Acute Poisoning - General Measures

It has been estimated that in the UK and USA over 10% of all acute adult medical admissions to hospital are due to acute poisoning. The most at risk groups are children under the age of and females aged 1 !"". About "000 adults and #$0 children die each %ear in the UK from acute poisoning. The most common t%pe of to&in ingested varies geographicall%' being prescribed medication in the developed countries and agricultural chemicals' h%drocarbons or traditional medicines in the developing nations.
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(ost of the discussion belo) is confined to drug and chemical poisoning.

Types of Poisoning

*eliberate o +verdose as self!harm or suicide attempt. o ,hild abuse - (unchausen.s s%ndrome b% pro&%. o Third part% /attempted homicide' terrorist' )arfare0. Accidental o (ost episodes of paediatric poisoning. o *osage error1 o Iatrogenic o 2atient error o 3ecreational use. 4nvironmental1 o 2lants o 5ood o 6enomous stings7bites. Industrial e&posures.

General Management
See specific management dependent on drug/s0 involved /contact poisons centre or To&base for current specific advise0.

Resuscitation
4&tent depends on state of patient' see Adult 89S and 2aediatric 89S Airway o Breathing o o o +pen' suction' maintain and intubate as necessar%. Assess )ork and effectiveness of ventilation. :ive o&%gen -assisted ventilation /avoid mouth!to!mouth0. 3espirator% depression ! +piates' ben;odia;epines' earl% salic%late poisoning Tach%pnoea ! metabolic acidosis eg salic%lates' methanol.

o Circulation o Attach a cardiac monitor' assess pulse' blood pressure and perfusion. 4stablish intravenous access.

o o Disability o o o

Tach%cardia7Irregular pulse ! salbutamol' antimuscarinics' tric%clics' <uinine' phenothia;ine' chloral h%drate' cardiac gl%cosides' amphetamines' and theoph%lline poisoning. If h%potensive consider giving fluid bolus /colloid0 or' if necessar%' inotropes. Assess consciousness level /:lasgo) ,oma Scale or A62U0 ,oma ma% suggest ben;odia;epines' alcohol' opiates' tric%clics' or barbiturates. ,heck pupils and e%e movements1 9arge ! Anticholinergics' s%mpathomimetics' tric%clics. Small ! opiates' cholinergics If opiates suspected give 0.=!$mg nalo&one iv7im ever% $!>mins up to 10mg until response /,hild1 10mcg7kg iv7im repeated up to 0.$mg7kg0' repeated doses ma% be re<uired thereafter as it has a shorter half!life than most opiates. Unreactive ! 8arbituarates' carbon mono&ide' h%drogen sulphide' c%anide7c%anogens' head in?ur%7h%po&ia. Une<ual ! slight variation can be normal ! but consider head in?ur%. Strabismus ! ,arbama;epine. 2apilloedema ! (ethanol' carbon mono&ide' glutethimide. @%stagmus ! ,@S agents e.g. phen%toin. ,heck blood glucose ! if h%pogl%caemic give 0ml 0% de&trose iv /,hild1 ml7kg of 10% de&trose iv0. A%pergl%caemia ! organophosphates' theoph%llines' (A+Is or salic%late. A%pogl%caemia ! insulin' oral h%pogl%caemics' alcohol or salic%late. Sei;ures ! if prolonged7recurrent initiall% give dia;epam !10mg iv /,hild1 0.$ !0." mg7kg iv or pr0 or mida;olam /0.1 mg7kg0 I(7I6. (an% drugs can induce sei;ures including tric%clics' theoph%lline' opiates' cocaine and amphetamines.

History
This ma% be unreliable Bhat )as taken' ho) much' )hen' and b% )hat routeC Bas alcohol consumed tooC An% vomiting since ingestionC 2ast medical histor%' current medications and allergies. Bas a suicide note leftC Is the patient pregnantC Aistories from others including1 famil%' friends' paramedics' police and observers. +btain past medical notes if possible.

General !amination

*irected cardiovascular' respirator%' abdominal and neurological e&amination. 6ital signs' pupils etc mentioned in 3esuscitation section above.

 Temperature1 A%pothermia /phenothia;ines' barbiturates' or tric%clics0 or h%perthermia /amphetamines' 4cstas%' (A+Is' cocaine' antimuscarinics' theoph%lline' serotonin s%ndrome0. (uscle rigidit% /4cstas%' amphetamines0. Skin ! c%anosis /methaemoglobinaemia0' ver% pink /carbo&%haemoglobinaemia' c%anide' h%drogen sulphide0' blisters /barbiturates' T,As' ben;odia;epines0' needle tracks' hot7flushed /anticholinergics0. 8reath ! ketones /diabetic7alcoholic ketoacidosis0' Dbitter almondsD /c%anide0' Dgarlic!likeD /organophosphates' arsenic0' Drotten eggsD /h%drogen sulphide0' organic solvents. (outh ! 2erioral acneiform lesions /solvent abuse0' dr% mouth /anticholinergics0' h%persalivation /paras%mpathomimetics0.

"n#estigations

4,: UE4' lab glucose' anion gap 7! lactate F osmolal gap. 95T F ,lotting /paracetamol' anticoagulants0. Arterial 8lood :ases. *rug levels /at appropriate interval1 2aracetamol' salic%latesG others1 theoph%lline' digo&in' lithium' anti!epileptics if it )as likel% that the% had been taken0. ,omprehensive to&icolog% screens not normall% indicated in the emergenc% treatment. ,arbo&%haemoglobin levels if carbon mono&ide suspected. Urinal%sis ! Crhabdom%ol%sis' save sample for possible to&icological anal%sis. ,H3 if pulmonar% oedema7aspiration suspected.

Differential Diagnosis

Aead trauma /especiall%' in the ethanol!into&icated patient0 Stroke 7 SAA (eningitis (etabolic abnormalities /such as h%pogl%cemia' h%ponatremia' or h%po&emia0 9iver disease 2ostictal state.

Treatment
:et more information o UK @ational 2oisons Information ,entres 0=I 0J00 J$JJ $ /automaticall% routed to nearest centre0 o To&base1 @ASnet and internet!based info from the @2I, /registration free > to @AS :2.s and hospitals0 o (ims ,olour inde& or TI,TA,1 to aid pill identification o 8@5 7 *ata Sheet ,ompendium. *econtamination if appropriate o Avoid contaminating %ourself and )ear protective clothing. o 4nsure area is )ell!ventilated. o The patient should remove soiled clothing and )ash him7herself if possible. o 2ut soiled clothing in a sealed container. o Bash all contaminated skin7hair )ith liberal amounts of )arm )ater -soap. *ecrease absorption o :astric empt%ing /,I1 unprotected air)a%' corrosives' h%drocarbons. S41 pulmonar% aspiration' oesophageal perforation0. @ote onl% >0% of gastric contents returned and onl% proven to be effective if )ithin 1 hour of

ingestion /so this is onl% generall% done if patients present earl% having taken a potentiall% fatal dose of drug0. ,ontroversiall% this is sometimes e&tended if dela%ed gastric empt%ing /coma' tric%clics' salic%lates0 is thought likel%. 4mesis ! no longer recommended. :astric lavage1 2lace patient in left lateral head do)n /$0K0 position' insert large />J!"050 bore tube L,hild1 1J to $=5M into stomach. 3emove contents )ith se<uential administration and aspiration of small /$00!>00ml0 <uantities of )arm )ater or saline L,hild1 10!$0ml7kg preferabl% salineM. Alternativel% the stomach contents can ?ust be aspirated. o Activated charcoal /oral' naso!gastric tube0 ! its large surface area adsorbs man% drugs /not iron' lithium' boric acid' c%anide' ethanol' eth%lene gl%col' methanol' malathion' **T' carbamate' h%drocarbons' strong acids and alkalis0. Ideall% used in a 1011 ratio )ith ingested drug' the usual dose is 0g for an adult L,hild1 1g7kgM. Used sometimes )ith cathartic agents e.g. magnesium sulphate' lactulose or sorbitol /be)are in %oung' old and renal insufficient0. Any oral anti$otes gi#en after charcoal may be ren$ere$ ineffecti#e% o Bhole bo)el irrigation ! uses large volume of an osmoticall% balanced' nonabsorbable pol%eth%lene gl%col electrol%te solution /e.g.Klean!2rep' :o9%tel%0. Used )ith iron' lithium' sustained!release or enteric!coated products' large ingestions' and ingested drug packets. Administer at 1 to $9 per hour po or @: L,hild1 >0 ml7kg7hrM' antiemetics ma% be re<uired' continue until rectal effluent clear /appro&imatel% > to J hours0. Increase elimination o 5orced diuresis ! no longer recommended. o Aaemoperfusion and acid7alkaline diuresis ! rarel% used no). o Aaemodial%sis ! severe salic%late' eth%lene gl%col' methanol' lithium' phenobarbitone and chlorate poisonings. o (ultiple doses of activated charcoal ! interrupts enterohepatic or enteroenteric recirculation. Use 0g "!hourl% /,hild 1g7kg0 or 1$. g hourl% /,hild 0.$ g7kg0 to reduce vomiting' but be)are severe constipation' fluid depletion and avoid repeating cathartic agent doses )ithin $"hrs.Used )ith carbama;epine' dapsone' phenobarbitone' <uinine' salic%late' colchicine' de&tropropo&%phene' digo&in' verapamil and theoph%lline overdoses. Supportive o (aintain A8,*s o +bservation and treatment of late complications1 e.g. liver failure' rhabdom%ol%sis. Specific antidote ! See Acute 2oisoning Antidotes and individual articles for relevant antidotes and antagonists.

Referral

(edical72aediatric ! for continued support7antidote administration' observation' cardiac monitoring. 2s%chiatric ! for all deliberate self!poisonings' those )ith suicidal ideation and if the countr%.s (ental Aealth Act has been emplo%ed to detain7treat.

Psychiatric assessment
8e s%mpathetic despite the hourN Intervie) relatives and friends if possible. Aim to establish1

 Intentions at time1 Bas the act plannedC Bhat precautions against being foundC *id the patient seek help after)ardsC *oes the patient think the method )as dangerousC Bas there a final act /eg suicide note0C Bhat problems led to the act1 do the% still e&istC Bas the act aimed at someoneC Is there a ps%chiatric disorder /depression' alcoholism' personalt% disorder' schi;ophrenia' dementia0C Bhat are his resources /friends' famil%' )ork' personalit%0C 2resent intentions and suicide risk. The follo)ing factors increase the chance of future suicide1 o +riginal intention )as to dieG o 2resent intention is to dieG o 2resence of ps%chiatric disorderG o 2oor resources' o 2revious suicide attemptsG o Sociall% isolatedG o Unemplo%edG o (aleG o +ver 0%rs old.

Pre#ention
Adult education *ouble!check dosage before administration. 6igilance b% health professionals to recognise the earl% signs of abuse and potential suicide. 2ut all medicines and household chemicals in a locked child!proof cupboard O1. m off the ground. Safel% dispose of medicines' chemicals )hich are not needed or out of date. Keep all medicines and chemicals in their original containers )ith clear label.