Toxicology

PWM Olly Indrajani

2012

Introduction
Given a large enough exposure, all
substances have the potential to be
poisons.
Poisoning occurs when exposure to a
substance
adversely
affects
the
function of any system within an
organism.
The setting of the poison exposure
may be occupational, environmental,
recreational, or medicinal.
Poisoning may result from varied
portals of entry, including inhalation,

DIFFERENTIAL DIAGNOSIS
BY CHIEF COMPLAINT

Although the poisoned patient may

present with varied symptoms and
complaints, the chief presenting
complaint or symptom may suggest a
diagnosis
Recognition of grouped symptoms
and
findings
consistent
with
a
toxidrome can guide diagnosis and
treatment in the poisoned patient.

Primary Considerations for

Presenting Chief Complaint in
the Poisoned Patient

Toxidromes

 Oral

ingestion was the commonest

route of exposure (Fig 1)
Most exposures occurred at the
patients own residence, and most
patients (75%) were managed onsite with assistance from a poison
information center and did not
require an emergency department
visit
Only 3% of patients required
critical care.

 Largest number of deaths were:

analgesics
Antidepressants
sedative/hypnotics/antipsychotics
Stimulants
street drugs
cardiovascular drugs
alcohols

 Of

all deaths:

5% increase compared to 1999

88% occurred in 20- to 99-year old

individual
The mortality rate was higher in
intentional rather than
unintentional exposures (79% vs
10.5%, respectively).

DIAGNOSIS
History and
physical
examination
Vital signs
Ocular findings
Mental status,
behaviour and
muscle tone
Poison control
center
consultation

Laboratory
evaluation:
Anion gap
Osmolal gap
Oxygen

saturation gap
Toxicology
screening

History and Physical

Examination
Although

the history is
important, it may be unreliable
or incomplete
Consider that family members,
friends, and pharmacists may
have additional information

In the absence of a classic

presentation or toxidrome,
separating patients with suspected
poisoning into broad categories
based on:
vital signs
ocular findings
mental status
muscle tone

can help determine drug or

toxin class

Vital Signs
Anticholinergic

and
sympathomimetic substances
increase heart rate, BP, and
temperature
In contrast organophosphates,
opiates, barbiturates, blockers, benzodiazepines,
alcohol, and clonidine cause
hypothermia, bradycardia, and
respiratory depression.

Ocular Findings
Anticholinergics and sympathomimetics
cause mydriasis
In contrast to anticholinergics overdose,
the pupils remain somewhat light
responsive in cocaine intoxication
Horizontal nystagmus is common in
alcohol intoxication
Other drugs causing nystagmus are
lithium, carbamazepine, solvents,
meprobamate, quinine, and primidone
Phencyclidine and phenytoin cause
horizontal, vertical, and rotary nystagmus

Mental Status, Behavior, and Muscle Tone

Initial Supportive
Measures

Airway, Breathing, Circulation

Often required before confirmation of
intoxication
With cervical spine precautions in place
(unless trauma has been excluded),
airway patency must be ensured in all
cases
Endotracheal intubation is not always
necessary when cough and gag reflexes
are present and there is adequate
spontaneous ventilation, but when there is
concern regarding airway protection and
clinical deterioration it is better to secure
the airway
Intubation is indicated in acute respiratory

 Other

specific indications
include the need for high levels
of supplemental oxygen in
carbon monoxide poisoning and
the need to protect the airway
for gastric emptying
Endotracheal intubation
decreases (but does not
eliminate) the risk of aspiration
which is approximately 11% in
the comatose patient with drug

 Depending

on the intoxication,
patients may present with
hypotension or hypertension,
bradyarrhythmias or
tachyarrhythmias
The pathogenesis of hypotension
varies and may include hypovolemia,
myocardial depression, cardiac
arrhythmias, and systemic
vasodilation
Treatment should be individualized,
but an initial strategy of rapid IV
normal saline solution infusion is

The vasopressor of choice depends

on the type of intoxication

Hypertension occurs in the setting of

sympathomimetic drugs,
anticholinergics, ergot derivatives,
phenylpropanolamine overdose, and
withdrawal from nicotine, alcohol,
and sedatives

Treatment of the hypertension

depends on its chronicity and
severity and the inciting agent

Hypertension-induced (reflex)

Coma Cocktail
Thiamine (100 mg by vein) is
administered to treat and/or avoid
Wernicke-Korsakoff syndrome in
comatose patients
Comatose patients should receive
dextrose, 50 g IV
Naloxone rapidly reverses coma,
respiratory depression, and
hypotension induced by opioids. An
initial dose of 0.2 to 0.4 mg is
administered IV (or endotracheally).

Prevention of
Absorption
Skin decontamination requires
removal of the toxin with
nonabrasive soap and water
Contaminated clothing may serve as
a reservoir for continued exposure
and must be removed with caution
and placed in plastic bags or other
containers that are impervious to the
toxin
Ocular decontamination may require
prolonged periods of irrigation with

PRINCIPLES OF
GASTROINTESTINAL
DECONTAMINATION
Gastrointestinal

(GI) decontamination
refers to therapies that may decrease the
amount of poison absorbed from the GI
tract lumen.

The

following methods of GI
decontamination are available:

A. Induced emesis
B.Gastric emptying or Gastric lavage (GL)
C. Activated charcoal combined with a
cathartic
D.Whole-bowel irrigation(WBI)

Emesis
Considered

only in fully alert

patients, and is virtually never
indicated after hospital
admission
Contraindications to its use
include poisoning with
corrosives, petroleum products,
or antiemetics.

A. Induced Emesis

Induced emesis utilizes syrup of ipecac to induce

vomiting, theoretically emptying the stomach
and reducing absorption of an ingested agent.
Syrup of ipecac induces vomiting by activation of
both local and central emetic sensory receptors.
Induced emesis has largely been abandoned in
clinical practice.
The most recent policy statements released by
both the American Academy of Pediatrics(2003)
and the American Association of Poison Control
Centers (2005) discourage the use of syrup of
ipecac in the out-of-hospital setting.

Gastric Emptying
GL through a 28F to 40F Ewald tube is
similarly aimed at physically removing a
toxin
Prior to inserting the Ewald tube, the
mouth should be inspected for foreign
material and equipment should be ready
for suctioning
Large gastric tubes (37F to 40F) are less
likely to enter the trachea than smaller
nasogastric tubes, and are necessary to
facilitate removal of gastric debris

 Nonintubated

patients must be
alert (and be expected to remain
alert) and have adequate
pharyngeal and laryngeal
protective reflexes
In semicomatose patients, GL
should be performed only after a
cuffed endotracheal tube has
been inserted.

GL is performed by instilling 200-mL

aliquots of warmed tap water until there is
clearing of aspirated fluid
Stomach contents should be retained for
analysis
Tap water may avoid unnecessary salt
loading compared to normal saline solution
Neither irrigant has been shown to
significantly alter blood cell or electrolyte
concentrations
After clearing, the Ewald tube may be
replaced by a nasogastric tube for
subsequent intermittent suctioning and/or
administration of activated charcoal.

American Academy of
Clinical Toxicology

does not recommend routine use of GL in

the management of poisoning unless a
patient has ingested a potentially lifethreatening amount of a poison and the
procedure can be undertaken within 60 min
of ingestion

B. Gastric Lavage
INDICATIONS

Ingestion of a
substance with
high toxic potential
and:
Within 1 hour of
ingestion
Ingested substance
is not bound by
activated charcoal
or has no effective
antidote.
Potential benefits
outweigh risks.

CONTRAINDICATIONS
Substance not meeting
above indications
Spontaneous emesis
Diminished level of
consciousness/unprotecte
d airway reflexes
(intubate first)
Ingestion of
hydrocarbons or caustic
agents
Foreign body ingestion
Patient is at high risk for
esophageal or gastric
injury (GI hemorrhage,
recent surgery, etc.).

TECHNIQUE
Recommended tube size is 3640 French for adults,
2228 French for
children.
Secure airway via intubation, if necessary.
Position patient in left-lateral decubitus position,
with head lowered below level of feet.
Confirm tube placement following insertion.
Aspirate any available stomach contents.
Lavage with 250 mL (1015 mL/kg in children)
aliquots of warm water or saline.
Continue until fluid is clear and a minimum of 2L has
been used.
Instill activated charcoal through same tube, if
indicated.
COMPLICATIONS
The primary risks are vomiting, aspiration, and
esophageal injury or perforation.

C. Activated Charcoal
INDICATIONS

Activated charcoal
(AC) is ingested by the
patient in order to
adsorb poisons within
the GI tract lumen.

Patient presents
within 1 to 2 hours
after ingestion.
Patient has ingested a
potentially dangerous
amount of a poison
adsorbed by charcoal

CONTRAINDICATIONS
Ingested substance is
poorly adsorbed by AC (eg,
iron, lithium, heavy
metals,toxic alcohols).
Diminished level of
consciousness/unprotected
airway reflexes (AC can be
given by naso- or
orogastric tube following
intubation)
Patient presents over 2
hours after ingestion.
Ingestion of caustic agents
Cases where endoscopy
will be required

INDICATIONS
DOSE

CONTRAINDICATIONS
RISKS

The recommended
dose of AC is a 10:1
ratio relative to the
ingested poison(ie,
ingestion of 1 g of
poison requires 10 g
of AC). Hence, the
commonED practice of
administering 50 to
100 g (1 g/kg) of AC to
an overdose patient
may be inadequate for
larger ingestions.

The primary risk of

single-dose AC is
vomiting.
Constipation and
diarrhea
Bowel obstruction does
not occur from singledose AC.
Repeated doses of
cathartics given with
charcoal may cause
dehydration or electrolyte
abnormalities.

D. Whole -Bowel Irrigation

Whole-bowel irrigation (WBI) flushes the GI tract to decrease the transit timeof luminal contents, thereby limiting absorption

Removal of
ingested drug
INDICATIONS
packets
(eg, body
stuffers)
Large ingestion of
a sustained-release
drug
Potentially toxic
ingestion that
cannot be treated
with activated
charcoal (eg,
lithium, lead, iron)

CONTRAINDICATIONS

Diminished level of
consciousness/unprot
ected airway reflexes
(intubate first)
Decreased GI motility
or bowel obstruction
Significant GI
hemorrhage
Persistent emesis

DOSE

Polyethylene glycol
(PEG) solution is
administered at a rate
of 12 L/hour.
This rate of
administration usually
requires a naso- or
orogastric tube.
Endpoints for therapy
are the appearance of
clear rectal effluent or
a total irrigation
volume of 10 L.

COMPLICATIONS

The primary risk

associated with WBI
is vomiting.
Patient discomfort:
Bloating, cramping,
and flatulence
WBI with balanced
PEG solutions does
not generally cause
electrolyte
abnormalities.

PRINCIPLES OF ENHANCED
ELIMINATION
The goal of enhanced elimination is to increase
the clearance of a poison from the body after
it has been systemically absorbed.
The following methods of enhanced
elimination are available:
A. Multiple-dose activated charcoal
B. Urinary alkalinization
C. Hemodialysis

Enhanced Elimination:
Drug Characteristics and
Examples

A. Multiple-Dose Activated
Charcoal
Uses repeated doses of activated charcoal
(every 24 hours) to increase poison
clearance.
MDAC exerts its effects through disruption
of enterohepatic circulation or direct
adsorption across the GI mucosal surface.
RISKS
The risks associated with MDAC are
similar to those with AC; however,there is
a greater risk of bowel obstruction with
MDAC.

INDICATIONS

CONTRAINDICATIONS

Drugs that have

enterohepatic
circulation and can
possibly be treated
with MDAC include:
Phenobarbital
Carbamazepine
(Tegretol)
Theophylline
Aspirin
Dapsone

MDAC is
contraindicated in
the same settings
as AC.

B. Urinary Alkalinization
Urinary alkalinization attempts to increase renal
elimination of a drug by increasing urine pH.
Urinary acidification to increase the clearance of
weak bases is not recommended due to the risk
of renal injury.
RISKS
Can precipitate hypokalemia and decrease
ionized calcium levels

INDICATIONS
Urinary
alkalinization only
affects the
clearance of drugs
that are weak
organic acids.
Aspirin (most
common use for
alkalinization)
Phenobarbital
Formic acid

CONTRAINDICATIONS

Poisoning with
agents that are not
weak organic acids
and are not
primarily cleared by
the kidneys
Patients who cannot
tolerate excess
sodium/water
loading (eg, CHF,
renal failure)

C. Hemodialysis
Hemodialysis (HD) directly removes
toxins from a patients plasma, using the
same technology applied to renal failure.
RISKS
HD requires central venous access, with
all the usual accompanying risks
(bleeding, pneumothorax, etc.).
HD must be used cautiously in patients
that are hemodynamically unstable.

INDICATIONS

CONTRAINDICATIONS

For HD to be useful in a
poisoned patient, the
ingested poison should
have the following
characteristics:
Low molecular weight
Low plasma proteinbinding
Small volume of
distribution
Poor endogenous
clearance
HD can also treat severe
acidosis caused by a toxin,
even if the toxin it self is
not readily dialyzable.

Toxins that do not

satisfy the
conditions listed
above.

Poison Control Center

Consultation
Regional

poison control center

consultation is highly recommended in
cases of suspected poisoning and to
help guide management in confirmed
cases
These centers provide 24-h emergency
and up-to date technical information.
They are staffed by nurses,
pharmacists, pharmacologists, and
physicians trained and certified in
toxicology

 SIKer

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 SIKER

DAERAH SURABAYA
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