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    Acute Poisoning Guidelines.

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    Manoj Kumar
    This document provides guidelines for acute poisoning, including key points on toxicity levels for different agents in toddlers, resuscitation methods, risk assessment factors, emergency management techniques, available antidotes, and enhanced elimination methods like dialysis. It includes tables of potentially harmful and lethal 1-3 tablet ingestions for healthcare providers as a reference.

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    Acute Poisoning Guidelines.

    Uploaded by

    Manoj Kumar
    39 views7 pages
    This document provides guidelines for acute poisoning, including key points on toxicity levels for different agents in toddlers, resuscitation methods, risk assessment factors, emergency management techniques, available antidotes, and enhanced elimination methods like dialysis. It includes tables of potentially harmful and lethal 1-3 tablet ingestions for healthcare providers as a reference.

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    hseguru@yahoo.in

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    This document provides guidelines for acute poisoning, including key points on toxicity levels for different agents in toddlers, resuscitation methods, risk assessment factors, emergency management techniques, available antidotes, and enhanced elimination methods like dialysis. It includes tables of potentially harmful and lethal 1-3 tablet ingestions for healthcare providers as a reference.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    39 views7 pages

    Acute Poisoning Guidelines.

    Uploaded by

    Manoj Kumar
    This document provides guidelines for acute poisoning, including key points on toxicity levels for different agents in toddlers, resuscitation methods, risk assessment factors, emergency management techniques, available antidotes, and enhanced elimination methods like dialysis. It includes tables of potentially harmful and lethal 1-3 tablet ingestions for healthcare providers as a reference.

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    Acute-Poisoning Guidelines.

    Key Points:
    1. Most toddler ingestions are insignificant, however a number of agents
    are highly toxic in a dose of 1-2 tablets in this age group (see table
    below)
    2. Resuscitation and risk assessment are described below, and may
    need to be performed concurrently. Most treatment is supportive
    3. In any patient whose developmental age is inconsistent with
    accidental poisoning, a non-accidental poisoning should be
    considered
    4. Admission should be considered for all adolescent patients with an
    intentional overdose
    5. Always check for Medicalert bracelet in any unconscious
    patient, or any other signs of underlying medical condition
    (fingerprick marks etc)

    Background
    All acts of deliberate self-harm must be taken extremely seriously. All
    intentional self-poisonings in adolescents require screening for paracetamol
    ingestion and admission. If unexplained symptoms exist a urinary drug
    screen may be indicated, though they are rarely of use in the short term.
    NAI or neglect should be considered particularly where accidental
    poisoning is not consistent with the developmental age of the child, the
    history is inconsistent, there is a past history of poisoning, illicit drugs or
    unusual poisoning from household substances. Infants under 1 do not self-
    administer medicines.
    Children are more susceptible to poisonings from exposure to some agents
    than adults. For example increased absorption from dermal exposure due
    to thin skin and higher surface area to weight ratio, and to inhaled toxins
    due to increased respiratory rate.

    Potentially harmful 1-3 tablet ingestions/ small exposures


    • Anticholinesterase inhibitors eg organophosphates - cholinergic syndrome, seizure
    • Baclofen (25 mg) - coma
    • Camphor - rapid decrease in conscious state, seizures, hypotension
    • Carbamazepine (400 mg) - coma
    • Centrally acting alpha adrenergic agonists eg clonidine - like opiate but more hypo
    bradycardia
    • Clozapine 100mg/ 200 mg - coma
    • Colchicine
    • Corrosives - strong alkali or acid - Gastroesophageal injury
    • Dextropropoxyphene 100 mg - Ventricular Tachycardia
    • Opiates eg buprenorphine (8 g sublingual or film absorbs in <5 min), codeine, met
    fentanyl
    • Hydrocarbon solvents/ kerosene / essential oils - decreased level of consciousnes
    aspiration pneumonia
    • Illicit/street drugs, eg amphetamine.
    • Loperamide and diphenoxylate
    • Naphthalene - 1 mothball (but most mothballs aren't naphthalene) - methaemoglo
    haemolysis
    • Podophyllin
    • Paraquat - oesophageal burns, multi-organ failure
    • Salicylates
    • Strychnine - muscle spasm and respiratory arrest
    • Venlafaxine 150 mg - seizures.

    Potentially lethal 1-3 tablet ingestions

    • Beta blockers eg propranolol - coma, seizures, Ventricular Tachycardia, hypoglyca


    • Calcium channel blockers - delayed onset bradycardia, hypotension, conduction d
    • Chloroquine / hydroxychloroquine - rapid onset coma, seizures, cardiovascular co
    • Ecstasy and other amphetamines - agitation, hypertension, hyperthermia
    • Oral hypoglycaemics eg sulphonylureas - hypoglycaemia may be delayed 8 hours
    • Tricyclic antidepressants - coma, seizures, hypotension, VT
    • Theophylline - seizures, Supraventricular Tachycardia, tachycardia, vomiting
    Risk Assessment:
    The aim is to determine if the ingestion/ contact is potentially harmful and to
    develop a management plan.
    The Poisons Information Centre may provide useful information about
    product ingredients and potential toxicity. Phone 13 11 26. Toxicologists
    are available 24/7 to provide specific clinical advice, and require the
    following clinical information:

    • Agent: (drug / substance, name and formulation - immediate or


    modified release)
    • Beware of the possibility of mixed overdose
    • Route - ingested, inhaled, topical exposure
    • Time of incident
    • Dose/ kg
    • Maximum amount of ingestion (include all medication that was
    potentially in the bottle or packet when calculating).
    • Beware of the possibility of inaccurate dose reporting on history
    taking.
    • Weight of child
    • Symptoms
    • Signs
    • If mixed or undetermined ingestion paracetamol level should be done.

    Resuscitation/Emergency Management
    A. Airway

    • Inability to protect airway may be with >GCS8 in poisonings. AVPU


    may be a more useful descriptor of conscious state.
    • Caustic ingestions

    B. Breathing
    C. Circulation

    • Dysrhythmias are frequently due to sodium channel blockade and


    may be treated with Sodium Bicarbonate. Alternately they may be
    caused by potassium channel blockade - treated with magnesium
    sulphate (MgS04)
    D1. Disability

    • Seizures - those due to poisoning are always generalized. Usually


    respond to benzodiazepines with barbiturates second line. Phenytoin
    is not recommended (as this is usually ineffective).
    • Consideration should be given to drug induced syndromes -
    malignant hyperthermia, serotonin syndrome and neuroleptic
    malignant syndrome
    • Check glucose level: treat if glucose <4 mmol/L (link hypoglycaemia)

    D2. Decontamination
    Eye

    • Copious irrigation with saline. Instillation of local anaesthetic eye


    drops and sedation may be required

    Skin

    • Remove clothes, rinse with copious water, then soap and water

    Gastrointestinal
    A variety of methods may be considered and should be discussed with a
    toxicologist before commencement as all require a risk / benefit analysis.
    Paediatric deaths have occurred from activated charcoal.

    • Emesis has no role in the hospital setting

    • Activated Charcoal has a very limited role in treatment and should


    not be used without consultation with a toxicologist, unless presents
    less than 1 hour after a potentially toxic ingestion with normal
    conscious state.

    Contraindications:

    • Patients with altered conscious state


    • Ethanol/glycols
    • Alkalis / corrosives
    • Metals - including Lithium, Iron compounds, potassium
    • Fluoride
    • Cyanide
    • Hydrocarbons
    • Mineral acids - Boric acid

    • Gastric Lavage has a very limited role in treatment. It requires


    intubation for airway protection and should not be used without
    consultation.

    • Whole Bowel Irrigation has a limited role in treatment of life-


    threatening ingestions of some slow release preparations and agents
    that do not bind to activated charcoal.

    D3 Drug antidotes see specific guidelines


    Specific antidotes may be available as part of a management plan.
    Serum drug concentrations may help in treatment decisions.

    Poisoning Antidote

    Anticholinergic syndrome Physostigmine

    Benzodiazepines Flumazenil

    Beta Blocker Glucagon

    Calcium channel blocker Calcium


    Insulin/ glucose
    Intralipid®

    Cyanide Hydroxocobalamin
    Dicobalt edetate
    Sodium thiosulphate

    Digoxin Digoxin immune Fab (Digibind)

    Ethylene glycol Ethanol


    Pyridoxine

    Iron Desferrioxamine
    Isoniazid Pyridoxine

    Local anaesthetics Intralipid®

    Methaemoglobinaemia Methylene Blue

    Methanol Ethanol

    Opiates Naloxone

    Oral hypoglycaemics Octreotide

    Organophosphate Atropine

    Paracetamol N-Acetyl Cysteine

    Organophosphates Pralidoxime

    Quinine induced hypoglycaemia Octreotide

    Tricyclic antidepressants Sodium bicarbonate

    Warfarin, long acting rodenticide anticoagulant Vitamin K

    E1 ECG E2 Exposure

    • Hyper/ hypothermia - >38.5°C requires urgent cooling

    E3 Enhanced elimination

    • Urinary alkalization

    Useful for salicylate toxicity if performed meticulously

    • Multi dose activated charcoal

    Whilst there is evidence of a pharmacokinetic effect, it is not evident that it


    improves clinical outcome
    • Dialysis

    Intermittent High flux haemodialysis removes small water-soluble toxins

    • salicylate,
    • toxic alcohols
    • lithium
    • theophylline
    • valproate
    • barbiturates
    • methotrexate

    Continuous renal replacement such as veno-veno haemofiltration has a low


    clearance rate and is only suitable where haemodialysis is not tolerated.
    Other methods such as peritoneal dialysis, charcoal haemoperfusion,
    exchange transfusion and plasmapheresis are less effective.
    Source: Trusted medical websites.

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