Approach to a toxicological patients

DR. HEND ELHELALY, MD

CLINICAL TOXICOLOGY, ASU

How to diagnose a Toxicological case

Poisoning  should  be  suspected  in  all   cases  of: sudden,  severe,  and  unexpected  illness.

▪Persistent vomiting of unknown origin and without fever

Non toxic exposure

The following general guidelines for considering an exposure nontoxic or minimally toxic will assist clinical decision making:

1. Identification of the product and its ingredients is possible.

2. The Consumer Product Safety Commission (CPSC) “signal words” CAUTION, WARNING, or DANGER does not appear on the product label.

3. The history permits the route(s) of exposure to be determined.

4. The history permits a reliable approximation of the maximum quantity involved with the exposure.

5. Based on the available medical literature and clinical experience, the potential effects related to the exposure are expected to be at most benign and self-limited, and do not require referral to a healthcare facility.

6. The patient is asymptomatic, or has developed the expected benign self-limited toxicity.

How to Manage?

Could You differentiate the following Terminology # Management # Diagnosis # Treatment # Provisional diagnosis # Final Diagnosis

Management

▪ First Evaluation and Assessment of emergency situations and ttt of life threatening conditions

▪Second revaluation, detailed history and full examinations and provisional diagnosis and start ttt.

▪ Thirdly Frequent revaluation and ttt of complications and follow up

History

▪Presenting complaint: IN patient's words (no medical terms);▪ analyze the Symptom (site –onset- duration –recurrence –what increase it, what decrease). ▪ Substance (name-ingredient -regular form –slow release- enteric coated) ▪Amount.▪Time of intoxication- delay.▪Symptoms. (Relation between time of ingestion and symptoms).▪Where - mode of intoxication-route. ▪Pre-consultation treatment (gastric lavage - emesis-antidotes)

▪A B C D▪Monitoring▪History:

Examination, investigation and final diagnosis

▪Emergency

▪Specific

▪Follow up serum choline esterase enzyme

Case I

20 years old male presented to the PCC ER 10 hours after ingestion of his mother tablets who known to be diabetic and hypertensive. The toxicologist had performed primary evaluation; the initial vital data were 100/70 mmhg, pulse 60/ minute and the patient looked pale. On the ER the patient was given syrup of ipecac and had started to vomit after that he was transferred to the observation room for follow up. Few minutes later the patient collapsed and underwent cardiac arrest. CPR was done and he was transferred to ICU unit where other life support measures were given. Detailed history about the medications of her mother and she told that she is on antihypertensive drugs. The patient was put on continuous cardiac monitoring which revealed specific ECG changes.

Investigations

Treatment

▪ Life saving Atropine

▪ Glucagon

▪ Supportive

▪ ICU and Cardiac Monitoring

▪ Cardiac inotropics

▪ Cardio-version and pacing

Case II

Twenty Two years old man was brought to the emergency department with coma and constricted pupils. Cyanosis and hypoventilation with crepitations were observed. Miosis, cold skin and multiple skin tracks were observed. Vital signs examination showed pulse 50 beat/min.Bl.Pr 90/60mmHg RR 6/min. In-addition, abdominal auscultation revealed no intestinal sounds. The patient suffered two attacks of convulsions. Blood samples were taken for investigations. Emergency management was done in ER then admitted to the ICU for mechanical ventilation and cardiac monitoring. After one day the patient died.

Treatment

▪ Naloxone (life saving) unless there is attack or history of convulsions

▪ If any avoid and try to restrain and give diazepam

▪ ICU & cardiac monitoring

Case III

200 workers at cloths factory in 10th of Ramadan presented to Ain Shams University hospitals PCC ER with vomiting, colics and flushing. Some of them told the resident that the beginning of symptoms appeared after their lunch. On examination Bl.Pr ranging from 100/60 to 80 /50, pulse was 100 to 120 Beat/min ans RR 16/min. 1 hour later three females went in drowsiness, peripheral tingling and numbness. The resident admitted 5 cases from them for 24 hours and others were discharged 6 hours later.

Group Poisoning????????????

Scrompoid? Tetradotoxin? Siguatora Toxin? 

Case IV

▪ A farmer found collapsed in his farm. Rescuer transferred him to ER, with history of repeated attacks of vomiting and diarrhea. On Examination he was found drowsy, weak, evident fasciculations and characteristic smell. Vital data examination revealed that, blpr: 100/70, Pulse: 50/min, RR 20/min, Tep: 36.5. he had constricted pupil, bilateral noisy breathing and increased intestinal motility.

▪ Life Saving Atropine

▪ Supportive therapy

OP

▪ ABCD

▪ History, Farm, Planet, Home, Child, house-hold

▪ Cardinal signs, smell

▪ Life saving ttt.

▪ DD

Corrosives

▪ Household, lap, homicidal

▪ 1st aid

▪ Nothing oral

▪ Local and systemic analgesics

▪ Follow up swallowing

▪ Surgery

Animal Poisoning – Scorpion

▪ Scorpion and Snake

▪ ABCD

▪ Follow up

▪ Antivenum if hypertension,

▪ Pulmonary crepitations

▪ Agitations or CNS toxicity

▪ 1-2 amp inchild

▪ Up to 5 amp in adulty

Snake Bite

Types of snake Copa viber

Local ---- ++++

Systemic Descending paralysis Coagulopathy, cardio and nephrotoxicity

investigation ABG CBC PT PTT Liver and kidney function testes

treatment Mechanical ventilation Plasma, whole blood and supportive

Antivenom skin test before Antivenom

THANK YOU

Dr.hend2008@yahoo.com

0226840902-022482331401001524119

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