poisoning, its types and emergent management.

it explain about definition, causes, types of poison, severity , diagnostic evaluation, complication of poisoning, emergent management, supportive management and nursing management.

1. SEMINAR ON POISONING MS . BHARTI SHARMA NURSING TUTOR BECON,JAMMU

2. INTRODUCTION : A poison is a chemical that harms the body. Poisonings can be accidental , occupational, or intentional. Natural or manufactured toxins can be ingested, inhaled, injected, splashed in the eyes, or absorbed through the skin. Poisoning is the fourth most common cause of accidents in children.

3. POISON / TOXIN: Substance able to produce adverse effects. Some of them are poisonous when taken in excessive amount, while some of them in any amount. Any substances ( liquid, solid or gas) that is harmful to the body when ingested, inhaled, injected, or absorbed through the skin. Does not include adverse reactions to medications taken correctly. INTENTIONAL POISONING :- A person taking or giving a substance with the intention of causing harm, e.g suicide and assault.

4. UNINTENTIONAL POISONING :- If the person taking or giving a substance did not mean to cause harm, e.g For recreational such as in an overdose or accidentally taken by a toddler . UNDETERMINED :- When the distinction between intentional and unintentional is unclear. ACUTE EXPOSURE :- Is a single contact that lasts for seconds, minutes or hours, or several exposures over about a day or less. CHRONIC EXPOSURE :- Is contact that lasts for many days, months or years.

5. SEVERITY AND REVERSEBILITY: Concentration ( dose) Contact time The potency of the chemical Type and condition of the exposed surface Functional reserve of the individual / affected tissue Presence of secondary complications Coexisting illness

6. HOW POISONING MAY OCCUR AND POISONOUS PRODUCTS: Overdosing on medicine or using medicine hat doesn’t belong to you. Being bitten or stung by venomous animals. Swallowing or sniffing paints. Coming in contact with poisonous chemicals. Touching poisonous plants. Inhaling poisonous gases such as carbon monoxide, or fumes from strong cleaning products. Pesticides. Petrochemical products e.g vasoline . Illegal drugs. Household cleaning products.

7. EFFECTS ON HEALTH : The effects of poisoning maybe None, Mild or Severe depending on :- 1. The amount of poison ingested . 2 . The nature of the substance. 3. The age of the person. 4. The nutritional status of the person. 5. The state of the stomach whether empty or full of food .

8. TOXIC SUBSTANCES HAVE SEVEN COMMON MAJOR PATHOPHYSIOLOGICAL MECHANISMS THAT MAY PRODUCE SYMPTOMS : Interfere with the transport or tissue utilization of oxygen e.g CO. Depress or stimulate CNS. Affect autonomic nervous system e.g. organophosphate. Affect the lungs by aspiration e.g hydrocarbon. Affect the heart and vasculature myocardial dysfunction e.g antidepressant. Produce local damage e.g. corrosive. Affect on the liver e.g acetaminophen .

9. COMMON SUBSTANCES CAUSING POISONING PERSON : Household agents : organophosphates, pesticides, rat poison,disinfectants and bleach. Medicines : Aspirin, P aracetamol , anti- convulsants drugs ( phenobarbiton ) Haematinics (iron and vitamins),Major tranquilizers ( phenothiazines ) , Some herbal therapies.

10. RECOGNITION : It may be easily observable that someone has been poisoned if : Chemical products are evident at the victim scene. Drugs are on or around the victim (medical or illegal). A syringe is in or next to victim. Warning signs of gases and chemicals are at/ around the location. Victim is conscious and tells first aider they have been poisoned . If none of these points are apparent in a possible poisoning case, there are numerous signs and symptoms to look for in the victim, that will enable you to establish if they have been poisoned.

11. SIGN AND SYMPTOMS OF POISONING: Lowe level of consciousness Altered mood : lethargic , violent, or hostile etc Differed breathing rate Increased or lowered heart rate Dilated or shrunken pupils Change of colour around mouth Cramps Nausea Vomiting D iarrhoea

12. LABORATORY STUDIES : HISTORY : Time , route and duration of exposure Name / amount of each drug / chemical Time of onset of the symptoms Nature / severity of symptoms Post medical and psychiatric history

13. CONT…….. PHYSICAL EXAMINATION : Vital signs Cardiopulmonary and neurological status.

14. CONT…….. Obtain a CBC count to rule out infectious cause. Chemistry tests may be useful in ruling out electrolyte disturbances. Hypokalemia , hyperglycemia, leukocytosis, proteinuria, glycosuria . ECG sinus tachycardia. RBC cholinesterase tests may reveal decreased activity, which confirms the diagnosis.

15. TREATMENT : EMERGENCY MAINTANANCE

16. EMERGENCY TREATMENT: 1. Supportive care ( vital signs ). 2. P revention of further poison absorbtion . 3. Enhancement of poison elimination. 4. Neutralization or Administration of specific antidote.

17. 1 . SUPPORTIVE CARE : Airway protection Oxygenation / ventilation Hemodynamic support Treatment of seizures Correction of temperature abnormalities Prevention of secondary complication

18. ALL SYMPTOMATIC PATIENTS SHOULD HAVE: IV line Oxygen supplementation Cardiac monitoring Baseline laboratory investigation Continous observation In case of seizures: give diazepam, phenobarbital For shock : legs are held up, elastic band are performed to the legs, fluid perfusion ( volume expanders) in order to increase the venous return.

19. 2 . PREVENTION OF FURTHER POISON ABSORBTION VOMITING: Spontaneously Apomorphine (CNS depression) Salt Vomiting is contraindicated : Corosive toxins Petrollium distillation products Coma , seizures ( aspiration)

20. 3. PREVENTION OF FURTHER POISON ABSORBTION : A.GASTRIC LAVAGE: In trandelenburg and left lateral decubitis position to prevent aspiration. It should be performed in first 4 hours (can be delayed to 6 hours in salicylates). It can be performed later if the poison taken after meals. CONTRAINDICATED : Corosive poison (acid, alkaline) Petrol distillation products It is too late for gastric lavage in a comatose patient; if wanted should be intubated.

21. B. ACTIVATED CHARCOAL: b y mouth or by a stomach tube before and after gastric lavage As an absorbtion for : a. alcohol-atropine- morphin - opium b. arsenic-barbiturates- nicotin - penicillin c. salicylates C. WHOLE BOWEL IRRIGATION : It may be particularly benefits in patients with foreign body, drug packed and slow release medication injections. Solutions for bowel cleansing are electrolytes and polyethyleneglicol .

22. D. DILUTION : Ingestion of corrosive ( acid- alkaline) B. water or other clean liquid. E. ENDOSCOPIC OR SURGICAL REMOVAL: - Ingestion of a potentially toxic foreign body that fails to transit the GI tract ( potentially lethal amount of a heavy metal- arsenic , iron, Hg, thallium). - Ingestion of packets of drugs ( cocaine).

23. 3. ENHANCEMENT OF POISON ELIMINATION: A. MULTIPLE DOSE ACTIVATED CHARCOAL: A dose of 1g/kg for every 2 to 4 hours ( with sorbitol as needed to enhance GI motility. B. FORCE DIURESIS AND ALTERATION OF URINARY pH: For the poisons that are excreted by the kidneys ( mannitol 20%-250ml-IV ) C. EXTRACORPORAL REMOVAL : Dialysis ( peritoneal or haemodialysis ) and exchange transfusion.

24. 4 . NEUTRALISATION: ABSORBTION: 1. Active carbon NEUTRALISATION OF THE ACIDS: 1.Milk of magnesium 2.Na HCO3 3.CaCO3 4.Ca(OH)2 NEUTRALISATION OF ALKALINE: 1. Asetic acid 2. Lemon juice 3. Orange juice

25. NURSING MANAGEMENT ASSESSMENT NURSING DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION

26. SUMMARY