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VcManuel A.

Mabayo

Poison?
A substance that, when introduced into or absorbed by a living organism, causes death or injury, esp. one that kills by rapid action.
Poisoning occurs when any substance interferes

with normal body functions after it is swallowed, inhaled, injected, or absorbed. The branch of medicine that deals with the detection and treatment of poisons is known as toxicology.

A poison is any substance that, when ingested,

inhaled, absorbed, applied to the skin, or produced within the body in relatively small amounts, injures the body by its chemical action.

History
Egyptians are said to have studied many

poisons as early as 3000BC.

Susrutha (350BC) described as how poisons

were mixed with food and drink, medicines, snuff, etc.. systemic correlation between the chemical and biologic information of the poisons known then.

Orfila-(1787-1853) was first to attempt a

Poisonings are a common occurrence. About 10 million cases of poisoning occur in the United States each year. In 80% of the cases, the victim is a child under the age of five. About 50 children die each year

from poisonings. Curiosity, inability to read warning labels, a desire to imitate adults, and inadequate supervision lead to childhood poisonings. The elderly are the second most likely group to be poisoned. Mental confusion, poor eyesight, and the use of multiple drugs are the leading reasons why this group has a high rate of accidental poisoning. A substantial number of poisonings also occur as suicide attempts or drug overdoses.

Poisons are common in the home and workplace, yet there are basically two major types. One group consists of products that were never meant to be ingested or inhaled, such as shampoo, paint thinner, pesticides, houseplant leaves, and carbon monoxide. The other group contains products that

can be ingested in small quantities, but which are harmful if taken in large amounts, such as pharmaceuticals, medicinal herbs, or alcohol.

Other types of poisons include the bacterial toxins

that cause food poisoning, such as Escherichia coli; heavy metals, such as the lead found in the paint on older houses; and the venom found in the bites and stings of some animals and insects. The staff at a poison control center and emergency room doctors have the most experience diagnosing and treating poisoning cases.

Poisoning from inhalation and ingestion of

toxic materials, both intentional and unintentional, constitutes a major health hazard and an emergency situation.

Nursing Alert!
The local poison control should be called

if an unknown toxic agent has been taken or if it is necessary to identify an antidote for a known toxic agent.

Goals:
To remove or inactivate the poison

before it is absorbed. To provide supportive care in maintaining vital organ function. To administer a specific antidote to neutralize a specific poison. To implement treatment that hastens the elimination of the absorbed poison.

If swallowed may be corrosive!


Alkaline

- lye, drain cleaners, toilet bowl cleaners, bleach, nonphosphate detergents, oven cleaners, and button batteries (used to power watches, calculators, or cameras). Acid - toilet bowl cleaners, pool cleaners, metal cleaners, rust removers, and battery acid.

Control of the airway, ventilation, and

oxygenation are essential.

Measures are instituted to stabilize

cardiovascular and other body functions.

What to be monitored closely?


ECG
Vital Signs Neurologic Status

SHOCK may result! If patient ingested corrosive poison (can

be a strong acid or alkaline substance), can be given WATER or MILK to drink for dilution.

However, dilution is not attempted if the patient

has acute airway edema or obstruction or if there is clinical evidence of esophageal, gastric, or intestinal burn or perforation. The following gastric emptying procedures may be used as prescribed: - Syrup of ipecac (never use with corrosive poisons) - Gastric lavage - Activated charcoal - cathartic

NURSING ALERT!
Vomiting is never induced after ingestion of

caustic substances (acid or alkaline) or petroleum distillates.

General signs and symptoms


Hypotension & Cardiac Dysrhythmias (possible) Seizures Pain Symptoms-odor, sweating, fever, delirium,

convulsions, burns of mouth, blindness, GI symptoms, abnormal movements, coma. Signs- miosis, mydriasis, blindness, facial twitching, dull & mask like expression, pallor, cyanosis, hypothermia, sweating, respiratory symptoms, CVS symptoms, CNS symptoms.

Poisoning severity Grades


None(0)- no symptoms or signs/vague

symptoms judged not to be related to poisoning. Minor(1)- Mild, transient & spontaneously resolving symptoms.

Moderate(2)- pronounced or prolonged symptoms. Severe(3)- severe or life threatening symptoms.

Diagnosis of Poisoning
Cardiac arrythmias. Tricyclic antidepressants,

amphetamine, aluminium phosphide, digitalis, theophylline, arsenic, cyanide, chloroquin. Metabolic acidosis. Isoniazid, methanol, salicylates, phenformin, iron, cyanide. GIT disturbances. Organophosphorus, arsenic, iron, lithium, mercury. Cyanosis. Nitrobenzene compounds, aniline dyes, and dapsone.

Basic Management of a poisoned patient


Antidotes are available for very few

commonly encountered poisons, and treatment is usually non-specific and symptomatic. In such cases management consists of emergency first aid and stabilization measures, appropriate treatment to reduce absorption, measures to enhance life support followed by psychiatric counseling.

Identification of Poison Identify the poison by careful history and helpful clues. Determine what, when and how much of the poison was ingested or inhaled. Find the supporting evidence for your diagnosis from the nature of the symptoms and physical signs.

Principles of Management
Keep the phone numbers of your doctor, hospital & emergency medical system near the phone. Removal of the patient from the site of poisoning. Initial resuscitation and stabilization. Symptomatic and supportive measures. Removal of unabsorbed poisons- from GI tract or from skin, eye. Hastening the elimination of absorbed poisons. Use of specific antidote if available Disposition of the patient with advice for prevention.

Emergency Stablization Measures


The unconscious patient should be transported

in the headdown semiprone position to minimize the risk of inhalation of gastric contents. A clear airway is established and ventilation is maintained. Potentially serious abnormalities such as metabolic acidosis, hyperkalemia and hypoglcymia may require correction as a matter of urgency. Neurological assessment is made by calculating the Glasgow Coma Score (GCS).

Initial resuscitation stabilization


Includes airway- proper positioning head

tilt and chin lift, suction of secretions from oropharynx, falling back of tongue is prevented by suitable airway tube. Breathing- oxygen via a mask, when gag/cough reflects is absent- ET tube inserted. if necessary positive pressure ventilation with ABG monitoring, respiratory stimulants for severe respiratory depression. Circulation- proper IV access, maintenance of fluid & electrolyte balance, IV drugs for treatment.

Removal of Toxin
The aim of decontamination procedures is to

reduce the absorption of poison. It can be achieved by: Eye decontamination. Ocular exposure to solvents, e.g., hydrocarbons, detergents, and alcohol, or corrosive agents, e.g., acid or alkalis require immediate local decontamination. This is achieved by copious irrigation with neutralizing solution (e.g., normal saline or water) for at least 30 minutes. Do not use acid or alkaline irrigating solution.

Dermal decontamination. Absorption of

organophosphorus and related compounds through cutaneous route can prove to be a fatal as oral route absorption. Cutaneous absorption depends on several factors such as lipid solubility, skin condition, location, caustic effect, physical conditions

Remove all contaminated clothes and irrigate the

whole body including nail, groin, skinfolds with water or saline as soon as possible after exposure and continue irrigating for at least 15 minutes. Water should not be used to decontaminate skin in exposures to sodium and phosphorus. In certain cases, specific agents may be indicated for skin decontamination (e.g., mineral oil for elemental sodium, Neosporin for super glue and calcium gluconate for hydrofluoric acid).

Gut decontamination. This includes (i)

gastric evacuation; (ii) adsorbent administration; and (iii) catharsis. Emesis is the preferred method of emptying the stomach in conscious children. Vomiting can be induced by (a) tickling the fauces with a finger, feather or a leafy twig of a tree; (b) administration of copious draughts of warm water; (c) gurgling with non-detergent soap; or (d) saline emetics in warm water. To prevent aspiration in small children, the head should be kept low.

Syrup of ipecac may be used for inducing emesis in children older than 6 months in a single dose of 10

mL for 6-12 months age, and 15 mL for children above 1 year of age. The dose may be repeated in 20 minutes for those more than 1 year of age. Induction of vomiting is contraindicatied in corrosive or kerosene poisoning and in comatose patients or those with absent gag reflex.

Gastric Lavage. If the vomiting does not occur

quickly, gastric lavage should be done promptly to remove the poison. In a symptomatic but alert patient with minor ingestion, activated charcoal alone by mouth is sufficient for gastrointestinal decontamination

Gastric lavage should not be performed in

children with poor gag reflex or corrosive ingestion. In kerosene poisoning, lavage may be done very cautiously if the child has consumed a large gulp of kerosene and is brought quickly to the hospital, otherwise it is better to avoid stomach wash.

Adsorbent administration
An agent capable of binding to a toxic agent in

the GIT is known as adsorbent. Activated charcoal is the most widely used adsorbent. It is created by subjecting carbonaceous material e.g., wood, coal etc. to steam at 600-900 degree Celsius and acid.

For the comatosed patient (Grade 3 or 4) with

potentially serious overdose, gastric lavage is followed by administration of activated charcoal via an orogastric or nasogastric tube within 1-2 hours of ingestion. Dose of activated charcoal administered should be atleast 10 times the dose of ingested toxic material. In asymptomatic patient presenting early or without reliable history, 15-30 gram of charcoal may be used.

Catharsis
Laxative and purgatives may be given in

poisoning with substances which do not cause corrosive action on gastrointestinal mucosa. Increased motility of the gut may reduce absorption. Commonly used cathartics include sorbitol and mannitol (1-2 g/kg), and magnesium or sodium sulfate (200-300 mg/kg). Do not give magnesium salt cathartics in cases with renal failure.

Supportive Therapy
Keep the airway open, give oxygen for

inhalation and be prepared for intermittent positive pressure respiration. Fluid and electrolyte balance is maintained. Circulatory failure should be managed to sustain life. Anemia is treated with packed cell transfusion.

Severe convulsions and status

epilepticus are treated with diazepam or midazolam. Renal failure is managed as per standard protocol; dialysis may be needed. Infections are treated with antibiotics. Fever and pain are relived with antipyretics and analgesics.

History taking
What poison was ingested. Time since ingestion. Total amount of poison ingested. Route of exposure. Progression of signs and symptoms since

ingestion. Family history of epilepsy, mental sub normality, bleeding disorder. Whether the patient is receiving other medications which may interact with the poison.

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