Introduction

“All substances are poisons: there is none which

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is not a poison. The right dose differentiates a

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poison and a remedy.”

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Paracelsus (1493–1541)
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as
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Philippus Aureolus Theophrastus Bombastus

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von Hohenheim

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Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Introduction
• Poisoning: contact with a substance that results in toxicity

• Symptoms: vary, but certain common syndromes may suggest

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ist
ac
particular classes of poisons

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• Diagnosis: primarily clinical, but for some poisonings, blood

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and urine tests can helpas
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• Treatment: supportive for most poisonings; specific antidotes
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are necessary for a few

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Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Introduction (contd)

• Most poisonings are dose-related

• Toxicity may also result from exposure to excess amounts of

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ist
ac
normally nontoxic substances

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• Some poisonings result from exposure to substances that are

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poisonous at all doses
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• Poisoning is distinguished from hypersensitivity and
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idiosyncratic reactions, which are unpredictable and not dose-

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related, and from intolerance, which is a toxic reaction to a

usually nontoxic dose of a substance
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Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Introduction (contd)
Four types of presentation commonly come across are:

• Fulminant: produced by massive dose, death appears rapidly

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ist
sometimes without preceding symptoms

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• Acute: produced by a single dose or several small doses taken

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in short period, onset of symptoms is abrupt

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• Chronic: produced by small doses taken over a long period of
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time, onset is insidious

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• Subacute: characterized by a mixture of features of acute and

chronic poisoning
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Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Introduction (contd)

• The majority of poisoned patients - acute exposure

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ist
• Most of them tell the doctor what the problem is, and indeed

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what they have taken or been exposed to

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• However, in an unconscious or uncooperative patient the
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as
diagnosis will have to be made on the basis of circumstantial
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or third party evidence

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Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Introduction (contd)

• In spite of all this significant proportion of cases the diagnosis

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remains uncertain.

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Why ?

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• There are only a very few toxic syndromes characterised by
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specific signs and symptoms
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Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Toxic syndromes

Anticholinergic syndrome

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ist
• Causes: Antihistamines, antiparkinsonian drugs, atropine,

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scopolamine, amantadine, antipsychotic, antidepressants,

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antispasmodics, skeletal muscle relaxants, many plants
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(especially Datura), and fungi (e.g. Amanita muscaria)
as
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Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Toxic syndromes

• Symptomatology: Delirium with mumbling speech,

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ist
tachycardia, dry hot skin, mydriasis, myoclonus, urinary

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retention, decreased bowel sounds. Convulsions and

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arrhythmias in severe cases
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as
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Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Cholinergic syndrome

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ist
ac
Causes: Organophosphates, carbamates, parasympathomimetic

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drugs, and some mushrooms

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• Symptomatology: Confusion, CNS depression, salivation,
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as
lacrimation, urinary and faecal incontinence, vomiting,
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sweating, fasciculations, seizures, miosis, pulmonary oedema,

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tachy/bradycardia

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Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Sedative syndrome

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ist
• Causes: Opiates, barbiturates, benzodiazepines, ethanol,

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clonidine

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• Symptomatology: Miosis, hypotension, bradycardia,
en
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as
hypothermia, CNS depression, hyporeflexia, coma, rarely
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convulsions
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Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Introduction (contd)

In most cases, non-specific features:

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ist
• Impairment of consciousness

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ar
• Respiratory/Cardiovascular depression

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en
• Dehydration due to vomiting/diarrhoea
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as

• Hypothermia
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• Convulsions
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• Cardiac arrhythmias

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Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Ocular clues

Table 2.2: Drugs/Poisons Producing Pupillary Changes

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ist
Miosis Mydriasis Nystagmus

ac
Barbiturates Alcohol (constricted in coma) Alcohol

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Benzodiazepines Amphetamines Barbiturates

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Caffeine Antihistamines Carbamazepine

Ph
Carbamates Carbon monoxide Phencyclidine

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Carbolic acid (Phenol) Cocaine Phenytoin

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Clonidine tB Cyanide
as
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Methyl dopa Datura (Atropine)

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Nicotine Ephedrine
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Opiates

Organophosphates

Parasympathomimetics

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Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Olfactory clues

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Odour Substance

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m
Acetone (apple-like) Chloroform, ethanol, isopropanol, lacquer

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Acrid (pear-like) Chloral hydrate, paraldehyde

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Bitter almond Cyanide

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Burnt rope Marijuana (Cannabis)

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Coal gas Carbon monoxide (CO)

Disinfectant (hospital odour) tB Carbolic acid, creosote

as
Arsenic, dimethylsulfoxide, organophosphates,
Garlicky
phosphorus, selenium, tellurium, thallium
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Mothballs Camphor, naphthalene

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Musty (fishy) Aluminium phosphide, zinc phosphide

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Carbon di sulfide, disulfiram, hydrogen sulfide,

Rotten egg
mercaptans, N-acetylcysteine

Shoe polish Nitrobenzene

Vinegar Acetic acid

Wintergreen Methyl salicylate

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Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Basic Management of a poisoned
patient
Stabilizations

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ist
• The initial survey should always be directed at the assessment

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and correction of life-threatening problems, if present

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• Attention must be paid to the airway, breathing, circulation,
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and depression of the CNS (the ABCD of resuscitation)
as
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Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Basic Management of a poisoned
patient
Evaluation

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ist
• If the patient is not in crisis, i.e. he is alert with normal speech

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and pulse, proceed to a complete, thorough, and systematic

Ph
ch
examination
en
tB
• As far as treatment is concerned, the emphasis should be on
as
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basic supportive measures

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Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Basic Management of a poisoned
patient
Decontamination

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ist
• This is with reference to skin/eye decontamination, gut

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evacuation and administration of activated charcoal

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Poison Elimination
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tB
• Depending on the situation, this can be accomplished by
as
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diuresis, peritoneal dialysis, haemodialysis, haemoperfusion,

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etc.

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Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Basic Management of a poisoned
patient
Antidote Administration

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ist
• Unfortunately, antidotes are available for less than 5% of

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m
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poisonings

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Nursing And Psychiatric Care
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as
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Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Stabilization

Respiratory insufficiency

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ist
• First establish an open airway

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ar
• Remove dentures (if any)

Ph
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en
• Use the chin lift and jaw thrust, to clear the airway obstructed
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by the tongue falling back
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• Remove saliva, vomitus, blood, etc. from the oral cavity by

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suction or finger-sweep method

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Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Stabilization

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Ph
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as
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Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Stabilization

• Place the patient in a semi-prone (lateral) position

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ist
• If required, insert an endotracheal tube

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• If ventilation is not adequate, begin artificial respiration with

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Ambu bag.
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as
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Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Stabilization

Oxygen therapy:

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ist
• This is done to raise the PaO2 to at least 45–55 mmHg

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ar
• Begin with 28% oxygen mask

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• Depending on the response as assessed by periodic arterial
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gas analysis, either continue with 28% or progress to 35%
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• If the condition is relentlessly deteriorating, consider assisted

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ventilation

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Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Stabilization

Circulatory failure

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ist
• Correct acidaemia, if present

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ar
• Elevate foot end of the bed (Trendelenberg position)

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en
• Insert a large bore peripheral IV line
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• Administer a fluid challenge of 200 ml of saline (10 ml/kg in

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children)
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Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Stabilization

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Ph
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as
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Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Stabilization

• Observe for improvement in blood pressure over 10 minutes

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ist
• Repeat the fluid bolus if BP fails to normalise and assess for

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signs of fluid overload

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Vasopressors of choice
en
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• Dopamine
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• Noradrenaline
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Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Stabilization

• Dopamine: Add 200 mg (1 ampoule usually), to 250 ml of 5%

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ist
dextrose in water to make a solution of ??? micrograms/ml

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• Begin with 1 to 5 micrograms/kg/ min (maximum being 15 to

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30 micrograms/kg/min), and titrate the dose to maintain
en
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systolic BP between 90 and 100 mmHg
as
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• Monitor BP every 15 minutes

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Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Stabilization

• Noradrenaline: Add 8 mg (2 ampoules usually) to 500 ml of

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5% dextrose solution to make a concentration of ???

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micrograms/ml

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• Start at 0.5 to 1 ml/min and titrate to a clinical response
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as
• Monitor BP every 5–10 minutes until a clear trend is
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established.
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Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Stabilization

Cardiac arrhythmias

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ist
• Lignocaine and amiodarone are generally first line agents for

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stable monomorphic ventricular tachycardia, particularly in

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patients with underlying impaired cardiac function
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as
• Sotalol is an alternative for stable monomorphic ventricular
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tachycardia
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• Atropine may be used when severe bradycardia is present

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Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Stabilization

Lignocaine

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ist
• Dose - Adult: 1 to 1.5 mg/kg IV push

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• Total dose should not exceed 3 mg/kg or more than 200 to

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300 mg during a one hour period
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as
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Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Stabilization

CNS depression

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ist
• Till recently it was recommended that in every case where the

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identity of the poison was not known, the following three

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antidotes (called the Coma Cocktail) must be administered
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(intravenously)
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• Dextrose—100 ml of 50% solution

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• Thiamine (Vitamin B1)—100 mg

• Naloxone—2 mg

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Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Stabilization

• All patients with depressed mental status should receive 100%

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ist
oxygen in a mask, (high flow—8 to 10 litres/min)

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Ph
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as
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Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Evaluation

Hypothermia

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Drugs causing hypothermia

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• Alcohols

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• Antidepressants tB
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• Barbiturates
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• Benzodiazepines
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Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Evaluation

Management of hypothermia:

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ist
• Cover with a blanket

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• Thermoneutral environment maintenance

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• Pre warmed IV fluids and inspired gases
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Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Evaluation

Hyperthermia

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ist
• Oral temperature above 102F is referred to as hyperthermia

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• If it exceeds 106F (which is very rare), there is imminent

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danger of encephalopathy
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Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Evaluation

Agents inducing hyperthermia

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• Amphetamines

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• Antidepressants

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• Cocaine tB
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• MAO Inhibitors
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Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Evaluation

Management of hyperthermia

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ist
• Remove all clothes, and pack the neck and groin with ice

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• Immersion in cold water bath (77oF) is very effective but

Ph
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dangerous in the elderly and in heart patients
en
tB
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• Stop cooling measures when core temperature falls below
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102F
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Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Evaluation

• Metabolic acidosis

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ist
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The drug of choice is sodium bicarbonate

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Dose

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en
• Add 2 to 3 ampoules of 8.4% NaHCO3 to 1 litre of 5% dextrose
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as
in water, infused intravenously over 3 to 4 hours.
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Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Evaluation

Convulsions (Seizures)

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ist
• Begin drug therapy with benzodiazepines

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ar
• Either lorazepam (0.1 mg/kg) at a rate of 2 mg/min, or

Ph
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diazepam (0.2 mg/kg) at a rate of 5 mg/min can be
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tB
as
administered IV
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• If status persists, administer 15–20 mg/kg phenytoin at 50

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mg/min (adults), or 1 mg/kg/min (children), by IV

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Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Decontamination
• Eye

• Skin

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ist
• Gut

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ar
-Emesis (syrup of ipecac, apomorphine)

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-Gastric lavage (stomach wash using Ewald tube)
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-Catharsis (sorbitol) (reduce transit time of drugs in GI tract)
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-Activated charcoal (adsorption)

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-Whole bowel irrigation/ lavage (PEG-Electrolyte lavage

solution combined together
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Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Removal of Toxin
Eye decontamination

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❑Ocular exposure to solvents, e.g., hydrocarbons, detergents,

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and alcohol, or corrosive agents, e.g., acid or alkalis require

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immediate local decontamination

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❑This is achieved by copious irrigation with neutralizing
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as
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solution (e.g., normal saline or water) for at least 15 minutes

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❑ Do not use acid or alkaline irrigating solution

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Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Removal of Toxin

• As a first-aid measure at home, a victim of chemical burns

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ist
should be instructed to place his face under running water or

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in a shower while holding the eyelids open

Ph
ch
• During transportation to hospital the face should be immersed
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tB
in a basin of water
as
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Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Removal of Toxin (contd)

– Dermal decontamination

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ac
❑Absorption of organophosphorus and related compounds

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through cutaneous route can prove to be a fatal as oral

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route absorption
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❑Cutaneous absorption depends on several factors such as
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lipid solubility, skin condition, location, caustic effect,

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physical conditions

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Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Removal of Toxin (contd)
• Remove all contaminated clothes and irrigate the whole body
including nail, groin, skinfolds with water or saline as soon as

.in
ist
possible after exposure and continue irrigating for at least 15

ac
m
minutes

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Ph
• Water should not be used to decontaminate skin in exposures

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en
to sodium and phosphorus tB
as
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• In certain cases, specific agents may be indicated for skin

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decontamination (e.g., mineral oil for elemental sodium,

Neosporin for super glue and calcium gluconate for
hydrofluoric acid) 42
Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Removal of Toxin (contd)
• Gut decontamination
This includes:
(i) gastric evacuation;

.in
ist
(ii) adsorbent administration; and

ac
m
(iii) Catharsis

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(iv) Emesis is the preferred method of emptying the stomach in

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conscious children.

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• Vomiting can be induced by:
tB
as
a) tickling the fauces with a finger, feather or a leafy twig
.L

of a tree;
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b) administration of copious draughts of warm water;

c) gurgling with non-detergent soap; or
d) saline emetics in warm water
43
Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Removal of Toxin (contd)

• Syrup of ipecac may be used for inducing emesis in children

.in
older than 6 months in a single dose of 10 mL for 6-12 months

ist
ac
age, and 15 mL for children above 1 year of age

m
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Ph
• Dose may be repeated in 20 minutes for those more than 1

ch
en
year of age tB
as

• Induction of vomiting is contra-indicated in corrosive or

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kerosene poisoning and in comatose patients or those with

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absent gag reflex

44
Faculty of Pharmacy © Ramaiah University of Applied Sciences
 CI of emesis

• Children less than 6 month

.in
• Strong acid and base

ist
ac
• Depression

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• Unconsciousness

Ph
ch
• Seizures
•
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Coma and convulsion tB
as

• Extremely rapid onset of action

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•
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Sharp objects
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• Hydrocarbons, petroleum products

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Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Gastric Lavage
✓ If the vomiting does not occur quickly, gastric lavage should be
done promptly to remove the poison

.in
✓ In a symptomatic but alert patient with minor ingestion,

ist
ac
m
activated charcoal alone by mouth is sufficient for

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Ph
gastrointestinal decontamination

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en
tB
✓ Child is kept in the left lateral position with the head hanging
as
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over edge of the table and the face down

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✓ A large single lumen tube with multiple distal ports is necessary

([Link]

46
Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Gastric Lavage (contd)

✓ A restraint is required for most children and mouth gag is

.in
placed in the mouth before the procedure

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ac
m
✓ Catheter is passed gently and free end is dipped under water

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Ph
to make sure that the catheter is not in the airway

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en
✓ Generally tap water is used for lavage and four or five washes
tB
as
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are done
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✓ Volume of each aliquot should be at least 10-15 mL/kg

47
Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Gastric Lavage (contd)
✓ After the fluid has been instilled, it should be removed by
gravity drainage or tube suction

.in
✓ Catheter is pinched before it is finally withdrawn or suction is

ist
ac
maintained during withdrawal to prevent aspiration

m
ar
Ph
✓ Gastric lavage should not be performed in children with poor

ch
en
gag reflex or corrosive ingestion
tB
as
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✓ In kerosene poisoning, lavage may be done very cautiously if

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the child has consumed a large gulp of kerosene and is brought

quickly to the hospital, otherwise it is better to avoid stomach
wash
48
Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Gastric Lavage (contd)

This procedure can be used: Good for patient if

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ist
• Unconscious

ac
m
ar
• Depression

Ph
ch
en
• Seizures tB
as

• Coma and convulsion

.L
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Contraindicated in patients who have ingested Acids, Alkali,

Hydrocarbons

49
Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Adsorbent
• An agent capable of binding to a toxic
agent in the GIT is known as

.in
ist
adsorbent

ac
m
ar
• Activated charcoal is the most widely

Ph
ch
used adsorbent
en
tB
• It
as
is created by subjecting
.L
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carbonaceous material e.g., wood,

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coal to steam at 600-900 degree

Celsius and acid
50
Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Adsorbent (Contd)
• For the comatosed patient (Grade 3 or 4) with potentially
serious overdose, gastric lavage is followed by administration of

.in
ist
activated charcoal via an oro-gastric or nasogastric tube within

ac
m
ar
1-2 hours of ingestion

Ph
ch
• Dose of activated charcoal administered should be at least 10
en
tB
times the dose of ingested toxic material
as
.L
w

• In asymptomatic patient presenting early or without reliable

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history, 15-30 gram of charcoal may be used

51
Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Catharsis
• Laxative and purgatives may be given in poisoning with
substances which do not cause corrosive action on

.in
ist
ac
gastrointestinal mucosa

m
ar
• Increased motility of the gut may reduce absorption.

Ph
ch
en
Commonly used cathartics include: sorbitol and mannitol (1-2
tB
as
g/kg), and magnesium or sodium sulfate (200-300 mg/kg)
.L
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• Do not give magnesium salt cathartics in cases with renal

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failure

52
Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Whole bowel irrigation

• This is a method that is being increasingly recommended for

.in
ist
late presenting overdoses when several hours have elapsed

ac
m
ar
since ingestion

Ph
ch
• It involves the instillation of large volumes of a suitable
en
tB
solution into the stomach in a nasogastric tube over a period
as
.L
w

of 2 to 6 hours producing voluminous diarrhoea

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Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Whole bowel irrigation

• Previously, saline was recommended for the procedure but it

.in
ist
resulted in electrolyte and fluid imbalance

ac
m
ar
• Today, special solutions are used such as PEG-ELS ( i.e.

Ph
ch
polyethylene glycol and electrolytes lavage solution combined
en
tB
together, which is an isosmolar electrolyte solution), and PEG-
as
.L
w

3350 (high molecular weight polyethylene glycol) which are

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safe and efficacious

54
Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Whole bowel irrigation

Indications

.in
ist
• Ingestion of large amounts of toxic drugs in patients

ac
m
ar
presenting late ( > 4 hours post-exposure)

Ph
ch
• Overdose with sustained-release preparations
en
tB
as
• Ingestion of substances not adsorbed by activated charcoal,
.L
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particularly heavy metals

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Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Whole bowel irrigation

• Ingestion of foreign bodies such as miniature disc batteries

.in
ist
(button cells), cocaine filled

ac
m
ar
• Ingestion of slowly dissolving substances: iron tablets, paint

Ph
ch
chips
en
tB
as
.L
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Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Summary

• Poisoning morbidity and mortality usually result from the acute

effects of the toxin on the cardiovascular, central nervous or

.in
ist
respiratory system

ac
m
ar
• Recommended screening tests for acute poisoning are the 12-lead

Ph
ch
ECG and serum paracetamol level
en
tB
as
• Methods of gastrointestinal decontamination include: induced
.L
w

emesis, gastric lavage, activated charcoal and whole bowel irrigation

w
w

57
Faculty of Pharmacy © Ramaiah University of Applied Sciences
 Summary

• Techniques of enhanced elimination include: multiple dose

.in
ist
activated charcoal, urinary alkalization, hemodialysis and

ac
m
ar
hemofiltration

Ph
ch
• Extracorporeal techniques of elimination can be used to
en
tB
enhance the elimination of toxins
as
.L
w
w
w

58
Faculty of Pharmacy © Ramaiah University of Applied Sciences