Management of posioning and drug overdose toxicity.pptx

This presentation — “Management of Poisoning and Drug Overdose Toxicity” — provides a comprehensive and clinically practical guide for medical students, residents, and healthcare providers to manage acute poisoning cases in emergency settings. Beginning with epidemiology and diagnosis, it explains the ABCDE resuscitation approach, detailed steps for decontamination (gastric lavage, activated charcoal, whole bowel irrigation), methods to enhance poison elimination (urine alkalinization, hemodialysis), and a structured antidote-based management algorithm. A dedicated section simplifies identification of toxic syndromes (toxidromes) including cholinergic, anticholinergic, opioid, sedative-hypnotic and serotonin syndrome. This PPT is exam-oriented, case-applicable, and ideal for MBBS/MD teaching and emergency medicine training.

1. Management of poisoning and drug overdose toxicity Presenter : Dr. Debendra Suman (JR-3) Department of Pharmacology & Therapeutics King George’s Medical University, Lucknow, U.P, India Email id: [email protected]

2. Contents History Introduction Epidemiology Diagnosis of poisoning Management approach for poisoning and drug overdose Removal of unabsorbed poison from the body Removal of absorbed poison from the body Administration of Antidotes Identification of Toxidromes Summary References

3. Specific learning objective At the end of this teaching learning session, co-learners will be able to: Describe the ABCDE resuscitation approach for poisoning cases Enumerate the methods used for removal of unabsorbed and absorbed poisons from the body Explain the indication and contraindications of gastric lavage and activated charcoal Enumerate various types of antidotes and their uses Explain the toxidrome approach in poisoning management

4. History Paracelsus – Swiss physician, and philosopher of the 16th century Father of Toxicology “All things are poison and nothing is without poison, only the dose permits something not to be poisonous” 30-07-2025 Dr. Debendra Suman 1

5. Introduction Poisoning refers to the development of dose-related adverse effects following exposure to chemicals, drugs, or others xenobiotics Drug overdose toxicity is often used interchangeably with poisoning Common medical emergency in any country In India - Pesticides In western countries - Drug overdose Commonest cause of poisoning 30-07-2025 Dr. Debendra Suman 2

6. Introduction COMMON POISONS AROUND US 30-07-2025 Dr. Debendra Suman 3

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9. Epidemiology According to WHO, 6,40,000 people die each year from poisoning globally Death rate is higher in developing countries compared to developed countries National data in India showed 70,000 people die annually from poisoning Mortality rate is of 2.4 per 1,00,000 population 30-07-2025 Dr. Debendra Suman 6

10. Epidemiology Easy access to pesticides leads to increase in poisoning rates Rural area and young adults (age 15–44) are mostly affected Organophosphate and aluminum phosphide are the most common pesticides that causes poisoning in India 30-07-2025 Dr. Debendra Suman 7

11. Diagnosis of poisoning History will be unreliable History, physical examination, routine and toxicological laboratory evaluation A thorough search of exposure environment (pill wrapper or bottle, suicide note) Mental status, vital signs, and pupillary examinations 30-07-2025 Dr. Debendra Suman 8

12. Management approach for poisoning and drug overdose The standard sequence of steps are Remove patient from exposure Initial assessment and stabilization(ABCs) History, physical examination and risk assessment Supportive care and monitoring Prevention of poison absorption Enhance elimination of poison Administration of specific antidotes Adequate Follow-up 30-07-2025 Dr. Debendra Suman 9

13. Immediate resuscitative measures

14. 1. Immediate resuscitative measures Look ABCDE of resuscitation Airway Breathing Circulation Depression of CNS/ Decontamination Evaluation of patient 30-07-2025 Dr. Debendra Suman 10

15. A. Airway Assessment by Assess protective reflexes Monitor oxygen saturation continuously If inadequate Clean airway (secretions, vomit) Endotracheal intubation Tracheostomy 30-07-2025 Dr. Debendra Suman 11

16. B. Breathing Assessment by Adequate tidal volume Perform Arterial blood gas analysis Capnography If inadequate Supplemental O2 therapy (mask or endotracheal intubation) Maintain tidal volume at 10-15 mL/kg 30-07-2025 Dr. Debendra Suman 12

17. C. Circulation Assessment by Check for presence or absence of radial, femoral, carotid pulse Start continuous cardiac monitoring (12- Lead ECG) If inadequate Secure IV access IV fluid administration Antidysrhythmic therapy Vasoactive agents Atropine ,Mg, NaHCO 3 CPR- Chest compressions 30-07-2025 Dr. Debendra Suman 13

18. D. Depression of CNS Glasgow coma scale Severe = ≤8 Moderate= 9-12 Minor = >13 30-07-2025 Dr. Debendra Suman 14 Score Eyes Verbal Motor 6 - - Obeys commands 5 - Oriented to time place and person Localise pain 4 Spontaneously Confused Withdrawal from pain 3 To voice Inappropriate words Abnormal flexion (decorticate) 2 To pain Incomprehensible sounds Abnormal extension (decerebrate) 1 No response No response No response Glasgow Coma Scale (GCS) 

19. D. Depression of CNS D also denotes- D econtamination D extrose (correct hypoglycaemia) D ialysis D isability evaluation D rugs 30-07-2025 Dr. Debendra Suman 15

20. E. Evaluation of patient Done when the patient is stabilized Undress the patient as needed by maintaining dignity and privacy of the patient Perform a thorough head-to-toe check- back, axilla, groin, under dressing Prevent hypothermia Systemic examination 30-07-2025 Dr. Debendra Suman 16

21. Removal of unabsorbed poison from the body

22. Contact Poisons Eyes – Irrigation with crystalloid solution Skin – Wash exposed area with soap and water, remove clothing , jewellery Eye irrigation 30-07-2025 Dr. Debendra Suman 17

23. Ingested poisons 1. Emesis An emetic is a substance that induce vomiting when administered orally or by injection E.g. Ipecac powder or syrup Obsolete now 30-07-2025 Dr. Debendra Suman 18

24. 2. Gastric Lavage Ewald’s or Boa’s tube Useful within 1 hours after ingestion Larger bore, faster lavage Ryle’s tube Less efficient for lavage Narrower, mainly for feeding and aspiration 30-07-2025 Dr. Debendra Suman 19

25. Indication of gastric lavage Life threatening Ingestion of a poison or drug, within 1 hrs of ingestion Ingestion of substances not absorbed by activated charcoal Massive overdose of drugs with delayed gastric emptying 30-07-2025 Dr. Debendra Suman 20

26. Contraindication of gastric lavage Corrosives ( exception - carbolic acid, oxalic acid, acetic acid) Loss of airway protective reflexes Sharp & pointed material ingestion (pins, needle, glass) Comatose patient Ingestion of hydrocarbons or volatile substances Late arrival of the patient (> 3 hrs.) Advance pregnancy, hypothermia or severe agitation Significant risk of Gastrointestinal hemorrhage or perforation 30-07-2025 Dr. Debendra Suman 21

27. Solutions used for gastric lavage Solution used Poison Castor oil with warm water Phenol(carbolic acid) Desferrioxamine (2 gm in 1 lit of water) Iron Potassium permanganate (1:5000) Oxidizable poison(alkaloids ,phosphorus, salicylates) Starch solution Iodine Potassium iodide Sodium iodide (1%) Tannic acid (4%) Heavy metal poisoning (Hg, Pb, As) Saline Barbiturate, Benzodiazepine,, Salicylate, Theophylline poisoning Tricyclic antidepressant overdose Organophosphorus poisoning (early stages, before atropine/pralidoxime) 30-07-2025 Dr. Debendra Suman 22

28. 3. Whole bowel irrigation Rapid administration of large volume of Polyethylene glycol- electrolyte lavage solution(PEG-ELS) Via nasogastric tube, patient sitting on toilet seat Administered @ 2000ml in adults Procedure continues until the rectal effluent is clear Give antiemetic before starting 30-07-2025 Dr. Debendra Suman 23

29. Whole bowel irrigation Indication Lithium & heavy metal poisoning  not absorbed by activated charcoal Toxic ingestions of sustained-release or enteric-coated drugs Body packing/stuffing (cocaine body packer syndrome) Contraindication Bowel perforation Bowel obstruction GI hemorrhage Uncontrollable vomiting 30-07-2025 Dr. Debendra Suman 24

30. 4. Endoscopic gastroscopy Button batteries Cocaine packets Mechanical bowel obstruction Iron bezoars 30-07-2025 Dr. Debendra Suman 25

31. What is coma cocktail? Dextrose – 100mL of 50% sol. Naloxone – 2 mg Thiamine [vitamin B 1 ] – 100 mg 30-07-2025 Dr. Debendra Suman 26

32. Removal of absorbed poison from the body

33. Removal of absorbed poison from the body Diaphoretics Drugs that increases sweating E.g. Alcohol, Antipyretics, Salicylates, Pilocarpine nitrate 2. Enhanced renal excretion Large amount of fluids are given (By forced diuresis) 30-07-2025 Dr. Debendra Suman 27

34. Removal of absorbed poison from the body 3. Urine alkalinization (Forced alkaline diuresis) Urine made alkaline by NaHCO 3 E.g. Aspirin, Barbiturates, Chlorpropamide, Methotrexate 4. Urine acidification ( Forced acidic diuresis ) Giving Ascorbic acid or Ammonium chloride E.g. Methadone, Amphetamine, Phencyclidine, Cocaine, Strychnine 30-07-2025 Dr. Debendra Suman 28

35. Removal of absorbed poison from the body 5. Hemodialysis Remove toxic substances directly from the bloodstream, when the kidneys cannot eliminate the toxin effectively Hemodialysis useful in : B - Barbiturates L - Lithium A - Alcohols (methyl, ethyl, isopropyl) S - Salicylates, Strychnine T - Theophylline, Thiocyanate 30-07-2025 Dr. Debendra Suman 29

36. Removal of absorbed poison from the body Dialysis is not effective in poisoning of : A - Amphetamine V- Verapamil O- Organophosphates, Opioids I- Imipramine D- Digitalis DIALYSIS- Diazepam 30-07-2025 Dr. Debendra Suman 30

37. Administration of antidote

38. Antidote “ It is a therapeutic substance used to counteract the toxic actions of a specified xenobiotic ” 30-07-2025 Dr. Debendra Suman 31

39. 30-07-2025 Dr. Debendra Suman 32 KMnO 4 = Potassium permanganate BAL= British Anti-Lewisite EDTA=Ethylenediaminetetraacetic acid

40. Activated charcoal It is a fine, black, odorless, tasteless powder Available as plain or sugar-coated tablets It acts mechanically by adsorbing the poison & retaining it within the pores Dose :- 50- 100 gm orally in adults 1g/kg body weight in children 30-07-2025 Dr. Debendra Suman 33

41. Indications- Barbiturates Benzodiazepine Opiates Nicotine Strychnine Antiepileptic drugs Salicylic acid Phenol Contraindication - Hydrocarbon Heavy metals Acid & Alkali Altered mental status Lithium Seizures Intestinal obstruction and perforation 30-07-2025 Dr. Debendra Suman 34 Activated charcoal

42. Chelating Agent Metal Poisoning Treated EDTA (Ethylenediaminetetraacetic acid) Lead Dimercaprol (British Anti-Lewisite, BAL) Arsenic, Mercury Dimercaptosuccinic acid (DMSA, Succimer) Lead Deferoxamine Iron Deferiprone, Deferasirox (oral iron chelators) Iron Penicillamine Copper 30-07-2025 Dr. Debendra Suman 35

43. Antidotes Poisoning or condition Antidote 1. Paracetamol 2. Atropine 3 Organophosphate 4 Theophylline 5 Digoxin 6 Opioid 7 Methanol Ethyl alcohol 8 Ergot alkaloids 9 β blocker 10 Isoniazid N Acetylcysteine Physostigmine Atropine β blocker Digibind Naloxone Fomepizole Nitroprusside Glucagon Pyridoxine 30-07-2025 Dr. Debendra Suman 36

44. Poisoning or condition Antidote 15 Cyanide 16 Warfarin 17 Heparin 18 Benzodiazepine Zolpidem 19 Valproate 20 Methotrexate 21 Scorpion sting 22 Calcium channel blockers 23 Tricyclic antidepressants 24 Narcotics Amyl nitrate, sodium thiosulphate, sodium nitrite and vit B 12 Vitamin K Protamine sulphate Flumazenil L-Carnitine Folinic acid Prazosin Calcium gluconate Sodium bicarbonate Naloxone 30-07-2025 Dr. Debendra Suman 37

45. What is universal antidote? It consists of : Activated charcoal Magnesium oxide Tannic acid 30-07-2025 Dr. Debendra Suman 38

46. Identification of Toxidromes

47. Identification of Toxidromes Toxidrome = Toxi c syn drome Unique signs and symptoms produced by specific toxins or drugs For early recognition and diagnosis of unknown poisoning Quick toxidrome identification - guides treatment, antidote administration, and supportive care in cases of poisoning 30-07-2025 Dr. Debendra Suman 39

48. Identification of Toxidromes 30-07-2025 Dr. Debendra Suman 40

49. 30-07-2025 Dr. Debendra Suman 41 Toxidrome Vital signs Mental status Pupils Other findings Cholinergic Toxidrome (Wet manifestations) Bradycardia Hypotension Tachypnoea Temp - normal or Slightly decreased Confused Coma Pinpoint pupil (Miosis) Diarrhea Urination Bronchorrhea Emesis Lacrimation Lethargy Sweating Salivation Examples: Pesticides, Insecticides, Nerve agents, Mushroom (Inocybe, Clitocybe), Nicotine Drugs -Physostigmine, Donepezil, Rivastigmine, Pilocarpine, Bethanechol Treatment: Atropine (Muscarinic receptor antagonist) Pralidoxime(Reactivates acetylcholinesterase)

50. 30-07-2025 Dr. Debendra Suman 42 Toxidrome Vital signs Mental status Pupils Other findings Examples Anti-Cholinergic (Dry manifestations) Hyperthermia (Hot as a hare) Tachycardia Hypertension Tachypnea Agitated Hallucinating (Mad as a hatter) Mydriasis Loss of accommodation (Blind as a bat) Dry skin (Dry as a bone) Vasodilation (Red as a beet) Hypoactive bowel movements Datura stramonium Atropa belladonna Drugs- Antihistamine Anti-Parkinson’s Antiemetics Antipsychotics Doxylamine Treatment: Antidote- Physostigmine Symptomatic care- IV fluids, temperature control, benzodiazepines for seizures Decontamination- Activated charcoal (1g/kg PO)

51. 30-07-2025 Dr. Debendra Suman 43 Toxidrome Vital signs Mental status Pupils Other findings Examples Sympathomimetic toxidrome Hyperthermia Tachycardia Hypertension Tachypnea Agitation Mydriasis Diaphoresis Hyperactive bowel movements Cocaine Amphetamine Methamphetamine MDMA Ephedrine Phenylephrine Caffeine Treatment: Antidote- No specific Antidote Active cooling only; avoid antipyretics Benzodiazepines are the first-line agents for managing for agitation, seizures, hypertension Benzodiazepines, If hypertension is severe and unresponsive, use titratable antihypertensives like nitroglycerin or nicardipine Activated charcoal (<1hr); whole bowel irrigation can be done

52. 30-07-2025 Dr. Debendra Suman 44 Toxidrome Vital signs Mental status Pupils Other findings Examples Opioids Hypothermia Bradycardia Hypotension Bradypnea CNS depression Coma Miosis Hyporeflexia Decreased bowel sound Cold extremities Needle stick injury Opioids( heroin, morphine, methadone, fentanyl, tramadol) Treatment: Antidote- Naloxone Competitive opioid receptor antagonist reversing CNS and respiratory depression It acts rapidly but has a shorter half-life than many opioids Repeated doses or infusion may be necessary Minimal side effects

53. 30-07-2025 Dr. Debendra Suman 45 Toxidrome Vital signs Mental status Pupils Other findings Examples Sedatives-hypnotic Toxidrome Hypothermia Bradycardia Hypotension Bradypnea CNS depression confusion Coma Normal or Miosis Slurred speech Hyporeflexia Benzodiazepines (Diazepam, clonazepam, alprazolam) Barbiturates Alcohols Treatment: Antidote-Flumazenil Contraindication: Known benzodiazepine dependence Unknown overdose ( if TCA involved) Seizure disorder Prolong QRS interval

54. 30-07-2025 Dr. Debendra Suman 46 Serotonin syndrome Neuroleptic malignant syndrome Rapid Onset Slow SSRIs, SNRIs, MAOIs, TCAs, Aetiology Anti-psychotics, sudden cessation of dopaminergic agents e.g. levodopa Tachycardia, Raised BP, hyperthermia, diaphoresis, rigidity, altered mental state Presentation Tachycardia, Raised BP, hyperthermia, diaphoresis, rigidity, altered mental state, delirium Hyperreflexia, clonus, tremor Neurological signs Hyporeflexia, “Lead-pipe” rigidity

55. 30-07-2025 Dr. Debendra Suman 47 Serotonin syndrome Neuroleptic malignant syndrome Dilated Pupils Normal Diarrhea, increased bowel sound Gastrointestinal features Normal Can be raised Creatinine kinase Raised Stop serotonergic drugs IV fluids and cooling Benzodiazepines cyproheptadine Management Stop antipsychotics IV fluids Dantrolene Bromocriptine

56. Summary 1. General Principles of Poison Management Immediate resuscitation Removal of unabsorbed & absorbed poison Antidote administration Symptomatic treatment Follow-up care 2. ABCDE Resuscitation Protocol A: Airway B: Breathing C: Circulation D: Depression of CNS E: Evaluation

57. 3. Contraindications of gastric lavage: Corrosives, Loss of airway protective reflexes, Sharp & pointed material ingestion (pins, needle, glass),Comatose patient….. 4. Other methods of removing unabsorbed ingested poison are: Emesis, WBI, EG 5. Coma cocktail: Dextrose, Naloxone, Thiamine 6. Removal of absorbed poison from the body- Diaphoretics, enhanced renal excretion, urine alkalization, urine acidification, hemodialysis 7. Dialysis not effective in poisoning of – Amphetamine, V, O, Imipramine, D, D 8. Universal antidote- Activated charcoal, Mg Sulphate, tannic acid

58. 9. Toxidromes (Toxic Syndromes) Cholinergic: DUMBBELLS, miosis, treat with atropine, avoid succinylcholine. Anticholinergic: Dry as a bone, hot as a hare, treat symptomatically. Sympathomimetic: Agitation, hypertension, no specific antidote. Opioid: Pinpoint pupils, respiratory depression, treat with Naloxone. Sedative-Hypnotic: CNS depression, Flumazenil (with caution). Neuroleptic Malignant Syndrome: Hypokinetic, Rigidity, fever, treat with Dantrolene. Serotonin Syndrome: Hyperkinetic, clonus, Fever, Cyproheptadine as antidote

59. Specific learning objectives achieved By the end of teaching learning session, co-learners are now able to Describe the ABCDE resuscitation approach for poisoning cases Enumerate the methods used for removal of unabsorbed and absorbed poisons from the body Explain the criteria for use and contraindications of gastric lavage and activated charcoal Enumerate various types of antidotes and their uses Explain the toxidrome approach in poisoning management

60. Further reading

61. References Dhattarwal S. Indian Journal of Forensic Medicine & Toxicology Editor in Chief. Indian Journal of Forensic Medicine & Toxicology" is peer reviewed quarterly journal It deals with Forensic Medicine. 18(3). Pannu AK, Bhalla A, Vamshi V, Upadhyay MK, Sharma N, Kumar S. Changing spectrum of acute poisoning in North India: A hospital-based descriptive study. Turk J Emerg Med. 2022 Oct 1;22(4):192–9. Jayawardene R, Madhuwanthi Hettiarachchi N, Mayurathan P, Manilgama R. Sri Lanka College of Internal Medicine-2. Consultant Physician in Internal Medicine, Toxicology Unit ,Teaching Hospital Peradeniya. 3. Senior Lecturer in Medicine Faculty of Health-Care Sciences, Eastern University of Sri Lanka. 4. Consultant Physician in Internal Medicine. New Jersey Poison Information and Education System (NJPIES). Antidote use guidelines. Newark (NJ): University Hospital; 2023 [cited 2025 Jul 25]. Available from: https://www.njpies.org Grover, et al.: Medical emergencies associated with psychotropic medications. Cherukuri H. General principles in the management of acute poisoning. Asia Pac J Med Toxicol . 2014 Mar;3(1):2–12. Deshmukh CD, Pawar AT. General Principles, Types, Diagnosis and Management of Poisoning. Scholars Academic Journal of Pharmacy. 2020 May 23;09(05):155–62. Aggrawal A. APC Textbook of Forensic Medicine and Toxicology. 1st ed. New Delhi: Avichal Publishing Company;

62. Audience questions

63. Questions Q1. What does the “ABCDE” approach stand for in the resuscitation of a poisoned patient? Q2. Name 3 drugs overdose that are effectively treated with dialysis? Q3. What does the universal antidote contain? Q4. What is the antidote for organophosphate poisoning? Q5. What are the gastric lavage contraindication? Q6. What is Coma cocktail? Q7. What is the management of opioid toxidrome?

64. THANK YOU