POISONING

a emergency treatment of poisoning.describe of ingested poisons,inhaled poisons,absorbed poison,food poisoning,injected poisoning,snake bite. management of treatment

1. POISONING Submitted to submitted by Mrs. beatricE AbigaIL koyel thander LecturER of nhcon 2 nd pbbsc

2. INTRODUCTION A poison is any substance that, when ingested , inhaled , absorbed, applied to the skin, or produced with in the body in relatively small amounts , injures the body by its chemical action. The branch of medicine that deals with the detection and treatment of poison is known toxicology.

3. DEFINITION • Poison is a substance ( solid/ liquid or gaseous ) , which if introduced in the living body, or brought into contact with any part there of, will produce ill health or death, by its constitutional or local effects or both.”

4. TYPES OF POISONING Ingested (swallowed) poisons Inhaled poisons : carbonmonoxide poisoning Absorbed : skin contamination of poisoning (chemical poison) Food poisoning Injected poison :stinging insect Snake bites

5. Ingested poison Ingested poison are those that have been swallowed. It includes common house hold and industrial chemicals, medications , inproperly prepared foods , plant materials, petroleum products and agricultural products made specifically to control rodents, weeds ,insects and crop diseases.

6. Sign and symptoms of ingested poison: Nausea and vomiting Burns on around the lips Drowsiness Deep and rapid breathing Sometimes with increasing fever Slow pulse Excessive salivation Sweating and nausea Diarrhoea Difficulty breathing

7. Patient care – ingested poison Emergency care step: Detect and treat immediately life threating problem in the initial assessment . Evaluate the need for the prompt transport for critical patients. Perform a focused history and physical exam including sample history . Used gloves hand to carefully removed any pills or fragments from the patient mouth. Asses the baseline vitals signs. Consult medicine direction, administers activated charcoals or water or milk to dilute it. Transport the patient with all containers , bottles and labels from the substance. Perform ongoing assessment enroute .

8. Inhaled poison are those that have been inhaling or breath in. Take the form of gases, vapours and sprays again many of these substances are in common use in the home, industry (from car exhaust , wood burning ,stoves and furnaces ) INHALED POISON

9. Carbon monoxide: Carbon monoxide is one of the most common inhaled poisons, usually associated with motor vehicle exhaust and fire suppression. carbon monoxide exerts its toxic effect By binding to circulating HB and thereby Reducing the oxygen carrying capacity of the blood HB absorbs carbon monoxide 200 times more rapidly than oxygen

10. Signs of carbon monoxide: Headache Nausea Breathlessness Collapse Dizziness Loss of consciousness Cyanosis Palpitation Muscle weakness

11. Investigation of inhaled poison: History :exposure history Acute unconsciousness/acute metabolic acidosis Pulse oximetry may over estimation oxygen saturation thus ABG should be used. Confirmation: carboxyhemoglobin

12. MANAGEMENT GOAL : To reverse the cerebral and myocardial hypoxia. INTERVENTION: Carry the patient to fresh air immediately ,open all doors and windows. Loosen all tight clothes. Initiate CPR if required administer 100% oxygen. Prevent chilling : wrap the patient blanket. Keep patient quite as possible.

13. Skin contamination of poisoning (chemical poison) Skin contamination injuries from exposure to chemicals are challenging because of the large number of offending agents with diverse actions and metabolic effects. The severity of chemical burn is determined by the mechanisms of action, the penetrating strength and concentration ,and the amount and duration of exposure of the skin to chemical .

14. Investigation of absorb the poison History: exposure history Inspection – skin burn or colour changes of skin

15. MANAGEMENT GOAL: Prevent skin from exposure. INTERVENTION: The skin should be drenched immediately with running water from a shower, hose, o r faucet. The skin of health care personnel assisting the patient should be appropriately protected if the burn is extensive or if the agent is significantly toxic or is still present . Prolonged lavage with generous amounts of tepid water is important . In the meantime, attempts to determine the identity and characteristics of the chemical agent are necessary for future treatment .

16. CONTD: The standard burn treatment appropriate for the size and location of the wound(antimicrobial treatment , débridement , tetanus prophylaxis as prescribed ) is instituted. Plastic surgery for further wound management.

17. FOOD POISIONING • Food poisoning is a sudden illness that occurs after ingestion of contamination of food or drink. • Botulism is a serious form of food poisoning that requires continual surveillance .

18. It may be caused by: – bacteria or their toxins – chemicals including metals – plants or fish – viruses – mycotoxins

19. HIGH RISK OF FOOD – Cooked poultry – Cooked meats – Dairy produce (milk, cream, etc.)– Soups, sauces and stocks – Shellfish, sea food – Cooked rice – Dishes containing eggs.

20. LOW RISK OF FOOD – Dried or pickled Foods – Chemically-preserved foods – Foods with high sugar content – Food with high salt content

21. ASSESMENT Determine the source and type of food poisoning ( suspected food, history ). Collect and assess food, gastric contents, vomitus, serum , and feces . Assess fluid and electrolyte balance. (Severe vomiting produces alkalosis, and severe diarrhea produces acidosis) Assess for Hypovolemic shock ( Lethargy, rapid pulse rate, fever, oliguria, anuria ,hypotension , and delirium ) Assess weight and serum electrolyte

22. MANAGEMENT Monitor respirations, blood pressure, sensorium , CVP (if indicated),and muscular activity. Measures are instituted to support the respiratory system (respiratory paralysis can occur with botulism, fish poisoning , and other food poisonings ) An antiemetic medication is administered parenterally. For mild nausea, the patient is encouraged to take sips of weak tea, carbonated drinks,or tap water. After nausea and vomiting subside, clear liquids are usually prescribed for 12 to 24 hours , and the diet is gradually progressed to a low-residue, bland diet .

23. CONTD: Use of drugs for the relief of pain & IV fluids to alleviate dehydration. (Staphylococcus -Should not be treated with antibiotics E.Coli , Botulism - For life threatening infection, transfusions & kidney dialysis

24. INJECTED POISONS :STINGING INSECT A person may have an extreme sensitivity to the venoms of the Hymenoptera (bees, hornets , yellow jackets, fire ants, and wasps ). Venom allergy ( IgE – mediated reaction) Although stings in any area of the body can trigger anaphylaxis, s tings of the head and neck are especially serious.

25. Clinical manifestation Generalized urticaria Itching Malaise Anxiety Laryngeal edema to severe bronchospasm Shock Death

26. Management Stinger removal. Wound care with soap and water is sufficient for stings . Scratching is avoided because it results in a histamine response . Ice application reduces swelling and also decreases venom absorption . An oral antihistamine and analgesic will decrease the itching and pain. In the case of an anaphylactic response, epinephrine ( aqueous) is injected subcutaneously (not intravenously )

27. SNAKE BITES Venomous snake bites are medical emergencies.

28. Contd : Snake venom consists primarily of proteins with a broad range of physiologic effects . Multiple organ systems, especially the neurologic, cardiovascular, and respiratory systems , may be affected.

29. MANAGEMENT Allow the victim should lie down. Remove constrictive items such as rings, provide warmth. Cleanse the wound, cover the wound with a light sterile dressing. Immobilize the injured body part below the level of the heart . Observe the sequence of events, signs and symptoms (fang punctures , pain , edema, and erythema of the bite and nearby tissues ). Assess laboratory data (complete blood count, urinalysis , and clotting studies ) Generally ice, tourniquets, heparin, and corticosteroids are not used during the acute stage .

30. Contd : Corticosteroids are contraindicated in the first 6 to 8 hours after the bite, because they may depress antibody production and hinder the action of antivenin( antitoxinmanu factured from the snake venom and used to treat snakebites). Parenteral fluids m ay be used to treat hypotension. Vasopressors are used to treat hypotension. Surgical exploration of the bite is rarely indicated . Observed closely for at least 6 hours. The patient is never left unattended

31. Administration of antivenin (antitoxin) Antivenin, which is most effective if administered with in 12 hours after the snake bite . A skin or eye test should be performed before the initial dose to detect allergy to the antivenin . However , because even the skin test can cause an anaphylactic reaction, patients Should not be tested unless antiveninis to be given. Administer Inj.TT Premedication with diphenhydramine and cimetidine decreases the allergic response to antivenin. Antivenin is administered as an intravenous infusion whenever possible, although intramuscular administration can be used. (The antivenin is diluted in 500 to 1000 mL of normal saline solution)

32. Fundamental of poisoning management Initial resuscitation and stabilization. Removal of toxin from the body. Prevention of further poison absorption. Enhancement of poison elimination. Administration of antidote. Supportive treatment. Prevention of re-exposure.

33. • 1. Initial resuscitation & stabilization : • First priorities are ABC’s. IV access – IV fluid. Endo tracheal intubation - to prevent aspiration a. Unconscious patients b . Respiratory depression/ failure Convulsions- give anticonvulsants

34. 2.Removal of Toxin : Copious flushing with water or saline of the body including skin folds, hair. • Inhalational exposure ✓ Fresh air or oxygen inhalation

35. 3. Prevention of poison absorption : • 1. Gastric Lavage • Done with water ,1:5000 potassium permanganate , 4% Tannic acid, saturatedlime wate ror starch solution with orogastric or Ewald’s tube. • Performed until clear fluid is obtained or a maximum of 3 L Contraindications : ✓ o Corrosive poisoning ✓ o Recent esophageal / gastric surgery ✓ o Unconscious patient

36. 3. Prevention of poison absorption Ipecac Syrup induced emesis .administered orally. Contraindications : corrosives CNS depression Rapidly acting CNS poisons ( cyanide, strychnine, camphor ) or seizures

37. 3. Prevention of poison absorption 3.Activated Charcoal: Charcoal absorbs ingested poisons within gut lumen allowing charcoal- toxin complex to be evacuated with stoolor removed by induced emesis / lavage. Dose – 1 g/kg body wt . Given orally as a suspension ( in water ) or through NG tube. Contraindications : • Mineral acids, alkalis, cyanide, fluoride ,iron

38. 3. Prevention of poison absorption 4. Whole bowel irrigation Administration of bowel cleansing solution containing electrolytes & polyethylene glycol. Orally or through gastric tube. Rate – 2 L/hr. ( 0.5 L /hr. in children ) End point- rectal fluid is clear. Position – sitting Contraindications : Bowel obstruction Ileus Unprotected airway

39. 4.Enhancement of Elimination of Poison • Forced alkaline diuresis • Infusion of large amount of NS + NAHCO3 Serious fluid and electrolytes disturbance may occur Need expert monitor Acidification of urine Enhance elimination of weak bases such as Phencyclidine & Amphetamine

40. 4.Enhancement of Elimination of poison Extracorporeal removal dialysis– peritoneal dialysis. alcohols , long acting salicylates ,lithium chelation Heavy metal poisoning Complex of agent & metal is water soluble & excreted by kidneys

41. 5.Administration of Antidote • Not all poisons have antidotes Typical Examples are mentioned only

42. 6.Supportive management 1. Control of the airway, ventilation, and oxygenation are essential . 2. In the absence of cerebral or renal damage, the patient's prognosis depends largely on successful management of respiration and circulation . 3. Measures are instituted to stabilize cardiovascular and other body functions. 4. ECG, vital signs, and neurologic status are monitored closely for changes . 5. An indwelling urinary catheter is inserted to monitor renal function . 6. Measures are instituted to remove the toxin or decrease its absorption . 7. The patient who has ingested a corrosive poison, which can be a strong acid or alkaline substance, is given water or milk to drink for dilution. • 8.Symptomatic management

43. 7.Prevention: Keep the household products and medications out of the reach of children . Use childproof safety caps on containers of medications and other potentially dangerous substances. Keep products in their original containers . Use poison symbols to identify dangerous substances . Dispose of outdated medications an household products .

44. NURSING DIAGNOSIS

45. Reference Text book of medical surgical nursing by “ Burnner and suddarth’s ” 12 th edition ,vol-2, Lippincott 2017-2019 page no- 2160-2163 Text book of medical surgical nursing by “ javed Ansari and davinder “2 nd edition vol 2 page no– www.who.org