management of poisoning

General PrinciplesofManagement of Poisoning.

TOPIC: INTRODUCTON AND STABILIZATION OF POISONING

NAME: RIYA VISAVADIYA

ROLL NO. : 86 MO. NO: 8153850989 Email ID :

[email protected]

BATCH - 2014

Introduction of Poisoning Poison is a substance [ solid, liquid or

gaseous] which if introduced in the living body 0r brought into contact with any part thereof will produce ill-health or death, by its constitutional or local effects or both.

Poisoning occurs when any substance

interferes with normal body functions after if is swallowed, inhaled or absorbed.

The branch of medicine that deals with the detection and treatment of poisons is known as Toxicology.

History The early history of poison is described in

the ancient Indian shastras , Egyptian papyri, Sumerian, BabyIonian ,Hebrew and Greek records.

Among vedas- AtharvaVeda (1500 BC) describes poisons.

Susrutha (350 BC) Described as how poisons were mixed with food and drink ,medicine , snuff etc.

The Italians brought the art of poisoning to its zenith prior to 6th century A.D.

Orfila (spanish chemist,1787-1853) was first to attempt a systemic correlation between the chemical and biologic information of the poisons known them.

Others who worked are Marsh, Magendie, Ambrose, Scheelle, Robert Christison and Rudolf Kobert.

May 3, 2023 General Management of Poisoning 7

EPIDEMIOLOGY

Poisoning both accidental and intentional are a significant contributor to mortality and morbidity throughout the world.

According to WHO three million acute poisoning cases with 2,20,000 deaths occur annually. Of these 90% of fatal poisoning occur in developing countries particularly among agricultural workers.


Acute poisoning forms one of the commonest causes of emergency hospital admissions.

It has been estimated that about 5 to 6 persons per lakh of populations die due to lake of proper immediate treatment of poisoning.

To prevent these deaths, poison centres were developed.

Poison Centers A Poison control center is a medical facility that is

able to provide immediate ,free and expert treatment advice and assistance over the telephone is case of exposure to poisonous or hazardous substances.

It answer questions about potential poisons in addition to providing treatment management advice about household products ,plants ,bites ,pesticides , food poisoning and fumes.

It is useful to prevent sudden massive poisonous outbreaks like Bhopal gas Tragedy.

Bhopal Disaster

It was a methyl isocynate (MIC) which leaked in Bhopal considered the world ‘s worst industrial disaster.

It exposed more than 5,00,000 people to toxic gases.

A mixture of poisonous gases flooded the city, causing great panic as people woke with burning sensation in their lungs.

Thousands died immediately from the effects of the gas.

Bhopal Gas Tragedy

General Management of PoisoningPrinciples of management consist of;

i. Stabilization.ii. Gut Decontamination.iii. Antidote administrationiv. Eliminationv. Symptomatic treatment.

Poisoning severity Grades None (0) – no symptoms or signs

judged not to be related to poisoning.

Minor (1)- Mild, transient and spontaneously resolving symptoms.

Moderates (2)- pronounced or prolonged symptoms.

Severe (3)- severe or life threatening symptoms.

Basic Management of a poisoned patientAntidotes are available for very few

commonly encountered poisons, and treatment is usually non-specific and symptomatic.

In such cases management and stabilization measures, appropriate treatment to reduce absorption, measures to enhance life support followed by psychiatric counselling.

Emergency Stabilization Measures The unconscious patient should be

transported in the head down semiprone position to minimize the risk of inhalation of gastric contents.

A Clear Airway and ventilation.

Potentially serious abnormalities such as metabolic acidosis, hyper kalamia and hypo glycemia may require correction as a matter of urgency.

Initial resuscitation stabilization Scandinavian Regime is a term used for

anti shock measures when the patient is going into shock.

It includes ABCD of resuscitation.A. AirwayB. BreathingC. CirculationD. Depression of CNS

AIRWAY Opening up and cleaning up the airway (oral

cavity , nostrils) of secretions, vomit or any other foreign body might be life saving.

Protecting and securing the airway by means of endo tracheal intubation may be necessary.

Proper positioning head tilt and chin lift and falling back of tongue is prevented by suitable airway tube must be present.


Endo tracheal Intubation

BREATHING If the arterial blood gas cannot be maintained

inspite of establishing an effective airway, then graduated supplement oxygen therapy either by a ventimask or through endo tracheal tube should be administered.

If necessary positive pressure ventilation with monitoring and respiratory stimulants for severe depression should be applied.

CIRCULATION

I.V. Fluid administration may be life sustaining line.

Maintenance of fluid and electrolyte balance and administration of I.V. Drugs for treatment is needed.

Depression of CNS should be corrected.An unconscious patient should be

turned to lie on one side to stop the tongue blocking the throat and to allow fluid to come out of the mouth. (recovery position)

Most of the poisoning cases , whether they are conscious or unconscious recover with supportive care alone.

Topic :- Differential Diagnosis of Poisoning

NAME: Samarth Dubey

ROLL NO. : 90

MO. NO: 9153850989

Email ID : [email protected]

BATCH - 2014

mailto:[email protected]



HOW CAN I MANAGE THE PATIENT?

History Taking

Physical Examination

Toxicological Screening


A. History Taking Agent & Amount

Time & Location of Exposure

Route

Intake of Other Substances

Circumstances of Exposure

Current Medications

Past Medical History

Pre-Hospital Treatment


B. Physical Examination(Because history can be incomplete or unreliable) Examine General Status

(height/weight/built/TPR, etc.)

See the Skin (color change)

Smell the breath (fruity/alcoholic/garlic, etc.)

Listen the Lungs

Hear the Heart

Asses the Abdomen

Perform Neurological Exam


B. Physical Examination

May need to remove clothing for thorough exam Check clothing for objects or substances Assess general appearance of patient –

Orientation, Agitation, confusion, or obtundation Ocular Examination

pupils size Nystagmus Reactivity to light dysconjugate gaze increased lacrimation

Oropharynx for increase salivation or excessive dryness

Extremities: fasciculation's, tremor


B. Physical Examination Heart: rhythm, rate,

regularity

Lungs: bronchorrhea or wheezing

Abdomen: bowel sounds, tenderness or rigidity

Neuro: CNS, reflexes, muscle tone coordination, cognition, ability to ambulate


Skin tells most

Rash – Allergic ReactionLead poisoning


Mees line – Arsenic Poisoning

Cyanosis – Cyanide poisoning


Jaundice Hypercarotenemia


THE SYMPTOMATIC PATIENT

Coma & Hypothermia

Hypotension

Hypertension

Arrhythmias

Seizures

Hyperthermia


Coma & Hypothermia Go hand-in-hand Ingestion of large doses of:

Antihistamines (diphenhydramine) Sedative/Hypnotic drug

(Benzodiazepines) Ethanol Opioids (Drug Abuse-Morphine) Antipsychotic (Clozapine) Antidepressants (TCAs)

Airway – Not needed if naloxone/ flumazenil works

Breathing – Pulse Oximetry Not Reliable in meth-HB/ CO poisoning

Circulation – Continuous BP/ECG monitoring

Drug – Naloxone/ Flumazenil/ Dextrose+Thiamine


Hypotension Drugs-

antihypertensive drugs(α-blockers/CCB/β-blockers)

disulfiram (ethanol Interaction) Iron Trazodone, quetiapine, and

other antipsychotic agents antidepressants

Poison- Cyanide Carbon monoxide Hydrogen sulfide Aluminum or zinc phosphide Arsenic Mushrooms (contain

pilocarpine)


Nature of poisoning Treatment

TCAs/Sod. channel blockers NaHCO3 50–100 mEq i.v.bolus injectionNE 4–8 mcg/mini.v. infusion(more effective than dopamine)

β-blockers Glucagon 5–10 mgi.v.

CCBs calcium chloride 1–2 g i.v.

Hypotension


Hypertension

Amphetamines Anticholinergics Cocaine Performance-enhancing products

Caffeine Phenylephrine Ephedrine Yohimbine

MAO inhibitors


Hypertension with…. Treatment

agitation and anxiety Lorazepam 2–3 mgi.v.

persistent nature Phentolamine 2–5 mgi.v.ORSod. nitroprusside0.25–8 mcg/kg/min i.v.

excessive tachycardia Propranolol 1–5 mgi.v.OREsmolol 25–100 mcg/kg/mini.v.ORLabetalol 0.2–0.3 mg/kgi.v.

Caution: Do not give β-blockers alone, since doing so may paradoxically worsen hypertension as a result of unopposed

alpha-adrenergic stimulation


Arrhyth

mias


Cause TreatmentElectrolyte imbalance

↑K+

↓K+, Mg2+,Ca2+

Correct accordingly

Ventricular arrhythmias Lidocaine/ Amiodaroneat usual antiarrhythmic doses

TCAs/diphenhydramine/class Ia antiarrhythmic drugs

NaHCO3 50–100 mEqi.v. bolus infusion

Torsades de pointes Mg(2 g i.v. over 2 minutes) or Overdrive pacing

Digitalis-induced arrhythmias

Digoxin specific antibodies

Chlorinated solvents/Chloral hydrate/freons/Sympathomimetic agents

Propranolol 1–5 mgi.v.OREsmolol 25–100 mcg/kg/mini.v.

Caution: Avoid class Ia antiarrhythmic agents (eg, procainamide, disopyramide), which may aggravate arrhythmias caused by tricyclic antidepressants.


Seizures Drugs-

Amphetamines, cocaine Antidepressants (especially

TCAs, bupropion, and venlafaxine)

Antihistamines (especially diphenhydramine),

Antipsychotics Camphor, isoniazid (INH) Chlorinated insecticides Tramadol Theophylline

Secondary causes- Hypoxia/hypoglycemia/

hypocalcemia/hyponatremia


Lorazepam, 2–3 mg, or diazepam, 5–10 mg, i.v.over 1–2 minutesORi.v. unavailable—midazolam, 5–10 mg i.m.

If convulsions continue, administer phenobarbital(For drug-induced seizures, phenobarbitalis preferred over phenytoin.)


Hyperthermia Amphetamines (MDMA;

“Ecstasy”), atropine and other anticholinergics

Cocaine, salicylates, strychnine

TCA SSRI(eg, fluoxetine,

paroxetine,sertraline) or their use in a patient taking an MAO inhibitor may cause serotonin syndrome

Antipsychotics (neuroleptic malignant syndrome [NMS])


Hyperthermia Removing the patient’s clothing Spray the skin with tepid water & fanning. Muscle rigidity/hyperactivity –

NM paralysis with a nondepolarizing neuromuscular blocker (eg, rocuronium, vecuronium)

Once paralyzed, patient must be Intubated Mechanically ventilated Sedated Use bedside EEG (paralysis - no convulsion but

seizure may exist)


Hyperthermia… Treatment

With rigidity /Malignant hyperthermia

Dantrolene 2–5 mg/kg i.v.

Neuroleptic malignant syndrome

Bromocriptine 2.5–7.5 mgorally daily

Serotonin syndrome Cyproheptadine 4 mgorally every hour (3-4 doses)ORChlorpromazine 25 mgi.v.OR50 mgi.m.


Toxicological Screening Serum osmolality & osmol gap Electrolytes and anion gap Blood glucose S. Creatinine BUN CK Urinalysis; e.g.-

Oxalate crystals with ethylene glycol poisoning Myoglobinuria with rhabdomyolysis

ECG Serum acetaminophen and ethanol quantitative

levels should be determined in all patients with drug overdoses


Laboratory test Observation

Osmol gap ↑s in presence of large quantities of low-molecular-weight substances

Anion gap ↑s due to poisoning of - Carbon monoxideCyanideEthylene glycolIron overloadINHMethanolMetforminIbuprofenSalicylates

GUT DECONTAMINATION

NAME:Ruchit Patel ROLL NO. : 87 MO. NO:

9824565789 Email ID :

[email protected]

BATCH - 2014

Principles of Decontamination

External Protect yourself and others Remove exposure Irrigate copiously with water or

normal saline Don’t forget your ABC’s

Internal Patient must be fully awake or

intubated Most common complication is

aspiration Very little evidence for their

use

Decontamination Skin

Protect yourself and other workers

Remove clothing Flush with water or normal

saline Use soap and water if oily

substance Chemical neutralization can

potentiate injury Corrosive agents injure skin

and can have systemic effects

Decontamination

Eyes Remove contact lens Flush copiously with water or

normal saline Use local anesthetic drops Continue irrigation until ph is

normal Slit lamp and fluorescein exam

Decontamination

Inhalation Give supplemental humidified oxygen Observe for airway obstruction Intubate as necessary

EMESIS

GAG REFLEX

IPECACUANHA The actions of ipecac are mainly those of

major alkaloids(emetine and cephaeline).

Action : Local : irritate the gastric mucosa Central: by stimulating the

medullary chemoreceptor trigger zone

induce vomiting.

INDICATION CONCIOUS PATIENT WITHIN 4 hrs

C/I COMATOSE PATIENT

IMPAIRED GAG REFLEX

COMPLICATION ASPIRATION PNEUMONIA

MALLORY WEISS SYNDROME

GASTRIC LAVAGE

Gastric lavage , also commonly called gastric irrigation, is the process of cleaning out the contents of the stomach.

Patient must be lying on left side or prone with head hanging over edge of bed,so that mouth is at lower layer than larynx.

Functioning of the technique is based on SYPHON ACTION.

Ewald’s tubeMaterials

used 1:5000 kmno4,5% sodium bicarbonate,4% tannic acid,1% sodium iodide and lime water

Technique Gastric lavage involves the passage of a tube (such

as an Ewald tube) via the mouth or nose down into the stomach followed by sequential administration and removal of small volumes of liquid.

The placement of the tube in the stomach must be confirmed either by air insufflations while listening to the stomach, by pH testing a small amount of aspirated stomach contents, or x-ray.

This is to ensure the tube is not in the lungs. In adults, small amounts of warm water or saline

are administered and, via a siphoning action, removed again.

INDICATION CONCIOUS PATIENT WITHIN 2 hrs

C/I CORRROSIVE POISON

COMATOSE PATIENT

COMPLICATION ASPIRATION PNEUMONIA

PERFORATION OF STOMACH

CATHARSIS

Sorbitol is cathartic of choice. Sodium sulphate may also be used.

ACTIVATED CHARCOAL

Activated carbon, also called activated charcoal, is a form of carbon processed to have small, low-volume pores that increase the surface area available for adsorption or chemical reactions.

DOSE-1gm/kg. SUPERACTIVATED CHARCOAL has

double adsorbing surface area as compared to activated charcoal.

It is not effective for a number of poisonings including strong acids or alkali, cyanide, iron, lithium, arsenic, methanol, ethanol or ethylene glycol.

WHOLE BOWEL IRRIGATION

WHOLE BOWEL IRRIGATION

Whole bowel irrigation (WBI) is a medical process involving the rapid administration of large volumes of an osmotically balanced POLYETHYLENE GLYCOL solution , either orally or via a nasogastric tube, to flush out the entire gastrointestinal tract.

Useful in lithium,iron,cocaine and heroine overdose.

Topic :- Antidote Administration

NAME: Sachin Patel

ROLL NO. : 88

MO. NO: 9159850809

Email ID : [email protected]

BATCH - 2014



Definition

According to WHO - “Antidote was defined as a therapeutic substance used to counteract the toxic action(s) of a specified xenobiotic.”


POISON WITH ITS SPECIFIC ANTIDOTES

Paracetamol

Methanol

Benzodiazepines

Opiates

:- Acetyl cysteine & Methionine

:- fomepizole & Ethyl Alcohol

:- Flumazenil

:- Nalaxone


Organophosphates :- Atropine

Dhatura :- Physostigmine

Botulinum toxin :- Guanidine

Methamoglobinemia :- Methelene blue (Nitrites)


Cyanide :- Amyl Nitrate + Na Thio

Sulphate

CO :- Hyper Baric Oxygen


Arsenic :- hydrated ferric oxide, DMSA,BAL

Copper :- Potassium ferrocyanide, Penicillamine

Ergot :- Sodium Nitroprusside

Lead :- EDTA, DMSA, BAL Iron :- Desferrioxamine Mercury :- Penicillamine, BAL,

Sodium formaldehyde


Cadmium :- N-Acetyl Penicillamine

Isoniazid :- pyridoxine Heparin :- Protamine

Sulphate Warfarin :- Vit. K1 TCA :- NaHCo3 Beta-blockers :- Glucagon Flourouracil,methotrexate :-

Leucovorin Cyclophospamide :- Mesna


CHEMICAL ANTIDOTE Common salt Silver Nitrate Mercury Chloride Copper Sulphate Phosphorus Arsenic Albumin Dialyzed iron


UNIVERSAL ANTIDOTE

It is a combination of physical and chemical antidotes

It is an absolute antidote and had only historical importance


Composition :- Magnesium oxide (1

part) neutralizes acid without gas formation

Charcoal (2 parts) absorbs alkaloids

Tannic acid (1 part) precipitates alkaloids


COMA COCKTAIL

It is combination of 3 medicines can be given in unknown poisoning with coma -

Dextrose (50%) 100 mlNalaxone 2 mgB1(Thiamine) 100 mg


CHELATING AGENTS EDTA BAL Succimer Penicillamine Desferrioxamine


EDTA

EDTA is prescription medicine, given by injection into the vein (intravenously) or into the muscle (intramuscularly).

more common in lead poisoning.

.


Intravenous EDTA is used to treat lead poisoning and brain damage caused by lead poisoning; to evaluate a patient's response to therapy for suspected lead poisoning; to treat poisonings by radioactive materials such as plutonium, thorium, uranium, and strontium; for removing copper in patients with Wilson's disease; and for treating high levels of calcium.


EDTA is also used intravenously for heart and blood vessel conditions including irregular heartbeat due to exposure to chemicals called cardiac glycosides, “hardening of the arteries” (atherosclerosis), chest pain(angina), high blood pressure, high cholesterol, and blood circulation problems such as intermittent claudication and Raynaud's syndrome


Specific precaution & warning Heart rhythm problems: EDTA might make

heart rhythm problems worse.

Diabetes: EDTA might interfere with blood sugar control because it can interact with insulin.

Low calcium levels in the blood (hypocalcemia): EDTA can decrease serum calcium levels, making hypocalcemia worse.


Liver problems and hepatitis: EDTA might make liver disease worse. Avoid using EDTA if you have a liver condition.

Kidney problems: EDTA can harm the kidney and might make kidney disease worse. EDTA doses should be reduced in patients with kidney disease. Avoid using EDTA if you have severe kidney disease or kidney failure.


British Anti Lewisite(BAL)

It is given by intramuscular route (5mg/kg

stat followed by 2 to 3mg/kg every 4 to 8

Hours for 2 days and then once a day for

10 days


Mechanism of action of BAL BAL has two SH groups. The two SH groups binds to

those metals that produce toxicity by interacting with sulfhydryl containing enzymes in the body.

BAL will combine with these metals forming BAL-metal complex thus dislodges the metal from acting site.


BAL is useful against metals that interfere with sulfhydryl enzymes in the body such as arsenic , mercury , bismuth , copper , antimony , and nickel.


Contraindication of BAL In liver damage

G6PD deficiency

Iron and cadmium toxicity


Side effects

Serious side effects: Fast heart rate, feeling anxious or

restless; Pain or tightness in your throat,

chest, or hands; Burning sensation of your throat,

mouth, or lips; or Burning sensation in your penis.


Less serious side effects include: Nausea, vomiting, stomach pain Numbness or tingling (especially around your

mouth) Headache Eye redness, swelling, or watering; Twitching of your eyelid Runny nose Increased sweating Mild fever or Pain, redness, or swelling where the needle is

placed.


SUCCIMER Also known as a

“Dimercaptosuccinic acid”.

Similar to BAL in chelating properties

Less toxic than BAL and orally effective

used against mercury , arsenic and lead poisoning.

EDTA is contraindicated in mercury


Side effects

Nausea Vomiting Loss of appetite Diarrhea


PENICILLAMINE Also known as “D-penicillamine Cuprimine” It is dimethyl cysteine , obtained as a degradation product

of penicilline and available in d-isomer and I-isomer form. d-isomer is more used because I-isomer is more toxic

and produce “optic neuritis”. Metabolized in body,excreted in urine&feces


Indications Copper poisoning :- drug of

choice

Mercury poisoning:- alternative to BAL

Chronic lead poisoning

Wilson’s disease

Cystinuria and cystine stone


Dose

For copper and mercury poisoning :- 1 to 1.5 gm/day in divided doses

For wilson’s disease :- 0.5 to 1gm/day in divided doses , one hour before meals or two hour after the meals to avoid the chelation of diatery metals.

Contraindicated in arsenic


Side effects

Diarrhea loss of appetite mild stomach pain nauseavomiting


DESFERRIOXAMINE Ferrioxamine is long chain iron containing

complex obtained from an actinomycete. Chemical removal of iron from it yields

desferrioxamine that has great affinity for iron.

Administrated orally , less absorbed and binds with iron and prevents iron absorption in GIT.


Mechanism of Action Desferrioxamine molecule

turns round the ferric ion and forms a stable non-toxic complex that is excreted in urine.

1 gram of desferrioxamine is capable of removing 85 mg of elemental iron.

It removes loosely bound iron and iron from hemosiderin and ferritin but not remove iron from Hb or cytochrome


Indication

Acute iron poisoning

Transfusion siderosis


Dose

Iron poisoning :- drug of choice Given intramuscularly-0.5 to 1gm

repeatedly 4 to 12 hourly Patient with shock receive

intravenous desferrioxamine – 15 mg/kg/hour with a maximum daily dose upto 360 mg/kg or upto 6 gm total.

Also useful in treatment of toxicity with radioactive heavy metals.


side effects

Diarrhea Dizziness Headache Mild stomach pain Nausea Stomach upset Vomiting

Topic –ENHANCED ELIMINATION OF

POISON NAME: Sagarika Upadhyay ROLL NO. : 89

MOBILE NO.:9099938328

Email.:-upadhyaysagarika@gmail. Com

BATCH - 2014

Once the absorption of a toxin has been reduced

by various methods, the next logical step is to

ENHANCED ELIMINATION OF POISON

of already absorbed toxinfrom the body.

ENHANCED ELIMINATION OF POISON

Forced diuresis

Hemodialysis & Peritoneal dialysis

Haemoperfusion

Multiple dose activated charcoal

General Management of Poisoning 105May 3, 2023

FORCED DIURESIS

Increased urine formation by diuretics or with manipulation of urine pH .

The renal tubular epithelium is relatively impermeable to the ionized molecules.

If the urinary pH is changed so as to produce more of ionized form of a chemical, it is trapped in the tubular fluid and is excreted in the urine.


Poison with following properties can be eliminated by FORCED DIURESIS:-

1. Substance excreted mainly by kidneys.2. Substance with low volume of

distribution.3. Substance with low protein binding.


IN ACIDIC URINE IN BASIC URINE

(after NaHCO3 infusion)

uncharged form(lipid-soluble,diffusible acrosslipid membranes)REABSORBED

Phenobarbital(pKa = 7.2)

anionic form(not lipid-soluble,not diffusible acrosslipid membranes)NOT REABSORBED

O

O

O

Phe

H5C2

HN

NH

O

O

O

Phe

H5C2

HN

N_

H+

H+


Manipulation of urinary pH This method acts depending on the extent of

ionization(pka)1>forced alkaline diuresis

By achieving urinary pH of 7.5 to 9 promotes excretion of drugs which are weak acids, such as:- Salicylates, phenobarbital, chlorpropamide,

methotrexateLithium. A solution of sodium bicarbonate 50 to 100

meq added to 1 liter of 0.45% saline administered at the rate of 250 to 500 ml/hr for first 1 to 2 hours.

Alkaline solution and diuretics should be administered to maintain a urinary output of 2 to 3 ml/kg/hr.


Diuretics are needed to maintain highurine flows.

To prevent hypokalaemia potassium added.

The vitals of the patient along with input/output, electrolytes andacid base status should be closely monitored.

Contraindicated:- in patients with shock, hypotension, renal failure and congestive heart failure.


2> Acid diuresis Is uncommonly used method for certain

poisons like amphetamine. Vitamin C titrated to acidic urine pH .

It is dangerous method because of the risk of:

Myoglobin precipitation in the renal tubules (rhebdomyolysis)

Metabolic acidosis Renal failure.


DIALYSIS Solute diffusion across a semi-permeable

membrane down a concentration gradient from

circulation into dialysate. Haemodialysis and Peritoneal are useful.

Dialysable substance for good results must have:Low volume of distribution.Low molecular weight.Low protein binding.

Dialysis is useful in ethanol, methanol, salicylates, phenobarbital, theophylline, ethylene glycol, and lithium intoxications. PeritonealGeneral Management of Poisoning 112May 3, 2023

A)Haemodialysis

Semipermeable membrane is of 4 category:-

Cellulose Substituted cellulose (e.g. cellulose acetate) Cellulosynthetic Synthetic (e.g. polysulphone, poly methacrylate, polyacrylonitrile)



Rate of diffusion depends on :- Magnitude of the concentration

gradient Membrane surface area Porosity & thickness of membrane conditions of flow on the two sides

of membrane. size of molecule Large size creatinine ( 113Da)

cleared less Small size urea(60Da) cleared

more


Consist of a plastic device with the facility to perfuse blood and dialysate compartments at very high flow rates.

The surface area of dialysis membrane in adult patient is usually in the range of 0.8 to 1.2 m2

THE DIALYSER


Two geometric configurations of dialysers:

1) Hollow fiber

Commonly used

Composed of bundles of capillary tubes through which blood circulates while dialysate travels on the outside of the fiber bundle.

2) Flat plate

Less frequently used

Composed of sandwiched sheets of membrane in a parallel plate configuration.


Hollow fiber

Flat plate

Dialyzers


Reprocessing &reuse of haemodialyzers

For the patient on chronic dialysis.

To reduce the expense of individual dialyzer.

Only the dialyzer unit is reprocessing or reused.

Either manual or automated.


It consist of

1. Sequential rinsing of the blood and dialysate compartments with water.

2. A chemical clearing step with reverse ultra –filtration from dialysate to blood compartment.

3. Tasting of the patency of the dialyzer. 4. Disinfection of dialyzer by Per acetic acid-

Hydrogen peroxide or formaldehyde.


Composition of commercial DIALYSATE for haemodialysis

SOLUTE BICARBONATE DIALYSATESodium( meq/L) 137-143Potassium( meq/L) 0-4.0Chloride( meq/L) 100-111Calcium( meq/L) 0-3.5Magnesium( meq/L) 0.75-1.5Acetate( meq/L) 2.0-4.5Bicarbonate( meq/L) 30-35Glucose( meq/L) 0-0.25


Blood delivery system

Using a roller mechanism.

moves blood at the flow rate 250 to 500mL/min.

Extracorporeal circuit

Dialysis access

Blood pump

Dialysis solution delivery system

Various safety monitors

It dilutes the dialysate concentrate with water.

Fistula Graft Catheter Through which the

blood is obtained for haemodialysis is called dialysis access.

Monitors temperature, conductivity,

flow of dialysate.


Fistula:-Anastomises of artery to vein

Graft :-prosthetic material b/n artery and vein

Catheter :-a double lumen cuffed catheter


Procedure:-

300-500mL/

min

500-800mL/

min

Clearance of urea =200-350mL/min


COMPLICATIONS:-

Hypotension(most common particularly in diabetics)

Muscle cramps

Electrolyte imbalance

Cross infections

Bleeding tendency (due to heparin)

Air embolism

B) Peritoneal dialysis peritoneum as semipermiable

membrane.

Infusing 1 to 3 L of a dextrose-containing solution into the peritoneal cavity allowing the fluid to dwell for 2 to 4 hr.

USE: especially in children in barbiturates, and salicylate poisoning.



Forms of peritoneal dialysis :-

A. CAPD=Continues ambulatory peritoneal dialysis

(During day & 3 to 4 time) (midnight dwell at bedtime and remains through

night)B. CCPD=Continues cyclic peritoneal dialysis (by an automated cycler & at night) (4 to 5 cycle while the patient sleeps) (in morning – discontinuation and routine activities)C. NIPD=Nocturnal intermitant peritoneal

dialysis (10 hrs – each night)

COMPLICATIONS : Intra-abdominal bleeding Perforation of abdominal organs Peritonitis Dehydration or over hydration.CONTRAINDICATIONS: Pregnancy Abdominal hernia Respiratory distress.


HEMOPERFUSION Using equipment similar to that for

haemodialysis, the blood is pumped directly through a column containing an adsorbent material ( either charcoal or Amberlite resin which is ion exchange resin).

Systemic anticoagulation is required. Often in higher doses than for haemodialysis

Thrombocytopenia is a common complication.


Because the drug or toxin is in direct contact with the adsorbent material, drug size, water solubility and protein binding are less important limiting factors.

For most drugs, hemoperfusion can achieve greater clearance than haemodialysis.

for example, the for phenobarbital haemolysis clearance

60-80mL/min hemoperfusion clearance 200-

300mL/min May 3, 2023 General Management of Poisoning 130

CONTRAINDICATIONS: Patients with coagulopathy Patients with uncontrolled hypotension

COMPLICATIONS: Thrombocytopenia Hypocalcaemia Hypoglycaemia Hypotension


Hemoperfusion machine


MULTIPLE DOSE ACTIVATED CHARCOAL

More than 2 doses of oral activated charcoal.

Free charcoal available in the intestines to bind any toxin

free toxin in the blood tends to diffuse out of the blood into the intestines binds the charcoal “gastrointestinal dialysis”.

It is simple, inexpensive, and safe and avoids the need for invasive procedures, such as haemodialysis and hemoperfusion.


DOSE: Optimum dose is unknown. Adult dose = from 50 to 100 grams per dose, administered at the rate no less than 12.5 grams/hr or

its equivalent. Children =Lower doses of 10-25 grams

are used.

Carbamazepine, dapsone, phenobarbital, theophylline, quinine, phenytoin .May 3, 2023 General Management of Poisoning 134

1. The toxin has long half life

2. Toxin has a significant enterohepatic circulation (digoxin, phenobarbital, theophylline )

3. Continuous release of toxin from sustained-release preparation

4. Toxin forms mass in the gut which is a source of continuous release of toxin.

5. The ingestion is very massive to be effectively adsorbed by a single dose of charcoal.


INDICATIONS :-

Contraindicated: in the presence of ileus ( disruption of the

normal propulsive ability of the gastrointestinal tract )

The use of multiple-dose charcoal for salicylate poisoning is controversial.

Not recommended for the elimination of astemizole, chlorpropamide, doxepin, imipramine, meprobamate, methotrexate, sodium valproate, tobramycin, and vancomycin.


The need for ministration of cathartics such as sorbitol remains unproven and is not recommended.

Should not be used in children

because of possible fluid and electrolyte disturbances.


In summary, physicians should take the best judgment according to the presence of contraindications and the effectiveness and availability of alternative treatment.



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management of poisoning

Health & Medicine

Transcript of management of poisoning