-Lec 10 - Given by: Shahd Al.Nasser (PharmD Candidate) Supervised by: Ghada I. Aboheimed (MSc, Lecturer)

1. List the information required to make the initial assessment regarding the substance involved, symptoms and previous treatment. 2. List the components of the history and describe the techniques for obtaining this information. A. Substance B. Amount C. Present medical condition 2

3. List and describe the references used to answer poison calls 4. Describe the possible treatment plans 5. Outline the follow-up to the poison call 3

4 I. Initial Assessment II. History III. Assessment IV. Treatment Plan V. Follow-up

 To determine relatively quickly how serious is the situation  in order to set priorities and determine if immediate first aid or referral is necessary 5

There are three main aspects of this assessment: A. Substance involved: inherent toxicity, e.g. caustics-drain cleaner, lye. B. Are symptoms present? 1. Irritated, discolored 2. Swollen lips, gums, tongue 3. Coughing, Convulsions 4. Acting unusual, Can't wake up 6

C. What has been done? 1. Is immediate first aid necessary e.g. dilution, washing area 2. Has incorrect first aid been done e.g. salt water as emetic 3. Is immediate ER referral indicated? 7

 Complete and detailed history as possible is one of most important factors in the assessment of the severity of the poisoning  In absence of symptoms, decision to initiate treatment based on history of exposure 8

A. Basic Information 1. Name of caller  Relationship of caller to victim - parent, friend, babysitter, MD, RN (registered nurse). 9

A. Basic Information 2. Name and age of victim. 3. Weight of victim 4. Phone number 5. Time of exposure  How long has it been? 10

A. Basic Information 5. Time of exposure  How long has it been? - By knowing about the onset and duration of action of the substance, one can determine whether the symptoms are consistent with the history of the amount and the time since exposure -In addition, treatment recommendations, such as whether or not to empty the stomach, may be influenced by the length of time since ingestion. 11

A. Basic Information 6. Route of exposure  Ingestion, Inhalation, Percutaneous, Ocular? 12

B. Substance  This information should include ingredients and their percentages  The substance involved may be unknown in patients who are comatose or who ingest tablets or capsules from an unmarked container, or who ingest an unidentified plant 13

B. Substance 1. Brand name and other identification, non- phosphate.  Warning label  Formulating, e.g. phosphate  Form, e.g. solid, liquid, gas  Concentration, e.g. industrial or household strength  Ingredients listed  When/where purchased? 14

B. Substance 2. Medication:  Read prescription label  Is there a drug imprint code?  What was it supposed to do? 15

B. Substance 3. Plant:  Which part?  Has it recently been sprayed?  Is nursery nearby for ID? 16

B. Substance 4. Is it possible anything else is also involved?  look around for any other open bottles, broken plants, etc. 17

C. Amount  If an accurate determination of the amount ingested is impossible, and the product is potentially toxic, one must assume that a potentially toxic amount was ingested, or that the total amount originally in the container was ingested. 18

C. Amount 1. Describe situation  Tell me exactly what happened?  Did you see him/her swallow? 2. Extract quantitative details  How many/much was there originally?  Count/measure how much is left?  When was it purchased?  Used often? 19

D. Symptoms  Determine whether symptoms are consistent with the substance involved; if not, determine what other substances or medical conditions may be responsible for these symptoms.  Severe signs and symptoms, such as respiratory and cardiovascular collapse, may necessitate immediate treatment.  Some treatment modalities are contraindicated when certain signs or symptoms are present (e.g., emetics in the comatose patient). 20

D. Symptoms  Present Medical condition.  Does he/she take any medicine regularly?  Has he/she been sick lately? The patient's medical history may influence the severity of the intoxication or treatment Some home remedies may complicate therapy whereas other prior treatment may influence subsequent recommendations 21

 The prediction of the severity of the exposure and the formulation of the treatment plan is based on: -The toxicity of the substance -The amount and mode of exposure when applied to the specific age, weight and condition of the victim and the circumstances of exposure 22

A. Toxicity of substance. Consult one of the following:  poisindex  Reference texts and articles  Manufacturer emergency number  Consultants and experts 23

 AAPC  Management of Poisoning - A handbook for health care workers By World Health Organization Management of Poisoning - A handbook for health care workers  TOXNET From the National Library of Medicine in the U.S., this site is a collection of databases on toxicology, hazardous chemicals, and related areas TOXNET

 Toxic Exposure Treatment Guides IPCS International Program on Chemical Safety. Toxic Exposure Treatment Guides  AACT - American Academy of Clinical Toxicology An organization uniting scientists and clinicians in the advancement of research, education, prevention and treatment of diseases caused by chemicals, drugs and toxins. AACT - American Academy of Clinical Toxicology

B. Circumstances of Exposure  Suicide  Accidental  occupational  Environmental  Drug abuse 26

C. Competency of caller  Will they be able to carry out instructions and make observations?  How important does caller consider exposure to be? 27

 The plan should consist of simple, explicit instructions and be communicated in a clear manner  It is a good idea to have the caller write the instructions down and repeat the details back to you 28

A. No treatment necessary B. First aid and observe at home  Will they be available for follow-up?  Do they understand what to watch for? 29

C. Syrup of Ipecac and observe at home?  Is syrup of Ipecac available?  Is caller competent and calm?  Will they be available for follow-up?  Do they understand what to watch for? 30

D. Refer to MD, ER or clinic in case of Highly toxic substance; unknown substance; unknown amount; signs symptoms not obvious, e.g. EKG changes; unstable situation.  Arrange transportation  Call ahead  Have they bring container, plant, etc. with them. 31

 Careful follow-up is vital to telephone management of a poison  Calls should be made at 1/2 hour, 2-4 hours, 12 hours or 24 hours. based on the assessment of the poisoning and the treatment recommended. 32

A. Has the victim remained asymptomatic?  Anything at all unusual?  Sleeping, eating, etc. normally 33

B. Were instructions followed?  How much Ipecac did you give?  Did you give water afterward?  How long did you wash the eye? 34

C. Was treatment effective?  Did victim vomit?  How many times?  Were pill fragments present?  Is he/she eating all right now? 35

D. Poison prevention teaching  Education and first aid  Poison proof now-low the odds of a repeat 36

E. Referral  Public health nurse  Clinic workers  Suicide prevention 37

Any Questions?..