Management of acute poisoning and organophosphate poisoning

Management of acute Poisoning
poison and management
organophosphate poisoning
organophosphate poisoning management

1. MANAGEMENT OF ACUTE POISONING - Manshad khan Pharmacology and Toxicology MS Pharm/2023-25/PT/17 NIPER HAJIPUR

2. Table of Contents Introduction Types of Poisoning General Poisons used in India Clinical signs of Poisoning Detection and Identification of Poison General Approaches Antidotes References

3. The World Health Organization (WHO) estimated that 640 thousand people had died annually due to poisoning, of which, majority deaths occurred in low-income and middle-income countries. The mortality rates due to poisoning are significantly higher in developing economies as compared to developed economies. National data in India estimated 70 thousand people died annually due to poisoning with a rate of 2.4 per 1,00,000 population. Introduction and Epidemiology- A poison is a substance that is capable of causing illness or harm to a living organism on contact or upon introduction to the body. .

4. Deliberate Poisoning:- Types of Poisoning:- Deliberate poisoning refers to the intentional administration or exposure of toxic substances to a person, animal, or environment with the explicit intent to cause harm. Accidental Poisoning:- Ingestion of a toxic substance not in- tended for internal use, or, if intended. for oral administration, potentially harm- ful in the amount consumed. Environmental Poisoning Industrial Exposures:- Toxic Industrial Chemicals (TICs):- Asbestos, Formaldehyde. Carbon Monoxide:- whenever fossil fuel is burned; headache, dizziness, lightheadedness Lead, Other heavy metals:- Lead poisoning from traditional eye makeup Water-borne Toxins:- Cryptosporidium- is a germ that causes diarrhea carcinogens, reproductive hazards, corrosives, or agents that affect the lungs or blood

5. General Poisons used in India :- • Organophosphorus poisoning • Organochlorides – Endosulphan poisoning • Rat poisons • Aluminum phosphide poisoning • Acetaminophen overdose • Barbiturate

6. Clinical Signs of Pharmaceutical agents causing poisoning and drugs of misuse Epigastric tenderness Epigastric tenderness:- NSAID’S, Salicylates Right Upper Quadrant:- Paracetamol BLOOD PRESSURE:- HYPOTENSION- TRICYCLIC ANTIDEPRESSANTS HYPERTENSION- COCAINE RESPIRATORY RATE:- IN-CREASED- SALICYLATES REDUCED- OPIODS PUPIL SIZE :- SMALL- CLONIDINE, OPIODS LARGE- TRICYLCIC ANTIDEPRESSANTS, COCAINE, ALCOHOL Rhabdomyolysis:- Amphetamines, caffiene Cereberal signs:- Anticonvulsants,alcohol Extrapyramidal signs:- phenothiazine Cyanosis: any CNS depressants drugs , Dapsone Heart Rate :- Tachycardia- TCA, digoxin Bradycardia- Calcium channel blocker Body Temperature:- Hyperthermia- - SSRI Hypothermia- CNS depressants

7. Detection and Identification of Poison:- Some basic test or color test for detection of Poison Test name Procedure Result Marquis reagent test marquis reagent – few drops on content of stomach. A purple coloration which gradually turns into violet and finally to blue color - OPIUM Fujiwara test Dilute 1ml of sample with 2ml of sodium hydroxide solution. Blue colour- cyanide Reins Ch test Copper black –antimony  Dull black-arsenic  Shiny black- bismuth  Silver colour- mercury Trinders test Add 100 ml of Trinder's reagent to 2ml urine and mix for 5 seconds. A violet color indicates the presence of salicylate. FPN test 5ml of ferric chloride solution , 45 ml of 20% solution of perchloric acid and 50 ml of 50% solution of nitric acid is added to make a final solution. m pink to red, orange , violet or blue color indicates presence of phenothiazines. Characterization Signs and symptoms Probable toxin Temperature Hypothermia (phenothiazines, barbiturates, or tricyclics) Hyperthermia (amphetamines, ecstasy, MAOIs, cocaine, antimuscarinics, theophylline, serotonin syndrome) Skin cyanosis ( methaemoglobinaemia ) very pink (carboxyhaemoglobinaemia, cyanide, hydrogen sulfide ) Blisters (barbiturates, tricyclic antidepressants (TCAs), benzodiazepines), needle tracks, hot/flushed (anticholinergics). Breath Ketone bitter almonds Garlic Rotten egg (diabetic/alcoholic ketoacidosis) Cyanide  (organophosphates, arsenic) Hydrogen sulfide . Mouth perioral acneiform lesions dry mouth Hypersalivation (solvent abuse) Anticholinergics), Parasympathomimetic General examination:-

8. General Approaches in management of poisoning :- • ABC (Airway, Breathing & Circulation) • History taking • Physical Examination • Toxidrome recognition • Decontamination • Specific Antidotes • Symptomatic and Supportive Care • Referral if needed Looking, listening and feeling for breathing Opening the airway with a head tilt-chin lift maneuver Perform chest compressions to support circulation in those who are non-responsive without meaningful breaths

9. Survey :- • Head To Foot Evaluation • Monitoring of Vitals :(Temp., B.P., H.R, R.R.,) • Breath Odor • System Examination • Look for Bite marks, Needle marks, and Ligature marks on the neck. • Continuous Monitoring Toxidromes :- Toxidrome Clinical Features Likely Poison Anticholinergic Agitation/delirium, mydriasis, dry skin, ileus, urinary retention, tachycardia Tricyclicantidepressants,antihistamines, Datura species Cholinergic Miosis, hypersalivation,lacrimation,bronchorrhoea,diarrhoea, urination ,fasciculations and muscle weakness Organophosphorus and carbamate insecticides, nerve agents Opioids Coma, miosis, reduced respiratory rate Opioid drugs, e.g morphine and heroin Sedatives and hypnotics Coma, hypotonia, hyporeflexia, hypotension Barbiturates, benzodiazepines, ethanol, zopiclone Serotonin Agitation, confusion, myoclonus, hyperreflexia, sweating, tremor, diarrhoea, incoordination/ataxia, Serotoninergic drugs , e.g citalopram, tramadol and ecstasy.

10. Decontamination :- Avoid contaminating yourself and wear protective clothing Ensue that the area is well ventilated Wash all contaminated skin with warm water + soap Decrease Absorbtion :-. Single-dose activated charcoal is the preferred in many cases The usual dose is 50 g for an adult (children: 1 g/kg) Poisoning with iron, lithium, boric acid, cyanide, ethanol, strong alkalis etc LIMITATIONS:- Delayed Absorption Potential Harm Rendered ineffective ;Antidotes

11. 2. Gastric lavage:- Gastric lavage means cleaning out the contents of the stomach. Technique:- Gastric lavage involves the passage of a tube via the mouth or nose down into the stomach. Patient should be lying on his left side or prone with head hanging over the edge of the bed and face down The end of tube is lubricated before passing it by depressing the tongue. Lavage is repeated until the returning fluid shows no further gastric contents. Gastric lavage can be done with: Complications 0.9% saline 5% sodium bicarbonate Aspiration pneumonia Bradycardia Mechanical injury to the stomach.

12. Antidotes:- An Antidote is a substance that counteracts with the effects of Poison. Modes of Action :- Inert Complex Formation :- Ex, Chelating agents for Heavy metals Accelerated Detoxification :- Ex: Thiosulphate accelerates conversion of Cyanide to Non-toxic Thiocyanide. 3. Reduced Toxic Conversion :- Ex: Ethanol inhibits metabolism of Methanol by competing for same enzyme ( Alcohol dehydrogenase) 4 . Receptor Site Competition:- Ex: Atropine blocks the effect of Anticholinesterase 5. Toxic Effect Bypass :- Ex: ex, giving 100% oxygen to bypass the toxicity of Cyanide. Poison/ drug Specific Antidote Paracetamol N- Acetylcystiene Cyanide Sodium thiosulphate, Dicobalt edetate. Atropine Physostigmine Organophosphate Atropine Oximes, (Pralidoxime) Oxalic acid Calcium gluconate Iron Desferoxamine Lead Calcium disodium versenate . Antidotes

13. Organophosphorus compounds Excessive sweating Salivation and drooling Nausea, vomiting, and diarrhea Difficulty breathing Pathophysiology of acute organophosphorus poisoning Management of Acute Organophosphate Poisoning Oranophosphorus pesticides are used widely for agriculture, vector control, and domestic purposes. Inhibition of acetylcholinesterase Accumulation of acetylcholine at cholinergic synapses Normal function of the autonomic, somatic, and central nervous systems Diagnosis Laboratory Tests: Cholinesterase Levels: P seudocholinesterase (BuChE) in the blood Blood Tests Urinalysis Detecting metabolites of organophosphates in urine. Sign or symptoms Recommended Therapy Excessive salivation, lacrimation, nausea and vomiting, diarrhea. Atropine, glycopyrrolate Bronchorrhea, bronchospasm Atropine, ipratropium, glycopyrrolate Hypotension Fluids, atropine, vasopressors, inotropes Bradycardia Atropine, glycopyrrolate Atropine dosage :- 0.05 mg/kg in every 15min

14. Calling Poison Help If the person is What We Can Do :- First steps :- Inhaled poison; _____________ Fresh air poison on skin; _________________ Rinse with water for 20 min. what substances you think the person may have swallowed when the substance was taken (how long ago) why the substance was taken (whether it was an accident or deliberate) how it was taken (for example, swallowed or inhaled) how much was taken (if you know) Took Poison 1‑800‑222‑1222 __

15. References: Van Having, D. J., D. J. H. Veale, and G. F. Müller. "Clinical Review: Emergency management of acute poisoning."  African Journal of Emergency Medicine  1.2 (2011): 69-78. Collee, G. G., and G. C. Hanson. "The management of acute poisoning." British journal of anesthesia 70.5 (1993): 562-573 Patel V , Ramasundarahettige C , Vijayakumar L , et al . Suicide mortality in India: a nationally representative survey. Lancet 2012;379:2343–51.doi:10.1016/S0140-6736(12)60606-0 pmid:http ://www.ncbi.nlm.nih.gov/pubmed/22726517 CrossRefPubMedWeb of Science Google Scholar Ahuja H , Mathai AS , Panna A , et al . Acute poisonings admitted to a tertiary level intensive care unit in northern India: patient profile and outcomes. J Clin Diagn Res 2015;9:UC01–4.doi:10.7860/JCDR/2015/16008.6632 World Health Organization. Suicide key facts, 2019. Available: https://www.who.int/news-room/fact- sheets/detail/suicide [Accessed 01 Oct 2019] https://poisonhelp.hrsa.gov/faq/first-steps-poisoning-emergency .

16. Thank you! RASHMIKA