Management of Toxicity€¦ · · 2018-02-19All substances are poisons: there is none which is...
Transcript of Management of Toxicity€¦ · · 2018-02-19All substances are poisons: there is none which is...
![Page 1: Management of Toxicity€¦ · · 2018-02-19All substances are poisons: there is none which is not a poison. The right dose differentiates a poison from a remedy. Highly toxic chemicals](https://reader030.fdocuments.in/reader030/viewer/2022013014/5acbde327f8b9a875a8bed01/html5/thumbnails/1.jpg)
![Page 2: Management of Toxicity€¦ · · 2018-02-19All substances are poisons: there is none which is not a poison. The right dose differentiates a poison from a remedy. Highly toxic chemicals](https://reader030.fdocuments.in/reader030/viewer/2022013014/5acbde327f8b9a875a8bed01/html5/thumbnails/2.jpg)
Poison (Toxicant): any substance or agent capable of
producing a deleterious response in a biological system
or living organism.
Poisoning= overdose toxicity
intoxication= toxicity due to foreign substance
![Page 3: Management of Toxicity€¦ · · 2018-02-19All substances are poisons: there is none which is not a poison. The right dose differentiates a poison from a remedy. Highly toxic chemicals](https://reader030.fdocuments.in/reader030/viewer/2022013014/5acbde327f8b9a875a8bed01/html5/thumbnails/3.jpg)
All substances are poisons: there is none which is
not a poison. The right dose differentiates a poison
from a remedy.
Highly toxic chemicals can be life saving when
given in appropriate doses.
(Poisons are not harmful at a sufficiently low dose)
An apparently non-toxic chemical can be toxic at
high doses. (Too much of a good thing can be bad!).
“Synthetic” does not meantoxic or poisonous
“Natural” does not meansafe or even low risk
![Page 4: Management of Toxicity€¦ · · 2018-02-19All substances are poisons: there is none which is not a poison. The right dose differentiates a poison from a remedy. Highly toxic chemicals](https://reader030.fdocuments.in/reader030/viewer/2022013014/5acbde327f8b9a875a8bed01/html5/thumbnails/4.jpg)
Poisoning episodes
Accidental:Children less than 5 years by sugar coated tablets.Inhalation of organophosphorus pesticides.Overdose.
Suicidal: in response to depression or specific life events.
Homicidal
Parasuicide: attention seeking behavior or attempt at suicide.
It is typically classified as a low lethality method i.e. aim is not death
![Page 5: Management of Toxicity€¦ · · 2018-02-19All substances are poisons: there is none which is not a poison. The right dose differentiates a poison from a remedy. Highly toxic chemicals](https://reader030.fdocuments.in/reader030/viewer/2022013014/5acbde327f8b9a875a8bed01/html5/thumbnails/5.jpg)
Routes of toxicant entry:
• Injection:
Through cuts or hypodermic needles into the skin, usually cause highest blood conc
• Inhalation:Through mouth/nose into respiratory system, 2nd highest blood level concentration.
• Ingestion:
Through mouth into stomach and GIT, produces 2nd lowest blood level.
• Dermal (Skin):
By absorption through skin membrane, lowest in blood level
![Page 6: Management of Toxicity€¦ · · 2018-02-19All substances are poisons: there is none which is not a poison. The right dose differentiates a poison from a remedy. Highly toxic chemicals](https://reader030.fdocuments.in/reader030/viewer/2022013014/5acbde327f8b9a875a8bed01/html5/thumbnails/6.jpg)
Management of Toxicity
![Page 7: Management of Toxicity€¦ · · 2018-02-19All substances are poisons: there is none which is not a poison. The right dose differentiates a poison from a remedy. Highly toxic chemicals](https://reader030.fdocuments.in/reader030/viewer/2022013014/5acbde327f8b9a875a8bed01/html5/thumbnails/7.jpg)
Management Principles:
Immediate and supportive measures.
Absorption prevention.
Elimination of toxicant.
Specific antidote.
1
2
3
4
![Page 8: Management of Toxicity€¦ · · 2018-02-19All substances are poisons: there is none which is not a poison. The right dose differentiates a poison from a remedy. Highly toxic chemicals](https://reader030.fdocuments.in/reader030/viewer/2022013014/5acbde327f8b9a875a8bed01/html5/thumbnails/8.jpg)
1) Immediate and Supportive measures
Ensure clear
First:
![Page 9: Management of Toxicity€¦ · · 2018-02-19All substances are poisons: there is none which is not a poison. The right dose differentiates a poison from a remedy. Highly toxic chemicals](https://reader030.fdocuments.in/reader030/viewer/2022013014/5acbde327f8b9a875a8bed01/html5/thumbnails/9.jpg)
1) Immediate and Supportive measures
Ensure clear
= Airway
= Breathing
= Circulation
It is of 1st
priority
First:
![Page 10: Management of Toxicity€¦ · · 2018-02-19All substances are poisons: there is none which is not a poison. The right dose differentiates a poison from a remedy. Highly toxic chemicals](https://reader030.fdocuments.in/reader030/viewer/2022013014/5acbde327f8b9a875a8bed01/html5/thumbnails/10.jpg)
1) Immediate and Supportive measures
Causes of air way obstruction:
Mucosal swelling.
Increased salivation (↓ Conscious).
Posterior displacement of the tongue.
Swallowing of foreign bodies (ex: Fish bone).
A=Air way
![Page 11: Management of Toxicity€¦ · · 2018-02-19All substances are poisons: there is none which is not a poison. The right dose differentiates a poison from a remedy. Highly toxic chemicals](https://reader030.fdocuments.in/reader030/viewer/2022013014/5acbde327f8b9a875a8bed01/html5/thumbnails/11.jpg)
1) Immediate and Supportive measures
Symptoms of airway obstruction:
Dyspnea.Air hunger.
Hoarseness (stridor).Cyanosis.
Diaphoresis. Drooling.
Tachypnea.
A=Air way
![Page 12: Management of Toxicity€¦ · · 2018-02-19All substances are poisons: there is none which is not a poison. The right dose differentiates a poison from a remedy. Highly toxic chemicals](https://reader030.fdocuments.in/reader030/viewer/2022013014/5acbde327f8b9a875a8bed01/html5/thumbnails/12.jpg)
1) Immediate and Supportive measures
Management of airway obstruction:
Head tilt and Chin lift maneuver.
A=Air way
Jaw thrust maneuver.
![Page 13: Management of Toxicity€¦ · · 2018-02-19All substances are poisons: there is none which is not a poison. The right dose differentiates a poison from a remedy. Highly toxic chemicals](https://reader030.fdocuments.in/reader030/viewer/2022013014/5acbde327f8b9a875a8bed01/html5/thumbnails/13.jpg)
1) Immediate and Supportive measures
Management of airway obstruction:
Nasopharyngeal or Oropharyngeal intubation
A=Air way
![Page 14: Management of Toxicity€¦ · · 2018-02-19All substances are poisons: there is none which is not a poison. The right dose differentiates a poison from a remedy. Highly toxic chemicals](https://reader030.fdocuments.in/reader030/viewer/2022013014/5acbde327f8b9a875a8bed01/html5/thumbnails/14.jpg)
1) Immediate and Supportive measures
Management of airway obstruction:
In case of comatosed patients:
Cuffed endotracheal intubation is required
to prevent aspiration because gag reflex
is completely absent in unconscious patients
![Page 15: Management of Toxicity€¦ · · 2018-02-19All substances are poisons: there is none which is not a poison. The right dose differentiates a poison from a remedy. Highly toxic chemicals](https://reader030.fdocuments.in/reader030/viewer/2022013014/5acbde327f8b9a875a8bed01/html5/thumbnails/15.jpg)
![Page 16: Management of Toxicity€¦ · · 2018-02-19All substances are poisons: there is none which is not a poison. The right dose differentiates a poison from a remedy. Highly toxic chemicals](https://reader030.fdocuments.in/reader030/viewer/2022013014/5acbde327f8b9a875a8bed01/html5/thumbnails/16.jpg)
1) Immediate and Supportive measures
Management of airway obstruction:
Excessive mucosal secretions &/or salivation:
Suction of excessive secretions by the aid of intubation.
A=Air way
In Emergency Cases:
Finally Emergency Cricothyrotomy.
![Page 17: Management of Toxicity€¦ · · 2018-02-19All substances are poisons: there is none which is not a poison. The right dose differentiates a poison from a remedy. Highly toxic chemicals](https://reader030.fdocuments.in/reader030/viewer/2022013014/5acbde327f8b9a875a8bed01/html5/thumbnails/17.jpg)
1) Immediate and Supportive measures
Causes of respiratory depression:
Drug-induced respiratory depression (Sedatives & hypnotic such as barbiturates & BDZs).
Pulmonary edema & pneumonitis.
Bronchospasm.
B = Breathing
![Page 18: Management of Toxicity€¦ · · 2018-02-19All substances are poisons: there is none which is not a poison. The right dose differentiates a poison from a remedy. Highly toxic chemicals](https://reader030.fdocuments.in/reader030/viewer/2022013014/5acbde327f8b9a875a8bed01/html5/thumbnails/18.jpg)
1) Immediate and Supportive measures
Management of respiratory depression:
Give supplemental oxygen
If necessary positive pressure ventilation ‘artificial respiration’·
Respiratory stimulants for severe respiratory depression
B = Breathing
![Page 19: Management of Toxicity€¦ · · 2018-02-19All substances are poisons: there is none which is not a poison. The right dose differentiates a poison from a remedy. Highly toxic chemicals](https://reader030.fdocuments.in/reader030/viewer/2022013014/5acbde327f8b9a875a8bed01/html5/thumbnails/19.jpg)
1) Immediate and Supportive measures
The shock is the clinical picture in which the patient shows signs of inadequate tissue perfusion.
Symptoms of shock:
C =Circulation
SHOCK
Coma
![Page 20: Management of Toxicity€¦ · · 2018-02-19All substances are poisons: there is none which is not a poison. The right dose differentiates a poison from a remedy. Highly toxic chemicals](https://reader030.fdocuments.in/reader030/viewer/2022013014/5acbde327f8b9a875a8bed01/html5/thumbnails/20.jpg)
1) Immediate and Supportive measures
Management of shock:
1-Trendlenburg position.
2-Saline Infusion.
C =Circulation
![Page 21: Management of Toxicity€¦ · · 2018-02-19All substances are poisons: there is none which is not a poison. The right dose differentiates a poison from a remedy. Highly toxic chemicals](https://reader030.fdocuments.in/reader030/viewer/2022013014/5acbde327f8b9a875a8bed01/html5/thumbnails/21.jpg)
1) Immediate and Supportive measures
Management of shock:If the patient doesn't respond to 2L infusion & the signs of shock persist, the vasopressors should be used:
C =Circulation
3-vasopressors
Dopamine
Norepinephrine
N.B.1) Dopamine at low dose stimulates dopamine receptors renal & mesenteric vasodilatation.
2) Dopamine at medium dose stimulates cardiac β1 receptors ↑cardiac contractility & C.O.P.
3) Dopamine at high dose stimulates α1
receptors systemic vasoconstriction.
2-5 µg/kg/minute infusion up to 20 µg/kg/minute
0.1-0.2 µg/kg/minute.
![Page 22: Management of Toxicity€¦ · · 2018-02-19All substances are poisons: there is none which is not a poison. The right dose differentiates a poison from a remedy. Highly toxic chemicals](https://reader030.fdocuments.in/reader030/viewer/2022013014/5acbde327f8b9a875a8bed01/html5/thumbnails/22.jpg)
1) Immediate and Supportive measures
After instituting ABC interventions, more detailed evaluation is required:
A. HISTORY:Collect any evidences (thrown tablets, empty bottles, any syringes, written notes .. etc).
Second:
![Page 23: Management of Toxicity€¦ · · 2018-02-19All substances are poisons: there is none which is not a poison. The right dose differentiates a poison from a remedy. Highly toxic chemicals](https://reader030.fdocuments.in/reader030/viewer/2022013014/5acbde327f8b9a875a8bed01/html5/thumbnails/23.jpg)
1) Immediate and Supportive measures
After instituting ABC interventions, more detailed evaluation is required:
B. PHYSICAL EXAMINATIONS- Careful evaluation of S&S searching for toxidromes
Second:
![Page 24: Management of Toxicity€¦ · · 2018-02-19All substances are poisons: there is none which is not a poison. The right dose differentiates a poison from a remedy. Highly toxic chemicals](https://reader030.fdocuments.in/reader030/viewer/2022013014/5acbde327f8b9a875a8bed01/html5/thumbnails/24.jpg)
TOXIDROMES
It is a group of signs and symptoms and/or characteristic effects
associated with exposure to a particular substance or class of substances.
Use all your senses, search for the clues
• LOOK
– Pupil Size
• FEEL
– Temperature, Sweating
• SMELL
– Alcohol
![Page 25: Management of Toxicity€¦ · · 2018-02-19All substances are poisons: there is none which is not a poison. The right dose differentiates a poison from a remedy. Highly toxic chemicals](https://reader030.fdocuments.in/reader030/viewer/2022013014/5acbde327f8b9a875a8bed01/html5/thumbnails/25.jpg)
1) Immediate and Supportive measures
After instituting ABC interventions, more detailed evaluation is required:
B. PHYSICAL EXAMINATIONS- Careful evaluation of vital signs (B.P, pulse, respiration,
temperature):
Second:
Hypertension Cocaine, amphetamines … etc
Rapid respiration Carbon monoxide.
Hypothermia C.N.S depressants.
![Page 26: Management of Toxicity€¦ · · 2018-02-19All substances are poisons: there is none which is not a poison. The right dose differentiates a poison from a remedy. Highly toxic chemicals](https://reader030.fdocuments.in/reader030/viewer/2022013014/5acbde327f8b9a875a8bed01/html5/thumbnails/26.jpg)
1) Immediate and Supportive measures
After instituting ABC interventions, more detailed evaluation is required:
B. PHYSICAL EXAMINATIONS
- Pinpoint miosis is a typical sign of opioids toxicity.- Mydriasis is very common with cocaine.
- Ulcers/signs of burns with corrosives.- Bitter almond odor with cyanide toxicity.- Gingival lead lines with lead intoxication.
Second:
Eye:
Mouth:
![Page 27: Management of Toxicity€¦ · · 2018-02-19All substances are poisons: there is none which is not a poison. The right dose differentiates a poison from a remedy. Highly toxic chemicals](https://reader030.fdocuments.in/reader030/viewer/2022013014/5acbde327f8b9a875a8bed01/html5/thumbnails/27.jpg)
1) Immediate and Supportive measures
After instituting ABC interventions, more detailed evaluation is required:
B. PHYSICAL EXAMINATIONS
- Cyanosis may be caused by airway obstruction and methemoglobinemia.
- Hyperactive bowel sound, cramping and diarrhea are associatedwith arsenic intoxication.
Second:
Skin:
Abdomen:
![Page 28: Management of Toxicity€¦ · · 2018-02-19All substances are poisons: there is none which is not a poison. The right dose differentiates a poison from a remedy. Highly toxic chemicals](https://reader030.fdocuments.in/reader030/viewer/2022013014/5acbde327f8b9a875a8bed01/html5/thumbnails/28.jpg)
2) Preventing absorption (Gut Decontamination)
It is usually not effective more than 4-6 after poison ingestion.
It is used only for orally ingested poisons.
Methods of gut decontamination:
Most clinical toxicologists recommend administration of activated charcoal.
Emesis Gastric Lavage
ActivatedCharcoal
CatherticsWhole Bowel
Irrigation
![Page 29: Management of Toxicity€¦ · · 2018-02-19All substances are poisons: there is none which is not a poison. The right dose differentiates a poison from a remedy. Highly toxic chemicals](https://reader030.fdocuments.in/reader030/viewer/2022013014/5acbde327f8b9a875a8bed01/html5/thumbnails/29.jpg)
2) Preventing absorption (Gut Decontamination)
Method:By the use of syrup of ipeca.The active ingredients are two alkaloids, emetine &cephaeline.Previous popular methods (fingertip stimulation,salt water, apomorphine) are ineffective.
Dose:In children 5-15 ml ipeca syrup + 120 ml water.adults 15-30 ml ipeca + 240 ml water.The dose can be repeated if emesis has not occurred in 30 minutes.If vomiting does not occur gastric lavage or activated charcoal is decided.
EmesisFor alert Pt
![Page 30: Management of Toxicity€¦ · · 2018-02-19All substances are poisons: there is none which is not a poison. The right dose differentiates a poison from a remedy. Highly toxic chemicals](https://reader030.fdocuments.in/reader030/viewer/2022013014/5acbde327f8b9a875a8bed01/html5/thumbnails/30.jpg)
2) Preventing absorption (Gut Decontamination)
Complications:
Contraindication: Children up to 6 months of age. Comatose patient because of increased risk of aspiration. Seizures (due to compromised gag reflex). Certain toxins:
Hydrocarbons& volatile substances.Corrosives (Caustics).
Ingestion of sharp objects.
Emesis
Lethargy DrowsinessProlonged vomiting
Diarrhea
![Page 31: Management of Toxicity€¦ · · 2018-02-19All substances are poisons: there is none which is not a poison. The right dose differentiates a poison from a remedy. Highly toxic chemicals](https://reader030.fdocuments.in/reader030/viewer/2022013014/5acbde327f8b9a875a8bed01/html5/thumbnails/31.jpg)