بسم الله الرحمن الرحيم Principles of Management of Poisoned Patient د/ عبد المنعم جودة مدبولى دكتوراة الطب الشرعي و السموم الإكلينيكية, مدرس الطب الشرعي و السموم الإكلينيكية, استشاري علاج التسمم بمستشفى بنها الجامعي 30/07/1438 Dr Abdelmonem G. Madboly

= treat patient, not poison Objectives (ILOs): General management of poisoned patient: Patient with normal mental status or alert patient (Stable). Patient with altered mental status or coma (Unstable). = treat patient, not poison

Dr Abdelmonem G. Madboly Role of Doctor Management: 1- Diagnosis 2- Treatment Medico-Legal Aspect 1- Manner 2- Samples 3- Authority inform 4- Tox. Report 26 April 2017 Dr Abdelmonem G. Madboly

Dr Abdelmonem G. Madboly Treatment Unstable 1- Emergency stabilization ABCDEs. 2- Initial therapy (Empiric antidote) 3. Emergent therapy. + تكمل من رقم 1 فى alert Stable Proper clinical evaluation. 2. Decontamination & Enhanced Elimination. 3. Antidote. 4. Sympt. (Supportive) ttt. 5. Discharge & follow up. 6- Prevention re-exposure = Treat the patient, not the poison 26 April 2017 Dr Abdelmonem G. Madboly

B = Breathing: How to know: Clinical exam. (Resp. rate, Cyanosis………..) Perform arterial blood gas )ABG) analysis to monitor: The adequacy of oxygenation by measuring PO2 (normal : 75-100 mmHg or 10-13.3 Kpa “kilopascal”) and O2 saturation (normal: 95-100% or 4.8-6.1 KPa) The adequacy of alveolar ventilation by measuring PCO2 (normal values are 36-46 mmHg). Pulse oximetry : مهمممم Not reliable in patients with methemoglobinemia or carbon monoxide poisoning.

Methods of O2 administration: Mouth to mouth. AMBU bag (Bag valve mask). Nasal cannula. Nasal musk. Mechanical ventilation (ventilator). + ttt of Cause: (respiratory arrest, bronchospasm, pulmonary aspiration, or noncardiogenic pulmonary edema).

C = Circulation: Cause of abnormal circulation: How to know: Hypotension & shock……………. Dysrhythmias……………………… Bleeding & hemorrhage………… How to know: Measure pulse and blood pressure Estimate tissue perfusion (urinary output, skin signs, pH). Insert an intravenous line, and draw blood samples. How to treat (hypotension)

ttt of Hypotension & shock: Position & Warming of patient . IV fluids (up to 2 L in adults or to a systolic blood pressure of 100 mmHg). Vasopressors (dopamine or dobutrex ). Continuous ECG monitoring: antiarrhythmic agents such as lidocaine or phenytoin Cardiopulmonary resuscitation (CPR) for cardiac arrest. ttt of cause (antidote). ttt of ppt factors “arrhythmogenic factors”: (hypoxia, met. acidosis, dysrhythmias & hypokalemia)

Depression (D) or Excitation (E): ttt of Coma (Coma cocktail): DONT ttt of depression (Coma cocktail): = dextrose, oxygen, thiamine & naloxone Excitation = seizures: Diazepam Phenobarbital Phenytoin General anaesthesia Drug elimination by haemodialysis. Treatment of violent patient (Agitati = Benzodiazepines & haloperidol. ttt of seizures (Convulsions): ttt of violent patient (Agitation)

II- Initial Therapy (Empiric Antidote ) DONT (Coma cocktail)

Def.: drugs which should be used as diagnostic or therapeutic agents for the comatose patient. Drugs: DON’T Dextrose (Hypertonic) 0.5 to 1 g/kg of 50% dextrose in water (D50W) for an adult, or D10W or D25W for a child. Oxygen 100% Naloxone (Narcan), 2 mg (5 ampoules, each 0.4 mg) intravenous for adults and children. Thiamine, 100 mg intravenous for an adult (usually unnecessary for a child).

Emergent therapy: Some urgent manifestations: Some specific antidotes. Coma ……………………………. Convulsions …………………… Pulmonary edema ………….. Cerebral edema …………….. Metabolic Acidosis …………. Some specific antidotes.