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Transcript of Acute poisoning guidelines for initial management
ACUTE POISONING GUIDELINES FOR INITIAL MANAGEMENT
Prof. Dr. Saad S Al Ani
Senior Pediatric Consultant
Head of Pediatric Department
Khorfakkan Hospital
Sharjah ,UAE
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INTRODUCTION
• The majority of poisonings are accidental, especially in the under-5 age group
• Intentional overdoses and substance abuse are seen in older children
http://emedicine.medscape.com/pediatrics_general/
04/12/2023 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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CONT.
• Deaths in children from poisoning are becoming increasingly rare
• Factors responsible for this decline include: 1. Introduction of child-resistant containers 2. Reducing the pack sizes of aspirin and acetaminophen 3. More effective management
http://emedicine.medscape.com/pediatrics_general/
04/12/2023 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
4
HOW CHILDREN DIFFER FROM ADULTS
• Pediatric patients may be particularly vulnerable to certain toxins at specific stages of childhood.
• Breast fed infants may be exposed to drugs or toxins excreted in breast milk; neonates have immature metabolic capabilities
http://emedicine.medscape.com/pediatrics_general/
04/12/2023 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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CONT.
• Toddlers, as they develop exploratory hand-to-mouth activity, may be exposed to a wide range of potential hazards
http://emedicine.medscape.com/pediatrics_general/
04/12/2023 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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GENERAL PRINCIPLES
Assess:Type of ingestion (drug, preparation)Time of incidentAmount of ingestion (include all medication
that was potentially in the bottle or packet when calculating)
Weight of child
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
04/12/2023 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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GENERAL PRINCIPLES
Cont.Is the ingestion potentially harmful?Beware of the possibility of mixed overdoseBeware of the possibility of inaccurate dose
reporting on history takingIf mixed or undetermined ingestion
Paracetamol level should be done
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
04/12/2023
Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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GENERAL PRINCIPLES
ManagementAirwayBreathingCirculationRemoval of poison (if necessary)Emesis
No role in the hospital setting
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
04/12/2023
Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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GENERAL PRINCIPLES
Cont.
Activated Charcoal The treatment of choice for most ingestions. Most effective when given within first hour.
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
04/12/2023
Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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GENERAL PRINCIPLES
Cont.
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
Activated Charcoal Contraindications: •Patients with altered conscious state
•The following agents:
6.Potassium and other metallic ions 1.Ethanol/glycols
7.Fluoride 2.Alkalis
8.Cyanide 3.Boric acid
9.Hydrocarbons 4.Lithium
10.Mineral acids 5.Iron compounds
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GENERAL PRINCIPLES
Cont. Whole Bowel Irrigation has a limited role in
treatment of some slow release preparations
Gastric Lavage has a very limited role in treatment and should not be used without consultation.
Specific antidotes may be available and serum drug levels may help in treatment decisions
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
04/12/2023
Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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GENERAL PRINCIPLES
Cont. All acts of deliberate self harm
must be taken extremely seriously.All intentional self poisonings in
adolescents require admission If unexplained symptoms exist a
urinary drug screen may be indicated
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
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INITIAL ASSESSMENT AND MANAGEMENT
The initial priority in treating poisoned children is the standard ABC (airway, breathing, and circulation) resuscitation approach
http://emedicine.medscape.com/pediatrics_general/
04/12/2023 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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A: ASSESS AIRWAY PATENCYBy looking, listening, and feeling for
air movement. If there is no air movement, try to open
the airway with simple maneuvers such as the jaw thrust or the use of airway adjuncts.
http://emedicine.medscape.com/pediatrics_general/
04/12/2023 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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CONT.Certain ingested agents may predispose
to airway edema and obstruction, including caustic agents, angiotensin-converting enzyme inhibitors, and plants containing calcium oxalate crystals (e.g. Dieffenbachia and Philodendron house plants)
http://emedicine.medscape.com/pediatrics_general/
04/12/2023 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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B: ASSESS THE ADEQUACY OF BREATHING
It is important to remember that succinylcholine may cause prolonged block in children who have a reduced cholinesterase concentration due to exposure to cocaine or organophosphate compounds: prolonged apneas of up to 7 h have been described.
http://emedicine.medscape.com/pediatrics_general/
04/12/2023 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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CONT.
Observing ventilatory frequency, use of accessory muscles, breath sounds, and oxygen saturations.
Reduced respiratory effort may require bag-valve-mask ventilation until a definitive airway can be secured
http://emedicine.medscape.com/pediatrics_general/
04/12/2023 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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C: ASSESS THE CIRCULATION
In terms of cardiovascular status (heart rate, arterial pressure, and capillary refill) and the effect of circulatory inadequacy on other organs (mental state, urine output, skin temperature, and colour).
http://emedicine.medscape.com/pediatrics_general/
04/12/2023 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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CONT.Hypotension should initially be treated
with a 20 ml/ kg crystalloid bolus, remembering that if it is caused by specific toxins such as β-blockers, the specific antidote should also be given, for example, glucagon
http://emedicine.medscape.com/pediatrics_general/
04/12/2023 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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CONT.Arrhythmias associated with poisoning
are best treated by: i. Correcting precipitating factors (e.g.
hyperkalaemia and acidosis) ii. Administering the appropriate
antidote;
http://emedicine.medscape.com/pediatrics_general/
04/12/2023 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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CONT.Children in cardiac arrest should be
treated according to standard guidelines (e.g. The Advanced Cardiac Life Support protocol), although it is important to address the need for a specific antidote, for example, sodium bicarbonate for tricyclic antidepressant (TCA) poisoning
http://emedicine.medscape.com/pediatrics_general/
04/12/2023 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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SALICYLATES POISONING
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SALICYLATES POISONING
Assessment
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
Symptoms
Seizures Tinnitus
Hyperthermia Vomiting
Dehydration Hyperventilation
Hypoglycemia Lethargy
Non cardiogenic pulmonary edema Coma
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SALICYLATES POISONING
Cont.• Initial respiratory alkalosis (may
be transient), followed by paradoxical aciduria (pH <6), then metabolic acidosis & Hypokalemia (± ongoing respiratory alkalosis).
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
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SALICYLATES POISONING
Patients Requiring TreatmentAcute ingestion ≥ 150mg/kgAll symptomatic patientsIngestion of unknown quantity
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
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SALICYLATES POISONING
Investigations Serum salicylate level at presentation (on
patients requiring treatment), and 2 hrly if symptomatic or enteric coated preparation. (Need to call the RCH lab to get test run urgently as it is sent to RMH for analysis)
Urea & electrolytes, creatinine, acid-base, glucose
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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SALICYLATES POISONING Management Asymptomatic
Charcoal 1g/kg (if <1 hour since ingestion unless enteric coated preparation)
Observe 6 hours & discharge if still asymptomaticIf enteric coated preparations, serial salicylate levels (2
hourly)Admit if levels have not plateaued at 6 hours post
ingestionI.V. bicarbonate infusion 1mmol/kg/hr to correct any
acidosis (pH <7.3)http://www.rch.org.au/clinicalguide/guideline_index/
Acute_Poisoning_Guidelines_For_Initial_Management/
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SALICYLATES POISONING
Cont. Symptomatic
All symptomatic patients require urgent medical assessment and investigations as above.
Charcoal 1g/kg unless altered conscious state (protect airway first)
I.V. fluid resuscitation to correct dehydration (use N. Saline)
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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SALICYLATES POISONING
Symptomatic (Cont.) I.V. bicarbonate infusion 1mmol/kg/hr, after initial
slow bolus of 2mmol/kg, (keep urine pH >7.5)Potassium replacement as requiredWorsening symptoms, convulsion, coma, contact
I.C.U. for respiratory support ± hemodialysisSalicylate level >7mmol/l following an acute
poisoning contact I.C.U. for consideration of hemodialysis.
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
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PARACETAMOL POISONING
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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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PARACETAMOL POISONING
Patients Requiring Management1. Acute ingestion of > 200 mg/kg2. Ingestion of unknown quantity3. Repeated supratherapeutic ingestion of > 100mg/kg/day
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
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PARACETAMOL POISONING
AssessmentConsider the possibility of co ingestions,
either accidental or deliberate
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
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PARACETAMOL POISONING
ManagementActivated charcoal is not useful in liquid ingestions
due to rapid absorptionActivated charcoal 1 g/kg may be considered in a
cooperative patient seen within 1 hour of tablet or capsule ingestion.
Serum paracetamol level at (or as soon as possible after) 4 hours post ingestion determines the need for N-acetyl cysteine (NAC) administration. (see nomogram)
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
04/12/2023
Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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PARACETAMOL POISONING
There is no benefit in measuring paracetamol level earlier than 4 hours
It is safe to wait for the paracetamol level to decide on the need for NAC in all cases that present within 8 hours of ingestion.
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
04/12/2023
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PARACETAMOL POISONING
Cont. Patients who present > 8 hours after a toxic ingestion /
symptoms of toxicity (RUQ pain or tenderness, nausea, vomiting) should be commenced on NAC immediately.
The decision to continue or cease NAC is then based on the paracetamol level.
Delaying NAC administration beyond 8 hours is associated with a progressive increased risk of liver injury.
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
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PARACETAMOL POISONING
There is little evidence to guide management in repeated supratherapeutic doses. Potential toxicity should be assessed when: > 200 mg/kg (or 10g) ingested over a 24
hour period> 150 mg/kg/day (or 6 g) ingested over a 48
hour period> 100 mg/kg/day ingested over a 72 hour period
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
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PARACETAMOL POISONING
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
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PARACETAMOL POISONING
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
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http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
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PARACETAMOL POISONING
N- Acetyl cysteine (NAC) Infusion Instructions
The standard administration of NAC is a 3 stage infusion giving a total dose of 300 mg/kg:
1. 150 mg/kg over the first hour
2. 50 mg/kg over the next 4 hours
3. 100mg/kg over the next 16 hourshttp://www.rch.org.au/clinicalguide/guideline_index/
Acute_Poisoning_Guidelines_For_Initial_Management/
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PARACETAMOL POISONING
Cont.For patients > 110 kg, calculate the dose based on
110 kg body weight.NAC may be diluted in 5% dextrose or 0.9%
saline (normal saline). It can also be diluted in combination dextrose-
saline solutions not exceeding these concentrations including 0.45% saline in 5% dextrose, and 0.9% saline in 5% dextrose.
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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PARACETAMOL POISONING
For adolescent / adult:1. 150 mg/kg in 250 or 500 ml over 1
hour2. 50 mg/kg in 500 ml over 4 hours3. 100 mg/kg in 1000 ml over 16 hours
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
04/12/2023
Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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IRON POISONING
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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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IRON POISONING
Background
Iron is found in several different forms in different medicines.
The important ingestion is the amount of elemental iron not the iron salt.
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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IRON POISONING
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
04/12/2023
Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
Table: Iron Medications
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IRON POISONING
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
04/12/2023
Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
Percentage elemental iron:• Ferrous fumarate 33%• Ferrous chloride 28%• Ferrous sulfate 20%• Ferrous chloride 28%• Ferrous gluconate 12%Iron is also found in plant fertilizers (e.g. sulphate of iron -20% elemental iron).
47
ASSESSMENT
Patients Requiring Assessment
1. Ingestion of > 40 mg/kg elemental iron. (approximately > ½ tablet/kg or 6.5 ml syrup/kg)
2. Ingestion of an unknown quantity.
3. Any symptomatic patients
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
04/12/2023
Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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HISTORY AND EXAMINATION
Initial symptoms: Usually occur within 20 minutes Nausea, vomiting, diarrhea, abdominal pain,
hypotension, Hematemesis, fever Gastrointestinal symptoms related to the corrosive
nature of iron may occur without systemic toxicity, however any symptoms require iron levels.
Lack of symptoms within the first 6 hours makes significant toxicity unlikely.
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
04/12/2023
Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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HISTORY AND EXAMINATION
Latent period:There is often 6-24 hour latent period when
initial symptoms resolve, before overt systemic toxicity
Thus improvement over this time may be a result of improvement or deterioration
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
04/12/2023
Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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HISTORY AND EXAMINATION
Other symptoms:Usually appear at 6-24 hours and last 12-24Tachycardia, vasoconstriction, hypotension
and shockMetabolic acidosis can occur.These are related to fluid shifts from
intravascular to extravascular compartments and cellular hypoxia
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
04/12/2023
Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
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HISTORY AND EXAMINATION
Multiple organ failure:Occurs 12-48 hours after ingestionParticularly hepatic failure
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
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Management
ABCSupportive therapy to maintain adequate
blood pressure and electrolyte balance is essential
I.V. fluid resuscitation 20 ml/kgPotassium and glucose administration as
necessary.http://www.rch.org.au/clinicalguide/guideline_index/
Acute_Poisoning_Guidelines_For_Initial_Management/
04/12/2023
Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
IRON POISONING
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Investigations
Asymptomatic patients:If tablet ingestion do AXR and if negative -
does not need further investigation or observation
If unknown amount or >60mg/kg ingested need serum iron levels 4 hourly until falling
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
04/12/2023
Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
IRON POISONING
54
All symptomatic patients should have the following investigations:
AXR if tablet ingestion ABG/CBG (acidosis) Glucose (hyperglycaemia)
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
04/12/2023
Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
IRON POISONING
55
Cont. Serum iron
Peak levels are usually seen at 4 hours.Levels taken after four hours may underestimate toxicity
because the subject iron may have either been distributed into tissues or be bound to ferritin.
In the case of slow release or enteric coated tablets, levels should be repeated at six to eight hours as absorption may be erratic.
Once desferroxamine is commenced, iron levels are not accurate at most labs using automated methods (including RCH)
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
04/12/2023
Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
IRON POISONING
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Cont. FBE (leukocytosis) U&E & Cr X-match Clotting (reversible early coagulopathy and late
coagulopathy secondary to hepatic injury) LFTs AXR may be helpful in evaluating gastrointestinal
decontamination after treatment if tablets have been ingested.
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
IRON POISONING
57
Cont. Decontamination Charcoal is of no benefit. Decontamination of choice is whole bowel irrigation
(WBI) with naso-gastric colonic lavage solution 30ml/kg/hr until rectal effluent clear (contraindicated if there are signs of bowel obstruction or haemorrhage).
WBI is indicated:If AXR reveals tablets, or capsules ingestedIn symptomatic patients
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
04/12/2023
Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
IRON POISONING
58
Antidote:Desferroxamine is a chelating agent which
forms a water soluble desferroxamine-iron complex.
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
IRON POISONING
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Consider desferroxamine in:Serum iron levels > 90 micromol/lLevel 60 - 90 micromol/l and tablets visible on XRay or
symptomatic (nausea, vomiting, diarrhea, abdominal pain, haematemesis, fever)
Any patient with significant symptoms of altered conscious state, hypotension, tachycardia, tachypnea, or worsening symptoms irrespective of ingested dose or serum iron level.
Do not wait for iron level if altered conscious state, shock, severe acidosis (pH <7.1), or worsening symptoms but commence Desferroxamine without delay.
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
IRON POISONING
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Dose: Desferroxamine 15 mg/kg/hr I.V. The rate is reduced after four to six hours so that the total intravenous dose in general does not exceed 80 mg/kg/24 hours.
Desferroxamine -iron complex is renally excreted. If oliguria or anuria develop, peritoneal dialysis
or hemodialysis may become necessary to remove ferrioxamine.
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
IRON POISONING
61
It is difficult to determine the endpoint for chelation therapy.
Significant poisoning usually requires 12 - 16 hours,
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
IRON POISONING
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Cont.
It is recommended to continue desferroxamine until:Patient is asymptomatic.decontamination completeanion-gap acidosis resolvedIron level (if measurable) is <54 micromol/L Desferroxamine has been associated with
pulmonary toxicity and should be used with caution if indications persist >24 hours.
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
IRON POISONING
63
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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
HYDROCARBON POISONING
64
Hydrocarbons Include: Petrol Kerosene Lighter Fluid Mineral Turpentine Paraffin Oil Lubricating Oil Furniture Polishes 2 Stroke Fuel Diesel Fuel White Spirit
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
HYDROCARBON POISONING
65
Assessment Main complication is Aspiration
Pneumonitis C.N.S. toxicity can be evident (either
depression or excitement)
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
HYDROCARBON POISONING
66
Symptoms: Coughing, choking, respiratory distress
ataxia, drowsiness, coma, convulsions
persistent burping (particularly seen after petrol ingestion
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
HYDROCARBON POISONING
67
Keep nil orally charcoal is contraindicated.Asymptomatic
Observe 6hoursDischarge if remains asymptomaticArrange review by LMO the following day
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
MANAGEMENT
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Symptomatic If develops respiratory symptoms (aspiration),
do CXR & O2 saturationGive O2 to maintain saturation > 94%If stable, admit to general medical wardIf increasing O2 requirements or increased
respiratory distress contact I.C.U. If altered conscious state at any time contact
I.C.U. http://www.rch.org.au/clinicalguide/guideline_index/
Acute_Poisoning_Guidelines_For_Initial_Management/
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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
MANAGEMENT (CONT.)
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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
ALKALIS POISONING
70
Alkalis include: Drain cleaners, Oven cleanersAutomatic dish washing liquids & powdersLaundry detergents, AmmoniaPortland cement
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
ALKALIS POISONING
71
pH of >11.5 is likely to cause significant GI ulceration
Attempt to obtain container to check contents and strength of substance.
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
ALKALIS POISONING
72
Corrosive potential varies with concentration of specific ingredients and preparations, ie liquid preparations are more likely to cause esophageal burns than powders.
Check preparations with Poisons Information Centre to determine whether ingested substance is weak, strong, irritant or corrosive in nature.
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
04/12/2023
Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
ALKALIS POISONING(CONT.)
73
ToxicityExposure may lead to severe burns of GIT, especially esophagusAbsence of mouth or pharyngeal ulcers does not preclude gastro- oesophageal lesions
Symptoms: May be minimalPainNausea & vomiting, drooling or refusing to eat and
drinkStridor, respiratory distress
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
04/12/2023
Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
ASSESSMENT
74
Activated charcoal is contraindicatedIf asymptomatic treat with fluid dilution:
10ml/kg of water (max 250ml)If asymptomatic after 4 hours and able to
eat and drink the patient can be safely discharged
If any symptoms, contact surgical registrar, & admit for oesophagoscopy
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
MANAGEMENT
75
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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
ANTICONVULSANT POISONING
76
CARBAMAZEPINE, PHENYTOIN, SODIUM VALPROATE, PHENOBARBITONE
Assessment CNS
Ataxia, drowsiness, coma, convulsions GIT
Nausea & Vomiting CVS
Hypotension, Arrhythmias Drug levels are available for some anticonvulsants e.g.
carbamazepine, phenytoin, phenobarbitonehttp://www.rch.org.au/clinicalguide/guideline_index/
Acute_Poisoning_Guidelines_For_Initial_Management/
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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
ANTICONVULSANT POISONING
77
All symptomatic patientsAcute ingestion of unknown quantityCarbamazepine ingestion of >20mg/kg (for
patients not on maintenance treatment) or the greater of more than twice the daily dose or 20mg/kg for patients on maintenance treatment
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
04/12/2023
Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
PATIENTS REQUIRING TREATMENT
78
Charcoal 1g/kg unless altered conscious state (protect airway first)
Mild symptoms (e.g. ataxia, blurred vision) observe 4 hours, discharge if symptom free
Moderate or persistent symptoms (after 4 hours of observation) Admit for observation
Severe symptoms Depressed conscious state or cardiac arrhythmias contact
I.C.U. .
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
MANAGEMENT
79
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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
TRICYCLIC OVERDOSE
80
AssessmentSymptoms Anticholinergic
vomiting, blurred vision, ataxia, tachycardia, urinary retention Antiadrenergic
vasodilatation Sodium Channel blockade
widened QRS (>0.12 ms) QT prolongation reduced cardiac contractility & hypotension
CNS Depression drowsiness, coma, convulsions
Symptomatic patients require urgent medical assessmenthttp://www.rch.org.au/clinicalguide/guideline_index/
Acute_Poisoning_Guidelines_For_Initial_Management/
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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
TRICYCLIC OVERDOSE
81
Charcoal 1g/kg unless altered conscious state (protect airway first)
Require ECG, cardiac monitoring Asymptomatic: observe for 6 hours post ingestion and
discharge if have a normal ECG just prior to discharge All symptomatic patients should be admitted If widened QRS on ECG commence Sodium Bicarbonate
infusion 1mmol/kg/hr, after initial slow bolus of 2mmol/kg If altered conscious state, widened QRS or arrhythmia
contact I.C.U. & protect airwayhttp://www.rch.org.au/clinicalguide/guideline_index/
Acute_Poisoning_Guidelines_For_Initial_Management/
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MANAGEMENT
82
Assessment
Symptoms CNS depression, drowsiness, comaRespiratory depressionHypotensionBeware additive toxicity with other CNS &
Respiratory depressants
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
BENZODIAZEPINE POISONING
83
Ingestion of ≥3 times recommended dose for age
All symptomatic patientsIngestion of unknown quantity
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
PATIENTS REQUIRING OBSERVATION
84
Charcoal is not usually of benefit (due to low order of toxicity)
If depressed state of consciousness, protect airway and contact ICU
Antidote available - Flumazenil, not indicated for ingestions and should only be used after discussion with consultant staff.
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
04/12/2023
Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
MANAGEMENT
85
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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
THEOPHYLLINE POISONING
86
AssessmentCNS
Agitation, hyperventilation, headache, convulsions
Cardiovascular Arrhythmias
GIT nausea & vomiting (may be intractable), thirst,
diarrheahttp://www.rch.org.au/clinicalguide/guideline_index/
Acute_Poisoning_Guidelines_For_Initial_Management/
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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
THEOPHYLLINE POISONING
87
Acute ingestion of ≥ 10mg/kgAny ingestion while on maintenance
theophyllineIngestion of unknown quantityAll symptomatic patients
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
PATIENTS REQUIRING TREATMENT
88
Theophylline levels should be determined on all patients requiring charcoal
Serial levels are required at 2 hours then every 2 hours until peak reached or decline demonstrated.
If slow release preparation has been taken:admit, continue levels at 4 hourly intervals after decline or plateau to ensure detection of secondary peak
Seizures are common at levels >330 micromol/L Haemoperfusion commonly needed at levels > 550
micromol/L. U&E, Cr and Glucose on all patients.
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
04/12/2023
Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
INVESTIGATIONS
89
Asymptomatic Charcoal 1g/kgObserve 4 hours. If no symptoms,
discharge if not slow release medication.If ingestion of slow release preparation,
admit for observation and serial drug levels
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
MANAGEMENT
90
Symptomatic Charcoal 1g/kg initially unless altered conscious state (protect
airway first) then 0.5g/kg 4 hourly, and whole bowel irrigation with colonic lavage solution 30ml/kg/hr.
Cardiac monitoring I.V. fluid resuscitation & maintenance of adequate hydration is
vital If depressed conscious state, arrhythmias or intractable vomiting
contact I.C.U. as likely to need intubation Severe intoxication may require haemoperfusion If agitated, may need sedation with a benzodiazepine or
phenobarbitone.
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
MANAGEMENT(CONT.)
91
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
ETHANOL POISONING
92
Ethanol Containing Preparations Light beer 2% Beer 5% Cider 5% Wine 10% Wine coolers 5% Fortified wine 20% Spirits 45% Liqueurs 30% Perfumes& colognes >60% Aftershaves 80% Mouth washes (some) 25% Methylated spirit 95% (does not contain methanol)
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
04/12/2023
Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
ETHANOL POISONING
93
Fatalities generally occur with blood levels > 86.8mmol/L (breath alcohol >0.4)
Assessment
Symptoms Nausea, vomiting, abdominal pain Hypoglycemia Ataxia, lethargy, coma, convulsions Respiratory depression
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
04/12/2023
Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
ETHANOL POISONING
94
Hypothermia Hypokalemia, metabolic acidosis Unexplained drowsiness, hypothermia or hypoglycemia in
adolescents may be ethanol induced. In adolescents ethanol ingestion often accompanies ingestion of other drugs.
Patients Requiring Treatment symptomatic patients
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
ETHANOL POISONING(CONT.)
95
Charcoal is of no benefit Check blood glucose in younger children Asymptomatic or Mild Symptoms (decreased
inhibition, slight incoordination) Observe for 2 hoursGive frequent carbohydrate containing drinksBreath alcohol if possibleIf remains symptomatic or symptoms worsen
admithttp://www.rch.org.au/clinicalguide/guideline_index/
Acute_Poisoning_Guidelines_For_Initial_Management/
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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
MANAGEMENT
96
Symptomatic (more than just mild symptoms or continued symptoms after 2 hours) Blood ethanol measurement, U& E, GlucoseI.V. fluidTemperature regulationAdmit.If unconscious or convulsions contact I.C.U.
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
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MANAGEMENT(CONT.)
97
American Association of Poison Control Centers: http://www.aapcc.org/dnn/Home.aspx
American Academy of Clinical Toxicology: http://www.clintox.org/index.cfm
Centers for Disease Control and Prevention, Section on Environmental health: http://www.cdc.gov/Environmental
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_Management/
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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
REFERENCES
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Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
THANK YOU