1. Dr.Dhaher JS Al-habbo FRCP London UK Assistant Professor in Medicine Department of Medicine
College of Medicine
POISONING

2. ‘Grandfather of Toxicology’
Paracelsus ( )
‘Grandfather of Toxicology’
"All things are poison and nothing is without poison, only the dose permits something not to be poisonous."
“The dose makes the poison”
therapeutic
effect
toxic
increasing dose

3. Recognition of poisoning Identification of agents involved
Taking a history in poisoning What toxin(s) have been taken and how much?
Recognition of poisoning
Identification of agents involved
Assessment of severity
Prediction of toxicity

4. Taking a history in poisoning What toxin(s) have been taken and how much?
What time were they taken and by what route?
Has alcohol or any drug of misuse been taken as well?
Obtain details of the circumstances of the overdose from family, friends and ambulance personnel
Ask the general practitioner for background and details of prescribed medication

5. Taking a history in poisoning What toxin(s) have been taken and how much?
Assess suicide risk (full psychiatric evaluation when patient has physically recovered)
Capacity to make decisions about accepting or refusing treatment?
Past medical history, drug history and allergies, social and family history?
Record all information carefully

6. EVALUATION OF THE ENVENOMED PATIENT
Neurotoxic paralysis
'Sleepy' or drooping eyelids
Difficulty swallowing, dysarthria and drooling
Limb weakness
Respiratory distress
Excitatory neurotoxicity.
Sweating, salivation, piloerection
Tingling around mouth, tongue or muscle twitching
Dyspnoea (pulmonary oedema)

7. Assessment of type and extent of envenoming
Coagulopathy.
Blood oozing from bite site and/or gums
Bruising
Melaena, haematemesis
Local effects :Pain, sweating, blistering, bruising etc.
Myolysis ; Muscle pain or weakness

8. Important substances involved in poisoning
IN UK
Analgesics, e.g. paracetamol and non-steroidal anti- inflammatory drugs (NSAIDs)
Antidepressants, e.g. tricyclic antidepressants (TCAs), selective serotonin re-uptake inhibitors (SSRIs) and lithium
Cardiovascular agents, e.g. β-blockers, calcium channel blockers and cardiac glycosides
Drugs of misuse, e.g. opiates, benzodiazepines, stimulants (e.g. amphetamines, MDMA, cocaine)
Carbon monoxide
Alcohol

9. Important substances involved in poisoning
In South and South-east Asia.
Organophosphorus and carbamate insecticides(mostly fatal)
Aluminium and zinc phosphide
Oleander
Snake venoms
Antimalarial drugs, e.g. chloroquine
Antidiabetic medication

10. Important substances involved in poisoning
Poisoning in old age
Aetiology: commonly results from accidental poisoning (e.g. due to confusion or dementia) or drug toxicity as a consequence of impaired renal or hepatic function or drug interaction. Toxic prescription medicines are more likely to be available.
Psychiatric illness: self-harm is less common than in younger adults but more frequently associated with depression and other psychiatric illness, as well as chronic illness and pain. There is a higher risk of subsequent suicide.
Severity of poisoning: increased morbidity and mortality result from reduced renal and hepatic function, reduced functional reserve, increased sensitivity to sedative agents and frequent comorbidity.

11. Epidemiology More than 2 million toxic exposures reported in 200
Over half were children < 6 years
Poisoning third leading cause of death from
Incidence of toxin related deaths increase 300%.
All chemicals have potential to be poisons if given a large enough dose
Poisoning occurs when exposure to a substance adversely affects function of any organ system

12. Examination Physiologic excitation – Physiologic depression –
anticholinergic, sympathomimetic, or central hallucinogenic agents, drug withdrawal
Physiologic depression –
cholinergic (parasympathomimetic), sympatholytic, opiate, or sedative-hypnotic agents, or alcohols
Mixed state –
polydrugs, hypoglycemic agents, tricyclic antidepressants, salicylates, cyanide

13. Physical Examination
Oropharynx for increase salivation or excessive dryness
CV: rhythm, rate, regularity
Lungs: bronchorrhea or wheezing
Abd: bowel sounds, tenderness or rigidity
Ext: fasiculations, tremor
Neuro: CN, reflexes, muscle tone coordination, cognition, ability to ambulate

14. Drug detection

15. Drug levels

16. General Management A (Airway) B (Breathing) C (Circulation)
D (Disability- /Glasgow Coma Scale)
DEFG ( Don’t ever forget the Glucose)
GET A SET OF BASIC OBSERVATIONS

17. Airway Airway obstruction can cause death after poisoning
Flaccid tongue
Aspiration
Respiratory arrest
Evaluate mental status and gag/cough reflex
Airway interventions
Sniffing position
Jaw thrust
Head-down, left-sided position
Examine the oropharynx
Clear secretions
Airway devices: nasal trumpet, oral airway
Intubation?
Consider naloxone first

18. Breathing Determine if respirations are adequate
Give supplemental oxygen
Assist with bag-valve-mask
Check oxygen saturation, ABG
Auscultate lung fields
Bronchospasm: Albuterol nebulizer
Bronchorrhea/rales: Atropine
Stridor: Determine need for immediate intubation

19. Circulation IV access Obtain blood work Measure blood pressure, pulse
Hypotension treatment:
Normal saline fluid challenge, 20 mL/kg
Vasopressors if still hypotensive
PRBC’s if bleeding or anemic
Hypertension treatment:
Nitroprusside, beta blocker, or nitroglycerin
Continuous ECG monitoring
Assess for arrhythmias, treat accordingly

20. Supportive care Vital signs, mental status, and pupil size
Pulse oximetry, cardiac monitoring, ECG
Protect airway
Intravenous access
cervical immobilization if suspect trauma
Rule out hypoglycaemia
Naloxone for suspected opiate poisoning

21. Preventing absorption
Gastric lavage
Not in unconscious patient unless intubated (risk aspiration)
Flexible tube is inserted through the nose into the stomach
Stomach contents are then suctioned via the tube
A solution of saline is injected into the tube
Recommended for up to 4hrs in Salicylate OD
Induced Vomiting
Ipecac - Not routinely recommended
Risk of aspiration

22. Preventing absorption
Activated charcoal
Adsorbs toxic substances or irritants, thus inhibiting GI absorption
Addition of sorbitol →laxative effect
Oral: g as a single dose
repetitive doses useful to enhance the elimination of certain drugs (eg, theophylline, phenobarbital, carbamazepine, aspirin, sustained- release products)
not effective for cyanide, mineral acids, caustic alkalis, organic solvents, iron, ethanol, methanol poisoning, lithium

23. Elimination of poisons
Renal elimination
Medication to stimulate urination or defecation may be given to try to flush the excess drug out of the body faster.
Forced alkaline diuresis
Infusion of large amount of NS+NAHCO3
Used to eliminate acidic drug that mainly excreted by the kidney eg salicylates
Serious fluid and electrolytes disturbance may occur
Need expert monitoring
Hemodialysis or haemoperfusion:
Reserved for severe poisoning
Drug should be dialyzable i.e. protein bound with low volume of distribution
may also be used temporarily or as long term if the kidneys are damaged due to the overdose.