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POISONING BY

THERAPEUTIC
AGENTS

Dr Jatin Dhanani

Potential Scenarios for the


Occurrence of Poisoning by
therapeutic drugs
Medication error
Prescribing
Dispensing
Administration
Environmental
exposure
Occupational
exposure
Therapeutic drug toxicity
Exploratory exposure by young children
Purposeful administration to harm
other
Purposeful administration
for selfharm

Most Frequently
Involved in Human
Poisoning
Substance
Analgesics
Personal care products
Cleaning substances
Sedatives-hypnotics
antipsychotics
Foreign bodies
Topical preparations
Cold and cough
medications
Antidepressants

with the Largest


Number of Human
Fatalities

%
12.5
9.1
8.7
6.2
5.1
4.5
4.5
4.0

Sedatives-hypnotics
antipsychotics
Acetaminophen
Opioids
Antidepressants
Cardiovascular drugs
Stimulants and street
drugs
Alcohols

Aspirin
Toxic dose: Acute (150-200mg/kg)
Chronic (100 mg/kg for 2 or more days)
PRESENTATION
Acute
Burning pain in throat and stomach, & Vomiting
f/b hyperpnoea, tinnitus, and lethargy
Respiratory alkalosis and compensatory
metabolic acidosis
Severe intoxication seizures, hypoglycemia,
hyperthermia, pulmonary edema , and coma
Death by CNS failure and cardiovascular collapse

Chronic
Elderly persons taking salicylates
therapeutically
confusion, dehydration, and metabolic
acidosis
Cerebral and pulmonary edema is more
common
morbidity and mortality rates are much
higher

Circumstances:
Acute suicidal
Chronic accidental or as therapeutic toxicity

Treatment
Emergency and supportive measures
ABC

Decontamination
Emesis
Gastric lavage

Specific drugs and antidotes: no antidote


Enhanced elimination
Urinary alkalinization: Add 100 mEq of sodium
bicarbonate to 1 L of 5% dextrose in quarter normal
saline and infuse intravenously at 200 mL/h
Hemodialysis & Hemoperfusion (serum levels
higher than 1000 mg/L)

Paracetamol
Paracetamol
metabolism

N-acetyl-P-benzoquinoneimin
glutathion
Detoxification
Liver & renal damage

Toxic Dose:
200 mg/kg in children and 6 7 gm in adults
PRESENTATION
Asymptomatic or Anorexia, nausea, or
vomiting
massive overdose - altered mental status &
metabolic acidosis
Transient prolongation of the prothrombin time
(PT/INR)
hepatic necrosis (raise AST & ALT)
acute fulminant hepatic failure with
Encephalopathy, metabolic acidosis, and a
continuing rise in PT/INR - Poor prognosis

Treatment
Emergency and supportive measures
General supportive care of liver and renal failure
Liver transplant

Antidotes
N-acetyl cysteine orally 5% sol 140 mg/kg f/b 70
mg/kg every 4 hr for 3 days

Decontamination
Administer activated charcoal orally within 3 hours
Avoid Gastric lavage

Enhanced elimination
Hemodialysis
effective but is not generally indicated
considered for very high levels (eg, >1000 mg/L) complicated
by coma and/or hypotension

Poisonings
DRUG CLASS EXAMPLE(S)

MENTAL
STATUS

H B R T PUP OTHER
R P R
IL
SIZE

Tremor,
diaphoresis

Ileus,
flushing

Sympathomi Cocaine
Agitation
metic
Amphetamine
Anticholinerg Diphenhydrami Delirium
ic
ne
Belladonna
atropa
Cholinergic Organophospha Somnolence/co

tes
ma
Opioid
Heroin
Somnolence/co

Oxycodone
ma
Sedative- Benzodiazepine Somnolence/co

hypnotic
s
ma
Barbiturates
Salicylate Aspirin
Confusion

Ca2+ channel Verapamil


blocker

SLUDGE
fasciculation

Diaphoresis,
vomiting

Therapy of
Poisoning
1. Emergency management
2. Decontamination
3. Enhancing the elimination
4. Antidote therapy

Decontamination

Indications for GI decontamination

Poison must be potentially dangerous


Time elapsed from exposure should be minimum
Able to be performed safely and with proper
technique

TECHNIQUES FOR DECONTAMINATION


Emesis by Syrup of Ipecac
Dose: 15 mL for children up to 12 years,
30 mL for older children and adults

Gastric Lavage
Saline lavage: 10 to 15 mL/kg (up to 250 mL) of fluid is
administered and withdrawn
Orogastric tube (24 FG for children & up to 40 FG for
adults)

Activated Charcoal
Dose: 0.5-2 g/kg up to 75-100 g
Complications: vomiting, constipation, pulmonary aspiration,
and death
C/I : suspected GI perforation, unconscious and delirious
patients

Whole Bowel Irrigation


Polyethylene glycol electrolyte solution: high molecular
weight & iso-osmotic
Dose: 25 to 40 mL/kg/h until the rectal effluent is clear
candidates for WBI include:
1) "body-packers" with intestinal packets of illicit drugs;
2) patients with iron overdose
3) patients who have ingested patch pharmaceuticals; and
4) patients with overdoses of sustained-release or bezoar-forming
drugs

Cathartics: two common categories


magnesium salts: magnesium citrate and magnesium sulfate
nondigestible carbohydrates: sorbitol

Elimination
Manipulating Urinary pH: Urinary Alkalinization
Weakly acidic drugs: "ion-trapping" in the urine
E.g. - Aspirin, phenobarbital, chlorpropamide,
methotrexate, and chlorphenoxy herbicides
100-150 mEq of sodium bicarbonate in 1L of D5% is
infused intravenously then titrated
C/I : in the presence of renal failure - worsen pulmonary
edema or congestive heart failure

Extracorporeal Drug Removal


(hemodialysis/hemoperfusion)
Ideal drug: low molecular weight, a low volume of
distribution, high solubility in water, and minimal protein
binding
Salicylate, methanol, ethylene glycol, lithium,
carbamazepine, and valproic acid

Antidote

POISONING INDICATION(S)
ANTIDOTE
Acetaminophen
Acetylcysteine
Organophosporus and carbamate Atropine sulfate, Pralidoxime
pesticides
chloride (2-PAM)
Valproate hyperammonemia
Carnitine
Iron
Deferoxamine
Cardiac glycosides
Digoxin immune Fab
Lead, mercury, arsenic
Dimercaprol (BAL)
Lead
EDTA, CaNa2
Methanol, ethylene glycol
Ethanol, Fomepizole
Benzodiazepines
Flumazenil
Cyanide
Hydroxocobalamin hydrochloride
Ca2+ channel blockers
Insulin (high dose)
Methotrexate
Leucovorin calcium
Opioids
Naloxone hydrochloride
Lead, mercury, copper
Penicillamine
Anticholinergic syndrome
Physostigmine salicylate
Isoniazid seizures
Pyridoxine hydrochloride
Coumarin, indanedione
Vitamin K1 (phytonadione)

The

mainstay of therapy for


poisoning is

good support of the Airway,


Breathing, Circulation, and vital
metabolic processes of the poisoned
patient until the poison is eliminated
from the body
specific antidotes are not commonly
needed

Thank
You

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