The document discusses the general principles of poisoning management. It covers 6 key areas: 1) stabilization and evaluation of patients, 2) gut decontamination techniques like induced vomiting, gastric lavage, and use of activated charcoal, 3) methods for poison elimination like forced diuresis and extracorporeal techniques, 4) administration of specific antidotes, 5) nursing care for comatose patients, and 6) providing psychiatric care and support for patients who poisoned themselves. The document provides detailed information on assessing patients, various decontamination procedures, poison elimination methods, common antidotes, and care considerations for poisoned individuals.

1. General principles involved
in the management of
poisoning
By Ashish Mehta

2. Clinical Toxicology

3. Branch of medical science that dealing with
poisoning resulted from the exposure or intake
of xienobiotics and also involved the chemical
and physical means used to counteracting the
adverse effects induced by such chemicals.

4. Poison
Any substance when introduced into living body by
any means or brought into contact with any body part
causes local or systemic effects or both results in ill
effects or even death of the individual. Such substance
is known as poison.

5. General principles of poisoning management:
It includes:
1. Stabilization and Evaluation
2. Gut decontamination
3. Poison elimination
4. Antidote administration
5. Nursing care
6. Psychatric care

6. 1. Stabilization and Evaluation:
• Direct initial investigation towards assessment and
correction of life-threatening problems(if present), is
the primary focus.
• It includes airway, breathing, circulation, depression
of CNS.
• If patient is not in crisis(normal speech and pulse)
go to complete, throughout and systematic
examination.
• Based on efficacy evaluation go for assisted
ventilation.

7. • Respiratory status is also measured by using a
Wright’s spirometer.
• According to HOFFMANN and GOLDFRANK for
coma patients in general where poison is not
identified, provide “COMA COCKTAIL”
• “COMA COCKTAIL” consists of 3 antidotes:
a) Dextrose(5% solution): 100ml i.v
b) Thiamine(Vitamin B1): 100ml i.v
c) Naloxone: 2ml i.v
• For METABOLIC ACIDOSIS, calculate “ANION
GAP”

8. • ANION GAP = (Na+K)-(HCO3+Cl)
= (140)-(24+104) = 12mmol/L
• Normal value = 12-16mmol/L
• If ANION GAP > 20mmol/L, suggest metabolic
acidosis.
• Poisons cause METABOLIC ACIDOSIS in 2 ways:
a) GAP ACIDOSIS: Increase in anion gap
b) NON-GAPACIDOSIS: No significance alteration
in anion gap

9. • Toxins associated with:
a) Failure of respiratory centre:
- Antidepressants - Neuroleptics
- Ethanol - Sedatives -
Opiates
b) Failure of respiratory muscle:
- Succinylcholine - Nicotine
- Cobra bite - Organophosphates
- Shellfish poisoning
c) Tachycardia & Hypotension:
- Antihistamines - Caffeine
- Atropine - Cannabis

10. d) Tachycardia & Hypotension:
- CO(cobalt) - CN(cyanide)
- Theophylline - Phenothiazines
e) Tachycardia & HTN:
- Amphetamines - Cocaine
- Phenylpropanolamine
f) Acid-Base Disorders:

12. 2. Gut Decontamination
• Defined as “Methods of poison removal from GIT”
• Methods include:
a) Emesis
b) Gastric lavage
c) Catharsis
d) Activated charcoal
e) Whole bowel irrigation(Whole gut lavage)

13. A. Emesis
 “Method of inducing a poisoned victim to VOMIT”
 Done by syrup administration of IPECAC
 Source of IPECAC: Root of shrub ‘Cephaelis
ipecacuanha / C. Acuminata’
 Found in west bengal
 Constituents of IPECAC: Cephaeline, Emetine,
Psychotrine(traces)
 Used in CONSCIOUS and ALERT poisoned
patients, who have ingested poison not earlier than
4-6hrs.

14.  Actions of IPECAC include:
1. Local activation of peripheral sensory receptors in
GIT
2. Central stimulation of CTZ(Chemoreceptor trigger
zone)
3. Activation of central vomiting center.
 Dose:
1. For adults: 30ml. Followed by 250-300ml water
2. For children: 15ml. Followed by 250-300ml water
3. Patient should be sitting upright

15. 4. If vomitting dosen’t occur within 30mins. Repeat
same dose. If no response, perform stomach wash
and remove poison and IPECAC consumed
 Complications associated with IPECAC induced
emesis include:
a) Arrhythmias
b) Myocarditis
c) Aspiration pneumonia
d) Mallory-Weiss tears
 Contraindications:
a) Pregnancy

16. b) Age > 1yr
c) Old patients
d) Coma
e) Convulsions
f) Corrosive poison consumption
g) Petroleum products consumption
h) Emetic poison consumption
B. Gastric lavage (Stomach wash)
 Defined as “GI decontaminationtechnique, that
aims to empty stomach of toxic substances, by
sequential and aspiration of small volumes of fluid
via orogastric tube”

17.  Used for people, who:
1. Have consumed a life-threatening dose
2. Exhibit morbility within 1-2hrs of ingestion
 Beyond 1-2hrs of ingestion, gastric lavage is
permitted in the following conditions:
1. Sustained release preparations
2. Delayed gastric emptying
 Procedure involved in stomach wash:
a) Explain procedure of stomach wash to the patient,
obtain his/her consent if he/she does not accept
avoid proceeding with the same

18. b) Perform endotracheal intubation in combatose
patients prior to lavage
c) Place patients (head down) on his left latereal side
and mark length of tube to be inserted (50cm for
adults, 25cm for children)
d) Tube used is called “Lavaculator”
e) Usually, Ewald tube/ Ryle’s tube (for children) is
used
f) Oral route for insertion is preferred
g) Nasal route can damages nasal mucosa causes
Epistaxis.

19.  Solutions for gastric lavage:

20.  Complications:
a) Aspiration pneumonia
b) Laryngospasm
c) Vagal inhibition
d) Cardiac arrhythimias
e) Stomach/esophageal perforation
 Precautions:
a) Avoid usage in people who consumed non-toxic
agents/non-toxic doses of toxic agents
b) Avoid usage as a deterrent to subsequent ingestions

21.  Contraindications:
a) Recent surgery
b) Advanced pregnancy
c) Coma
d) Alkali ingestion
e) Acid congestion
f) Convulsant ingestion
g) Petroleum products ingestion

22. C. Catharsis:
 Definition:
“Process of inducing purgation, and thus providing
relief from poisoning and poisoning effects”
 Classes:
1. Ionic / Saline:
o Substance alters physiochemical forces within
intestinal lumen, causes osmotic retention of fluid
that activates mortility reflexes and enhances
empulsion
o Doses:

23. a) Magnesium citrate: 4ml/kg
b) Magnesium sulfate: 30g (250mg/kg in children)
c) Sodium sulfate: 30g (250mg/kg in children)
2. Saccharides:
o Sorbitolis is cathartic of choice
o Avoid in young children to avoid hypernatremia
o Dose: 50ml. Of 70% solution
 Efficacy of cathartics:
o Cathartics decrease transit time of drugs in GIT

24. o No documentation on it decreasing mobility /
mortality in poisoning
D. Activated Charcoal:
• Properities:
o Fine, black, odourless, tasteless powder
o Possess large surface area
• MOA:
o Charcoal absorbs poisons on its surface and prevent
their absorption in GIT.
• Dose:
o 1g/kg body weight (for adults: 50-100g: for
children: 10-30g)

25. • Procedure:
o In activated charcoal add 4-8 times quantity of
water, convert it into slurry administer to patient
after lavage/emesis/solely
• Demerits
o Unpleasent taste
o Vomiting provocation
o Diarrhea
o Pulmonary aspiration
o Intestinal obstruction
• Contraindications:
o Proven ileus

26. o Small bowel obstruction
o Caustic ingestion
o Petroleum products ingestion
• Charcoal absorption properities:
1. Well- Absorbed:
o Neuroleptics
o Antihistamines
o Atropine
o BZDs
o Barbiturates
o Beta-blockers
o Chloroquine

27. 2. Moderately absorbed:
o Oral hypoglycemic agents
o Kerosene
o Paracetamol
o Phenol
o Salicylates
3) Poorly absorbed:
o Alcohol
o Cyanide
o Corrosives
o Heavy metals
o Ethylene glycol

28. E. Whole bowel irrigation (whole bowel lavage):
• General properities:
o Defined as “Process of instillation of large volumes of a
suitable solution via a nasogastric tube for 2-6hrs, causing
diarrhea”
o Solutions used include:
1. PEG-ELS (polyehylene glycol + electrolytes lavage
solution)
2. PEG-3350 (high molecular weight PEG)
• Indications:
o Ingestion of large quantity of toxic drugs >4hrs. Post-
exposure
o SR preparations overdose

29. o Ingestion of substance not adsorbed by charcoal (heavy
metals)
o Ingestion of miniature disc batteries, cocaine filled
packets (body packer syndrome) etc.
o Ingestion of slowly dissolving substances: Iron tablets,
paint chips, etc.
• Procedure:
o Insert nasogastric tube into stomach, instill solution at
room temperature (2litre/hr. in adults, and 0.5litre/hr. in
children) and make patient sit on commode.
Use metoclopramine i.v (10mg in adults, 0.3mg/kg in
children) to reduce emesis, continue procedure. Until
rectal efflucent is clear (in 2-6hrs)

30. 3. Poison Elimination
• Methods include:
A. Forced Diuresis:
o Defined as “Phenomenon of increasing urine
formation, using diuresis and fluid, that can
enhance excretion of drugs, their overdose, and
treat poisoning.”
o Alkaline diuresis is opted
o Examples used for forced diuresis:
a) Salicylates
b) Barbiturates

31. B. Extracorporeal techniques:
Include:
 Haemodialysis:
o “Process of purifying bloodof a person, whose
kidneys are not working properly. Using a dialysis
machine (atrificial kidney)”
o All drugs are not dialyzable
o Before going for this, keep following things in
mind:
a) Substance should easily diffuse though dialyzable
membrane
b) Presence of significant portion of substance in
plasma water

32. c) Pharmacological effect should be directly related to
blood concentration
d) Drugs with extensive PPB. increased molecular weight
& decreased water solubility can’t be used
o Indications:
a) Lithium
b) Phenobarbitone
c) Salicylates
d) Amphetamine
e) Quinone
f) Heavy metals
g) Ethylene glycol
h) Methanol

33.  Haemoperfusion:
o “Process, by which large volumes of patient’s blood
are passed over an adsorbent, in order to remove
toxins from blood”
o More eff
o More effective than Haemodialysis
o Indications to include:
a) Barbiturates
b) Chlorpromazine
c) Diazepam
d) Dapsone
e) Paracetamol
f) Salicylates

34. g) Phenols
h) Digoxin
 Peritoneal dialysis:
o “Process, that involves patient’s peritoneum as a
membrane, across which fluids and dissolved
substances (electrolytes, urea, albumin, etc) are
exchanged from blood”
 Hemofiltration:
o In hemofiltration patient’s blood passes through a set
of tubing (filtration via machine) to a semipermeable
circuit membrane (filter). Removal of waste products
takes place + water (ultrafiltrate) via convection .
Replacement fluid is also added and blld is returned to
patient

35. 4. Antidote Administration
• There are 6 MOAs of antidotes:
A. Inert complex formation:
o Antidote binds to poison and forms inert complex and
then excreted from body
o Example:
a) Dicobalt edetate for cyanide poisoning
b) Prussian blue for thallium
 Plasmapheresis:
o “Process of removal, treatment and rectum of
blood plasma components into blood
circulation”

36. B. Accelerated detoxification:
o Example:
a) Thiosulphate accelerates detoxification of cyanide into
thiocyanate
b) Acetycysteine shows action of glutathione combines with
hepatotoxic paracetamol metabolities, result in it’s
detoxification
C. Decrease toxic conversion:
o Ethanol competes for alcohol dehydrogenase and prevents
methanol conversion into toxic metabolites
D. Receptor site competition:
o Antidote displaces toxin from receptor site antagonizes
toxic effects

37. o Example: naloxine antagonizes opiate effects
E. Receptor site blockade:
o Atropine blocks muscarinic receptor sites, that blocks
effects of anticholinesterases
F. Toxic effects bypass:
o Example: 100% oxygen used in cyanide poisoning
SPECIFIC ANTIDOTES AND THEIR INDICATIONS:

38. 5. Nursing Care:
• Mainly applicable for Comatose patients
• Include:
a) Attention to pressure points to prevent development of
decubitis ulcers
b) Hourly attention
c) Use of pillow in between legs
d) Use of repple mattres
e) In absence of spontaneous blinking, use methyl
cellulose eye drops to prevent exposure keratitis/secure
eyelids with adhesive tape

39. f) Change bed linen frequently if it is soaked in
urine/stained with feces
g) For urinary incontinence, in males: use sheath
urinal; for females: use indewelling silastic
catheter, inserted aspectically
h) To prevent pneumonias, associated with gastric
content inhalation. Focus on intubation/change
position of patient into semi prone, with head
slightly dependent
i) Sufficient bronchial toilet with regular aspiration of
secretions, is required
j) Passive physiotherapy (to prevent stiffness and
music atrophy)
k) Prophylactic antibiotics, if necessary

40. 6. Psychiatric Care
• Psychosocial assessment and support (based on
assessment of patient’s sensorium and alertness) for
patients, who have taken overdoses/with suicidal
ideation is required
• Careful examination of patient’s psychosocial state
(depressed, uncooperative, non-responsive, agitated,
anxious, violet/ psychotic). Allows focus on
psychosocial alternatives (immediate/long term
treatment/ disposition, continued follow-up and out
patient care)

41. Thank
You