2.  Sudden onset of unexplained illness in a person with  Psychotic illness  Family conflicts  Economic crisis  Occupational exposure  H/O alcohol consumption

3.  Talk with the patients, family, friends and persons whoever brought the victim regarding:  TYPE OF POISON AND QUANTIFICATION  MODE OF ENTRY  TIME SINCE EXPOSURE  DURATION OF EXPOSURE  TREATMENT PRIOR  SYMPTOMS RELATED TO THE PRE- DOMINANT ORGAN DYSFUNCTION

4.  Try to establish the intent  Enquire for possibilities of multiple poisonings  Alcohol abuse  Any previous incidence of suicidal attempt  Insist to bring the container  Ask for any psychiatric illness  Ask for other co- morbid conditions  Verify whether pregnant or not  Family history of drug intake

5. 1. Head To Foot Evaluation 2. Monitoring Of Vitals (Temp.,B.P., H.R, R.R.,) 3. System Examination (Cvs, Rs, Cns, Abd) 4. Look For Bite Marks, Needle Marks, and Ligature Mark in the neck. 5. Continuous Monitoring

13.  In the process of evaluation, there are 4 important toxindromes, we need to look into: 1. Cholinergic 2. Anticholinergic 3. Sympathomimetic 4. Sedatives/hypnotics

14. SMALL PUPILS WET MOUTH SWEATING WET EYES VOMITING SLOW PULSE DIARHOEA FITS UNCONCIOUSNES S Organophosphorous Carbamate Muscuranic agonists

15. DRY HOT SKIN FEVER THIRST DRY MOUTH LARGE PUPILS FAST PULSE DIFFICULTY IN PASSING URINE HALLUCINATIONS FITS SHALLOW BREATHING UNCONCIOUSNESS Atropine overdosage Datura poisoning Mushroom poisoning Cyclic antidepressants Antihistamines Antipsychotics Antiparkinsonism

16. Delusion Paranoia Tachycardia Hypertension Hyperreflexia Diaphoresis Piloerection Mydriasis Seizures Sympathetic agonists Methylxanthines Ergot alkaloids MAO inhibitors Thyroid hormones Cocaine, Amphetamine

17. H/O INTAKE OF TABLETS UNCONCIOUSNESS LOW TEMPERATURE HYPO TENSION SHALLOW BREATHING SKIN BLISTERS BETWEEN THE FINGERS, KNEES OR ANKLES BARBITURATES BENZODIAZEPINES ALCOHOL ANTIPSYCHOTICS ANTICONVULSANTS

18. Akathisia Dystonia Parkinsonism Tremors Neuroleptics Serotonin receptor antagonists L-dopa Cyclic antidepressants Antihistamines

19. Agitation Confusion Mutism Seizures Diarrhea Diaphoresis Labile hypertension Mydriasis Flushing Coma Cocaine Amphetamine SSRI cyclic anditdepressants MAO inhibitors

20.  Slow absorption Anticholinergics, Carbamazepines, Drug packets, Enteric coated pills, Opioids, salicylates  Slow distribution Cardiac glycosides, Lithium, Metals, Salicylate  Toxic Metabolite Acetaminophen, CCl 4, Ethylene glycol, Methanol, Methemoglobin inducers, OPC and mushroom toxins

21.  (2×Na)+Glucose/18 +BUN(mmol/dl)/2.8 (mg/dl) Difference between measured and calculated osmolality  Normal osmolao gap should be <12  Increased in Ethylene & Propylene glycol, ethanol, methanol, Acetone, Valproic acid, mannitol, glucose Calcium and Magnesium

22.  Na + – (Cl¯+ HCO 3 ¯)  Normal anion gap is 12±2  Increased: Asphyxiants, Ethylene and Propylene glycols, Methanol, paraldehyde, salicylates, Acetone, Valproic acid  Decreased: Bromide, Iodine, Lithium and Nitrate

23.  Hydrocarbons and volatile gases irritate the nose, pharynx and upper airways causing cough and choking  Kerosene can cause aspiration and pneumonitis  Sometimes they may cause pulmonary edema

24.  Miosis: OPCs and carbamates, Narcotics, phenothiazines, barbiturates, clonidine  Mydriasis: Atropine, Belladonna group of alkaloids, tricyclic antidepressants, cocaine, LSD  Nystamus: Barbiturates, Phenytoin, Phencyclidine

25.  Increased salivation  OPCs, carbamates, corrosives, Arsenic  Dry mouth  Atropine, Belladonna, anticholinergics and narcotics

26.  Organophosphate and carbamate  Heroin and methadone  Barbiturates  Toxic fumes  Hydrocarbons

27.  Gastric lavage and blood sample should be sent for toxicological analysis  Routine samples for CBC, RFT, electrolytes and LFT  Coagulation profile  CPK and LDH  Amylase and lipase  Urine sample for RBCs, myoglobin and protein

28.  If possible, blood level of alcohol  X ray chest, neck, abdomen and wherever needed.  CT or MRI brain  Doppler studies to rule out thrombosis

29. THANK YOU