Dr Hemanth S Naik

Drug Poisoning & Overdosage

Dr Hemanth S Naik

Definitions

Common Drug Poisoning

DO Evaluation

Management

Case Scenario

Drug Abuse

Presentation Flow

Dr Hemanth S Naik

PoisonAny substance which when administered in living body through any route (Inhalation, Ingestion, surface absorption etc) will produce ill-health or death by its action which is due to its physical chemical or physiological properties.

Dr Hemanth S Naik

DrugAny substance or product that is used or intended to be used to modify or explore physiological systems or pathological states for the benefit of the recipient.

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Common Drug Poisoning

Analgesics

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Common Drug Poisoning

Barbiturates&

Benzodiazepines

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Common Drug Poisoning

Narcotics

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DO EvaluationMotive

Co-Morbidity

Related Drug

CO-Ingestion

Symptoms & Signs

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Motive

Accidental

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Motive

Suicidal

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Motive

Homicidal

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Co-morbidity

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Related DrugType

Time

Preparation

Dosage

?

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Co-Ingestion

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Symptoms & SignsHyperventilation

Amphetamine

Cocaine

Isoniazid

Anticholinergics

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Symptoms & SignsHypoventilation

Barbiturates

Opioids

Ethanol

Sedative-hypnotics

Capnograph

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Symptoms & Signs

Hypothermia

Ethanol

Sedatives

Opioids

Barbiturates

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Hypotension

Antihypertensives

Barbiturates

Diuretics

Symptoms & Signs

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Symptoms & Signs

Normal: 60-100 bpmBradycardia: <60 bpmTachycardia : >100 bpm

Bradycardia

Opioids

Digoxin

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InvestigationsBlood Glucose Test

SpO2

Serum Chemistry

Drug & Toxin Levels

ECG

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Management

ABCGIT

Decontamination

Enhance Elimination

Antidote

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GI Tract Decontamination

Emesis Oro Gastric

Lavage

Activated Charcoal

Whole Bowel Irrigation

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Seldom use, have Risk

Acute ingestion of potentially toxic substance ( < 1hr)

Pre-hospital setting with long transport time to medical care

Emesis

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Oro Gastric Lavage (GL) Large-bore fenestrated

orogastric tube (36-40 Fr) Require protected

airway Amount of poison

ingested is potentially life threatening

Within 60 minutes of ingestion (Except anti-cholinergic < 12 hr ingestion; salicylate < 24 hr ingestion)

Contraindications• Caustic/ Corrosive

ingestion• Large foreign bodies • Airway not protected• Suspected UGI injury• Hypoxia

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Activated Charcoal

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Large Surface Area Binding property  Interrupts

Enterohepatic & Enteroentric Circulation

Activated Charcoal

One gram of activated carbon has the surface area (>400 m2) of approximately two tennis courts (260 m2) !

Dr Hemanth S Naik

Activated Charcoal

• Single Dose: 1g/kg• Multiple Dose: 0.5g/kg Q2-6H Dose

• Digoxin;Amitriptyline;Phenobarbitone; Dozepin;Theophylline;Salicylates;Phenobarbital;Dapsone;phyentoin;carbamazepine;Aspirin

Indication

• Ileus • GI perforation• Loss of airway protection

Contraindication

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Whole Bowel Irrigation• Mechanically flushing

the ingested poison out of the GIT before it can be absorbed into the body

• Iso-osmolar solution of polyethylene glycol

• Rate: 1-2L per hour (minimally)

• P.O. or R/T, Entire procedure usually takes 4 to 6 hours

• Till rectal effluent clear

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Whole Bowel Irrigation

IndicationNot well-absorbed by activated charcoal

(e.g. Fe, Li, Pb, Zn)

Sustained release/ Enteric coasted preparation

Rising drug level despite GL/AC

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Enhance Elimination

•Urinary Alkalinization

•Saline Diuresis

•Haemodialysis and Haemoperfusion

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AntidoteDrug Antidote

Benzodiazepine Flumazenil

Beta blockers Glucagon

Calcium blockers Calcium

Iron or Aluminum Deferroxamine

Isoniazide (INH) Vit B6

Methemoglobinemia Methylene blue

Methanol Ethanol

Opioid Naloxone

TCA anti-depressants Sodium bicarbonate

Coumarin Vit K1

Acetaminophen N-acetylcysteine

substance which can counteract a form of poisoning

Case Scenario

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Case

Nausea & VomitingAbdominal Pain

Child aged about 4 years

History of ingestion of unknown white tablets

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EvaluationMotive

Co-Morbidity

Related Drug

CO-Ingestion

Symptoms & Signs

Accidental

None

Not Determined

Suggestive of Paracetamol Poisoning

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•90-95% hepatic•t1/2: prolonged

•>90% Non-toxic sulfate & glucuronide conjugates pathway

•Increase in NAPQI, depletes glutathione stores->NAPQI accumulates

•Hepatocellular centribular necrosis and renal injury

•90-95% hepatic•t1/2: 2-3 hrs

•>90% Non-toxic sulfate & glucuronide conjugates pathway

•<5% by cytochrome P450 2E1 to N-acetyl-para-benzoquinoneimine (NAPQI),

Paracetamol

Therapeutic Overdose

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Paracetamol Overdose

• 0.5-24h• Nausea, vomiting, abdominal pain

Phase 1

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Management

ABCGIT

Decontamination

Enhance Eliminatio

nAntidote

AirwayBreathingCirculation

Gastric Lavage

Activated Charcoal

Urine Alkanizatio

nN-Acetyl Cysteine

Drug Abuse

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MorphineMorpheus-God of Dreams

Opiate analgesic

Addiction

Dependence

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Opium

NarcoticLatex of opium poppies Papaver somniferum

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Cultivation

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History

Sumerians4000 BC

Hippocrates460-357 BC

Opium War17th Century

F. W. Serturner1803

Sumerians4000 BC

Hippocrates460-357 BC

Opium War17th Century

F. W. Serturner1803

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Opium

NaturalMorphinecodeine

Semi SyntheticHeroin

HydromorphoneOxymorphone

oxycodone

SyntheticMeperidineMethadone

Fentanyl, etc

Classification

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Extraction

Raw Opium Morphine

BaseHeroin Base

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Heroin

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Medication• Methadone• Levo-alpha-acetyl-

methadol (LAAM)• Buprenorphine• Naltrexon

Behavioral Therapy • Counseling • Build Self Confidence• Build Personality

Treatment

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?

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Thank You