MANAGEMENT OF A CASE OF ACUTE

POISONING

Ifra Iqbal2nd Prof, MBBS

Steps For treatment of poisoning cases

1) Removal of the patient from the source of exposure

2) Removal of the unabsorbed poison

3) Elimination of the absorbed poison

4) Use of specific antidote5) Symptomatic

Management

ROLE of antidotes in poisoning

An antidote is any substance which prevents the action of a poison or neutralize the poison or produce signs and symptoms opposite to those produced by the poison.

Types of antidotes

Antidotes may be of the following types:Mechanical/Physical AntidotesChemical AntidotesPhysiological/Pharmacological AntidotesChelating AgentsSerological AntidoteUniversal Antidote

Mechanical antidotes

• These act by minimizing the absorption of a poison. For example,

• Demulcents Eg., egg albumin• Adsorbents Eg., activated animal

charcoal• Diluents Eg., Water• Bulky Food EG., Boiled rice

Chemical antidote

These act by chemically reacting with the poison and forming a non-toxic complex. For example,

• Vinegar(Acetic Acid) for alkalies• Magnesium oxide for acids• Potassium permanganate for

oxidisable poisons like alkaloids, barbiturates, phosphorus.

Physiological antidote

These act by producing effects opposite to those of the poison. For example,

• Atropine for Organophosphate Poisoning

• Naloxone for Morphine Poisoning• Barbiturate for Strychnine

Chelating agents

• These act by forming chelate with metallic poisons available in circulation and facilitate their elimination from body by renal excretion.

Examples Of Chelating agents:

• Dimercaprol (3-4mg/kg body weight) for Arsenic, Mercury poisoning

• E.D.T.A. (1 gm twice a day by slow I.V. drip) for Lead Poisoning

• Penicillamine(3mg/kg body wt/day) for Copper Poisoning

• Desferrioxamine(8-12gm daily in divided doses) for Iron Poisoning

Serological antidote• These are immunological anti-

sera used to neutralize the poison antigens.

• For example, Anti snake venom serum for

snake bite poisoning.

Universal antidote

Universal Antidote is a combination of physical and chemical antidotes. When the exact nature of the poison is not known, universal antidote is administered to the patient.

It consists of:• Activated Charcoal – 2 parts• Magnesium oxide – 1 part• Tannic acid – 1 part

SYMPTOMATIC MANAGEMENT

Nausea and Vomitting

• Chlorpromazine hydrochloride • Either injection or orally (5

c.c.ampule/10 c.c.ampule )

Relieving pain

Body pain : Paracetamol Ibuprofen Diclofenac sodiumAbdominal pain : Atropine injection

SAFEGUARDING RESPIRATION

1) Clearing the airways + elevation of lower limb + O2 + CO2(5%) + Nikethamide(1-3c.c.,I/V or deep I/V or even intra-cardiac)

2) Endotracheal Intubation3) Tracheotomy4) Oxygen Inhalation5) Artificial Respiration

Management Of Circulatory Failure

• NA + Methyl amphetamine injection• Elevation Of foot end of the bed

(Trendelenburg Position)• Use Of Vasopressors like Dopamine

(2-20 µg/kg/min)• Use Of Plasma Expanders (Plasma/

Whole Blood/Low Molecular Weight Dextran)

Pulmonary oedema

• 60% O2 inhalation + Atropine sulphate + Aminophylline + Sedative

• 50 c.c. syringe ( 40 c.c. Glucose solution + 10 c.c. Aminophylline ),infused slowly.

• Followed by Deriphylline injection – I/M or I/V (cubital vein )

Coma:• AnalepticsCerebral oedema:• Hypertonic Urea(30%) or 20% I/V Mannitol or Sorbitol

Oedema glottis:• Epinephrine 1:1000• Atropine(0.5-1 mg injection)• Cortisone

Narcosis :•Morphine•Short acting barbiturate•To prevent narcosis : • Laptozol, Nikethinamide etc.

Cardiac arrest: • Cardiac massage• Caffeine• Digitalis• Nicotinamide• Xylocaine • Digoxin VAGAL INHIBITION:

Atropine

Hepatic coma

• Deeply sedated : 10% Glucose solution is to be administered bottle after bottle

• Monosodium glutamate – 500 ml

Control of convulsions

• The patient is given Diazepam (0.2-0.4 mg/kg) slow I.V. upto a maximum of 10 mg at a time. If I.V. administration isn’t possible, Diazepam is to be administered per rectally.

Allergy

Anti-histaminics : Promethazine Chlorpromazine

DermatitisAl acetate/MgSO4/Na2 CO3/KMnO4

Cough:• Antitussives or Expectorants

Respiratory Infections:• Antibiotics

Diarrhoea

• Without antibiotics: Pectin+Bismuth+Kaolin

• With antibiotics: All fluoroquinolones

Abdominal distensionNasogastric or Intestinal intubation

Management of hypothermia

• In cases of mild hypothermia, a warm room and a blanket are required

• In severe cases of hypothermia, the patient is to be given a warm water bath(42’C) or by heating the inspired air.

• Pilocarpine/Physostigmine

MANAGEMENT OF HYPERTHERMIA

• The patient’s clothes are removed.• The regions of the patient’s neck and

groin are to be packed with ice.• Otherwise, the patient is immersed

upto the neck in cold water bath(25’C).

Correction of fluid or electrolyte imbalances

Correction of hyponatremia

• The patient is given 0.9% NaCl over 15-30 minutes at a time.

Correction of hypernatremia

• The patient is given 0.2% NaCl over several hours

Correction of hypokalemia

• The patient is given 4-6 mEq of Potassium per kg per day orally or in an IV solution not exceeding 40-60 mEq/L

Correction of hyperkalemia

• The patient is given Furosemide 1 mg/kg I.V.

• In severe cases, the patient is administered 10% Calcium Gluconate (5-10 ml) I.V.

Correction of metabolic acidosis

• Sodium bicarbonate(1-2 mEq/litre) I.V. is given over 15-30 minutes.

CORREction of hypocalcemia

• The patient is given 10% Calcium Gluconate(2ml/kg/day) I.V.

Coma cocktailThis is a combination of three

antidotes that is often given to poisoned patients exhibiting CNS depression. It consists of:

• Naloxone(2mg)• Thiamine(100mg)• Dextrose(50 ml of 50% solution)

•Thank you!