Poisoning

detail description of the poisoning

1. RAMAIAH INSTITUTE OF NURSING EDUCATION AND RESEARCH. “SEMINAR ON POISONING AND DRUG OVERDOSE MANAGEMENT” SUBMITTED TO: PREPARED BY Mrs. Malathi K Ms . Saheli Chakraborty . Lecturer II year M.SC Nursing. Dept . of Medical Surgical Nursing. RINER.

2. INTRODUCTION:- Poisons is anything that kills or injures through its chemical actions. The word ‘ Potare ’ meaning ‘to drink’. Poisoning is caused by swallowing, injecting, breathing in or otherwise being exposed to a harmful substance. Immediate first aid management is very important in a poisoning emergency, because it can save a person’s life.

3. DEFINITION OF POISONING: Poisoning is the lethal disruption of the body’s physiological mechanism by the induction of an exogenic biological or chemical agent. Any substance which when administered in living body through any route (ingestion, inhalation, injected or surface absorption etc.) will produce ill health or death by its action which is due to its physical, chemical or physiological properties; called as poisoning.

4. 3. CLASSIFICATION OF POISON: Corrosives : Acids Alkali (Na, Ca, K) Organic ( Eg . Oxalic acid, Carbolic acid) Inorganic ( Eg . H 2 SO 4 , HCl ) 2. Irritant : Organic (Plant eg . Capsicum, Riccnus ) , (Animal eg Snake, scorpion, bee.) Inorganic (Metal eg . Hg, Zn), Non-metal ( Hallogen , phosphorus) Mechanical (Glass, nail , hair)

5. 3. Systemic poison: Nervous Cerebral Spinal ( Nux vomica ) Peripheral ( cuare hemlock conium) CNS stimulates CNS depressants Deliriants Eg . Antidepressants (alcohol, methanol, ether) (Cocaine, cannabis etc.)

6. Cardiac ( Nicotine, aconite, Cyanide, tobacco) Respiratory ( CO, H 2 S, CO 2). 4. Miscellaneous: This include- Argochemicals . Pesticides ( Organophosphorus ) Fumigants ( Alphos ) Rhodenticides ( Thalium , Zn Phosphide ).

7. 4. SOURCES OF POISON: Domestic or household sources: Detergents, disinfectants, cleaning agents, antiseptics, insecticides. Agricultural and horticultural sources: Insecticides, pesticides, fungicides and weed killers. Industrial sources: Poisons are manufactured or poisons are produced as by products. Commercial sources: Store house, distribution centres, selling shops.

8. From uses as drugs and medicines: Wrong medication, overmedication and abuse of drugs. Food and drink: Preservatives of food grains or other food material, additives, accidental contamination of food and drink. Miscellaneous sources: Snake bite poisoning, city smoke, sewer gas poisoning etc.

9. 5. CLASSIFICATION OF POISONING

10. A. CLASSIFICATION OF POISONING BASED ON EXPOSURE :- Acute poisoning: caused by an excessive single dose, or several dose of a poison taken over a short interval of time. Chronic poisoning: caused by smaller doses over a period of time, resulting in gradual worsening . Eg : Arsenic, phosphorus, and opium. Sub acute poisoning: Shows features of both acute and chronic poisoning. Fulminant poisoning: Produces by a massive dose. In this death occur rapidly , sometimes without preceding symptoms.

11. B. CLASSIFICATION OF POISONING BASED ON MOTIVES:- 1. Intentional poisoning: A person taking or giving a substance with the intention of causing harm. Eg . Suicide and assault. 2. Unintentional poisoning: If the person taking or giving a substance did not mean to cause harm. Eg . For recreational such as in an ‘overdose’ or ‘accidentally taking by a toddler’. 3. Undetermined poisoning: When the distinction between intentional and unintentional is unclear.

12. 6. COMMON POISONING :- Organophosphorus poisoning. Lead poisoning. Corrosive poisoning. Carbon monoxide poisoning. Drug poisoning - Acetaminophen, opioid , Salicylate . Cadmium poisoning. Mercury poisoning. Ammonia poisoning. Snake bite poisoning. Food poisoning .

13. 7. ETIOLOGY OF POISONING: Medications Drug overdose. Occupational exposure. Cleaning detergents/ paints. Carbon monoxide gas from furnace heaters. Insecticides. Insects and snake bite. Certain cosmetics. Certain household plants, animals. Food poisoning ( Botulism)

14. 8. CLINICAL MANIFESTATION: Blue lips. Skin rashes. Difficulty in breathing Diarrhoea. Nausea/ Vomiting. Fever. Headache. Weakness. Loss of consciousness. Giddiness/Drowsiness. Double vision. Abdominal/ Chest pain. Palpitations Anorexia. Numbness Muscle twitching. Seizures

15. 9. DIAGNOSTIC EVALUATION: History collection: It includes time, route, duration of exposure, name and amount of each drug, the time of onset, type of first aid measures provided, medical and psychiatric history. Physical examination: Changes in behaviour and signs and symptoms, vital sign, neurological status, examination of eyes (size, reactivity), skin exam (rash, bullae , colour,warmth ) etc. Hallucination Petroleum products leaves a distinctive odour on the breath. Examination of vomit particle to know about the composition of the poisonous particle. Blood tests. Urine tests.

16. 1. ORGANOPHOSPHORUS POISONING :- Poisoning that caused by organophosphates are called as organophosphorus poisoning. Widely used in agricultural sector as pesticides. Leading agent for poisoning. Occurs most commonly as a suicide attempt in farming areas of the developing world and less commonly by accident. Exposure can be from drinking, breathing in the vapors , or skin exposure.

17. SOURCES OF ORGANOPHOSPHATES :- Insecticides - malathion , parathion, ethion , diazinon Nerve gases - ( sarin , woman, tabun – German military used it for warfare), VX(invented by the English for warfare) ophthalmic agents - echothiophate , isoflurophate Herbicides - tributes [DEF], merphos

18. PATHOPHYSIOLOGY:- Inhibition of carboxyl ester hydrolyses, particularly acetylcholinesterase ( AChE ). AchE degrades Ach into choline and acetic acid. OP, phosphorylates the serine hydroxyl group. Once AChE has been inactivated, Ach accumulates throughout the nervous system, resulting in overstimulation of muscarinic and nicotinic receptors.

19. MODE OF TRANSMISSION :- Organophosphates can be absorbed cutaneously, ingested, inhaled, or injected. Although most patients rapidly become symptomatic, the onset and severity of symptoms depend on the specific compound, amount, route of exposure, and rate of metabolic degradation.

20. CLINICAL SIGNS AND SYMPTOMS : Muscarinic effects Nicotinic effects CNS effects 1. MUSCARINIC EFFECTS: SLUDGE (salivation, lacrimation , urination, diarrhea , GI upset, emesis) DUMBELS (diaphoresis and diarrhea ; urination; miosis ; bradycardia , bronchospasm, bronchorrhea ; emesis; excess lacrimation ; and salivation). 2. NICOTINIC EFFECTS : muscle fasciculation, cramping, weakness and diaphragmatic failure. Autonomic nicotinic effects include hypertension, tachycardia, mydriasis, and pallor.

21. 3. CNS EFFECTS : Anxiety Emotional liability Restlessness Confusion Ataxia Tremors Seizures Coma impaired memory lethargy psychosis Respiratory paralysis

22. 4. SYSTEMIC EFFECTS : Cardiovascular - Bradycardia , hypotension, hypertension, and noncardiogenic pulmonary edema Respiratory - Rhinorrhoea , bronchorrhea , bronchospasm, cough, severe respiratory distress. Gastrointestinal – Hyper salivation, nausea and vomiting, abdominal pain, diarrhea , fecal incontinence. Genitourinary – Incontinence Ocular - Blurred vision, miosis , Optic neuropathy, retinal degeneration, defective vertical smooth pursuit, myopia Ears : Ototoxicity is possible Endocrine effects: Hypoglycemia , or hyperglycemia

23. DIAGNOSTIC EVALUATION : Check RBC and Plasma cholinesterase levels. Leukocytosis Hemoconcentration Metabolic or respiratory acidosis Hyperglycemia Hypokalemia Hypomagnesemia Elevated troponin levels Elevated amylase levels Elevated liver function test results ECG - prolonged QT interval, elevated ST segments, and inverted T waves. Initial sinus tachycardia may progress to sinus bradycardia with PR prolongation.

24. MANAGEMENT :- GOALS OF TREATMENT : Reduce absorption of toxin Enhance elimination Neutralize toxin. RESUSCITATION : Airway – Early Intubation to secure airway and prevent aspiration Breathing – Ensure adequate ventilation. Intubate when in respiratory distress. Circulation – Obtain large bore IV access. Start IV fluids if victim is in hypotension Decontamination – Remove any garments of the toxin in contact with the patient.

25. REDUCE ABSORPTION : Removal from skin, eyes and hair Emesis induction Gastric Lavage. Activated charcoal and cathartics Whole bowel irrigation Endoscopic or surgical removal of ingested chemical Remove clothing and cleanse patient with soap and water - OPs hydrolyze easily in aqueous soon with high Ph. Discard clothing properly - hazardous waste. Protect self- OPs penetrate through latex and vinyl gloves; use neoprene gloves and gowns. Irrigate the eyes of patients with ocular exposure using isotonic sodium chloride solution or lactated Ringer’s solution

26. ATROPINIZATION: Adequacy of atropinization . Mandatory targets: • SBP > 90 mm Hg • Hr > 110 b/min • Clear lung fields Other targets: • Pupils mid position • Bowel sounds just present ATROPINIZATION DOSE : 1. Bolus Dose Administration: 2-5 mg Atropine every 10-15 min followed by maintenance using reduced doses 2. Incremental dose administration with rapid escalation: 1.8 – 3 mg Atropine by IV infusion, repeat every 5 min interval doubling the dose each time.

27. Other medication includes: IV glycopyrolate or diphenhydramine if atropine is not available. Benzodiazepines- Facilitates GABA and depress CNS by limbic and reticular formation. AMBULATORY MANAGEMENT: Monitor till recovery. Counsel client and others exposed.

28. 2. LEAD POISONING : Lead is a very strong poison, when ingested or inhaled. Lead enters the blood stream and it inhibits the production of hemoglobin and inactivates essential enzymes in the brain and nervous system. Symptoms: Abdominal pain, cramping, muscular weakness and fatigue, aggressive behaviour, low appetite, constipation, headache. Severe exposure leads to : Nervous system disorder, anemia , high blood pressure, death. Management : Chelation   therapy - It is a medical procedure that involves the administration of  chelating  agents to remove heavy metals from the body. ( Eg . Ethylene diamine tetra acetic acid ( EDTA ), Succimer / Chemet (has become the preferred chelating agent).

29. PREVENTION: Keep home as dust free as possible. Advice family member to maintain personal hygeine , hand washing before each meals. If water has tasted high in lead, consider installing an effective filtering device, or switch to bottled water for drinking and cooking. Do not store wines, spirits, or vinegar based salad in lead crystal for long periods of time , because lead can get into the liquid.

30. 3. CORROSIVE POISONING :- A corrosive is a substance that fixes, destroys, and erodes the surface with which it comes into contact. Swallowed poisons may be corrosive. Corrosive poison include Alkaline agents and Acid agents. ALKALINE products include- drain cleaners, toilet cleaners, bleach, detergents, button batteries. ACID products include- pool cleaners, toilet cleaners, bowl cleaners, metal cleaners, rust removers battery acid.

31. CLINICAL FEATURES : GIT : Severe pain of lips, mouth, throat, chest and abdomen. Excessive salivation. Dysphagia Epigastric pain and hematemesis . Symptoms and signs of GI perforation. Respiratory system Cough Dyspnea Bronchoconstriction Pulmonary edema Chemical pneumonitis Eyes and skin Pain at the site of exposure Burns at the site of exposure Erythema and vesicle formation

32. MANAGEMENT OF CORROSIVE POISONING Emergency management: Control of the airway. Ventilation. Oxygenation. ECG, vital signs and neurologic status are monitored closely for changes. Observe patient for signs and symptoms of shock. Obtain blood specimen. Insertion of indwelling urinary catheter Measures to remove the toxin or decrease its absorption.

33. Gastric emptying procedure: Syrup of ipecac to induce vomiting in the alert patient. Gastric lavage. (Gastric aspirate is saved and sent to the laboratory for testing). Activated charcoal administration if the poison is one that is absorbed by charcoal. Cathartic when appropriate . In case of infective measures administer multiple doses of charcoal and diuresis (for the substances excreted by the kidneys) can be used. Dialysis, Hemoperfusion . Other management: Management of hypotension, cardiac dysarrhythmias, seizures. Analgesic, antibiotics, nutritional therapy, collagen synthesis inhibitors, H2 blocker etc, Esophageal dilation, stent placement and surgery

34. 4. CARBON MONOXIDE POISONING Carbon monoxide is odorless , colorless , non irritating produced by the incomplete combustion of carbon-based fuels. Carbon monoxide bind to hemoglobin and form a compound called carboxyhemoglobin and reduces the amount of hemoglobin and tissues become starved to oxygen. CARBON MONOXIDE SOURCES :- Anything that burns coal, gasoline, kerosene, oil, propane or wood. This include- Cars Cigarettes Indoor and portable heating systems. Water heaters that use natural gas. Kerosene heaters, stoves. Open-flame fires Charcoal grills

35. CLINICAL FEATURES: General : Dizziness, fatigue, muscle weakness. Respiratory: Breathing problems including no breathing, shortness of breath or rapid breathing. Neurological : Headache, drowsiness, disorientation, convulsions, coma, unconsciousness. Stomach/ Intestine: Nausea, vomiting, stomach pains, loss of appetite. Heart: Chest pain, wheezing, palpitations. Hyperventilation Rapid or abnormal heart beat.

36. 5. SNAKE BITE POISONING: Only 375 of the 3000 species of snakes in the world are poisonous. In india 216 species of snakes are found of which only 52 are reported to be poisonous. SYMPTOMS OF SNAKE BITE POISONING: Local reaction- fang mark, pain, bruishing , edema within 36 hours of injury, petechiae , ecchymosis , erythema , loss of function in the effected area and necrosis. Systemic reaction: nausea, vomiting, dizziness, tachycardia, muscle fasciculations , GI bleeding, respiratory problems. Neurological symptoms- constricted pupil, drowsiness, weakness, seizures.

37. MANAGEMENT: Treatment focuses on preventing the spread of venom. Rings, watches and restrictive clothing should be removed. Affected leg should be immobilized. Incision of the wound is controversial. Caffeine , alcohol and smoking should be avoided because it increases the spread of venom. Pain should be treated with acetaminophen. Tetanus prophylaxis should be administered. Debridement and fasciotomy should be done to remove venom. Antivenom snakebite treatment therapy should be initiated.

38. ANTIVENOM SNAKEBITE THERAPY ENVENOMATION SIGNS AND SYMPTOMS ANTIVENOM THERAPY None Fang mark, no swelling, no haemorrhage, no paresthesia. Not given, only tetanus prophylaxis. Mild to moderate Fang mark, swelling, pain, systemic reaction, haemorrhage, paresthesia. Crotalidae Polyvalent Immune FAB . 4-6 vials (3000-4500 mg) infused over 1hr slowly for 10 min. no control of symptoms then 2 vials every 6 hr for 18 hr.

39. FIRST AID MANAGEMENT OF POISONING: Step: 1: Check for safety before approaching the victim Ensure safety for yourself, victim and any others before approaching to give first aid. If safe and necessary, remove the victim to a safer area. Note any information about the nature of the poisoning incident, e.g. tablets, berries, burns, around the mouth etc. Step: 2: Check the victim’s level of consciousness If unconscious If breathing normally, turn the victim on the side to clear and open the airway. If not breathing normally, begin CPR —see Resuscitation. If there are burns around the mouth, wipe the area clean before starting CPR —See Resuscitation.

40. If conscious : If the mouth is burnt from a corrosive poison, wipe the area with a moist cloth or tissues. Check for remaining steps for ingested (swallowed) poisons, inhaled poisons, absorbed poisons and injected poisons (excluding venoms). NURSING MANAGEMENT : It include: SIRES S= Stabilize the client. I= Identify the toxic substances. R= reverse its effect. E= eliminate the substance from the body. S= support the client physically and psychosocially.

41. Other nursing management include – Maintain ABG, ABC. ECG and cardiac monitoring. Periodic physical examination. vital signs, check for complication . Maintain intake and output status. Maintain nutrition of patient. Provide need based care to the patient.

42. PREVENTION OF POISONING : Destroy all medicine that are no longer being used. Store poisons and inedible products separately from edible products. Do not transfer poisonous substances from their original container to an unmarked one. Never tell the child that the medicine he is being given is candy. Explain about the drug that it is being given to make him better. Always read the labels of chemical products before using them.

43. DRUG OVERDOSE: A drug overdose is the ingestion or application of a drug or other substance in quantities much greater than are recommended. An overdose may result in a toxic state or death. Drug overdoses occur when a person takes more than the medically recommended dose of a prescription. However, some people may be more sensitive to certain medications so that the high end of the therapeutic range of a drug may be toxic for them.

44. ETIOLOGY AND RISK FACTORS FOR DRUG OVERDOSE Young children may swallow drugs by accidental because of their curiosity about medications they find. Taking many different medications. Abuse of drug ( eg . Opioids ): Male gender more. Low income. Mental health impairment. Doctor shopping. High daily dose of medications. IV drug abuse.

45. CLINICAL FEATURES : Vital sign values can be increased, decreased or completely absent. Skin may become cool, sweaty or hot and dry. Seizure may occur. Chest pain is possible and can be caused by heart and lung damage Shortness of breath may occur. Respiration can be rapid, slow, deep or shallow. Abdominal pain, nausea, vomiting, Organ damage may occur.

46. ADMINISTRATION OF ANTIDOTES DRUG OVERDOSE ANTIDOTES Cholinesterase inhibitors eg . OP poisoning, insecticides, carbamates , nerve gas Atropine Iron Deferoxamine . Insulin Dextrose 5% Mercury, arsenic, heavy metal Dimercaprol , disodium edetate , penicillamine . Lead EDTA Methanol, ethylene glycol Ethanol Sympathomimetics Phentolamine

47. DRUG OVERDOSE ANTIDOTES Acetaminophen Acetylcystine Narcotics Naloxone Cyanide Amyl nitrite, sodium nitrite, sodium thiosulfate Carbon monoxide Oxygen Atropine, Tricyclic antidepressants Physostigmie Ergots alkaloids Nitroprusside , propranolol . Anticoagulants eg Warfarin Vitamin K Cholin esterase inhibitors 2 PAM

48. Other management of drug overdose includes: Respiratory care. Supportive care. Cardiovascular therapy. Prevention of drug absorption: GI decontamination. Activated charcoal use Gastric lavage Whole bowel irrigation. Dilution. Syrup of ipecac. Catharsis and psychological counselling.