management of poisoning
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General PrinciplesofManagement of Poisoning.
TOPIC: INTRODUCTON AND STABILIZATION OF POISONING
NAME: RIYA VISAVADIYA
ROLL NO. : 86 MO. NO: 8153850989 Email ID :
riyasvisavadiya@gmail.com
BATCH - 2014
Introduction of Poisoning Poison is a substance [ solid, liquid or
gaseous] which if introduced in the living body 0r brought into contact with any part thereof will produce ill-health or death, by its constitutional or local effects or both.
Poisoning occurs when any substance
interferes with normal body functions after if is swallowed, inhaled or absorbed.
The branch of medicine that deals with the detection and treatment of poisons is known as Toxicology.
History The early history of poison is described in
the ancient Indian shastras , Egyptian papyri, Sumerian, BabyIonian ,Hebrew and Greek records.
Among vedas- AtharvaVeda (1500 BC) describes poisons.
Susrutha (350 BC) Described as how poisons were mixed with food and drink ,medicine , snuff etc.
The Italians brought the art of poisoning to its zenith prior to 6th century A.D.
Orfila (spanish chemist,1787-1853) was first to attempt a systemic correlation between the chemical and biologic information of the poisons known them.
Others who worked are Marsh, Magendie, Ambrose, Scheelle, Robert Christison and Rudolf Kobert.
May 3, 2023 General Management of Poisoning 7
EPIDEMIOLOGY
Poisoning both accidental and intentional are a significant contributor to mortality and morbidity throughout the world.
According to WHO three million acute poisoning cases with 2,20,000 deaths occur annually. Of these 90% of fatal poisoning occur in developing countries particularly among agricultural workers.
May 3, 2023 General Management of Poisoning 8
Acute poisoning forms one of the commonest causes of emergency hospital admissions.
It has been estimated that about 5 to 6 persons per lakh of populations die due to lake of proper immediate treatment of poisoning.
To prevent these deaths, poison centres were developed.
Poison Centers A Poison control center is a medical facility that is
able to provide immediate ,free and expert treatment advice and assistance over the telephone is case of exposure to poisonous or hazardous substances.
It answer questions about potential poisons in addition to providing treatment management advice about household products ,plants ,bites ,pesticides , food poisoning and fumes.
It is useful to prevent sudden massive poisonous outbreaks like Bhopal gas Tragedy.
Bhopal Disaster
It was a methyl isocynate (MIC) which leaked in Bhopal considered the world ‘s worst industrial disaster.
It exposed more than 5,00,000 people to toxic gases.
A mixture of poisonous gases flooded the city, causing great panic as people woke with burning sensation in their lungs.
Thousands died immediately from the effects of the gas.
Bhopal Gas Tragedy
General Management of PoisoningPrinciples of management consist of;
i. Stabilization.ii. Gut Decontamination.iii. Antidote administrationiv. Eliminationv. Symptomatic treatment.
Poisoning severity Grades None (0) – no symptoms or signs
judged not to be related to poisoning.
Minor (1)- Mild, transient and spontaneously resolving symptoms.
Moderates (2)- pronounced or prolonged symptoms.
Severe (3)- severe or life threatening symptoms.
Basic Management of a poisoned patientAntidotes are available for very few
commonly encountered poisons, and treatment is usually non-specific and symptomatic.
In such cases management and stabilization measures, appropriate treatment to reduce absorption, measures to enhance life support followed by psychiatric counselling.
Emergency Stabilization Measures The unconscious patient should be
transported in the head down semiprone position to minimize the risk of inhalation of gastric contents.
A Clear Airway and ventilation.
Potentially serious abnormalities such as metabolic acidosis, hyper kalamia and hypo glycemia may require correction as a matter of urgency.
Initial resuscitation stabilization Scandinavian Regime is a term used for
anti shock measures when the patient is going into shock.
It includes ABCD of resuscitation.A. AirwayB. BreathingC. CirculationD. Depression of CNS
AIRWAY Opening up and cleaning up the airway (oral
cavity , nostrils) of secretions, vomit or any other foreign body might be life saving.
Protecting and securing the airway by means of endo tracheal intubation may be necessary.
Proper positioning head tilt and chin lift and falling back of tongue is prevented by suitable airway tube must be present.
May 3, 2023 General Management of Poisoning 18
Endo tracheal Intubation
BREATHING If the arterial blood gas cannot be maintained
inspite of establishing an effective airway, then graduated supplement oxygen therapy either by a ventimask or through endo tracheal tube should be administered.
If necessary positive pressure ventilation with monitoring and respiratory stimulants for severe depression should be applied.
CIRCULATION
I.V. Fluid administration may be life sustaining line.
Maintenance of fluid and electrolyte balance and administration of I.V. Drugs for treatment is needed.
Depression of CNS should be corrected.An unconscious patient should be
turned to lie on one side to stop the tongue blocking the throat and to allow fluid to come out of the mouth. (recovery position)
Most of the poisoning cases , whether they are conscious or unconscious recover with supportive care alone.
May 3, 2023 General Management of Poisoning 22
Topic :- Differential Diagnosis of Poisoning
NAME: Samarth Dubey
ROLL NO. : 90
MO. NO: 9153850989
Email ID : dubeysamarth@gmail.com
BATCH - 2014
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HOW CAN I MANAGE THE PATIENT?
History Taking
Physical Examination
Toxicological Screening
May 3, 2023 General Management of Poisoning 27
A. History Taking Agent & Amount
Time & Location of Exposure
Route
Intake of Other Substances
Circumstances of Exposure
Current Medications
Past Medical History
Pre-Hospital Treatment
May 3, 2023 General Management of Poisoning 28
B. Physical Examination(Because history can be incomplete or unreliable) Examine General Status
(height/weight/built/TPR, etc.)
See the Skin (color change)
Smell the breath (fruity/alcoholic/garlic, etc.)
Listen the Lungs
Hear the Heart
Asses the Abdomen
Perform Neurological Exam
May 3, 2023 General Management of Poisoning 29
B. Physical Examination
May need to remove clothing for thorough exam Check clothing for objects or substances Assess general appearance of patient –
Orientation, Agitation, confusion, or obtundation Ocular Examination
pupils size Nystagmus Reactivity to light dysconjugate gaze increased lacrimation
Oropharynx for increase salivation or excessive dryness
Extremities: fasciculation's, tremor
May 3, 2023 General Management of Poisoning 30
B. Physical Examination Heart: rhythm, rate,
regularity
Lungs: bronchorrhea or wheezing
Abdomen: bowel sounds, tenderness or rigidity
Neuro: CNS, reflexes, muscle tone coordination, cognition, ability to ambulate
May 3, 2023 General Management of Poisoning 31
Skin tells most
Rash – Allergic ReactionLead poisoning
May 3, 2023 General Management of Poisoning 32
Mees line – Arsenic Poisoning
Cyanosis – Cyanide poisoning
May 3, 2023 General Management of Poisoning 33
Jaundice Hypercarotenemia
May 3, 2023 General Management of Poisoning 34
THE SYMPTOMATIC PATIENT
Coma & Hypothermia
Hypotension
Hypertension
Arrhythmias
Seizures
Hyperthermia
May 3, 2023 General Management of Poisoning 35
Coma & Hypothermia Go hand-in-hand Ingestion of large doses of:
Antihistamines (diphenhydramine) Sedative/Hypnotic drug
(Benzodiazepines) Ethanol Opioids (Drug Abuse-Morphine) Antipsychotic (Clozapine) Antidepressants (TCAs)
Airway – Not needed if naloxone/ flumazenil works
Breathing – Pulse Oximetry Not Reliable in meth-HB/ CO poisoning
Circulation – Continuous BP/ECG monitoring
Drug – Naloxone/ Flumazenil/ Dextrose+Thiamine
May 3, 2023 General Management of Poisoning 36
Hypotension Drugs-
antihypertensive drugs(α-blockers/CCB/β-blockers)
disulfiram (ethanol Interaction) Iron Trazodone, quetiapine, and
other antipsychotic agents antidepressants
Poison- Cyanide Carbon monoxide Hydrogen sulfide Aluminum or zinc phosphide Arsenic Mushrooms (contain
pilocarpine)
May 3, 2023 General Management of Poisoning 37
Nature of poisoning Treatment
TCAs/Sod. channel blockers NaHCO3 50–100 mEq i.v.bolus injectionNE 4–8 mcg/mini.v. infusion(more effective than dopamine)
β-blockers Glucagon 5–10 mgi.v.
CCBs calcium chloride 1–2 g i.v.
Hypotension
May 3, 2023 General Management of Poisoning 38
Hypertension
Amphetamines Anticholinergics Cocaine Performance-enhancing products
Caffeine Phenylephrine Ephedrine Yohimbine
MAO inhibitors
May 3, 2023 General Management of Poisoning 39
Hypertension with…. Treatment
agitation and anxiety Lorazepam 2–3 mgi.v.
persistent nature Phentolamine 2–5 mgi.v.ORSod. nitroprusside0.25–8 mcg/kg/min i.v.
excessive tachycardia Propranolol 1–5 mgi.v.OREsmolol 25–100 mcg/kg/mini.v.ORLabetalol 0.2–0.3 mg/kgi.v.
Caution: Do not give β-blockers alone, since doing so may paradoxically worsen hypertension as a result of unopposed
alpha-adrenergic stimulation
May 3, 2023 General Management of Poisoning 40
Arrhyth
mias
May 3, 2023 General Management of Poisoning 41
Cause TreatmentElectrolyte imbalance
↑K+
↓K+, Mg2+,Ca2+
Correct accordingly
Ventricular arrhythmias Lidocaine/ Amiodaroneat usual antiarrhythmic doses
TCAs/diphenhydramine/class Ia antiarrhythmic drugs
NaHCO3 50–100 mEqi.v. bolus infusion
Torsades de pointes Mg(2 g i.v. over 2 minutes) or Overdrive pacing
Digitalis-induced arrhythmias
Digoxin specific antibodies
Chlorinated solvents/Chloral hydrate/freons/Sympathomimetic agents
Propranolol 1–5 mgi.v.OREsmolol 25–100 mcg/kg/mini.v.
Caution: Avoid class Ia antiarrhythmic agents (eg, procainamide, disopyramide), which may aggravate arrhythmias caused by tricyclic antidepressants.
May 3, 2023 General Management of Poisoning 42
Seizures Drugs-
Amphetamines, cocaine Antidepressants (especially
TCAs, bupropion, and venlafaxine)
Antihistamines (especially diphenhydramine),
Antipsychotics Camphor, isoniazid (INH) Chlorinated insecticides Tramadol Theophylline
Secondary causes- Hypoxia/hypoglycemia/
hypocalcemia/hyponatremia
May 3, 2023 General Management of Poisoning 43
Lorazepam, 2–3 mg, or diazepam, 5–10 mg, i.v.over 1–2 minutesORi.v. unavailable—midazolam, 5–10 mg i.m.
If convulsions continue, administer phenobarbital(For drug-induced seizures, phenobarbitalis preferred over phenytoin.)
May 3, 2023 General Management of Poisoning 44
Hyperthermia Amphetamines (MDMA;
“Ecstasy”), atropine and other anticholinergics
Cocaine, salicylates, strychnine
TCA SSRI(eg, fluoxetine,
paroxetine,sertraline) or their use in a patient taking an MAO inhibitor may cause serotonin syndrome
Antipsychotics (neuroleptic malignant syndrome [NMS])
May 3, 2023 General Management of Poisoning 45
Hyperthermia Removing the patient’s clothing Spray the skin with tepid water & fanning. Muscle rigidity/hyperactivity –
NM paralysis with a nondepolarizing neuromuscular blocker (eg, rocuronium, vecuronium)
Once paralyzed, patient must be Intubated Mechanically ventilated Sedated Use bedside EEG (paralysis - no convulsion but
seizure may exist)
May 3, 2023 General Management of Poisoning 46
Hyperthermia… Treatment
With rigidity /Malignant hyperthermia
Dantrolene 2–5 mg/kg i.v.
Neuroleptic malignant syndrome
Bromocriptine 2.5–7.5 mgorally daily
Serotonin syndrome Cyproheptadine 4 mgorally every hour (3-4 doses)ORChlorpromazine 25 mgi.v.OR50 mgi.m.
May 3, 2023 General Management of Poisoning 47
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Toxicological Screening Serum osmolality & osmol gap Electrolytes and anion gap Blood glucose S. Creatinine BUN CK Urinalysis; e.g.-
Oxalate crystals with ethylene glycol poisoning Myoglobinuria with rhabdomyolysis
ECG Serum acetaminophen and ethanol quantitative
levels should be determined in all patients with drug overdoses
May 3, 2023 General Management of Poisoning 49
Laboratory test Observation
Osmol gap ↑s in presence of large quantities of low-molecular-weight substances
Anion gap ↑s due to poisoning of - Carbon monoxideCyanideEthylene glycolIron overloadINHMethanolMetforminIbuprofenSalicylates
May 3, 2023 General Management of Poisoning 50
GUT DECONTAMINATION
NAME:Ruchit Patel ROLL NO. : 87 MO. NO:
9824565789 Email ID :
ruchitpatel@gmail.com
BATCH - 2014
Principles of Decontamination
External Protect yourself and others Remove exposure Irrigate copiously with water or
normal saline Don’t forget your ABC’s
Internal Patient must be fully awake or
intubated Most common complication is
aspiration Very little evidence for their
use
Decontamination Skin
Protect yourself and other workers
Remove clothing Flush with water or normal
saline Use soap and water if oily
substance Chemical neutralization can
potentiate injury Corrosive agents injure skin
and can have systemic effects
Decontamination
Eyes Remove contact lens Flush copiously with water or
normal saline Use local anesthetic drops Continue irrigation until ph is
normal Slit lamp and fluorescein exam
Decontamination
Inhalation Give supplemental humidified oxygen Observe for airway obstruction Intubate as necessary
EMESIS
GAG REFLEX
IPECACUANHA The actions of ipecac are mainly those of
major alkaloids(emetine and cephaeline).
Action : Local : irritate the gastric mucosa Central: by stimulating the
medullary chemoreceptor trigger zone
induce vomiting.
INDICATION CONCIOUS PATIENT WITHIN 4 hrs
C/I COMATOSE PATIENT
IMPAIRED GAG REFLEX
COMPLICATION ASPIRATION PNEUMONIA
MALLORY WEISS SYNDROME
GASTRIC LAVAGE
Gastric lavage , also commonly called gastric irrigation, is the process of cleaning out the contents of the stomach.
Patient must be lying on left side or prone with head hanging over edge of bed,so that mouth is at lower layer than larynx.
Functioning of the technique is based on SYPHON ACTION.
Ewald’s tubeMaterials
used 1:5000 kmno4,5% sodium bicarbonate,4% tannic acid,1% sodium iodide and lime water
Technique Gastric lavage involves the passage of a tube (such
as an Ewald tube) via the mouth or nose down into the stomach followed by sequential administration and removal of small volumes of liquid.
The placement of the tube in the stomach must be confirmed either by air insufflations while listening to the stomach, by pH testing a small amount of aspirated stomach contents, or x-ray.
This is to ensure the tube is not in the lungs. In adults, small amounts of warm water or saline
are administered and, via a siphoning action, removed again.
INDICATION CONCIOUS PATIENT WITHIN 2 hrs
C/I CORRROSIVE POISON
COMATOSE PATIENT
COMPLICATION ASPIRATION PNEUMONIA
PERFORATION OF STOMACH
CATHARSIS
Sorbitol is cathartic of choice. Sodium sulphate may also be used.
ACTIVATED CHARCOAL
Activated carbon, also called activated charcoal, is a form of carbon processed to have small, low-volume pores that increase the surface area available for adsorption or chemical reactions.
DOSE-1gm/kg. SUPERACTIVATED CHARCOAL has
double adsorbing surface area as compared to activated charcoal.
It is not effective for a number of poisonings including strong acids or alkali, cyanide, iron, lithium, arsenic, methanol, ethanol or ethylene glycol.
WHOLE BOWEL IRRIGATION
WHOLE BOWEL IRRIGATION
Whole bowel irrigation (WBI) is a medical process involving the rapid administration of large volumes of an osmotically balanced POLYETHYLENE GLYCOL solution , either orally or via a nasogastric tube, to flush out the entire gastrointestinal tract.
Useful in lithium,iron,cocaine and heroine overdose.
Topic :- Antidote Administration
NAME: Sachin Patel
ROLL NO. : 88
MO. NO: 9159850809
Email ID : sachinpatel1243@gmail.com
BATCH - 2014
May 3, 2023 General Management of Poisoning 70
Definition
According to WHO - “Antidote was defined as a therapeutic substance used to counteract the toxic action(s) of a specified xenobiotic.”
May 3, 2023 General Management of Poisoning 71
POISON WITH ITS SPECIFIC ANTIDOTES
Paracetamol
Methanol
Benzodiazepines
Opiates
:- Acetyl cysteine & Methionine
:- fomepizole & Ethyl Alcohol
:- Flumazenil
:- Nalaxone
May 3, 2023 General Management of Poisoning 72
Organophosphates :- Atropine
Dhatura :- Physostigmine
Botulinum toxin :- Guanidine
Methamoglobinemia :- Methelene blue (Nitrites)
May 3, 2023 General Management of Poisoning 73
Cyanide :- Amyl Nitrate + Na Thio
Sulphate
CO :- Hyper Baric Oxygen
May 3, 2023 General Management of Poisoning 74
Arsenic :- hydrated ferric oxide, DMSA,BAL
Copper :- Potassium ferrocyanide, Penicillamine
Ergot :- Sodium Nitroprusside
Lead :- EDTA, DMSA, BAL Iron :- Desferrioxamine Mercury :- Penicillamine, BAL,
Sodium formaldehyde
May 3, 2023 General Management of Poisoning 75
Cadmium :- N-Acetyl Penicillamine
Isoniazid :- pyridoxine Heparin :- Protamine
Sulphate Warfarin :- Vit. K1 TCA :- NaHCo3 Beta-blockers :- Glucagon Flourouracil,methotrexate :-
Leucovorin Cyclophospamide :- Mesna
May 3, 2023 General Management of Poisoning 76
CHEMICAL ANTIDOTE Common salt Silver Nitrate Mercury Chloride Copper Sulphate Phosphorus Arsenic Albumin Dialyzed iron
May 3, 2023 General Management of Poisoning 77
UNIVERSAL ANTIDOTE
It is a combination of physical and chemical antidotes
It is an absolute antidote and had only historical importance
May 3, 2023 General Management of Poisoning 78
Composition :- Magnesium oxide (1
part) neutralizes acid without gas formation
Charcoal (2 parts) absorbs alkaloids
Tannic acid (1 part) precipitates alkaloids
May 3, 2023 General Management of Poisoning 79
COMA COCKTAIL
It is combination of 3 medicines can be given in unknown poisoning with coma -
Dextrose (50%) 100 mlNalaxone 2 mgB1(Thiamine) 100 mg
May 3, 2023 General Management of Poisoning 80
CHELATING AGENTS EDTA BAL Succimer Penicillamine Desferrioxamine
May 3, 2023 General Management of Poisoning 81
EDTA
EDTA is prescription medicine, given by injection into the vein (intravenously) or into the muscle (intramuscularly).
more common in lead poisoning.
.
May 3, 2023 General Management of Poisoning 82
Intravenous EDTA is used to treat lead poisoning and brain damage caused by lead poisoning; to evaluate a patient's response to therapy for suspected lead poisoning; to treat poisonings by radioactive materials such as plutonium, thorium, uranium, and strontium; for removing copper in patients with Wilson's disease; and for treating high levels of calcium.
May 3, 2023 General Management of Poisoning 83
EDTA is also used intravenously for heart and blood vessel conditions including irregular heartbeat due to exposure to chemicals called cardiac glycosides, “hardening of the arteries” (atherosclerosis), chest pain(angina), high blood pressure, high cholesterol, and blood circulation problems such as intermittent claudication and Raynaud's syndrome
May 3, 2023 General Management of Poisoning 84
Specific precaution & warning Heart rhythm problems: EDTA might make
heart rhythm problems worse.
Diabetes: EDTA might interfere with blood sugar control because it can interact with insulin.
Low calcium levels in the blood (hypocalcemia): EDTA can decrease serum calcium levels, making hypocalcemia worse.
May 3, 2023 General Management of Poisoning 85
Liver problems and hepatitis: EDTA might make liver disease worse. Avoid using EDTA if you have a liver condition.
Kidney problems: EDTA can harm the kidney and might make kidney disease worse. EDTA doses should be reduced in patients with kidney disease. Avoid using EDTA if you have severe kidney disease or kidney failure.
May 3, 2023 General Management of Poisoning 86
British Anti Lewisite(BAL)
It is given by intramuscular route (5mg/kg
stat followed by 2 to 3mg/kg every 4 to 8
Hours for 2 days and then once a day for
10 days
May 3, 2023 General Management of Poisoning 87
Mechanism of action of BAL BAL has two SH groups. The two SH groups binds to
those metals that produce toxicity by interacting with sulfhydryl containing enzymes in the body.
BAL will combine with these metals forming BAL-metal complex thus dislodges the metal from acting site.
May 3, 2023 General Management of Poisoning 88
BAL is useful against metals that interfere with sulfhydryl enzymes in the body such as arsenic , mercury , bismuth , copper , antimony , and nickel.
May 3, 2023 General Management of Poisoning 89
Contraindication of BAL In liver damage
G6PD deficiency
Iron and cadmium toxicity
May 3, 2023 General Management of Poisoning 90
Side effects
Serious side effects: Fast heart rate, feeling anxious or
restless; Pain or tightness in your throat,
chest, or hands; Burning sensation of your throat,
mouth, or lips; or Burning sensation in your penis.
May 3, 2023 General Management of Poisoning 91
Less serious side effects include: Nausea, vomiting, stomach pain Numbness or tingling (especially around your
mouth) Headache Eye redness, swelling, or watering; Twitching of your eyelid Runny nose Increased sweating Mild fever or Pain, redness, or swelling where the needle is
placed.
May 3, 2023 General Management of Poisoning 92
SUCCIMER Also known as a
“Dimercaptosuccinic acid”.
Similar to BAL in chelating properties
Less toxic than BAL and orally effective
used against mercury , arsenic and lead poisoning.
EDTA is contraindicated in mercury
May 3, 2023 General Management of Poisoning 93
Side effects
Nausea Vomiting Loss of appetite Diarrhea
May 3, 2023 General Management of Poisoning 94
PENICILLAMINE Also known as “D-penicillamine Cuprimine” It is dimethyl cysteine , obtained as a degradation product
of penicilline and available in d-isomer and I-isomer form. d-isomer is more used because I-isomer is more toxic
and produce “optic neuritis”. Metabolized in body,excreted in urine&feces
May 3, 2023 General Management of Poisoning 95
Indications Copper poisoning :- drug of
choice
Mercury poisoning:- alternative to BAL
Chronic lead poisoning
Wilson’s disease
Cystinuria and cystine stone
May 3, 2023 General Management of Poisoning 96
Dose
For copper and mercury poisoning :- 1 to 1.5 gm/day in divided doses
For wilson’s disease :- 0.5 to 1gm/day in divided doses , one hour before meals or two hour after the meals to avoid the chelation of diatery metals.
Contraindicated in arsenic
May 3, 2023 General Management of Poisoning 97
Side effects
Diarrhea loss of appetite mild stomach pain nauseavomiting
May 3, 2023 General Management of Poisoning 98
DESFERRIOXAMINE Ferrioxamine is long chain iron containing
complex obtained from an actinomycete. Chemical removal of iron from it yields
desferrioxamine that has great affinity for iron.
Administrated orally , less absorbed and binds with iron and prevents iron absorption in GIT.
May 3, 2023 General Management of Poisoning 99
Mechanism of Action Desferrioxamine molecule
turns round the ferric ion and forms a stable non-toxic complex that is excreted in urine.
1 gram of desferrioxamine is capable of removing 85 mg of elemental iron.
It removes loosely bound iron and iron from hemosiderin and ferritin but not remove iron from Hb or cytochrome
May 3, 2023 General Management of Poisoning 100
Indication
Acute iron poisoning
Transfusion siderosis
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Dose
Iron poisoning :- drug of choice Given intramuscularly-0.5 to 1gm
repeatedly 4 to 12 hourly Patient with shock receive
intravenous desferrioxamine – 15 mg/kg/hour with a maximum daily dose upto 360 mg/kg or upto 6 gm total.
Also useful in treatment of toxicity with radioactive heavy metals.
May 3, 2023 General Management of Poisoning 102
side effects
Diarrhea Dizziness Headache Mild stomach pain Nausea Stomach upset Vomiting
Topic –ENHANCED ELIMINATION OF
POISON NAME: Sagarika Upadhyay ROLL NO. : 89
MOBILE NO.:9099938328
Email.:-upadhyaysagarika@gmail. Com
BATCH - 2014
Once the absorption of a toxin has been reduced
by various methods, the next logical step is to
ENHANCED ELIMINATION OF POISON
of already absorbed toxinfrom the body.
ENHANCED ELIMINATION OF POISON
Forced diuresis
Hemodialysis & Peritoneal dialysis
Haemoperfusion
Multiple dose activated charcoal
General Management of Poisoning 105May 3, 2023
FORCED DIURESIS
Increased urine formation by diuretics or with manipulation of urine pH .
The renal tubular epithelium is relatively impermeable to the ionized molecules.
If the urinary pH is changed so as to produce more of ionized form of a chemical, it is trapped in the tubular fluid and is excreted in the urine.
General Management of Poisoning 106May 3, 2023
Poison with following properties can be eliminated by FORCED DIURESIS:-
1. Substance excreted mainly by kidneys.2. Substance with low volume of
distribution.3. Substance with low protein binding.
General Management of Poisoning 107May 3, 2023
IN ACIDIC URINE IN BASIC URINE
(after NaHCO3 infusion)
uncharged form(lipid-soluble,diffusible acrosslipid membranes)REABSORBED
Phenobarbital(pKa = 7.2)
anionic form(not lipid-soluble,not diffusible acrosslipid membranes)NOT REABSORBED
O
O
O
Phe
H5C2
HN
NH
O
O
O
Phe
H5C2
HN
N_
H+
H+
General Management of Poisoning 108May 3, 2023
Manipulation of urinary pH This method acts depending on the extent of
ionization(pka)1>forced alkaline diuresis
By achieving urinary pH of 7.5 to 9 promotes excretion of drugs which are weak acids, such as:- Salicylates, phenobarbital, chlorpropamide,
methotrexateLithium. A solution of sodium bicarbonate 50 to 100
meq added to 1 liter of 0.45% saline administered at the rate of 250 to 500 ml/hr for first 1 to 2 hours.
Alkaline solution and diuretics should be administered to maintain a urinary output of 2 to 3 ml/kg/hr.
General Management of Poisoning 109May 3, 2023
Diuretics are needed to maintain highurine flows.
To prevent hypokalaemia potassium added.
The vitals of the patient along with input/output, electrolytes andacid base status should be closely monitored.
Contraindicated:- in patients with shock, hypotension, renal failure and congestive heart failure.
General Management of Poisoning 110May 3, 2023
2> Acid diuresis Is uncommonly used method for certain
poisons like amphetamine. Vitamin C titrated to acidic urine pH .
It is dangerous method because of the risk of:
Myoglobin precipitation in the renal tubules (rhebdomyolysis)
Metabolic acidosis Renal failure.
General Management of Poisoning 111May 3, 2023
DIALYSIS Solute diffusion across a semi-permeable
membrane down a concentration gradient from
circulation into dialysate. Haemodialysis and Peritoneal are useful.
Dialysable substance for good results must have:Low volume of distribution.Low molecular weight.Low protein binding.
Dialysis is useful in ethanol, methanol, salicylates, phenobarbital, theophylline, ethylene glycol, and lithium intoxications. PeritonealGeneral Management of Poisoning 112May 3, 2023
A)Haemodialysis
Semipermeable membrane is of 4 category:-
Cellulose Substituted cellulose (e.g. cellulose acetate) Cellulosynthetic Synthetic (e.g. polysulphone, poly methacrylate, polyacrylonitrile)
General Management of Poisoning 113May 3, 2023
May 3, 2023 General Management of Poisoning 114
Rate of diffusion depends on :- Magnitude of the concentration
gradient Membrane surface area Porosity & thickness of membrane conditions of flow on the two sides
of membrane. size of molecule Large size creatinine ( 113Da)
cleared less Small size urea(60Da) cleared
more
May 3, 2023 General Management of Poisoning 115
Consist of a plastic device with the facility to perfuse blood and dialysate compartments at very high flow rates.
The surface area of dialysis membrane in adult patient is usually in the range of 0.8 to 1.2 m2
THE DIALYSER
May 3, 2023 General Management of Poisoning 116
Two geometric configurations of dialysers:
1) Hollow fiber
Commonly used
Composed of bundles of capillary tubes through which blood circulates while dialysate travels on the outside of the fiber bundle.
2) Flat plate
Less frequently used
Composed of sandwiched sheets of membrane in a parallel plate configuration.
May 3, 2023 General Management of Poisoning 117
Hollow fiber
Flat plate
Dialyzers
May 3, 2023 General Management of Poisoning 118
Reprocessing &reuse of haemodialyzers
For the patient on chronic dialysis.
To reduce the expense of individual dialyzer.
Only the dialyzer unit is reprocessing or reused.
Either manual or automated.
May 3, 2023 General Management of Poisoning 119
It consist of
1. Sequential rinsing of the blood and dialysate compartments with water.
2. A chemical clearing step with reverse ultra –filtration from dialysate to blood compartment.
3. Tasting of the patency of the dialyzer. 4. Disinfection of dialyzer by Per acetic acid-
Hydrogen peroxide or formaldehyde.
May 3, 2023 General Management of Poisoning 120
Composition of commercial DIALYSATE for haemodialysis
SOLUTE BICARBONATE DIALYSATESodium( meq/L) 137-143Potassium( meq/L) 0-4.0Chloride( meq/L) 100-111Calcium( meq/L) 0-3.5Magnesium( meq/L) 0.75-1.5Acetate( meq/L) 2.0-4.5Bicarbonate( meq/L) 30-35Glucose( meq/L) 0-0.25
May 3, 2023 General Management of Poisoning 121
Blood delivery system
Using a roller mechanism.
moves blood at the flow rate 250 to 500mL/min.
Extracorporeal circuit
Dialysis access
Blood pump
Dialysis solution delivery system
Various safety monitors
It dilutes the dialysate concentrate with water.
Fistula Graft Catheter Through which the
blood is obtained for haemodialysis is called dialysis access.
Monitors temperature, conductivity,
flow of dialysate.
May 3, 2023 General Management of Poisoning 122
Fistula:-Anastomises of artery to vein
Graft :-prosthetic material b/n artery and vein
Catheter :-a double lumen cuffed catheter
May 3, 2023 General Management of Poisoning 123
Procedure:-
300-500mL/
min
500-800mL/
min
Clearance of urea =200-350mL/min
May 3, 2023 General Management of Poisoning 124
COMPLICATIONS:-
Hypotension(most common particularly in diabetics)
Muscle cramps
Electrolyte imbalance
Cross infections
Bleeding tendency (due to heparin)
Air embolism
B) Peritoneal dialysis peritoneum as semipermiable
membrane.
Infusing 1 to 3 L of a dextrose-containing solution into the peritoneal cavity allowing the fluid to dwell for 2 to 4 hr.
USE: especially in children in barbiturates, and salicylate poisoning.
May 3, 2023 General Management of Poisoning 125
May 3, 2023 General Management of Poisoning 126
Forms of peritoneal dialysis :-
A. CAPD=Continues ambulatory peritoneal dialysis
(During day & 3 to 4 time) (midnight dwell at bedtime and remains through
night)B. CCPD=Continues cyclic peritoneal dialysis (by an automated cycler & at night) (4 to 5 cycle while the patient sleeps) (in morning – discontinuation and routine activities)C. NIPD=Nocturnal intermitant peritoneal
dialysis (10 hrs – each night)
COMPLICATIONS : Intra-abdominal bleeding Perforation of abdominal organs Peritonitis Dehydration or over hydration.CONTRAINDICATIONS: Pregnancy Abdominal hernia Respiratory distress.
May 3, 2023 General Management of Poisoning 127
May 3, 2023 General Management of Poisoning 128
HEMOPERFUSION Using equipment similar to that for
haemodialysis, the blood is pumped directly through a column containing an adsorbent material ( either charcoal or Amberlite resin which is ion exchange resin).
Systemic anticoagulation is required. Often in higher doses than for haemodialysis
Thrombocytopenia is a common complication.
May 3, 2023 General Management of Poisoning 129
Because the drug or toxin is in direct contact with the adsorbent material, drug size, water solubility and protein binding are less important limiting factors.
For most drugs, hemoperfusion can achieve greater clearance than haemodialysis.
for example, the for phenobarbital haemolysis clearance
60-80mL/min hemoperfusion clearance 200-
300mL/min May 3, 2023 General Management of Poisoning 130
CONTRAINDICATIONS: Patients with coagulopathy Patients with uncontrolled hypotension
COMPLICATIONS: Thrombocytopenia Hypocalcaemia Hypoglycaemia Hypotension
May 3, 2023 General Management of Poisoning 131
Hemoperfusion machine
May 3, 2023 General Management of Poisoning 132
MULTIPLE DOSE ACTIVATED CHARCOAL
More than 2 doses of oral activated charcoal.
Free charcoal available in the intestines to bind any toxin
free toxin in the blood tends to diffuse out of the blood into the intestines binds the charcoal “gastrointestinal dialysis”.
It is simple, inexpensive, and safe and avoids the need for invasive procedures, such as haemodialysis and hemoperfusion.
May 3, 2023 General Management of Poisoning 133
DOSE: Optimum dose is unknown. Adult dose = from 50 to 100 grams per dose, administered at the rate no less than 12.5 grams/hr or
its equivalent. Children =Lower doses of 10-25 grams
are used.
Carbamazepine, dapsone, phenobarbital, theophylline, quinine, phenytoin .May 3, 2023 General Management of Poisoning 134
1. The toxin has long half life
2. Toxin has a significant enterohepatic circulation (digoxin, phenobarbital, theophylline )
3. Continuous release of toxin from sustained-release preparation
4. Toxin forms mass in the gut which is a source of continuous release of toxin.
5. The ingestion is very massive to be effectively adsorbed by a single dose of charcoal.
May 3, 2023 General Management of Poisoning 135
INDICATIONS :-
Contraindicated: in the presence of ileus ( disruption of the
normal propulsive ability of the gastrointestinal tract )
The use of multiple-dose charcoal for salicylate poisoning is controversial.
Not recommended for the elimination of astemizole, chlorpropamide, doxepin, imipramine, meprobamate, methotrexate, sodium valproate, tobramycin, and vancomycin.
May 3, 2023 General Management of Poisoning 136
The need for ministration of cathartics such as sorbitol remains unproven and is not recommended.
Should not be used in children
because of possible fluid and electrolyte disturbances.
May 3, 2023 General Management of Poisoning 137
In summary, physicians should take the best judgment according to the presence of contraindications and the effectiveness and availability of alternative treatment.
May 3, 2023 General Management of Poisoning 138
May 3, 2023 General Management of Poisoning 139
THANK YOU
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