مشروع إعداد طبيب حكيم ناجح- المعهد العربي للتنمية المهنية المستدامة دورة الطوارئ و التخدير و الرعاية 8-4-2014

1. Approach to a
toxicological
patients
DR. HEND ELHELALY, MD
CLINICAL TOXICOLOGY, ASU

2. How to diagnose a Toxicological case
Poisoning should be suspected in all cases
of: sudden, severe, and unexpected illness.
▪Persistent vomiting of unknown origin and without
fever

3. Non toxic exposure
The following general guidelines for considering an exposure
nontoxic or minimally toxic will assist clinical decision making:
1. Identification of the product and its ingredients is possible.
2. The Consumer Product Safety Commission (CPSC) “signal words”
CAUTION, WARNING, or DANGER does not appear on the product label.
3. The history permits the route(s) of exposure to be determined.
4. The history permits a reliable approximation of the maximum
quantity involved with the exposure.
5. Based on the available medical literature and clinical experience,
the potential effects related to the exposure are expected to be at
most benign and self-limited, and do not require referral to a
healthcare facility.
6. The patient is asymptomatic, or has developed the expected

4. How to Manage?
Could You differentiate the followingCould You differentiate the following
TerminologyTerminology
## ManagementManagement
# Diagnosis# Diagnosis
# Treatment# Treatment
# Provisional diagnosis# Provisional diagnosis
# Final Diagnosis# Final Diagnosis

5. Management
▪ First Evaluation and Assessment
of emergency situations and ttt of life threatening conditions
▪ Second revaluation, detailed history and full
examinations and provisional diagnosis and start ttt.
▪ Thirdly Frequent revaluation and ttt of
complications and follow up

6. History
▪Presenting complaint: IN patient's words (no medical terms);
▪ analyze the Symptom (site –onset- duration –recurrence –what
increase it, what decrease).
▪ Substance (name-ingredient -regular form –slow release- enteric
coated)
▪Amount.
▪Time of intoxication- delay.
▪Symptoms. (Relation between time of ingestion and symptoms).
▪Where - mode of intoxication-route.
▪Pre-consultation treatment (gastric lavage - emesis-antidotes)

7. ▪A B C D
▪Monitoring
▪History:

8. Examination, investigation and final diagnosis
▪Emergency
▪Specific
▪Follow up serum choline esterase enzyme

9. Case I
20 years old male presented to the PCC ER 10 hours after
ingestion of his mother tablets who known to be diabetic and
hypertensive. The toxicologist had performed primary evaluation; the
initial vital data were 100/70 mmhg, pulse 60/ minute and the
patient looked pale. On the ER the patient was given syrup of ipecac
and had started to vomit after that he was transferred to the
observation room for follow up. Few minutes later the patient
collapsed and underwent cardiac arrest. CPR was done and he was
transferred to ICU unit where other life support measures were given.
Detailed history about the medications of her mother and she told
that she is on antihypertensive drugs. The patient was put on
continuous cardiac monitoring which revealed specific ECG changes.

10. Investigations

11. Treatment
▪ Life saving Atropine
▪ Glucagon
▪ Supportive
▪ ICU and Cardiac Monitoring
▪ Cardiac inotropics
▪ Cardio-version and pacing

12. Case II
Twenty Two years old man was brought to the
emergency department with coma and
constricted pupils. Cyanosis and hypoventilation
with crepitations were observed. Miosis, cold
skin and multiple skin tracks were observed.
Vital signs examination showed pulse 50
beat/min.Bl.Pr 90/60mmHg RR 6/min. In-
addition, abdominal auscultation revealed no
intestinal sounds. The patient suffered two
attacks of convulsions. Blood samples were
taken for investigations. Emergency

13. Treatment
▪ Naloxone (life saving) unless there is attack or history of convulsions
▪ If any avoid and try to restrain and give diazepam
▪ ICU & cardiac monitoring

14. Case III
200 workers at cloths factory in 10th
of Ramadan presented to
Ain Shams University hospitals PCC ER with vomiting, colics and
flushing. Some of them told the resident that the beginning of
symptoms appeared after their lunch. On examination Bl.Pr ranging
from 100/60 to 80 /50, pulse was 100 to 120 Beat/min ans RR
16/min. 1 hour later three females went in drowsiness, peripheral
tingling and numbness. The resident admitted 5 cases from them
for 24 hours and others were discharged 6 hours later.
Group Poisoning????????????
Scrompoid? Tetradotoxin? Siguatora Toxin?

15. Case IV
▪ A farmer found collapsed in his farm. Rescuer transferred him to
ER, with history of repeated attacks of vomiting and diarrhea. On
Examination he was found drowsy, weak, evident fasciculations
and characteristic smell. Vital data examination revealed that,
blpr: 100/70, Pulse: 50/min, RR 20/min, Tep: 36.5. he had
constricted pupil, bilateral noisy breathing and increased
intestinal motility.
▪ Life Saving Atropine
▪ Supportive therapy

16. OP
▪ ABCD
▪ History, Farm, Planet, Home, Child, house-hold
▪ Cardinal signs, smell
▪ Life saving ttt.
▪ DD

17. Corrosives
▪ Household, lap, homicidal
▪ 1st
aid
▪ Nothing oral
▪ Local and systemic analgesics
▪ Follow up swallowing
▪ Surgery

18. Animal Poisoning – Scorpion
▪ Scorpion and Snake
▪ ABCD
▪ Follow up
▪ Antivenum if hypertension,
▪ Pulmonary crepitations
▪ Agitations or CNS toxicity
▪ 1-2 amp inchild
▪ Up to 5 amp in adulty

19. Snake Bite
Types of snake Copa viber
Local ---- ++++
Systemic Descending paralysis Coagulopathy, cardio and nephrotoxicity
investigation ABG CBC PT PTT Liver and kidney function testes
treatment Mechanical ventilation Plasma, whole blood and supportive
Antivenom skin test before Antivenom

20. THANK YOU