Clinical toxicology

lecture of clinical toxicology
dr.hossam kandeel

1. DR/ HOSSAM KANDEEL

2. نع لاـق هنع الله يضر ةريره يبأ:
ىلص الله لوسر لاق هيلع الله ملسو
( ثلاث نم لاإ هلمع عطقنا دبعلا تام اذإ :
حلاص دلو وأ ، هب عفتني ملع وأ ، ةيراجةقدص
هل وعدي)

10. Our rules

16. •General :
- Emergency ABCD approach for unconscious pt
- Diagnosis
- steps of treatment

•Special :
- Most common toxins

18. A-Airway
•Ensure patent air way , if not :
 open :
- Triple maneuver
- Tubes
 clean :
- finger sweep
- suction

19. Triple maneuver

20. 2- Tubes
•Oropharyngeal

•Cuffed endotracheal

•Tracheostomy

21. Oropharyngeal tubes

22. Tubes “endotracheal “

23. Tracheostomy

24. Clean
- finger sweep


- suction

25. Sweep

26. Suction

27. Suctioning

28. Don’t forget
•Ensure patent air way , if not :
 open :
- Triple maneuver
- Tubes
 clean :
- finger sweep
- suction

29. Breathing
•Ensure adequate breathing by
Look
Feel
Listen
Give O2 mask

30. Look listen and feel

31. Circulation
•Pulse  if no pulse start CPR
•2 wide bore cannula avoid hypotension


•shock : - elevate lower limb
- saline

32. Treatment of shock

33. Disability
•Convulsion 
One fit : nothing is done

More than one fit : neuril amp (diazepam )
- dose  ampule slowly IV
- repeat it in need  not more than 3 times

34. Convulsions

36. 2- diagnosis
•History taking

•Clinical picture

•Investigation

•Differential diagnosis

38. First question

39. 2
nd
question

40. 2- diagnosis
•History

•Clinical picture “and rapid examination “

•Investigation

•Differential diagnosis

41. Clinical picture “
and
rapid examination “

42. Check vital signs
•Blood pressure
•Pulse
•Temperature
•Respiratory rate
level of conscious
•Glasgow coma scale

43. 2- diagnosis
•History

•Clinical picture

•Investigation

•Differential diagnosis

44. Investigations
•Routine :
-Blood
-Biochemical : Rft . Lft
-Others “ ECG – x-rays “
•Specific :
- According to the drug

45. Rapid investigations if needed

•Random blood glucose why ?

•ABG

•ECG

46. 2- diagnosis
•History

•Clinical picture

•Investigation

•Differential diagnosis

49. 5 minutes discussion


What about your goals

51. •If you don’t want
,you will find an
excuse .

52. In order to succeed your
desire for success should
be greater than your fear
of failure

53. Steps of treatment

•Decontamination

•Elimination

•Supportive and symptomatic

54. Decontamination
•Emesis

•Gastric lavage

•Local antidote

55. Emesis
Types
•Mechanical :
-gag reflex
•Chemical
-Central : apomorhine
-Peripheral
-Mixed
Indications ???

56. Gag reflex

57. Induction of vomiting XXXXXX

58. Emesis
•The rule in emesis is

“emesis is indicated to be contraindicated “

Hossam kandeel

60. Decontamination
•Emesis

•Gastric lavage

•Local antidote

61. Gastric lavage
not used routinely nowadays
•Indications :
-Failure of emesis
-Drugs which are sustained release
-To administrate activated charcoal
-Tricyclic antidepressant
•Contraindications :
-Corrosive except phenol ?
-Kerosene
-Chronic poisoning
-Time passed more than 6 hours except …,….

62. Method of gastric lavage

63. Method of gastric lavage

64. Decontamination
•Emesis

•Gastric lavage

•Local antidote

65. Local antidote
•Activated charcoal

•Demulcent

•NB : precipitation is a local antidote mechanism
“Nablion”

66. Activated charcoal
•Give it to all toxins except

67. Method of administration
•Dose : 1gm /kg
•Method : dose + water or juice + cathartics + antiemetic
•You can repeat it again

•Very useful in gut dialysis

68. Activated charcoal

69. Eucarbon = charcoal tablets
10.5LE

70. Demulcent
•What do you think about it ?

71. Elimination
•Diuresis and dialysis

•Specific antidote


•Special for each toxin

72. Supportive ttt
•Hypotension : elevate leg + saline

•Convulsions : neuril amp. Slowly IV

•Hyperthermia : cold fomentation + paracetamol

•Hypothermia : warming

•Urine retention : catheterization

75. Special types of toxins
“most common cases “
1.Organophosphate
2.Hydrocarbon ingestion
3.Primperan toxicity
4.Carbon monoxide
5.Opioid
6.Paracetamol and aspirin
7.Naphthalene
8.Zinc phosphide
9.Snake bite

76. Organophosphate

•Mechanism :
increase ACH via inhibition of ACHE enz.
how ?

•History :
-farmer
- suicidal attempt

78. Clinical picture
•Clinical picture : DUMBBELS  increase all secretions
D Diarrhea  GIT  Nausea- vomiting- colic
U Uremia  Bladder incontinence of urine
M Moises  Pin- point- pupil
B Bronchi  Bronchospasm and wheezes -Branchorrhea
B Bradycardia, hypotension
E Emesis
L Lacrimation
S Salivation .
Sever cases vomiting , diarrhea Metabolic acidosis

79. Clinical pic. Cont………..
 Due to nicotinic action
-Stimulation: TMF  Tremors – Muscle cramps-
Fasciculation
-Inhibition : Muscle  wasting  paralysis
Due to centeral action:
-Stimulation CNS  Restlessness- irritability –
agitation
-Inhibition CNS  Stupor-coma-R.C depression

80. Treatment
•As general steps
ABCD  corner stone in treatment
•If skin is exposed  wash the skin

•Antidote :
- atropine 2amp IV every 10minutes
Till
Dryness of chest secretion
- Oximes 1gm  in hospital

81. Hydrocarbon
•History : ……..

•Clinical picture :……………….

•Treatment :
- O2 inhalation
- Zantac amp
- Solucortef vial 3.5 ?????????
- Penicillin ??????
No emesis or gastric lavage

82. Kerosene poisoning

83. Primpran
•Clinical picture : ………
•Treatment :
Stop it
According to the age :
-Less than 2ys  ½ amp “avil- solucortef “
-More than 2ys  1amp “avil – solucortef “

84. Carbon monoxide
•History :………………..
•Clinical picture :…………
•Treatment :
-as general
- O2 , O2
- hyperbaric O2

85. Mode of poisoning

87. Opioid + tramadol 
•History ………
•Clinical triad :
coma
RC depression
 pin point pupil
•Treatment
As general
 lavage and charcoal
Antidote :
Naloxone amp : 18LE  amp +200cc water
for 1hour

88. Pinpoint pupil

89. Analgesic
•Paracetamol :
 history
Clinical picture
Treatment : general + lavage +18doses of oral NAC
•Aspirin : 0.3gm / kg
 history  
Clinical picture : tinnitus ???
Treatment  

90. Others
•Naphthalene balls :


•Zinc phosphide :


•Snake bit :who was the most famous person he/ she dead
by it suicidal ?.

•Corrosive

91. Naphthalene ball

92. Snake bites
•In Egypt most of snakes not toxin
•Hernid viper vs copra
•Management
At scene:
1-Calm pt and try to identify snake
2-Splint in fractures→ immobilize the bitten limb.
3-Apply tourniquet proximal to site of bite and released for (30seconds) every
15 minutes’.
4-Suction over bits marks→ batter than incisions to prevent infection to wound
by incised instrument.

93. Tourniquet ??

94. - At hospital: →

1. support→ monitor vital signs
2.Analgesic
3.Antibiotics.
4.Anti-tetanus
5.Anti-venoum
→ preparation: prepared on hors
→ types : Monovalent-pentavalent
→Action: neutralize toxin
→ Dose - Mild→5vials
- Moderate→10vials
- Sever→15 vials

95. Suction of toxin

97. Poisonous and non

99. Feed back
•Lecture
-information
- duration
- interruption
- Presentation
•Lecturer
-Speed
-Management of lecture
-Your participation with me