessment of Coma, Edinburgh Classification [A(alert),V(verbal), P(painful), U(unresponsive)]

Grade of severity
0
1

2

3

4

Definition (AVPU)

Fully Conscious(Alert)

Drowsy but responsive to vocal command (Verbal)
Unconscious but responsive to minimal painful stimuli
Unconscious and just responsive to strong painful stimuli (Painful)
Unconscious and no response to stimuli (Unresponsive)

Clinical assessment of poisoned patient should be neurological, Depression of respiration, circulation, and metabolic function.

We determine how the alert/verbal/painful/unresponsive (AVPU) responsiveness scale (alert, responsive to verbal stimulation, responsive to painful stimulation, and unresponsive) corresponds to the Glasgow Coma Scale (GCS) when assessing consciousness level in the poisoned patient. Of the 1,384 patients studied, 1,138 patients were alert, 114 patients responded to a verbal stimulus, 87 patients responded to a painful stimulus, and 15 patients were unresponsive. The median GCS(Glasgo Coma Scale) scores with interquartile ranges (IQR) for each AVPU responsiveness category were 15 (IQR 15), 13 (IQR 12 to 14), 8 (IQR 7 to 9), and 3 (IQR 3), respectively. There was a degree of overlap between the range of GCS scores for each category. Nursing staff recorded more difficulty using the GCS than the AVPU responsiveness scale. Alcohol-intoxicated patients proved to be the most difficult to assess. All patients who were unresponsive required intubation. No patient with a GCS score greater than 6 was intubated.

CONCLUSION:

Each AVPU category can be shown to correspond to a range of GCS scores. The AVPU responsiveness scale appears to provide a rapid simple method of assessing consciousness level in most poisoned patients, but difficulty was still observed in assessing alcohol-intoxicated patients.

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Management Plan

Support The Vital Functions
Symptomatic Treatment
Prevent Absorption
Enhance Excretion
Specific Antidote & specific Treatment
Supportive care
Prevent and treat secondary complications
Prevention of re-exposure

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Cardio- Circulatory Failure

Cardiac Arrest- CPR instituted;; ABC

External Cardiac Massage, Pace Maker, Defibrillator.

Monitoring of Patients in Shock

Core/ Peripheral temperature,
Fluid intake and urine output
Blood Pressure Monitoring
Continuous ECG Monitoring to detect arrhythmia

Treatment of Circulatory Failure

Correct Hypoxia
Correct acidosis
Head down & Elevate foot of bed
If no response, then I.V. fluid, dopamine, and digitalis considered

Clinical assessment of circulatory function in acute poisoning is often difficult since the features of typical shock may not be apparent in presence of central nervous depression and hypothermia. True shock occurs in less than 10% of cases of acute poisoning but when it does occur it poses a very serious threat to recovery. In practice shock should be presumed if blood pressure is less than 80mm in younger patients and less than 90mm in those who are above 50 years.

Whether alive-Feel for Carotid Pulse; Auscultate Heart; Watch for Respiration. CPR- instituted- A. Airway- Keep Open; B. Breathing- Start Resp.Resus. Immediately; C. Circulation- Cardiac massage; Level of Consciousness. Other Threats to Life- If Alive and Breathing Whether Cyanosed; Whether Systolic B.P. Lower than 80 mm of Hg in young or less than 90 in those who are above 50yrs (Presume shock and treat for shock) CPR- Head down position, Raise Foot end of bed, If B.P. under 80mm then then Dopamine, Digitalis if heart failure.

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A. Clear the airway of vomitus or debris extend the neck and raise the chin

B. Breathing – direct mouth-to-mouth

Indirect mouth-to-mouth breathing

Circulation cardiac massage (see text)

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Respiratory Failure�With fast Respiratory Rate

No action needed if Pharyngeal reflex present and resp. adequate for oxygenation
Oxygen Therapy

Low concentration of O2(25%) humidified should be administered
Ambu bag as emergency measure till intubation arranged
6 to 8 Lt. Per minute
Watch for PaO₂& PaCO₂ Level

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Respiratory Rate More Than 20 per Minute�As a Result of

Acidosis
Acute Pulmonary Oedema
Pneumonia (inhalation/ hypostatic)
Adult Respiratory Distress Syndrome ( Develops 12-48 hours after initial poisoning)

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Respiratory Rate Less than 12

If respiratory rate less than 12/mt then the Patient put on ventilator
Use of Respiratory stimulant

Ideally used during period that Ventilator not available
Evidence that it will benefit the pt. is weak
Aim is return of pharyngeal reflex and adequate respiration
Watch for overdose-twitching in face or extremities

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Maintenance of Clear Airway

Remove dentures, debris and secretions
If drowsy but with good cough & gag reflex

Nurse semiprone, neck extended & insert oropharyngeal airway

If Unconscious & Gag reflex in Doubtful

Insert cuffed endotracheal tube, neck slightly flexed

Keep airway patent by regular aspiration of secretion- every ½ hour
Tracheostomy should be considered if intubation required for more than 7-10 days

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Breathing Difficulty

NO

YES

O2 Estimation By Pulse Oximeter

Obtain Control of Airway, Ventilation and Oxygenation

Examine for Other Vital Signs: Pulse- rate, regularity, Vol, B.P./ Level of Consciousness, Orientation

Are These Life Threatening?

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YES

Cardiac monitoring
Blood Gas Analysis
Blood Glucose and Electrolyte Estimation
Central Intravenous Lining

NO

1.Consider giving hypertonic glucose IV

2Thiamine

3.Naloxone

4. Treat dangerous symptoms like seizure,

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Preventing Absorption

Ligating proximal to bite/ injection site

Washing Eyes/ skin/ Change clothe

Emesis Induced in cases of

All conscious patients.
Poison taken within 4 hours (up to 12 hrs after tricyclic antidepressants and up to 24 hrs after salicylate poisoning.)
Where there is no convulsion
Contraindicated in poisoning by corrosives & Petroleum products

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Preventing Absorption

Syrup Ipecac (diluted) 15 ml for child & 30 ml in adults followed by water

Successful in 95% within 15 to 30 minutes.

Apomorphine 6 mg Subcutaneous adult or 0.06 mg / kg child

Vomiting within 3-5 mts,
Can be given even to uncooperative Pts.
Action too violent. Cannot be used where respiration depressed.

Very effective in removing poison within first hour
First vomitus preserved for analysis to detect poison

Not ipecac fluid extract which is 14 times concentrated and may cause death if given as such.

Syrup of ipecac (Not ipecac fluid extract that is 14 times more concentrated and may cause death) comes in 30 ml phials. 15 ml orally in children above 6 months to 12 yrs. In older and adult up to 30 ml. Give water to drink if stomach empty. Ipecac acts due to its local effect on gut as well as on the chemoreceptor trigger zone (CTZ) in area of postrema of medulla. Ipecac is generally effective even cases of antiemetic poisoning due to its local action. Emetine present in ipecac can cause damage to heart (not with the low dose used to induce emesis in cases of poisoning) and its prolonged use for reducing weight has caused cardiomyopathy, ventricular fibrillation and death

Apomorphine Cannot be used where resp.depressed or respiratory depressant caused the poisoning.

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Gastric Lavage

Most effective in orally taken life threatening poisonings (taken in large dose) specially where poison was taken within an hour
Indications

Where Emetic failed to induce vomiting
Performed in all unconscious patients irrespective of time of ingestion as gastric motility & emptying may be delayed-iron (Bezoarformation) Salicylates,
Poisons which reduce gastric motility- Anticholinergics, Opioids

May be considered in

K. Oil & Corrosive poisoning like Paraquat with caution

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Gastric Lavage

Done only if good cough reflex present or cuffed endotracheal tube inserted
Contraindication

Not done in corrosive acids and alkali poisoning

Precautions

In cases of chronic alcoholism, liver disorder & oesophageal varices- soft & narrow tube is used
Mechanical injury to the throat oesophagus and stomach
Cuffed endotracheal tube to prevent aspiration

If patient unconscious, gag reflex doubtful, or K. Oil poisoning

PrecautionsGastric Lavage should not be used routinely (if at all) in Poisonings

In rare cases, when indicated, it should only be used by those trained in proper technique

IndicationsRarely indicated in 2012 Poor efficacy Significant nasal trauma from large bore tubes Historically used in severe ingestion cases Overdose or Ingestion within 1 hour Extraordinary overdose with a potentially toxic amount of medication Specific overdose after 1 hour Ingested drug slows peristalsis Anticholinergics Opioids (Narcotics) Ingested drug forms Bezoar Salicylates, Iron, ContraindicationsInsignificant overdose Corrosive Ingestion (strong acid or alkali) Hydrocarbon Ingestion (high aspiration risk) Minimally effective if given >1 hour post-ingestion Increased risk of Gastrointestinal Bleeding or perforation, Unprotected airway (e.g. Altered Level of Consciousness) Complications Aspiration Pneumonia Laryngeal trauma Esophageal Perforation, Epistaxis, Electrolyte imbalance, Hypothermia, Preparations Activated Charcoal in aqueous solution (preferred due to lower Emesis, aspiration risk) Activated Charcoal in Sorbitol, Technique Consider Endotracheal Intubation in advance Indicated for neurologic Impairment Use a large bore tube (28 French Ewald tube) Larger tubes however cause considerable nasal trauma, Position patient, Head down, Left lateral decubitus, Technique, Aspirate first prior to fluid lavage, Instill lavage fluid into Stomach Adult 100-300 cc warm water or Normal Saline per wash, Child 10-15 cc/kg warm Normal Saline per wash, Aspirate fluid back and dispose of fluid

Repeat lavage, Repeat until aspirate clears of pill fragments and similar debris of concern, Single dose is sufficient in many cases, If repeated, alternate aqueous and Sorbitol charcoal preparations every 2 hours,

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Technique of Gastric Lavage

Keep the patient in left lateral position or prone
Pass lubricated Ewald tube large bore(28-40 French gauge)
Tube inserted up to 50cm,(30cm in children) mark
Ensure that tube is in stomach by aspiration or blowing air in tube or lowering funnel in water before lavage
First lavage done with plane water. 50ml Preserved
Use small amount 250-300 ml of 1:2000 dilution of Pot. permanganate or tannic acid or specific antidote if known
Use warm fluid, continue lavage till aspirate clear, empty the stomach completely in each cycle.

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Antidote

Antidote is an agent that counteracts the action of a poison.

chemical antidote one that neutralizes the poison by changing its chemical nature.
mechanical antidote one that prevents absorption of the poison.
physiological antidote one that counteracts the effects of the poison by producing opposing effects.
Specific antidote:- Antivenin
Nonspecific

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Universal Antidote

Universal Antidote:- A mechanical mixture of

Powdered animal charcoal (or burnt toast)- 2 parts by weight,
Magnesium oxide-1part by weight,
Tannic acid (strong tea)- 1 part by weight.
The mixture should be stored dry and when required to be administered add 15 gm of mixture to ½ glass of warm water

Used to be given but now not favoured

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Activated Charcoal

Activated charcoal alone- 30-100 gm as water slurry with purgative. Most important intervention in orally taken poisons.

Given:- charcoal: poison ratio of 10:1
Repeat every 2-6 hrs till comes in stool
Not very effective in heavy metals, alcohols, volatile hydrocarbons, and corrosives poisoning

Activated charcoal slurry is prepared by mixing 50 gm (10 spoonful) in a glass of water

Activated Charcoal is a highly absorbent gritty black material that is commonly found in air and water filters. Activated Charcoal is created by carbonizing organic matter in a kiln under anaerobic conditions and activating the material with oxidizing gases like steam or air at high temperatures. This oxidative process erodes the charcoal's internal surfaces and increases its adsorption capacity by creating an internal network of very fine pores. Usually bone char, coconut shells, peat, coal, petroleum coke, and sawdust are the starting materials for making Activated Charcoal.

Good grade activated charcoal considered very effective in preventing absorption of most of drugs and chemicals by adsorbing chemicals on the surface of charcoal particles and therefore reducing absorption from the gut. Activated charcoal also enhances diffusion of poisons from body to gastroentestinal tract and to the charcoal particles. During the last two decades charcoal used alone (not universal antidote containing also magnesium oxide and tannic acid) is increasing with corresponding decrease in use of ipecac induced vomiting and gastric lavage in the treatment of poisoning. Studies have failed to show a benefit in using ipecac or lavage plus activated charcoal as compared to using activated charcoal alone.

Activated charcoal slurry is prepared by mixing 50 gm(10 table spoonful) in a glass of water and given orally or through tube. If charcoal is in excess then poison once attached remains attached without the risk of being desorbed. Activated charcoal should not be used simultaneously with ipecac as the active principle of ipecac is also adsorbed and emetic effect is reduced. Similarly charcoal may also adsorb antidotes given orally and reduce their action on the poison.

Activated Charcoal detoxifies the body in several manners.�1. Purifies the 6-8 liters of digestive fluids that are secreted daily which in turn helps remove foreign substances from the blood.�2. Adsorbs the intoxicant substance and its metabolites that are excreted into the small intestine from the biliary (bile) tract, preventing their reabsorption.�3. Adsorbs drugs that diffuse back into the stomach and intestines.�4. Decreases the detoxification work load of the liver.

Hydrocarbons are a heterogenous group of organic substances that are primarily composed of carbon and hydrogen molecules. They are quite abundant in modern society. Some of the most commonly ingested hydrocarbons include gasoline, lubricating oil, motor oil, mineral spirits, lighter fluid/naphtha, lamp oil, and kerosene.^[1]Other common sources of hydrocarbons include dry cleaning solutions, paint, spot remover, rubber cement, and solvents. In addition, many volatile substances that contain hydrocarbons (eg, glue, propellants) are commonly abused for their euphoric effects. The hydrocarbons can be derived from either petroleum or wood. Petroleum distillates include kerosene, gasoline, and naphtha, whereas wood-derived hydrocarbons include turpentine and pine oil. The length of the chains as well as the degree of branching determine the phase of the hydrocarbon at room temperature; most are liquid, but some short-chain hydrocarbons (eg, butane) are gas at room temperature, whereas other long-chain hydrocarbons (eg, waxes) are solid at room temperature.

Toxicity from hydrocarbon ingestion can affect many different organs, but the lungs are the most commonly affected organ. The chemical properties of the individual hydrocarbon determine the specific toxicity, while the dose and route of ingestion affect which organs are exposed to the toxicity. Unlike the aromatic or aliphatic hydrocarbons, the halogenated hydrocarbons tend to cause a wider range of toxicity.

The recreational use of inhaling hydrocarbons and other volatile solvents for the purposes of creating a euphoric state is becoming increasingly common. Several methods are used for this abuse, including "sniffing" (directly inhaling vapors), "huffing" (placing a hydrocarbon-saturated rag over the mouth and nose and then inhaling), or "bagging" (inhaling via a plastic bag filled with hydrocarbon vapors).

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Cathartic

Used in association with universal antidote or charcoal slurry
Purgatives

Mag.Sulph-250mg/kg
Sod.Sulphate 250-500mg/kg,
Sodium citrate250mg/kg
Phosphosoda250mg/kg
Sorbitol-1g/kg

Whole bowel irrigation

With colonic lavage soln.

Colyte, GoLYTELY

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Enhancing Excretion

Forced diuresis

5% Dextrose soln. I.V. + Diuretic to maintain urinary output of 500 ml/hr

Bromide, Barbiturates, Lithium

Forced Alkaline Diuresis pH 7.5 to 8.5

Sodibicarb or molar lactate added
Serum & urine electrolyte & ECG monitored
Contraindicated in Shock, cardiac failure & renal impairment
Used in poisoning by :-Barbiturates, Phenylbutazon, salicylates, Nitrofuran, Probenecid

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Enhancing Excretion

Forced Acidic Diuresis (Vit C, Thiazide, methenamine mandelate, ammonium chloride)

Said to aggravate renal problem & cause myo-globinuria & methaemoglobinaemia
Amphetamine, Pethidine, Quinine, chloroquine poisoning

Chelating agents-

BAL (Dimercaprol), Deep IM-Arsenic, Gold, Mercury, Copper, Bismuth
EDTA Given I.V.- The best for Lead
Penicillamine & Succimer Adv of being given orally

Drugs that make the urine more acidic include Vitamin C, thiazide diuretics, methenamine mandelate, an antibiotic used to prevent or control but not treat urinary tract infections, and ammonium chloride, used to treat alkalinity in the blood

These are substances which act on metallic poisons in blood forming harmless chelates which are easily excreted in urine. BAL is also called Dimercaprol useful in Arsenic,mercury, copper,gold, bismuth. Given deep I.M. EDTA- Best chelating agent for lead Given IV as orally not absorbed

Penicillamine is a very good chelating agent and given orally.

Peritoneal Dialysis:-The abdomen is cleaned in preparation for surgery, and a catheter is surgically inserted with one end in the abdomen and the other protruding from the skin.^[2] Before each infusion the catheter must be cleaned, and flow into and out of the abdomen tested. A large volume of fluid is introduced to the abdomen over the next ten to fifteen minutes.^[3] The total volume is referred to as a dwell^[4] while the fluid itself is referred to as dialysate. The dwell can be as much as 2.5 litres, and medication can also be added to the fluid immediately before infusion.^[3] The dwell remains in the abdomen and waste products diffuse across the peritoneum from the underlying blood vessels. After a variable period of time depending on the treatment (usually 4–6 hours^[3]), the fluid is removed and replaced with fresh fluid. This can occur automatically while the patient is sleeping (automated peritoneal dialysis, APD), or during the day by keeping two litres of fluid in the abdomen at all times, exchanging the fluids four to six times per day (continuous ambulatory peritoneal dialysis, CAPD).^[4][5]

The fluid used typically contains sodium, chloride, lactate or bicarbonate and a high percentage of glucose to ensure hyperosmolarity. The amount of dialysis that occurs depends on the volume of the dwell, the regularity of the exchange and the concentration of the fluid. APD cycles between 3 and 10 dwells per night, while CAPD involves four dwells per day of 2-2.5 litres per dwell, with each remaining in the abdomen for 4–8 hours

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Peritoneal Dialysis

Hypertonic fluid about 2-2.5 Lt put in peritoneal cavity for 4-6 hrs then replaced with fresh fluid.
Continued till clinical improvement.
Used in Barbiturate and other poisons in absence of facility for haemodialysis

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Haemodialysis & Haemoperfusion

Used rarely & selectively
It is 5-10 times more effective than peritoneal dialysis
In poisoning by Salicylate, methanol, ethylene glycol,& theophylline & Barbiturate- effective
In many poisons where there is good clearance by dialysis, total body removal may be extremely small due to large vol. Distribution
Haemoperfusion over activated charcoal or resin useful in some situations

done in theophylline, salicylate & paraquat poisoning not responding to other treatments

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Supportive therapy as in other medical emergencies is the most important aspect of the treatment of poisoning�“Treat the patient, not the poison”

There are two types of acidosis--metabolic and respiratory. Metabolic acidosis occurs when your kidneys can’t get rid of acid buildup or when your body gets rid of too much base. Bases neutralize acids, and vice versa. Respiratory acidosis occurs when your lungs do not properly eliminate the carbon dioxide (CO2). When CO2 builds up in your blood, it becomes more acidic

Causes:- Airway obstruction(Respiratory)

Metabolic acidosis starts in the kidneys instead of the lungs. It occurs when they can’t eliminate enough acid or when they get rid of too much base. There are three major forms of metabolic acidosis:

Diabetic acidosis occurs in people with poorly managed diabetes. Ketones build up in the body and acidify the blood.

Hyperchloremic acidosis results from a loss of sodium bicarbonate. This base helps to keep the blood neutral. Both diarrhea and vomiting can cause this type of acidosis. Lactic acidosis occurs when there is too much lactic acid in your body. Many things can cause a buildup of lactic acid. These include chronic alcohol use, heart failure, cancer, seizures, liver failure, prolonged lack of oxygen, and low blood sugar. Even prolonged exercise

kidney failure, dehydration, aspirin or methanol poisoning

rapid and shallow breathing

confusion

fatigue

headache

sleepiness

lack of appetite

breath that smells fruity – this is a sign of diabetic acidosis/ketoacidosis

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Other Measures

Specific Antidote &Treatment of poisons
Symptomatic Treatment

Pulmonary or brain oedema, convulsion, arrhythmia, hypo/hyperthermia, hypo/ hypertension, acidosis, ketosis etc.

Treatment of organ damage

Liver, kidneys, heart, & brain

Supportive care

Maintain physiologic homeostasis until detoxification occurs
Prevent and treat secondary complications

Prevention of re-exposure

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Adhesives; Antibiotics, topical Antifungals, topical; Barium sulphate; Blackboard chalk (Ca carbonate); Bleach, Candles (insect-repellent type may be toxic); Carboxymethylcellulose (dehydrating material packed with drugs, film, and other products); Castor oil; Cigarettes (small amounts ingested by a child); Clay, art and craft; Contraceptives; Corticosteroids, topical; Detergent liquid; Diaper rash cream and ointment; Dry cell battery (alkaline); Fabric softeners, Glow products (eg, glow sticks, glow necklaces); Glycerol; Graphite; Gums (eg, acacia, agar, ghatti); Ink (amount in one ballpoint pen); Iodide salts;

NONPOISONOUS HOUSEHOLD ITEMS

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Kaolin Lanolin; Linseed oil (not boiled); Lipstick; Lotion, calamine (excluding products with antihistamines or local anaesthetics); Lozenges, throat (without local anaesthetics); Magnesium silicate (antacid); Make-up; Matches; Mineral oil (if not aspirated); Newspaper; Paint, water-colour or water-based; Paraffin; Pencil lead (graphite); Perfumes and colognes; Petrolatum jelly; Putty; Shaving cream; Silica (silicon dioxide); Soap (bath or dishwashing); Starch and sizing; Talc (except when inhaled); Toothpaste (with or without fluoride); Vitamins, children's multiple with or without iron; Vitamins, multiple without iron;

Cont.

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Telephone Numbers for Help

AI1MS New Delhi Dept. of Pharmacology-1800 116 117
Medical Helpline (Andhra Pradesh, Gujarat, Uttarakhand, Goa, Tamil Nadu, Rajasthan, Karnataka, Assam, Meghalaya, Madhya Pradesh, UP, and Bihar): 108
Cochin- 09895282388

+91 484 285 8056/+91 484 285 6034

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