Conferencia del Dr. Enrique Paris, Intoxicaciones

1. Epidemiología y Tratamiento
general de las intoxicaciones.
XV Congreso Chileno Medicina Familiar.
X Congreso Nacional Médicos Atención
Primaria.
Dr.Enrique Paris M.
Director Centro Información Toxicológica
Pontificia Universidad Católica de Chile
CITUC.

2. The price of life
Acute respiratory
infection 18%
Other
24%
Diarrhoea 15%
Malaria 11%
Measles 5%
Human Immunodeficiency
Virus (HIV) 4%
Perinatal diseases
(within 7 days of birth)
23%
Deaths associated
with malnutrition:
54% Annual expenditure on pet food
in North America and Europe
1998
Annual cost of scaling-up vaccination,
malaria prevention and
essential treatment to reach
every child in the developing world
2001
US$ 7.5 billion
US$ 17 billion
AUSTRALIA
REP.
KOREA
DPR
KOREA
TIMOR-LESTE
MICRONESIA,
FED. STATES OF
ANTIGUA & BARBUDA
BARBADOS
ST LUCIA
TRINIDAD & TOBAGO
PALAU
ST KITTS & NEVIS
ST VINCENT & GRENADINES
BAHAMAS
ZIMBABWE
UGANDA
TURKMENISTAN
UZBEKISTAN
TAJIKISTAN
KYRGYZSTANGEORGIA
AZERBAIJAN
ARMENIA
MADAGASCAR
SRI LANKA
JAMAICA
CUBA
DOMINICAN
REP.
BRUNEI DAR.
M A L A Y S I A
SAUDI
ARABIA
C H I N A
M O N G O L I A
VIET NAM
CAMBODIA
LAO
PDR
THAILAND
I N D I A
BHUTAN
BANGLADESH
ISL. REP.
IRAN
PAKISTAN
AFGHANISTAN
T U R K E Y
IRAQ
CYPRUS SYRIAN ARAB
REPUBLIC
LEBANON
ISRAEL
JORDAN
BAHRAIN
QATAR
UAE
OMAN
KUWAIT
YEMEN
NEPAL
K A Z A K H S T A N
U S A
C A N A D A
ALGERIA
NIGER
CHAD
S U D A N
NIGERIA
CENTRAL AFRICAN
REPUBLIC
DEM. REP.
CONGO
ETHIOPIA
ANGOLA
E G Y P T
MOROCCO
LIBYAN
ARAB
JAMAHIRIYA
MAURITANIA
SENEGAL
GAMBIA
CAPE VERDE
SAO TOME
& PRINCIPE
GUINEA-BISSAU
GUINEA
LIBERIA
CÔTE
D’IVOIRE
BURKINA
FASO
GHANA
BENIN
CAMEROONEQUATORIAL
GUINEA
GABON
CONGO
NAMIBIA
BOTSWANA
SOUTH
AFRICA
MOZAMBIQUE
MALAWI
ZAMBIA
UNITED REP.
TANZANIA
BURUNDI
RWANDA
KENYA
DJIBOUTI
SOMALIA
TOGO
SIERRA LEONE
SWAZILAND
MALI
LESOTHO
ERITREA
GUATEMALA
EL SALVADOR
MEXICO
HAITI
BOLIVIA
PARAGUAY
B R A Z I L
VENEZUELA
COLOMBIA
HONDURAS
NICARAGUA
COSTA RICA
PANAMA
ECUADOR
PERU
GUYANA
SURINAME
BELIZE
ARGENTINA
URUGUAY
CHILE
PHILIPPINES
NEW
ZEALAND
PAPUA
NEW
GUINEA
I N D O N E S I A
JAPAN
R U S S I A N F E D E R A T I O N
MAURITIUS
MALDIVES
COMOROS
SEYCHELLES
SINGAPORE
DOMINICA
GRENADA
MYANMAR
SOLOMON
ISLANDS
TUVALU
MARSHALL
ISLANDS
NAURU
TONGA
SAMOA
NIUE
COOK
ISLANDS
KIRIBATI
FIJI
VANUATU
TUNISIA
CROATIA
ITALY
REP.
MOLDOVA
UKRAINE
FYR MACEDONIA
LITHUANIA
LATVIA
ESTONIA
ALBANIA
AUSTRIA HUNGARY
BULGARIA
ROMANIA
GREECE
SERBIA &
MONTENEGRO
POLAND
SLOVENIA
BELARUS
RUSSIAN
FED.UNITED
KINGDOM
IRELAND
DENMARK
FRANCE
SPAIN
ANDORRA
S. MARINO
PORTUGAL
GERMANY
SWITZ.
BELGIUM
LUX.
NETH.
ICELAND
NORWAY
FINLAND
SWEDEN
SLOVAKIA
CZECH
REPUBLIC
MALTA
MONACO
BOSNIA &
HERZEGOVINA
Under-five mortality rate per 1000 live births
2000
Beacons of hope
greatest improvement
in child mortality rate
1970–2000
over 175
101 – 175
26 – 100
11 – 25
10 and under
no data
Child mortality rate
Main causes of child mortality
2002
The biggest killers of children under five
ProducedbyMyriadEditions
O
TheWorld’s Forgotten
Children
ver 10 million children
under five die every year –
98 per cent of them in developing
countries. Widespread
malnutrition hampers children’s
growth and development, opening
the door to the biggest killers of
children under five: perinatal
diseases, pneumonia, diarrhoea,
and malaria. This presents a sharp
contrast to the situation in the
industrialized world, where junk
food and a sedentary lifestyle have
triggered an unprecedented
epidemic of obesity in children,
leading to diabetes and heart
disease in adult life.
The last three decades have
witnessed an impressive decline in
child mortality, from 17 million a
year in the 1970s. Yet these gains
have not been enjoyed
everywhere. In some countries of
sub-Saharan Africa, child
mortality is rising as wars and the
ravage of the AIDS epidemic
undermine the medical, social and
economic structures of society.
At the turn of the century, the
world joined together in the fight
against poverty, and committed
itself to the Millennium
Development Goals, adopted by
the United Nations in 2000. “To
reduce by two-thirds the
under-five mortality rate between
1990 and 2015” may be the most
ambitious of these goals.
Aiko is safely delivered in Kumamoto,
Japan, and can expect to live about 85
years. At the same time, Mariam comes
into this world in one of the poorest areas
of Freetown, Sierra Leone. She is
underweight and vitamin-deficient, and
has a 30% chance of dying before her
fifth birthday.
Today, 35% of Africa’s children are
at higher risk of death than they
were ten years ago.
From Inheriting the World: The Atlas of Children's Health and the Environment © WHO
World Health Organization
"It is not enough
to prepare our children for the world;
we must also prepare the world
for our children.”
Luis J. Rodriguez (1954– )
Niños y Medio Ambiente.

3. A U S T R A L I A
REP.
KOREA
DPR
KOREA
TIMOR-LESTE
MICRONESIA,
FED. STATES OF
ANTIGUA & BARBUDA
BARBADOS
ST LUCIA
TRINIDAD & TOBAGO
PALAU
ST KITTS & NEVIS
ST VINCENT &
GRENADINES
DOMINICA
BAHAMAS
ZIMBABWE
UGANDA
TURKMENISTAN
UZBEKISTAN
TAJIKISTAN
KYRGYZSTANGEORGIA
AZERBAIJAN
ARMENIA
MADAGASCAR
SRI LANKA
JAMAICA
CUBA
DOMINICAN
REP.
BRUNEI DAR.
M A L A Y S I A
SAUDI ARABIA
C H I N A
M O N G O L I A
VIET NAM
CAMBODIA
LAO
PDR
THAILAND
I N D I A
BHUTAN
BANGLADESH
I S L . R E P .
I R A N
PAKISTAN
AFGHANISTAN
T U R K E Y
IRAQ
CYPRUS SYRIAN ARAB
REPUBLIC
LEBANON
ISRAEL
JORDAN
BAHRAIN
QATAR
UAE
OMAN
KUWAIT
YEMEN
NEPAL
K A Z A K H S T A N
U S A
C A N A D A
ALGERIA
NIGER
CHAD S U D A N
NIGERIA
CENTRAL
AFRICAN REPUBLIC
DEM. REP.
CONGO
ETHIOPIA
ANGOLA
E G Y P T
MOROCCO
LIBYAN
ARAB
JAMAHIRIYA
MAURITANIA
SENEGAL
GAMBIA
CAPE VERDE
SAO TOME
& PRINCIPE
GUINEA-BISSAU GUINEA
LIBERIA
CÔTE
D’IVOIRE
BURKINA
FASO
GHANA
BENIN
CAMEROON
EQUATORIAL
GUINEA
GABON
CONGO
NAMIBIA
BOTSWANA
SOUTH
AFRICA
MOZAMBIQUE
MALAWI
ZAMBIA
UNITED REP.
TANZANIA
BURUNDI
RWANDA
KENYA
DJIBOUTI
SOMALIA
TOGO
SIERRA LEONE
SWAZILAND
MALI
LESOTHO
ERITREA
GUATEMALA
EL SALVADOR
MEXICO
HAITI
BOLIVIA
PARAGUAY
B R A Z I L
VENEZUELA
COLOMBIA
HONDURAS
NICARAGUA
COSTA RICA
PANAMA
ECUADOR
PERU
GUYANA
SURINAME
BELIZE
ARGENTINA
URUGUAY
CHILE
PHILIPPINES
NEW
ZEALAND
PAPUA
NEW
GUINEA
I N D O N E S I A
JAPAN
R U S S I A N F E D E R A T I O N
MAURITIUS
MALDIVES
COMOROS
SEYCHELLES
SINGAPORE
GRENADA
MYANMAR
SOLOMON
ISLANDS
WEST BANK
AND GAZA
TUVALU
MARSHALL
ISLANDS
NAURU
TONGA
TOKELAU
SAMOA
NIUE
COOK
ISLANDS
KIRIBATI
FIJI
VANUATU
TUNISIA
CROATIA
ITALY
REP.
MOLDOVA
UKRAINE
FYR MACEDONIA
LITHUANIA
LATVIA
ESTONIA
ALBANIA
AUSTRIA HUNGARY
BULGARIA
ROMANIA
GREECE
SERBIA &
MONTENEGRO
POLAND
SLOVENIA
B-H
BELARUS
RUSSIAN
FED.UNITED
KINGDOM
IRELAND
DENMARK
FRANCE
SPAIN
PORTUGAL
GERMANY
SWITZ.
BELGIUM
LUX.
NETH.
ICELAND
NORWAY
FINLAND
SWEDEN
SLOVAKIA
CZECH
REPUBLIC
MALTA
How children are injured
Causes of deaths worldwide
due to unintentional injuries
for children under 15 years
2002
Road traffic accidents
boys girls
Poisonings
boys girls
Falls
boys girls
111 559
71 261
19 818
15 797
22 294
14 713
Fires
boys girls
34 238
39 969
Drowning
boys girls
89 955
55 104
Deaths due to road traffic accidents of children aged 0–14 years
per 100 000
2002
by WHO sub-region
20.0 and over
10.0 – 19.9
5.0 – 9.9
2.5 – 4.9
under 2.5
no data
Dying on the roads
ProducedbyMyriadEditions
Child Injuries
are Preventable
rowning is the most
common cause of injuries
for infants, killing approximately
60 000 children under five every
year and leaving roughly the same
number permanently disabled.
Children also suffer burns from
open fires and kerosene stoves,
and are injured in falls at home,
at school and at playgrounds.
In older children, however, the
overriding cause of injuries is
road traffic accidents, killing
approximately 180 000 children
under 15 each year. Children are
rarely the cause of road traffic
accidents but suffer as pedestrians,
cyclists and passengers. Boys,
often given greater freedom to
roam, are more likely to be
injured than girls.
Injuries are unnecessary and
avoidable. The use of seatbelts
and child car seats, and the
wearing of helmets are essential
to prevent the death of child
passengers or cyclists. Traffic
measures such as checking vehicle
roadworthiness, enforcing speed
limits and prosecuting drunk
drivers are particularly important
in developing countries, where
roads tend to be poorly
maintained and the number of
vehicles is growing rapidly.
Injuries from road traffic
accidents already cost developing
countries US$ 65 billion a year –
more than the annual amount of
development assistance they
receive.
D
Emeka slipped while drawing water from
the river near her village in Nigeria and
did not return home . . .
From Inheriting the World: The Atlas of Children's Health and the Environment © WHO
World Health Organization
Deaths from road accidents
are projected to rise by 65%
by 2020, mostly in
developing countries.

5. LIFETIME EXPOSURES
Birth 6 m 1 yr 5 yr 16 yr 45 yr 65yr
Intrauterine
Breastfeeding
Occupational exposure
“Normal” food
Soil: ingestion
Soil: dermal
Domestic environments
Drinking water
Air

6. www.cituc.cl

7. EPIDEMIOLOGIA

8. EPIDEMIOLOGIA

9. EPIDEMIOLOGIA

10. EPIDEMIOLOGIA

12. Intoxicaciones.
♦ Primeros Centros Toxicológicos 60’.
♦ Formados por Pediatras.
♦ Campañas Masivas.
♦ Semana de la Prevención.
♦ Uso Responsable del Medicamento.

13. Intoxicaciones.
♦ CITUC. 63 53 800 .
♦ Http://escuela.med.puc.cl
♦ Fundado 1992.
♦ Financiamiento: Ley de Donaciones.
♦ Llamadas diarias : prom. 90.
♦ Llamadas acumuladas : 310.000
♦ Cituc@med.puc.cl - www.cituc.cl

14. Intoxicaciones.
♦ Personal y Base de Datos CITUC.
♦ 1 Secretaria.
♦ 5 Enfermeras.
♦ 4 Químicos Farmaceúticos.1 Dr. Tox.
♦ 16 Internos de Medicina y QF.
♦ 1 Médico Intensivista Pedíatra.
♦ 1 Médico Laboratorio.
♦ Micromedex. Intox.

15. Intoxicaciones.
♦ CITUC.
♦ Entregar una información profesional,
oportuna, adecuada y actualizada, para
contribuir al manejo del Paciente
Intoxicado.

16. EPIDEMIOLOGIA

17. EPIDEMIOLOGIA

18. EPIDEMIOLOGIA

19. EPIDEMIOLOGIA

20. 0 1000 2000 3000 4000 5000 6000 7000 8000 9000 10000
Medicamentos
Prod. Ind. Y Químicos
Productos Aseo
Fitosanitarios
Animales
Plaguicidas domésticos
Cosméticos
Metales
Cuerpo Extraño
Alimentos
Gases
Plantas
Otro
SUSTANCIAS MAS
FRECUENTES
Llamadas

21. 0 1000 2000 3000 4000
Sistema Nervioso Central
AINES
Sistema Respiratorio
Antibióticos
Sist. Hormonal
Sist. Nervioso Autónomo
Sistema Cardiovascular
Vitaminas/Minerales
Antisépticos/desinfectantes
Agentes gastrointestinales
Otros
MEDICAMENTOS MAS
FRECUENTES
LLAMADAS

22. GRUPO MAS FRECUENTE SNC
0 200 400 600 800 1000
BENZODIAZEPINAS
ANTIDEPRESIVOS
FENOTIAZINAS
Y DROGAS
RELACIONADAS
ANTICONVULSIVANTES
ANFETAMINAS
OTRAS DROGAS SNC
LLAMADAS

23. PRODUCTOS DE ASEO
0 200 400 600 800 1000
CLORO
DETERGENTES
LAVALOZAS
OTROS
AGENTES
LIMPIADORES
LLAMADAS

24. PRODUCTOS INDUSTRIALES
0 200 400 600 800 1000 1200
HIDROCARBUROS
ALCOHOLES
ACIDOS/ALKALIS
PEGAMENTOS
OTROS
LLAMADAS

25. OTRO
10%
ANTICOAGU-LANTE
35%
PIRETROIDES
25%
ORGANOFOSFORADOS
30%
PLAGUICIDAS DE USO
DOMESTICO

26. Figure
1.
A
21-­‐year-­‐old
dental
assistant
a1empted
suicide
by
injec8ng
10
ml
(135
g)
of
elemental
mercury
(quicksilver)
intravenously.
She
presented
to
the
emergency
room
with
tachypnea,
a
dry
cough,
and
bloody
sputum.
While
breathing
room
air,
she
had
a
par8al
pressure
of
oxygen
of
86
mm
Hg.
A
chest
radiograph
showed
that
the
mercury
was
distributed
in
the
lungs
in
a
vascular
pa1ern
that
was
more
pronounced
at
the
bases.
The
pa8ent
was
discharged
aNer
one
week,
with
improvement
in
her
pulmonary
symptoms.
Oral
chela8on
therapy
with
dimercaprol
was
given
for
nine
months,
un8l
the
pa8ent
stopped
the
treatment;

27. Intoxicaciones.
♦ Diagnóstico.
♦ - Sospechar el Diagnóstico.
♦ - Anamnesis.
♦ - Examen Físico . Sindromes Tóxicos.
♦ - Examenes de Laboratorio.

28. Intoxicaciones.
♦ Sindromes Tóxicos.
♦ - Sindrome Anticolinérgico.
♦ - Sindrome Colinérgico.
♦ - Sindrome Opiode Alcohólico.
♦ - Sindrome Catecolaminérgico.

29. Intoxicaciones.
Síndromes Tóxicos.
Síndrome Anticolinérgico.
Causas.
Antihistamínicos, antidepresivos tricíclicos
antiespasmódicos, chamico, atropina.CBZ.
Sintomatología.
Taquicardia, vasodilatación, retención
urinaria, silencio abdominal, alucinaciones
y convulsiones.Midriasis.Mucosas secas.

30. Intoxicaciones.
Síndromes Tóxicos.
Síndrome Colinérgico.
Causas.
Hongos, carbamatos, órganofosforados,
fisostigmina.
Sintomatología.
Depresión SNC, hipotonía, salivación,
lagrimación, incontinencia urinaria y fecal,
bradicardia y convulsiones.Miosis.

31. Intoxicaciones.
Síndromes Tóxicos.
Síndrome Opioide alcohólico.
Causas.
Codeína, morfina, barbitúricos, BDZ,
etanol, clonidina.
Sintomatología.
Coma, depresión respiratoria, hipotensión,
miosis, bradicardia, hipotermia, edema
pulmonar, shock distributivo.

32. Intoxicaciones.
Síndromes Tóxicos.
Síndrome Catecolaminergico.
Causas.
Cocaína, amfetaminas, efedrina, cafeína,
pseudoefedrina, fenilpropanolamina.
Sintomatología.
Taquicardia, hipertensión, hipertermia,
diaforesis, midriasis, convulsiones y
arritmias.Dolor anginoso.

33. Intoxicaciones.
♦ Tratamiento .
♦ Siempre tratar primero al Paciente:
♦ ABC de la Reanimación.
♦ Después tratar al Tóxico.
♦ “ABC” de la Intoxicación.

34. Intoxicaciones.
♦ Tratamiento .
♦ Siempre tratar primero al Paciente:
♦ ABC de la Reanimación.
Via Aerea Permeable.Oxigenar.
Asegurar una buena ventilacion.
Dos vias venosas gruesas.
Monitoreo Cardíaco. Saturación.

35. Intoxicaciones.
♦ “ABC” de la Intoxicación.
♦ - evitar la absorción.
♦ - favorecer la adsorción.
♦ - favorecer la eliminación.
♦ - antagonizar al tóxico.

36. Intoxicaciones.
♦ Evitar absorción : Lavado Gástrico.
Solo en la primera hora post ingestión.
Proteger la vía aerea si existe compromiso de
Conciencia.
Indicado principalmente en Tóxicos que
comprometen gravemente la vida del paciente.
Contraindicado en Caústicos e Hidrocarburos.

37. Intoxicaciones.
♦ Favorecer adsorción :Carbón Activado.
Muy Importante.
Dosis Unica. 2 a 3 gr /kg Niños.
Dosis Secuenciales. 0,5 a 1 gr/ kg
c/4, 6 u 8 hrs.
Contraindicado en Caústicos y Obst.Intestinal
Inutil en Litio y Fierro.

38. Intoxicaciones.
♦ Carbón Activado.
Concomitantemente usar Lactulosa.
10 a 15 ml con cada dosis de Carbón.

39. Intoxicaciones.
♦ Favorecer la Eliminación.
Ventilación del lugar del accidente.
Forzar diuresis. Alcalinizar o Acidificar
orina.
Lavado Gastrointestinal total. Solución de
Colon.
Oxigenar . Cámara Hiperbárica.

40. Intoxicaciones.
♦ Antagonizar al Tóxico.
Usar un Antagonista no es la Panacea.
Lo importante es Tratar al Paciente.

41. Intoxicaciones.
♦ Paradoja.
Uso de flumazenil en Intoxicación
Mixta de BDZ y Antidepresivos Tricíclicos.
¿ se debe usar flumazenil ?

42. Intoxicaciones.
Antídotos.
♦ N-Acetilcisteína.
♦ Atropina.
♦ Benztropina.
♦ Difenhidramina.
♦ Digibind.
♦ Etanol.
♦ Fitomenadiona
♦ Glucagón.
♦ Flumazenil.
♦ Glucosa.
♦ Naloxona.
♦ Obidoxima.
♦ Oxígeno.
♦ Piridoxina.
♦ Succimer.
♦ Fomepizol.

43. Intoxicaciones.
♦ Prevención.
♦ - Educación a toda la Familia.
♦ almacenar correctamente los tóxicos.
♦ - Uso correcto del Medicamento.
♦ - Promover el Envase Seguro.
♦ - Promover los Centros de Información.

44. Intoxicaciones.
♦ Gracias !