1. Approach to Acute PoisoningBy
Adel Altamimi,MD
EM consultant

2. paracetamol before one hour , he is fully conscious ,alert
25 years male present after ingestion of 20 tap of
paracetamol before one hour , he is fully conscious ,alert
and vital signs are stable.
Next step?
induce vomiting
gastric lavage
activated charcoal
extract blood for investigation and send for level at 4 hours

3. 16 years female present with sever decrease in level of conscious after ingestion of large amount of epilepsy medication
She is unconscious, normal BP and HR
Next step?
NG and gastric lavage
intubated and ventilated
CT brain
IV fluids

4. 30 years K/C of depression came with tonic colonic
SZ aborted with Benz , the patient intubated because
of decrease level of conscious , BP 100/60 HR 160
Next step
CT brain
EEG
ECG
TOX screen

5. Acute poisoning is a dynamic medical illness usually representing an acute and potentially life threatening exacerbation of a chronic underlying psychosocial disorder.
the patient’s form a heterogeneous group that requires a systematic approach based on early resuscitation where needed, risk assessment to guide further management and early consideration of the underlying psychosocial issues.
the overall mortality rate from drug overdose and poison exposure is %.
the mortality rate for hospitalized patients is approximately 1 to 2 %.

6. 5% of all ICU admission . Acute poising :
account for 5 to 10 percent of all emergency department visits.
5% of all ICU admission .
The most commonly implicated poisoning exposures were due to analgesics .

7. Toxidrome:
Physical findings attributed to a specific class of toxins that can provide important clues to narrow the differential diagnosis.

11. The general rules have many exceptions, and polydrug overdoses may result in overlapping and confusing mixed syndromes.

12. General Approach : Resuscitation Examination Risk assessment
Investigation
Decontamination
Antidotes.
Supportive Therapy .
Disposition .

13. Resuscitation:
initial assessment and treatment should target potential life threats and occur in an appropriately staffed and equipped resuscitation area.
extended ABC approach ( low threshold of intubation).
VITAL SIGNS !

14. Consider intubation in
depress level of conscious.
sever acidosis
respiratory failure.
risk of aspiration (gastric lavage)

15. Early detection of
Seizure ( benzodiazepein)
Hypoglycemia
Hypothermia
Hypotension
Arrhythmia.

16. in cardiac arrest from toxicological causes , resuscitation should be prolonged.

17. Examination:
Detailed examination:
Vital signs
Eyes
Mucous Membranes
Breath and Bowel sounds
Skin Assessment
Reflexes

19. Risk assessment :
Agent(s)
Dose(s)
Time since ingestion
Current clinical status
Patient factors

20. Investigation:
ECG and paracetamol level are the only routine tests.
ECG provide diagnostic and prognostic information.
Urine toxicology screens are of little use in the acute setting.

23. Further tests are required as indicated by the specific presentation
calculate the Anion gap

24. Anion gap:
Na+ – (Cl- + HCO3-)
An elevated anion gap strongly suggests the presence of a metabolic acidosis.The normal anion gap varies with different assays, but is typically 4 to 12mmol/L.
High anion metabolic acidosis.

26. Decontamination :
The sooner decontamination is performed, the more effective it is at preventing poison absorption.

27. Severity of poisoning
Time from ingestion
Risk of intervention

28. Activated charcoal:
1g/kg
usually given if patient presents within 1 hour of ingestion.
can reduce absorption of many drugs: aspirin, para, phenobarbitone, digoxin, carbamazepine, theophylline, phenytoin.
little value with: acids, alkalis, arsenic,, cyanide,, ethanol, ethylene glycol, heavy metals, hydrocarbons, iodide, iron, lithium, methanol.

29. Gastric lavage:
should be only consider in patient present with toxic lethal dose in first one hour after exposure with protected airway.
associated with visceral damage and aspiration.
don’t give with corrosive, caustic, acids or petroleum ingestion.

30. Whole-bowel irrigation:
using polyethylene glycol (golytely).
suitable for conscious patients who have ingested tablets that don’t bind well to charcoal and can be identified on a plan radiograph.
don’t use with charcoal
1-4 L/hr until patient passes clear fluid from bowel.
Vomiting is common side effect.

31. Enhanced elimination techniques:
the goal of enhanced elimination is to increase the clearance of the poison from the body , after it has been systemically absorbed .

33. Exposure of the eye to caustic chemicals and irritants requires immediate irrigation with large amounts of water or readily available fluids.

34. Antidote :
Antidotes dramatically reduce morbidity and mortality in certain intoxications, but they are unavailable for most toxic agents and therefore are used in only about 1 percent of cases.
They may prevent absorption, bind and neutralize poisons directly, antagonized-organ effects, or inhibit conversion to more toxic metabolites.

35. naloxone (opiates)
digibind (digoxin)
NaHCO3 (sodium channel blockers)
high dose insulin euglycemic therapy (calcium channel blockers and beta- blockers)

36. Supportive care:
Supportive care is the most important aspect of treatment .
Supportive care for the poisoned patient is generally similar to that utilized for other critically ill patients, but certain issues are managed slightly differently.

37. Drug-associated agitated behavior :
generally best treated with benzodiazepine administration, supplemented with high potency neuroleptics (eg,haloperidol) as needed.

38. Disposition :
Patients who develop only mild toxicity and who have only a low predicted severity can be observed in the emergency department until they are asymptomatic.
An observation period of four to six hours is usually adequate for this purpose.

39. Patients with moderate observed toxicity or those who are at risk for such on the basis of history or initial laboratory data should be admitted to an intermediate-care floor or an appropriate observation unit for continued monitoring and treatment.

40. Summary
Common ED problem.
Look for toxidrome
ABC
ECG

41. Paracetamol level
Antidotes
Supportive care