TOXICOLOGY | MIDTERM | PRINCIPLES OF MANAGING THE POISONED OR OVERDOSED PATIENT

Star%ng point
- have used a clinical approach to the poisoned or overdosed pa1ent that
emphasizes “trea1ng the pa1ent rather than trea1ng the poison”. Signs and Symptoms
Alimentary features
- prepared to administer a specific an1dote immediately in those instances when • Pain and ulcera1on of the oral cavity
nothing else will save a pa1ent, all poisoned or overdosed pa1ents will benefit • Saliva1on
from an organized, rapid, clinical management plan • Dryness of mouth
• Nausea and vomi1ng

In 1970’s
- advocate a standardized approach to a comatose and possibly overdosed adult Laboratory Inves%ga%on
pa1ent, typically calling for the intravenous administra1on of 50 mL of D50W, 100 - Hematological and biochemical inves1ga1ons are o`en performed on the
mg of thiamine, and 2 mg of naloxone, as well as 100% oxygen at high flow rates. poisoned pa1ent who is seriously ill.

- compensate for the previously idiosyncra1c style of overdose management

encountered in different healthcare seIngs and for the unfortunate likelihood Examina%on of urine
that omiIng any one of these measures at the 1me that care was ini1ated in the 1. Green or blue urine
emergency department would result in omiIng it altogether. 2. Orange or orange red urine
3. Urine which is grey to black in color strongly suggests poisoning with compounds
containing phenols and cresols (Lysol),
4. Primidone may crystallize in the urine as it cools. If the urine is then shaken whorls
Today.... of shimmering, highly refrac1le crystals can be seen.
- widespread availability of accurate rapid reagent bedside tes1ng for blood
glucose
Inspec%on of blood and plasma
- pulse oximetry for oxygen satura1on 1. Freshly drawn venous blood that is chocolate-brown in color suggests
methemoglobinemia and possible poisoning with oxidizing agents such as
- individualized approach to determine the need for and in some instances more chlorates, aniline, nitrates
precise amounts of dextrose, thiamine, naloxone, and oxygen.
2. Pink or brown discolora1on of plasma, assuming blood sample was taken
- closer examina1on of the actual benefits and risks of various gastrointes1nal with care, suggest hemolysis and possible poisoning with chlorates, nitrates
emptying interven1ons.

- Apprecia1on of the poten1al for significant adverse effects associated with all
types of gastrointes1nal emptying interven1ons and recogni1on of the absence Laboratory Finding Possible Toxic Cause
of clear evidence-based support of efficacy, Hematology
Common with poisons which cause 3ssue
Leukocytosis necrosis
Leukopenia/Thrombocytopenia Colchicine and other cytotoxic drugs
Sources of Poison Hepatotoxins (paracetamol, carbon
• Domes1c or household sources tetrachloride, phenylbutazone, isoniazid),
• Agricultural and hor1cultural sources Industrial sources oral an3coagulants (warfarin and
• Commercial sources Prothrombin Time Prolonga3on coumarins)
• From uses as drugs and medicines Urea and Electrolytes
• Food and drink Cardiac glycosides, chloroquine, beta-
• Miscellaneous sources Hyperkalemia adrenergic blockers, potassium salts
Hypokalemia Diure3cs, sympathomime3c drugs
Bicarbonate Reduced Carried out in arterial blood gas analysis
Arterial Blood Gas Analysis
HOW ARE POISONS CLASSIFIED? Methanol, ethylene glycol, salicylates
• according to the site and mode of ac1on Metabolic Acidosis (rarely), cyanide, isoniazid
• according to mo1ve or nature of use Respiratory Acidosis CNS depressant drugs
Salicylates, 2,4D and related compounds
Respiratory Alkalosis LSD, sympathomime3cs
LOCAL ACTION Glucose
• Corrosive Insulin, oral hypoglycemic agents, ethanol,
salicylates, may also complicate severe toxic
• irritants
Hypoglycemia hepa3c necrosis
Hyperglycemia Drugs causing hepa3c necrosis
SYSTEMIC
• Cerebral
• Spinal
• Peripheral Nerves
• Cardiac Poisons
• Asphyxiants
• Miscellaneous
4 STEPS OF TOXIC ASSESSMENT

1. 1ABCDE Assessment (Airway, Breathing, Circula1on, Disability and Exposure)

Poisons can be classified into
1. Homicidal
2. Name the Toxidromes (signs and symptoms)
2. Suicidal
3. Accidental
3. Risk Assessment
4. Abor1facient
• Drug: What, How much, When, etc..
5. Stupefying agents
• Pa1ent: How, BW, Co-Med, Co-Morb
6. Agents used to cause bodily injury
7. Ca\le Poison
4. General Treatment: DEAD
8. Arrow poison
• Decontamina1on
9. Aphrodisiacs
• Elimina1on
• An1dote
• Disposi1on
Diagnosis of Poisoning
- history given by the pa1ents, by a witness to the episode or on circumstan1al
evidence.
- findings on physical examina1on
DECONTAMINATION
Goal: Decrease the absorp1on or delay absorp1on of toxic agents
• Is there Contraindica1on?
History Taking:
• Indica1on?
• Nature of the poison
• Is it effec1ve?
• Quan1ty of the poison
TOXICOLOGY | MIDTERM | PRINCIPLES OF MANAGING THE POISONED OR OVERDOSED PATIENT
Gastric Lavage
Ac%vated Charcoal
Whole Bowel Irriga%on

Gastric Lavage
- Gastric tube and flushing 300 ml Water or NS

Contraindica%on
• corrosive
• vola1le substances
• Reduced consciousness
• Agitated/uncoopera1ve
• ABC instability

Perform within 1 hour of inges1on considered within 4 hours depending on the drug

Ac%vated Charcoal
- Used as a binding agent to prevent absorp1on Charcoal
- 50g in water either drink or gastric lavage

Contraindica%on
- Absent bowel movements
- Ileus
- GI hemorrhage
- Agitated or uncoopera1ve

Whole Bowel Irriga%on

- Used when there are drugs involved that will not bind to AC
- Slow released prepara1on
- 3-6L of polyethylene glycol, either drink or NG

Contraindica1on

ENHANCE ELIMATION
MDAC
URINE ALKALINIZATION
EXTRACORPOREAL TECHNIQUES

Mul%ple Dose Ac%vated Charcoal

Interrupts enterohepa1c circula1on:
• Theophylline
• Phenobarbital
• Dapsone
• Carbamazepine
• Quinine

URINE ALKALINIZATION
- Alkalinize urine by sodium bicarbonate, ionizes weak acids (aspirin,
phenobarbital)
- Aim for urine pH of 7.5 and serum pH between 7.45 to 7.55 --- BEWARE OF
HYPOKALEMIA

EXTRACORPOREAL TECHNIQUES
- Hemodialysis and hemofiltra1on
- Notable toxins that can be eliminated this way:
• Isopropanolol
• Salicylates
• Theophylline
• Uremia
• Methanol
• Barbiturates
• Lithium
• Ethylene glycol

DISPOSITION