POISONING MANAGEMENT

1. POISONING
MANAGEMENT
SUDESHNA BANERJEE
M.SC 1ST YEAR
HFCON

2.  The development of dose related adverse effects
following exposure to chemicals, drugs or other
xenobiotics.
Poisoning occurs when any substance interferes with
normal body functions after it is swallowed, inhaled,
injected, or absorbed.
POISONING

3. CLASSIFICATION
Intentional poisoning
Unintentional poisoning
Undetermined

4. ROUTES OF POISONING
Inhalation:
Gases: ammonia, chlorine
Vapors: carbon monoxide
Sprays: insecticides
Volatile liquid chemicals: change easily from
liquid to gas

5. Ingestion:
Household and industrial chemicals,
medications
Improperly prepared/ preserved food
Plant materials
Petroleum products

6. Common poisonous plants
JIMSON WEED/ DATURA BELLADONA

7. RHUBARB DUMB CANE

8. Injection:
Intra venous – Benzodiazepines, barbiturates,
tricyclic antidepressants etc.
Intramuscular – Benzodiazepines, opioids
etc.
Subcutaneous – Botulinum toxin
Intra- dermal – Local anesthetics,
organophosphates

9. Absorption:
Corrosives or irritants
Through bloodstream
Insecticides and chemicals

11. ACID POISONING
Superficial burns after only 1 second of contact
Full thickness burns after 30 seconds
SIGNS & SYMPTOMS
Swollen lips, brown or black streaks
Edematous tongue
Pharyngeal pain, hoarse & husky voice, chalky-white
teeth
Corrosion of mucous membranes of mouth, throat,
esophagus

12. Intense thirst
Stridor, drooling
Epigastric pain spread over abdomen &
thorax
Constipation
Sunken eyes, pupils dilated

13. COMPLICATIONS
Upper airway obstruction & injury
GI haemorrhage
Esophageal and gastric perforation
Sepsis
Tracheobronchial necrosis, atelectasis

14. BENZODIAZEPINES POISONING
Anxiolytic & hypnotic agents.
USES
Anxiety disorders
Seizure disorders
Insomnia
Mania

15. SIGNS AND SYMPTOMS
MILD: Drowsiness , Ataxia , Weakness
MODERATE TO SEVERE :Vertigo , slurred
speech, nystagmus, lethargy , hypotension,
respiratory depression, coma (stage 1 & 2 ).

16. COMA 1 (Stage 1): Responsive to painful
stimuli but not to verbal or tactile stimuli, no
disturbance in respiration or BP
COMA 2 (Stage 2):Unconscious, not
responsive to painful stimuli

17. LEAD POISONING
Clinical symptoms- >70µg/100ml in blood
Normal adult ingest- 0.2 to 0.3mg of
lead/day
 All lead compounds are toxic
 MOST Dangerous- lead arsenate,lead
oxide,lead carbonate.
 Least toxic-lead sulphide.

18. CLINICAL FEATURES
Abdominal colic
Constipation
Loss of appetite
Blue lines on gums
Stippling of red cells
Anemia
Wrist drop
Foot drop
Insomnia
Headache
Mental confusion

19. MANAGEMENT
Saline purge (remove lead from the gut)
d-penicillamine(promote Pb excretion in urine)
Substitution
Isolation
Good housekeeping
Periodic medical examination of workers

20. SNAKE BITE
 Snake venom is a Combination of enzymes & Non-
Enzymatic polypeptides.
 Acidic
CLINICAL FEATURES
Burning pain
Swelling and discolouration
Serosanguinous discharge

21. PRE-PARALYTIC STAGE:
Emesis
Headache
LOC
PARALYTIC STAGE:
Ptosis
Ophthalmoplegia
Drowsiness
Dysarthria
Dysphagia
Convulsions
Respiratory failure

22. MANAGEMENT: LOCAL
Tourniquet: Between wound & heart, Pressure
adequate to occlude lymphatics only, Released for
few seconds every 10 minutes.
Immobilize affected limb: Elastocrepe bandage may
be applied
Clean with Normal Saline
if bite <1hr old: Short skin incision and suction

23. SPECIFIC MANAGEMENT
Antivenom is immunoglobulin purified from the
serum or plasma of a horse or sheep that has been
immunised with the venoms of one or more species
of snake
ASV IN INDIA: Polyvalent
COBRA
KRAIT
RUSSEL’S VIPER
SAW SCALED VIPER

24. ASV INDICATION
Neurotoxicity
Haemotoxicity
Nephrotoxicity
Cardiotoxicity
Rhabdomyolysis
Repeated vomiting

25. Others:
-Local swelling involving more than half of the
bitten limb.
-Rapid extension of swelling.
-Development of an enlarged tender lymph
node draining the bitten limb

26. TIMING OF ASV
Best effects are observed within
four hours of bite
Efficacious even 6-7 days after the
bite from vipers

27. MECHANICAL VENTILATION
If patient has respiratory distress or bulbar
paralysis- intubate and ventilate.
If delayed can cause aspiration or hypoxia and
cardiac arrest.
Even if the facility for MV is not available
ambuing can save the day.
This helps even during transport.

28. FOOD POISONING
Microorganisms:
Staphylococcus aureus
Salmonella typhi
Shigella
Vibrio cholera
Streptococcus
E. coli
Protozoa:
Entamoeba histolytica
Giardia lamblia

29. SIGN AND SYMPTOMS
Nausea
Vomiting
Abdominal cramps
Chills
Diarrhea
Fever
Headache
Vertigo
Numbness of face and neck
Convulsions

30. TREATMENT
Symptomatic treatment should be done
Salmonella: we can provide ciprofloxacin
Fluid replacement and electrolyte
replacement should be done
Streptococcus: penicillin, erythromycin
E. coli: ciprofloxacin

32. ANTIDOTES COMMONLY USED
SUBSTANCES ANTIDOTES
Acetaminophen
Narcotics
Cyanide
Carbon monoxide
N-acetylcysteine
Naloxone
Nitrates
Oxygen

33. SUBSTANCES ANTIDOTES
Atropine
Ethanol
Iron
Dextrose 50%
Lead, mercury,
arsenic
Lead
Physostigmine
Vitamin k
Organophospates
Methanol
Deferoxamine
Insulin
Dimercaprol
EDTA
Atropine
Anticoagulants;
warfarin

34. MANAGEMENT
Initial resuscitation & stabilization:
First priorities are ABC’s
I/V access – I/V fluids
Endo tracheal intubation - to prevent
aspiration
Unconscious patients
Respiratory depression/ failure
Convulsions- give anticonvulsants

35. Management for a responsive patient
• Execute a Primary Survey
(Inquire as to what poison was consumed, the
amount and how long ago it was taken )
• Reassure the victim
• Monitor the vital signs of the victim
• Don’t encourage vomiting
• Contact Poisons Information Centre; 1800 116
117 / 26589391 / 26593677
(Get medical advice or assistance)

36. An unconscious or unresponsive patient
 Seek an ambulance immediately on 102 or 108
 Execute a Primary Survey
(Try to determine what poison was consumed, the
amount and how long ago it was taken)
 Monitor the vital signs of the victim
 If available give patient supplemental oxygen

37. Management of Ingested Poisons
Swallowed poisons may be corrosive. Corrosive poisons
include alkaline and acid agents that can cause tissue
destruction after coming in contact with mucous
membranes. Control of airway, ventilation, and
oxygenation are essential
Syrup of ipecac to induce vomiting in the alert
patient( never use with corrosive poisons)
Gastric lavage for the obtunded patient, gastric
aspirate is saved and sent to the laboratory for
testing

38. Activated charcoal is administered only if the
poison is adsorbed by charcoal
(phenobarbital, carbamazepine)
Cathartic, when appropriate.
e.g. lactulose

39. GASTRIC LAVAGE
It is the aspiration of stomach contents and
washing out of the stomach by means of large
bore gastric tube
It is contraindicated:-
After acid or alkali ingestion
In the presence of seizures
Recent esophageal / gastric surgery
Unconscious patient

40. Done with water ,1:5000 potassium
permanganate , 4% Tannic acid, saturated
lime water or starch solution with
orogastric or Ewald’s tube
Performed until clear fluid is obtained or
a maximum of 3 L

41. Ewald’s tube

42. Lavage decreases ingestant absorption by an
average of :-
• 52 % if performed within 5 min of ingestion
• 26 % if performed at 30 min
• 16 % if performed at 60 min

43. CAUTION; GASTRIC LAVAGE
Gastric lavage is not without hazard. Death due to
inadvertent pulmonary placement of the tube and
subsequent instillation of lavage fluid may occur
Epistaxis commonly occurs when the tube is
inserted nasally; oral placement is preferred
Gastric lavage is employed when emetic therapy
can’t be used

44. IPECAC SYRUP INDUCED EMESIS
Administered orally
Dose :-
30 ml – adults
15 ml – children
10 ml – small infants
Contraindications:
Corrosives
CNS depression or seizures
Rapidly acting CNS poisons ( cyanide, strychnine )

45. Caution; ipecac solution
Home remedy methods of inducing vomiting such
as manual stimulation of the posterior pharynx
Drinking salt water or mustard water, eating raw
eggs
These measures are often unsafe and ineffective,
The only recommended method of producing
emesis is administration of syrup of ipecac

46. Always ascertain that the gag reflex is intact before
giving ipecac
Frequently re assess the person; someone who was
awake when the ipecac was administered may be
obtunded when emesis occurs, and aspiration may
result

47. ACTIVATED CHARCOAL
Charcoal adsorbs ingested poisons within gut lumen
allowing charcoal- toxin complex to be evacuated
with stool or removed by induced emesis / lavage
Dose – 1 g/kg body wt.
Given orally as a suspension ( in water ) or through
NG tube
Contraindications:
Mineral acids, alkalis, cyanide, fluoride ,iron

48. WHOLE BOWEL IRRIGATION
Administration of bowel cleansing solution containing
electrolytes & polyethylene glycol
Orally or through gastric tube
Rate – 2 L/hr. ( 0.5 L /hr. in children)
End point- rectal fluid is clear
Position – sitting
Contraindications :
Bowel obstruction
Unprotected airway

49. FORCED ALKALINE DIURESIS
Infusion of large amount of NS+NAHCO3
Used to eliminate acidic drug that mainly
excreted by the kidney
e.g. salicylates
Serious fluid and electrolytes disturbance may
occur
Need expert monitoring

50. EXTRACORPOREAL REMOVAL
Dialysis
– Acetone, Barbiturates, Bromide, Ethanol, Ethylene
glycol, Salicylates, Lithium
– Less effective when toxin has large volume of
distribution (>1 L/kg), has large molecular weight, or
highly protein bound
Peritoneal Dialysis
– Alcohols , long acting salicylates, Lithium

51. CHELATION
Heavy metal poisoning
Complex of agent & metal is water
soluble & excreted by kidneys
Eg. British antileucyte, EDTA,
• BAL – Arsenic, Lead, Copper, Mercury
• EDTA- Cobalt, Iron, Cadmium

52. GUT LAVAGE
used in managing selected poisonings, e.g.
herbicides
The procedure involves instillation of warmed
electrolyte solution into the stomach via a tube
regulated by a peristaltic pump delivering
approximately 75 ml/min
the goal of gut lavage is to rid the bowel of toxic
substances

53. CATHARTICS
Administered to hasten excretion of a toxic
substance and thus minimize further absorption
from the bowel
Commonly used cathartics are magnesium sulfate,
sodium sulfate, and magnesium citrate
Oil-based cathartics (castor oil) are contraindicated
because of the danger of aspiration pneumonitis

54. NURSING ADVICES
Keep syrup of ipecac readily available in all house
holds where children live or visit. It is important to
know and understand direction for the use of syrup
ipecac.
Give phone number of the nearest poison control
center or other appropriate care facility.
Encourage adults to move dangerous substances to
high shelves and childproof locks on doors of these
cabinets.

55. Advise adults that many house, garden, and wild
plants are poisonous and should be removed from
children’s environment. Familiarize self with
poisonous plants in your area.
Use childproof safety caps on containers of
medications and other potentially dangerous
substances.

56. Keep products in their original containers.
Use poison symbols to identify dangerous
substances.
Dispose of outdated medications and
household products.

57. Nursing diagnosis
• Risk for injury/ suffocation related to contact with
chemical or poisonous agents.
• Risk of choking related to increased danger of
accidental suffocation
• Post-traumatic reaction related to painful and
prolonged reaction to attempted self harm

58. Recent Advances in the Management
of Poisoning Cases
• Deaths due to poisoning are on the rise over the years,
despite advanced knowledge regarding their
pharmacokinetics and pathology, and newer and better
techniques being developed for the management of
poisoning cases. Though the general principles of
treatment of a poisoned patient remain the same,
traditional methods like gastric lavage, for example,
have taken a back seat. There has been gaining
popularity of newer methods like use of activated
charcoal and a variety of newer antidotes.

59. Some Newer Antidotes
• Hydroxycobalamin: cyanide poisoning
• Digoxin specific antibodies (Fab
antibodies):
indicated in life threatening
arrhythmia/hyperkalemia caused by
intoxication with cardiac glycosides.

60. • Octreotide: A synthetic polypeptide that
antagonizes pancreatic insulin release, it is
indicated in overdose of insulin or oral
hypoglycemic agents, mainly sulphonylurea.
• Succimer (2,3dimercaptosuccinicacid): it is a
chelating agent used for the treatment of lead,
mercury and arsenic poisoning. It is the water
soluble analogue of dimercaprol and can be taken
orally.