POISONING emergency for nursing student

This course is designed for nurses in emergency room

1. POISONING

2. Objectives General approach to the poisoned patient Toxidromes Specific antidotes Decontamination and enhanced elimination

3. POISONING Poisoning continues to be a preventable cause of morbidity and mortality especially in children and adolescents. Patients may present with a specific history of exposure, Some may present with unexplained signs or symptoms and no history of exposure.

4. A poisoning occurs when exposure to a substance adversely affects the function of any system within an organism. The setting of exposure may be occupational, environmental, recreational, medicinal or suicidal. Poisoning may result from varied portals of entry including, inhalation, ingestion, cutaneous Exposure and injection

5. Poisoning emergencies commonly present to emergency departments.  The clinical effects encountered in poisoned patients are dependent on numerous variables, such as the dose, the length of exposure time, and the pre-existing health of the patient.

6. The prognosis and clinical course of recovery of a patient largely depends on the quality of care delivered within the first few hours in the emergency setting. Patients can present with various clinical symptoms, including abdominal pain, vomiting, tremor, altered mental status, seizures, cardiac dysrhythmias , and respiratory depression.

7. Attempts to identify the poison should never delay life-saving supportive care. First patient has to be stabilized, Then we needs to consider how to minimize the bioavailability of toxin not yet absorbed, which antidotes (if any) to administer, and if other measures to enhance elimination are necessary

8. Pattern of TASH poisoning Acute poisoning is an important problem. And out of the of 116 adult patients presented to Tikur Anbessa Specialized University Hospital from January 2007 to December 2008 showed that females outnumbered males and that mean age was 21 years.

9. Most being (96.5%) intentional self-harm poisonings. Household cleansing agents were the leading causes (43.1%) followed by organophosphate (21.6%) and phenobarbitone (10.3%).

10. Pediatrics A study done on childhood poisoning showed that is not an uncommon problem. And that Most of the children were poisioned with drugs prescribed for themselves or family poisioning . Most of the incidents were unintentional. Most of the incidents occurred at home. ( Tigist Bacha )  

11. Gondar University Organophosphates, rat poison and alcohol were implicated in the majority of the cases for suicidal as well as para -suicidal intentions.

12. General Approach The general approach to the diagnosis and management of the poisoned patient can be described using a two-pronged model, The first is basic emergency medical care The second is obtaining history, performing a focused physical examination, and deciding on the appropriate diagnostic tests to be performed.

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14. General approach

15. History Taking Historical facts should include the type of toxin or toxins, Time of exposure (acute versus chronic) Amount taken, And route of administration (i.e., ingestion, intravenous and inhalation) Why the exposure occurred (accidental, suicide attempt, euphoria, therapeutic misadventure).

16. History of psychiatric illness or previous suicide attempts. inquire about all drugs taken, including prescription, over-the-counter medications, vitamins, and herbal preparations Info from family, friends and para medic personnel, if any, can be helpful.

17. In case of occupational exposure, personnel should obtain a description of the work environment and contact people at the site for relevant information.

18. Identify the substance Identify the substance Obtaining the original toxic substance Containers found near or on patient Through accurate history

19. Physical Exam performing an overly detailed physical examination is a low priority compared with patient stabilization. A directed examination can, however, yield important diagnostic clues. Once the patient is stable, a more comprehensive physical examination can reveal additional signs suggesting a specific poison.

20. dynamic change in clinical appearance over time may be a more important clue than findings on a single P/E. Vital sign : detecting signs such as tachycardia, hyperthermia, and hypotension through addressing the patient’s vital sign help in making the differential Diagnosis.

21. Bradycardia ( PACED) Propranolol ( B blocker), poppies ( opiates), propoxyphene , physostigmine Anticholinestrase drugs, antiarrythmics Clonidine , Calcium Channel blocker Ethanol or other alcholos Digoxin , digitalis

22. Tachycardia (FAST) Free base or other forms of cocaine Anticholinergics , antihistamines, antipsychotics, amphetamines, alcohol withdrawal Symphathomimetics (cocaine, caffeine, amphetamines, phencyclidine), solvent abuse, strychnine Theophylline , tricyclic antidepressants, thyroid hormones

23. Hypothermia (COOLS) C arbon monoxide O pioids O ral hypoglycemic, Insulin L iquors (alcohol) S edative-hypnotics

24. Hyperthermia (NASA) N euroleptic malignant syndrome, A ntihistamines S alycilates , Serotonin syndrome, sympathomimietcs A nticholinergics , antidepressants, antipsychotics

25. Hypotension (CRASH) C lonidine , calcium channel blockers R odenticides (arsenic, cyanide containing) A ntidepressants, aminophilline , antihypertensives S edative-hypnotics H eroine or other opioids

26. Neurologic examination : A systematic neurologic evaluation is important, particularly with patients exhibiting altered mental status. Toxicologic causes of coma rarely cause focal neurologic deficits. Seizures are a common presentation of an unknown overdose,

27. Common poisons that cause soma: Lead, lithiuim Ethanol, ethylene glycol TCA, Heavy metals, oral hypoglycemics Carbon monoide

28. Poisons that cause Seizures: Organophosphates TCAs Sympathomimetics Isoniazid , insulin Methylxanthines Benzodiazepin withdrawal

29. Pupillary changes

30. Other general neurologic signs include fasciculations (organophosphate poisoning), rigidity (tetanus and strychnine), tremors (lithium and methylxanthines ), speech-mumbling ( anticholinergics ), and dystonic posturing ( neuroleptic agents).

31. SKIN Skin: a careful examination of the skin should be performed. The absence of diaphoresis is an important clinical distinction between sympathmimetics and anticholinergics . Bullous lesions may be associated with sedative hypnotic drug-induced coma, and barbiturate poisoning.

32. Blue skin indicates methemoglobinemia or hypoxia. Odor: some poisons produce odors characteristic enough to suggest the diagnosis, garlic –organophosphate insecticides sulfur dioxide and hydrogen sulfide produce a noxious rotten-egg smell. Some odors may be more subtle and cannot be detected easily.

33. Labs Several simple, readily available laboratory tests may provide important diagnostic clues. electrolytes, blood urea nitrogen, creatinine , serum glucose, a measured bicarbonate level, arterial blood gases a pregnancy test is essential in females of child bearing age.

34. Plasma Concentrations Are essential for: CO poisoning, Paracetamol , Salicylates , theophyline , TCA, Lithium, digoxin and metals.

35. Toxidromes Identification of the constellation of signs and symptoms that define a specific toxicologic syndrome. may narrow a differential diagnosis to a specific class of poisons.

36. Toxidrome Common Causes Sign & Symptom Anticholinregic Antihistamines, Atropine, Scopalamine Sedation, Hallucinations, Mydrasis, Dry skin, Dry mucous Membrane, Decreased bowel sounds & urinary retention Sedative – Hypnotics Baributrates, Benzodiazepins Sedation, normal pupils, respiratory depression Sympathomimetic Cocaine, Amphitamine Agitation, mydrasis, tachycardia, hypertension, hyperthermia, diaphoresis Cholingeric Organophosphates& Carbametes Altered mentation , seizure, miosis , lacrimation , urination, diaphoresis, bronchospasm , bronchorrhea , vomiting, bradycardia Opoids Meperidine, Codiene Sedation, miosis , decreases bowel sounds, respiration depression

37. Many toxidromes have several overlapping features and toxidrome findings may be affected by individual variability & comorbid conditions.

38. Decontamination Decontamination: Terminating topical exposures. Contaminated clothing should be removed and safely disposed of. Wash skin and hair with soap and water while wearing gloves. Eye exposures: irrigate with copious amounts of water or saline for 10-15 minutes.

39. Ipecac syrup induces emesis through direct irritant action on the stomach & central action at the chemoreceptor trigger zone. Not currently recommended in hospitals lack of evidence for improved outcomes and risks including delayed administration of oral antidotes and other decontamination products, aspiration, and complications from prolonged emesis and retching.

40. Risks: pulmonary aspiration, epistaxis , laryngospasm , hypoxia, sinus bradycardia & mechanical injury Contraindications: patients with decreased LOC, unprotected airway, ingestion of corrosives, volatile substances and GI hemorrhage.

41. Gastric Lavage Indication : ingestion of large amounts of tablets and capsules with a high inherent toxicity with 2 hrs. Method: Insert a large bore orogastric tube(32-40 F) Place patient head down, left lateral decubitus Aspirate fluid from stomach prior to fluid lavage Install water or saline into stomach: 200-300ml Aspirate fluid back & repeat till aspirate clears

42. Early post-ingestion activated charcoal Minimizes systemic absorption from the GIT Indication: consider use within 1hr of ingestion of the poisonous substance. Method: Route: oral or instill via NG tube Adult dose: 50-100g (1-1.5g/kg) as a slurry in 400-800ml water Shake vigorously to ensure adequate dispersion

43. Risks: no systemic effects, but may induce vomiting, constipation, diarrhea Contraindicated: decreased LOC or unprotected airway. Avoid (no value): strong acids, alkali, corrosives, heavy metals, cyanides, lithium, hydrocarbons (paraffin), methanol and ethylene glycol.  

44. Multi-dose activated charcoal Enhance elimination of drugs already absorbed Interrupting enterohepatic circulation. Indication: ingestion of large doses of Carbamazepine , dapsone , phenobarbitone , quinine, theophlline , Salicylates , sustained release formulations. Method: after first dose of charcoal, follow up dose of 25g every 2hrs or 50g every 4hrs, Until clinical conditions and lab parameters improve. Contraindications: diminished bowel sounds, proven ileus or small bowel obstruction

45. Whole bowel irrigation Uses a laxative agent such as polyethylene glycol to fully flush the bowel of stool and unabsorbed xenobiotics . Contraindicated in ileus , bowel obstruction or perforation, and in patients with hemodynamic instability. May be considered for substantial ingestions of iron, sustained release products, enteric coated products and lead poisioning .

46. U rinary alkilinization Infusion of sodium bicarbonate to raise urinary pH to enhance clearance of toxins excreted by kidneys 1-2 mEq /kg NaHCO3 IV push 3 ampules of NaHCO3 in 850 cc of D5W at 1.5X maintenance fluid rate Target urinary pH 7.5-8.5 Monitor electrolytes

47. Extracorporal Removal: Hemodialysis   Less effective when toxin has large volume of distribution (>1 L/kg), has large molecular weight, or highly protein bound. Acetone, Barbiturates, Bromide, Ethanol, Ethylene glycol, Salicylates , Lithium Peritoneal Dialysis Alcohols, long acting salicylates , Lithium

48. Antidotes Although most poisonings are managed primarily with appropriate supportive care, there are several specific antidote agents that may be employed.

49. Commonly used antidotes

50. Summary The management of the poisoned patient who has an unknown exposure can be diagnostically and therapeutically challenging. The history and physical examination, along with a small dose of detective work, can often provide the clues to the appropriate diagnosis.

51. Ultimately, the management of the critically poisoned patient centers on careful supportive care. Care of the critically poisoned patient may be further maximized with appropriate decontamination , antidote administration , elimination enhancement and pharmaceutical interventions.

52. Approach to poisioned pt ABC Oxygen, monitors, IV access Full set of vitals including O2 sat Gather history and collateral information Check glucose Physical exam: skin, cardio, resp , GI, neuro Disability : GCS, pupils Drugs: onsider universal antidotes Decontamination Draw Labs *Contact poison centre if available* Specific antidotes and supportive care

53. Questions?????