2. Management protocol for Hydrocarbons intoxication
Examples: Benzene, Kerosene, Gasoline, paint strippers…etc.
High volatility with low surface tension leading to increased risk for aspiration
and rapid absorption even from skin exposure.
Mode of intoxication: mainly accidental especially in children.
Main symptoms: GI e.g. Nausea, vomiting & Respiratory e.g. dyspnea, distress.
Main signs: tachypnea, characteristic odor, vomitus on clothes and CNS e.g.
drowsiness
Skin decontamination under running tap water is of high priority in our
management.
Oxygen flow: nasal cannula or through face mask.
Antiemetics e.g. cortiplex B6.
Assess the grade of respiratory distress through intercostal retractions, nasal
flaring, tachypnea (rapid shallow breathing). If > 40-60/min. it indicates
impending respiratory failure.
We may use stool softeners e.g. Glycerin pediatric suppository to decrease GI
distension so that decreasing the elevation of the diaphragm to decrease the
work of breathing.
Assess for associated co-ingestion e.g. organophosphorus insecticides.
Nebulized B2 agonists bronchodilators if wheezy chest is found.
On admission, Beside symptoma c TTT and follow up e.g. nebulizer/6h,
antiemetics, regular follow up of vital data and IV fluids, we may add
prophylactic antibiotics.
Watch for the development of chemical pneumonitis with its sequalae up to
ARDS and respiratory failure which may require mechanical ventilation.
Watch for skin lesion that may appear e.g. blisters and bullae and manage
accordingly.
Labs: Glucose, Na, K, LFTs, ABG
Imaging: CXR and ECG
N.B. gastric lavage and emesis are generally C/I in these cases BUT if there is a
clear history of large volume ingestion along with disturbed conscious level,
we may perform gastric lavage ONLY under ETT coverage to minimize the risk
of aspiration.
3. Management protocol for Organophosphorus & Carbamate intoxication
Examples: Malathion, black granules rodenticide…etc.
Mode: Accidental, suicidal or Homicidal ( Carbamate ).
Main symptoms: Muscarinic e.g. pinpoint pupil, sweating,
lacrimation, salivation, diarrhea, urination, vomiting and
pulmonary secretions & Nicotinic e.g. fasiculations and muscle
weakness.
Once symptomatic equals admission.
If the patient is very weak, we intubate and administer the
obidoxime.
Life saving measure is Atropine..Till the chest secretions Dry.
GI decontamination via Emesis or gastric lavage according to the
degree of weakness.
Oxygen is preferred prior to atropine administration to preserve
the cardiac oxygen supply adequate.
After decontamination and stabilization, admit the symptomatic
pt. for symptomatic ttt, follow up + atropine + obidoxime course
if indicated.
Avoid severe atropinization that presents with blurred vision,
urinary retention and hallucinations.
Labs: Glucose, Na, K, serial pseudocholinesterase measurement,
LFTs and renal function tests.
No use of Oximes for Carbamate.
Imaging: CXR esp. if mechanically ventilated, ECG.
N.B. rising of the cholinesterase level may be deceiving due to
redistribution of the toxin.
Long term follow up for the development of intermediate
syndrome and neuropathy..etc.
4. Management protocol for opiate and opioids
Examples: Morphine, Heroin…etc.
Mode: mostly accidental overdose
Route: ingestion, injection or snuffing
Firstly, assess the vital date i.e. airway, breathing, B.P, pulse
Assess the neurological system and exclude other causes of
disturbed conscious level i.e. detect whether signs of
lateralization are present or not.
Assess for the need of intubation and mechanical ventilation e.g.
if GCS<8 TO Protect the airway.
If available, Naloxone can be given to reverse the respiratory
depression take care not to cause acute withdrawal that may end
up with seizures. N.B. the t1/2 of naloxone is short so, you must be
ready to intubate if indicated.
Main signs: pinpoint pupil, bradypnea, hypotension and
bradycardia along with disturbed consciousness.
Order CT scan to exclude possible intracranial bleeding as a cause
of the disturbed consciousness especially if there are signs of
lateralization.
Labs: Glucose, Na, K, urine screen for opiates and possible co-
ingestions, ABG
If you suspect aspiration or ARDS: order CXR
Order ECG to detect potential arrhythmias
If you suspect rhabdomyolysis: order CK
If prolonged coma prior to arrival, suspect ischaemic
encephalopathy and order MRI
Care of the coma in ICU.
5. Management protocol for Carbon Monoxide intoxication
Circumstances: mainly in winter. Closed space, fire to warm up or
during showering, fires, running vehicles in garage…etc.
Main presentation: Nausea, vomiting, abdominal pain,
HEADACHE, dizziness, disturbed consciousness…etc.
Assess the vital data e.g. B.P, pulse and R.R and assess the GCS
Exclude other causes of disturbed consciousness.
Firstly, apply high flow OXYGEN as soon as possible.
We may add measures to decrease the ICT e.g. steroids and
Mannitol (1-2 gm/kg) provided that the B.P and renal function
allow that.
Antiemetics to stop the vomiting.
Labs: Glucose, Na, K, ABG, CarboxyHB level, renal function tests
and cardiac biomarkers.
Imaging: CT scan to exclude intracranial bleeding, ECG
If disturbed conscious level that doesn't improve with the above
mentioned measures, intubate and mechanically ventilate the pt.
with 100% oxygen for 6 h. then gradual weaning.
Symptomatic TTT and regular follow up of the vital data and labs
in the ICU.
Assess the need for Hyperbaric oxygen sessions e.g. cardiac
arrhythmias, changes in the mental status, pregnant females and
persistent non-improving symptoms.
If there is cardia ischaemia: the main line of TTT is
oxygen/Hyperbaric oxygen.
If you suspect rhabdomyolysis: order CK
If you suspect permanent neurological sequalae e.g. affection of
the basal ganglia: order MRI
Order long term follow up for potential future neurological
sequalae.
6. intoxicationTheophyllineagement protocol forMan
Mode: mostly suicidal or accidental overdose
Main symptoms: repeated vomiting, dyspnea, palpitation, tremors
and dizziness.
Main signs: Tachycardia, hypotension, agitation, tremors, tachypnea
Take careful history about the drug( amount, form e.g. SR,
delay…etc.) and assess the vital data including the B.P, pulse and R.R.
Gastric decontamination via induction of emesis (without Epicac) or
gastric lavage especially for the sustained release forms.
Multiple Dose Activated Charcoal.
Admission of the patient is mandatory.
Order Glucose, Na, K, ABG, Theophylline level
Order ECG along with cardiac biomarkers to detect possible
arrhythmias or ischaemia.
If you suspect rhabdomyolysis, order Creatine Kinase level
For intractable vomi ng, give cor plex B6 , primperan or even
Ondansetron for severe cases. Avoid phenothiazines as they decrease
the threshold of seizures.
Fluid replacement is of major priority with correction of the
underlying electrolyte abnormalities e.g. low K.
For severe agitation or seizures, give Diazepam or phenobarbital.
Assess for the need of hemodialysis e.g. very high level, non-
correctable metabolic acidosis, severe CNS or cardiac manifestations.
If there is hypotension, IV fluids then norepinephrine if no adequate
response.
For SVT, give propranolol or verapamil.
For ventricular arrhythmias, give Lidocaine.
7. Management of Acetaminophen intoxication
Take careful history and assess for co-ingestion e.g.
salicylates…etc.
Assess the vital data e.g. pulse, B.P and R.R.
Main symptoms: Asymptomatic or GI symptoms.
Gastric decontamination if the delay period allows i.e.
usually done if < 2h delay.
Assess the toxic dose: > 150 mg/kg or usually > 7.5 gm.
If the time since ingestion is between 4 h- 24 h, order
acetaminophen level and compare it to the normogram.
If the level is high, admission is mandatory.
If the level is not toxic, Discharge the patient with
outpatient follow up of Liver function tests and you may
also prescribe N-acetyl Cysteine sachets as a measure for
any potential liver damage.
Labs: Glucose, Na, K, Liver function tests, acetaminophen
level, kidney function tests and ABG
Start N-Acetyl Cysteine course orally or intravenously if
there is repeated vomiting. We may also give the oral form
through a Ryle tube.
Oral dose: Loading 140 mg8/kg then maintenance 70
mg/kg for 17 doses with serial acetaminophen level and
LFTs.
Watch for any allergic reactions if the IV form is used.
8. Management protocol for Calcium Channel Blockers Intoxication
Take careful history and assess for co-ingestions.
Assess the vital data including the B.P, pulse and R.R.
Admission is mandatory.
Gastric decontamination via induction of emesis or gastric lavage
is done if the vital data are stable & the delay < 2h (Except for the
sustained release forms) then activated charcoal is given as
MDAC.
ECG is done on admission and serially thereafter.
CNS manifestations sometimes occur e.g. dizziness, syncope or
seizures.
If brady-arrhythmias are present, start Calcium gluconate or
chloride slowly intravenous. Atropine also can be given
concurrently.
If the brady-arrhythmias are resistant to TTT, urgent cardiology
consultation for temporary pacing.
If Hypotensive, start IV crystalloids or colloids and administer
dopamine if there is inadequate response.
If there is resistant hypotension, we may revert to intra-aortic
balloon pump as a temporary measure to help tissue perfusion
via the failing heart.
Order: Glucose, Na, K, ABG and serial electrolyte panel
monitoring.
If you suspect cardiogenic pulmonary edema: order CXR and
monitor the CVP.
If cardiogenic shock develops, Dobutamine is a better option
than dopamine.
9. intoxicationBeta BlockersManagement protocol for
Take careful history and assess for co-ingestions.
Assess the vital date especially the pulse, B.P and R.R.
Main symptoms: dizziness, syncope and dyspnea.
Main signs: Bradycardia, hypotension and wheezy chest (most
specific).
CNS manifestations may occur e.g. coma or seizures!!
GI decontamination via induction of emesis is done only if the vital
data are stable and the delay is < 2h.
Multiple Dose Activated Charcoal is used thereafter.
Admission of the patient is mandatory.
Order ECG on admission and serially thereafter.
If there is bradycardia, administer atropine IV.
If atropine resistant or accompanied with hypotension and other
features of hemodynamic instability, administer Glucagon as an
antidote IV.
If bradycardia is still resistant to TTT, Urgent cardiology consultation
for temporary pacing.
For hypotension, give IV crystalloids or colloids, dopamine,
Norepinephrine if the response is inadequate.
If the hypotension in resistant to all of the above measures, Urgent
cardiology consultation to put an intra-aortic balloon pump as a
temporary life-saving measure.
Order: Glucose, Na, K, ABG and serial electrolyte panel monitoring.
If you suspect cardiogenic pulmonary edema, order CXR and monitor
the CVP.
For seizures, administer BZP or phenobarbital.
For bronchospasm, administer regular nebulized B2 agonists.
10. intoxicationDigitalisManagement protocol of
Take careful history and assess for co-ingestions.
Assess the hemodynamic status of the patient i.e. Pulse, B.P and R.R.
Main symptoms: Nausea, vomiting, diarrhea, dizziness.
Main signs: irregular brady-arrhythmias, hypotension. Patient may
come with manifestations of heart failure if the toxicity occur on top
of the already compromised cardiac functions.
Admission of the patient is mandatory.
Induction of emesis is done only if the patient is hemodynamically
stable and the delay is <2 h. Atropine is preferred to be given before
emesis to reverse the reflex vagal stimulation during emesis.
Multiple dose activated charcoal is of a high priority in management.
ECG is done on admission and serially thereafter.
Any type of arrhythmias can occur with digitalis toxicity. Down
sloping of the ST segment is usually seen but it is not specific.
The most specific arrhythmia is: Atrial tachy-arrhythmia with A-V
block
If pt. is bradycardic, atropine is administrated and repeated as
needed.
If there is no response to atropine, Urgent cardiology consultation for
temporary pacing.
For Hypotension, administer IV fluids BUT Never to order any ca++
containing fluids e.g. Ringer's...etc.
Dopamine can be used for resistant hypotension.
Fab fragment antidote is highly expensive so, it is not usually
available BUT it is the best line of TTT if available.
Order: Glucose, Na, K, Mg++
, ABG, Renal function tests. Electrolyte
panels should be ordered serially and corrected promptly.
If you suspect cardiogenic pulmonary edema, order CXR and serially
measure the CVP and manage accordingly.
11. Food poisoningManagement protocol of
The first step is to take a detailed history of the circumstance, the type of
food, the presenting symptoms…etc.
The most important step is to EXCLUDE other causes of the presenting
symptoms e.g. Organophosphorus, Botulism, Carbon Monoxide….etc.
before you establish a diagnosis of acute gastroenteritis.
Careful examination especially of the abdomen to EXCLUDE surgical
causes of the presenting complaint(s).
Assess the vital date including the pulse, B.P and R.R.
Assess the degree of dehydration if present and order IV fluid
resuscitation if needed (preferably with Panthol or Ringer's lactate
solutions).
Symptomatic TTT in the ER via antispasmodic, antiemetic and H2 blocker
ampoules.
Establish the need to get admitted or discharged on outpatient TTT or
referral to the Fever hospital according to the presenting complaints &
the severity of the case.
Presence of blood and mucus in the diarrhea suggest a bacterial (e.g.
shigella, EHEC) or protozoal (e.g. E.histolytica) which need specific TTT in
addition to the other symptomatic and supportive measures.
If the main complaint is dyspnea with history of eating preserved food
products, think of MetHb and manage accordingly.
If symptoms develop after ingestion of some plant materials, keep them
under observation or admit them as the symptoms are usually severe and
fluctuating in appearance.
If there is history of perioral and limb numbness & weakness along with
dizziness and other neurological manifestations, think of Ciguatera or
Tetradoxin toxicity and manage accordingly ( may need gastric lavage up
to mechanical ventilation).
If there is itching, blistering, skin rash, wheezing after fish ingestion, think
of Scombroid poisoning and manage with antihistamines, steroids and
other supportive measures if needed.
Prescribe outpatient TTT if the case is mild and recommend some dietary
instructions for the next few days.