Poison Control

2. Poison Control

3. Epidemiology - In 1986, � 2 million poisoning reported to AAPCC ? 406 ? death. ? 90%: home & accidental. ? 5.6%: suicide ? the majority involved children. ?< 2 years ? � 40%. ? < 6 years � 60%.

4. Drugs involved in adult poisoning: - Alcohol, heroin, morphine, marijuana, cocaine� - Phenobarbital, secobarbital, amobarbital. - Diazepam, flurazepam, chlorpromazine. - Phencyclidine, amitriptyline, amphetamine. - Aspirin, acetaminophen, sleep aids.

5. Common toxicities in children: 1- plants 6- Aspirin. 2- Soaps, detergents* 7- Analgesics.* 3- Antihistaminic, cold prep* 8- Disinfectants.* 4- Perfumes, colognes* 9- Fingernail prep.* 5- Vitamins. 10- Insecticides.* Others - Petroleum products* (hydrocarbons). - Oven & drain cleaners. - Iron containing prep.

6. Sources of Poison Information - It includes textbooks, journal articles, microfiche systems, computer database and poison centers. 1- Micromedex ? Poisindex ? Drugdex ? Emergindex 2- Poisindex: listing of poisonous commercial products and plants. ? ingredients ? amounts or conc ? appropriate management procedures which updated regularly and reviewed�..

7. - Poisindex is available on microfiche or compact disk and is updated quarterly. 3-Poison centers:(major source of information) 1- Consultation in treating poisoned patients. 2- Telephone advice. 3- Public education & prevention programs. 4- Health professional training & continuing education. 5- Research in toxicology &poison prevention.

8. - Poison information specialists: especially trained nurses, and pharmacists answer calls 24 hours a day, 7 days a week under the administration of physician medical director. - They give information on toxicity, clinical effects, and treatment recommendation

9. Managing poison casesTelephone advice 1- Remain calm. 2-Ask the parent's name, address & phone ?. 3-Ask if poisoning by ingestion, inhalation,� the name of product, amount, time of episode.. 4- If you are unfamiliar with the product�.. 5-Ask the child's age &wt what he's doing now? 6- If he ingested something require hospital care ? call an ambulance.

10. 7- If ipecac is warranted, recommend the proper dose. 8- If he come into contact with poisonous subst. ? remove adjacent clothing, flood the skin with water ? call ambulance to the closest emergency dept.

11. 9- If he inhaled a poison ? loosen clothing, move him to fresh air. If he's not breathing ? CPR. Regardless his condition ? never drink or eat until examined by medical personnel. 10- Even non-toxic subst. ? call in 1-2 hr to check. 11- If home treatment is required? follow up call at 1,4,& 24 hr. 12- If in doubt ? immediate visit to the closest emergency dept.

12. First aid/Home management - In case of ingestion, inhalation or contact with poison ? advise the parent to: 1- Call the regional poison control center or emergency dept. 2- Have the container in hand� 3- Write down all instructions.

13. 4- For ingested poisons: I -Dilute the ingestant with water or milk (a cup for a child, 2-3 cups for adults) I-Dilution has 2 functions: 1- ? gastric irritation 2- add bulk to a stomach needed later for emesis - Don't force him to drink if he is drowsy, unconscious, having seizures, take solid dosage forms (tab �)

14. II- Induce emesis ? contraindication 1- Convulsants (emesis ? seizures) 2- Hydrocarbon (aspiration to lung ?pneumonitis) 3- Corrosives (acids or alkali) 4- unconscious or comatose 5- Cardiovascular dis. 6- < 6 months of age (poor gag reflex) Dose of ipecac: * 1-12 y ? 15 mL followed by water or juice, may repeat in 20 min if no emesis. * > 12 y ? 30 mL as above

15. - Don�t stick a finger in the child�s mouth to induce vomiting ( ? risk of injury) 5- For inhaled toxins: - Remove the child out of the toxin fumes. - Loosen clothing. - CPR if necessary

16. 6- For contact poisons: - Remove clothing adjacent to the affected area. - Flood the skin with water. - Call ambulance or go to the nearest emergency dept.

17. Pre-hospital treatment of poisoned patient 1- Duties of paramedical personnel: - Bring items as: pill bottle, needle,� to emerg. dept. - Collect information on type, route & duration of exposure.

18. 2- Precautions for health care providers: - Avoid mouth-to-mouth breathing (risk of poisoning, transmission of infectious dis.), use pocket mouth. - Use gloves ( risk of needle stick injury) - Dispose needles & dressings appropriately. - Clean & disinfect reusable items. - Wash hands between patient encounters.

19. 3- Field treatment: - Ipecac & water to induce emesis. - 5% dextrose solution IV (all unconscious pat.) - 2 mg naloxone, all unconscious pat. - Oxygen. - Eye irrigation (topical exposure). - Draw bl. samples if possible. - Save urine & stomach contents for toxicol. screening.

20. 4- Hazardous materials: - They are those constituting a threat to people, animals, plants or the environment. - Many hazardous materials are non-toxic per se: ex: polyurethane is non-toxic unless burned ? release cyanide gas.

21. Risk groups:1- Workers (industry).2- Firefighters.3- Public.4- Emergency medical technicians.5- Hospital personnel. Types of hazardous materials: - Carbon monoxide. - Cyanide. - Caustics, corrosives. - Formaldehyde. - Heavy metals.

22. Types of injuries: 1- Thermal (electrical, burns). 2- Radiation (type, distance, time of exposure, degree of shielding). 3- Asphyxiation. 4- Chemical (pesticides, organophosphates) 5- Biological agents (AIDS, hepatitis).

23. The two most common routes of injury: Skin contacts and inhalation N.B: - Burning plastics ? hydrogen halides. Incomplete combustion? CO - Carbon tetrachloride ? Phosgene gas

24. Clinical Findings: 1- Respiratory sympt.: bronchospasm, dyspnoea, wheezing, burning in chest. 2- GI sympt.: nausea, vomiting, diarrhea, hepatic dysfunction. 3- Renal dysfunction. 4- Central & peripheral nervous system: headache, tremor, peripheral neuropathy.

25. Lab. Findings: - Arterial bl. gases. - Complete bl. cell count. - Electrolytes. - BUN, creatinine. - Blood glucose.

26. Personal safety precautions: - Breathing devices or filter masks. (# toxic gases). - Impermeable protective clothing. - Showers, eye irrigation.

27. Diagnosis of Poisoning - History. - Physical examination. 1- General *The autonomic syndromes summarized as follows: 1- a-adrenergic syndrome: ? hypertension with reflex bradycardia & dilated pupils. (phenylephrine, phenylpropanolamine & methoxamine).

28. 2- �-adrenergic syndrome: ? �2 vasodilatation ?hypotension, tachycardia. (terbutaline, metaproterenol, caffeine, theophylline). 3- Mixed a & � adrenergic syndrome: ? hypertension, tachycardia, dilated pupils, sweaty skin & dry mucous membrane. (cocaine, amphetamines�

29. 4- Sympatholytic syndrome: ?? bl. press. & pulse rate, pinpoint pupils & ? peristalsis. (clonidine, methyl-dopa, opiates�..) 5- Nicotinic cholinergic syndrome: ? Initial tachycardia followed by bradycardia & ms. fasciculation followed by paralysis. (nicotine, succinyl choline).

30. 6- Muscarinic cholinergic syndrome: ? bradycardia, miosis, sweating, hyperperistalsis, wheezing, xss salivation & urinary incontinence. 7- Mixed cholinergic syndrome: ? miosis, sweating, ?peristalsis, ms.fasciculation may progress to ms.weakness & paralysis. (organophosphates, carbamate insecticides, physostigmine).

31. 8- Anticholinergic syndrome: ? tachycardia with mild hypertension, dilated pupil, the skin is flushed, hot & dry,? peristalsis and urinary retention. (atropine, antihistaminics, anticholinergics).

32. 2- Eye findings -Dilated reactive pupil ?alcohol, cocaine -Dilated fixed pupil ? atropine -Constricted pupil? organophosphorus insecticides, phenol 3- Abdominal findings -Colic ?heavy metals, organophosphorus insecticides -Diarrhea? all heavy metals except lead. -Constipation? lead

33. 4- Skin findings *Sweating *Flushed red skin: CO, boric acid, chemical burns (corrosive). *Pale coloration: sympathomimetics, if severe ? art. vasospasm (ergot or amphetamine). *Cyanosis: hypoxia,methemglob,sulfhemoglob, cyanide

34. 5- Odors Acetone odor ? acetone, isopropyl alc. Bitter almond odor ? cyanide. Wintergreen odor ? methyl salicylate. Garlic odor ? arsenic, selenium, thallium.

35. Clinical Laboratory Tests 1- Serum osmolality & osmolar gap The osmolar gap ?in presence of low molec. wt subst. e.g. ethanol, glycols. 2- Hyperglycemia & hypoglycemia *Hyperglycemia > 500 mg/dL ? dehydration, electrolyte imbalance, coma. - maintain the airway, assist ventil., suppl. O2. - IV normal saline. - IV insulin.

36. *Hypoglycemia < 40 mg/dL ? permanent brain injury - IV 50% dextrose. - maintain airway, assist ventilat., suppl. O2.

37. 3- Hypernatremia & Hyponatremia *Hypenatremia > 145 meq/L caused by ?? Na intake ? ? water loss ? ? ADH - Drugs: cathartic abuse, lithium, mannitol. - Treatment depends on the cause: *Hypovolemia ? normal saline. *Volume overload ? combination of 5% dextrose + furosemide. *Lithium-induced nephrogenic diabetes insipidus ? normal saline, discontinue lithium. ? oral indomethacin & hydrochlorthiazide.

38. *Hyponatremia < 120 meq/L -Drugs: amitriptyline, chlorpropamide, clofibrate. -Treatment depends on the cause: ? depletional ? normal saline ? dilutional ? salt & water restriction, bed rest, treat the 1ry disorder.

39. 4- Hyperkalemia & Hypokalemia *Hyperkalemia > 5 meq/L (arrhythmia) ? Peaked T wave & prolonged PR intervals - Drugs: fluoride, dig. glycosides & ACEI. - Treatment: IV CaCl2 IV NaHCO3 IV glucose + insulin Monitor ECG.

40. *Hypokalemia < 3.5 meq/L (ms. weakness, hyporeflexia) ? Flattened T wave & prominent U wave. - Drugs: theophylline, barium, caffeine. - Treatment: KCl (oral, IV). Monitor serum K & ECG.

41. 5- Renal failure - Drugs cause renal failure by different mechanisms: *Direct nephrotoxic ? acetaminophen, aminoglycosides, mercury. *Rhabdomyolysis: (tubular pptn of myoglobin) ? CO, cocaine, amphetamine. *Hemolysis ? Arsine, naphthalene.

42. -Assessment: ? Sr Cr, BUN, oliguria or anuria. -Treatment: *Specific treat ?acetylcysteine for acetaminophen ?dimercaprol for Hg ?IV fluids for rhabdomyolysis. *Hemodialysis.

43. 6- Hepatic failure - Caused by direct hepatocellular damage, creation of hepatotoxic intermediates or hepatic vein thrombosis. -Drugs: acetaminophen, CCl4,Cu, insecticides. - Assessment: *After 24-36 hr ? ? transaminase then ? to normal (3-5 days). *Bilirubin & prothrombin time, hypoglycemia (poor prognosis).

44. - Treatment: *Spec. treat. for acetaminophen overdose (acetyl cyst.). * Monitor transaminase, bilirubin & glucose levels. * Intensive care for hepatic failure & encephalopathy (gl. For hypoglycemia & lactulose for encephalopathy)

45. Staff precautions in Toxicological Emergencies - Methods of nosocomial transmission: 1- Needle stick injury. 2- Ungloved repeated contact with bl.,secretions from infected pat. 3- Non-parenteral exposure to infectious bl. - Infection control precautions: Sharp items Masks Gloves Eye covering Gown Ventilation devices

46. N.B - Hands should washed immediately if contam. - No weeping dermatitis or exudative lesions involved in any invasive procedure or pat. care.

47. - Suggested protocol after exposure:A- Possible HIV exposure 1- After parenteral or muc.memb. exposure to blood? the source pat. should be assessed clinically. If the assess. suggest that infection may exist: ? serologic testing

48. *If the pat. declines testing or test + ve ? the victim should be evaluated clinically & serologically ? if seronegative ? retested after 6 weeks & periodically thereafter 3, 6, 12 months (seroconversion in 6 �12 weeks). *If the source pat. is seronegative ? no follow up.

49. Possible Hepatitis B exposure - The availability of an effective vaccine against hepatitis B ? minimize the occupational risk. - If exposure occurs: ? the source pat. should be tested for the presence of hepatitis B surface Ag & the exposed person tested for the presence of hepatitis B surface Ab.

50. *If the source pat. is �ve for Ag & the exposed person is +ve for Ab ? no further action. *If the source pat. is +ve for Ag & the exposed person is �ve for Ab ? the exposed person should receive hepatitis B Ig as soon as possible & follow up at 30 days for a repeat dose.

51. Advanced Poisoning Treatment & Life Support (APTLS) 1- Primary survey (life-threatning problems) Airway maintenance Breathing (ventilation) Circulation (pulse, bl.press.) Disability (assess level of unconsc. with AVPU, check pupil size) Expose (undress the patient)

52. 2- Resuscitation Phase: (simultaneous with 1ry survey) - ECG monitoring & suppl. O2. - IV access (50% dextrose, naloxone, thiamine) - Initial antidote treatment. 3- Secondary survey: - Full history - Head-to-toe physical examination - Radiologic & diagnostic Lab. tests. 4- Definitive care: - The less immediately life-threatening problems are managed.

53. Resuscitation - Respiratory resuscitation is performed when pat. needs either: *? O2 delivery (e.g. cyanosis) *rate of respiration is insufficient for proper external respiration. -Begin resuscitation in less than 5 min to avoid brain damage.

54. - The 1st step is to assess the victim responsiveness. Gently shake the victim and shout are you Ok? If no answer or show signs of heart attack ? CPR is needed. A: Airway (open the airway) ? tilt the head back by lifting the chin. B: Breath (if the person is not breathing), close the nose and give him 2 rescue breaths, then check signs of circulation (coughing, breathing,..

58. - If there is sudden cessation of the heart leading to serious hypoxia to vital signs? cardiac resuscitation C: Circulation (chest compression) place the heel of one hand in the center of the chest with the heel of the 2nd hand on top, position your body over your hands (to squeeze the heart bet. the sternum & the vertebrae).

60. - Interpose one breath between 5 compressions (2 rescuers), or two breathes between 15 compressions (1 rescuer). - Repeat the cycle to a total 60 compressions and 8 ventilations / min. N.B 1 rescuer ?15:2 2 rescuer?5:1 *Signs of cardiac arrest: unconsciousness, dilated, reactive pupils, apnoea. -

62. - Evaluation of effectiveness of CPR: *CNS function by eye activity. i.e. normal size of pupil& reactive to light. * carotid pulse.

64. - Complications can occur during CPR: *Vomiting. *Gastric distension. *Aspiration of gastric acidity or contents. *Chest injury. *Damage to heart & liver.

65. Antidotes ---------------------------------------------------------------- Poison Antidote --------------------------------------------------------- Acetaminophen N-acetylcysteine Atropine Physostigmine Carbon monoxide Oxygen Cholinergic agents Atropine Clonidine Naloxone Cyanide Amyl nitrite Na nitrite Na thiosulfate

66. ------------------------------------------------------------- Poison Antidote --------------------------------------------------------- Ethylene glycol Ethyl alc. - Heavy metals disod. Edetate Penicillamine -Iron Deferroxamine -Isoniazid Pyridoxine -Narcotics Naloxone -Organophosphates Atropine

67. N.B. - Analeptics (caffeine..) CNS stimulant ? # pat. with ? airway reflexes (seizures). - Apomorphine: emetic agent ? respiratory depressant (parenterally).

68. General Approach to Patients in Coma 1- Primary survey: Follow APTLS. 2- Initial therapy: A- IV medications: 50mL 50% dext. 2-10 mg naloxone. 100 mg thiamine. B- Decontamination: gastric lavage. skin decontamination.

69. 3- Secondary survey: i.e. general examination to search for other causes of coma. ?- Structural - Head trauma (ecchymosis, palpable fracture, unilateral dilated Pupil, otorrhea) - Subarachnoid hemorrhage (stiff neck).

70. II- Non-structural -Infection (meningitis,encephalitis,hepatic failure) - Hyper/hypo-thermia. - Hypertensive encephalopathy. - Hypoxia. - Metabolic encephalopathy. *Diabetic, uremic, hyper/hypocalcemia, natremia. *Hypothyroid. - Seizures. - Shock.

71. - Toxins: antihistaminics CO Antipsycotic Cyanide BB Ethanol BZ Lithium Salicylates Organophosphates

72. 4- Neurological examination: *pupil, fundoscopic exam. *motor response to pain. *caloric testing. 5- Lab. tests: Complete bl. count, glucose, electrolytes. Urinalysis. X-rays (cervical spine, head CT). 6- Treatment Drugs or toxin-induced coma ? supportive treatment.

73. General Approach to Patients with Seizures 1- Toxins Amphetamine Lidocaine Aminophylline Lithium CO NSAIDs Cocaine Strychnine Cyanide TCA

74. 2- Metabolic Hypoxia Hypo/hypernatremia, hypo/hypercalcemia. Hypo/hyperglycemia. 3- Alcohol or sedative withdrawal 4- Structural abnormalities *Cerebro-vascular accident, intracerebral bleeding (trauma). *Tumor, degenerative disorders. 5- Infection. 6- Uremia

75. Treatment: *Follow APTLS. *Cerv.spine immob. until trauma ruled out. *In non-trauma? position on side. *Lab.tests (electrolytes, anticonvulsants levels). *Treat. of status epilepticus.

76. General approach to Syncope Causes: *Cardiovascular Ventricular tachycardia. Bradycardia, complete heart block Aortic stenosis, myocard. infarction. Non-cadiovascular* Situational Orthostatic hypotension Seizure disorder Metabolic Drug-induced

77. Factors suggesting cardiac causes: - Age > 55 years. - ?. - History of chronic heart disease. - History of ventricular arrhythmia. - Atrial fibrillation. - Short warning period prior to syncope. (sweating, blurred vision, general numbness, pallor, shortness of breath).

78. Treatment:1- Primary survey - APTLS. - Glucose, naloxone, thiamine in all patients with altered mental status. 2- Secondary survey: A- History - Tongue biting ? seizure - Palpitation, chest pain, short warning period ? cardiac. - Drug history: diuretics, �-blockers, vasodilators, antihypertensives,hypoglycemics.

79. - Postural change, trauma, pain, fear ? situational - Poor oral intake, polyuria, diarrhea ? vol. depletion. B- Physical examination: - Vital signs: pulse, bl. press. - Head & neck: evidence of trauma, tongue bite� - Cardiac: evidence of aortic stenosis (click- murmur..).

80. C- Laboratory: - Blood glucose. � Sr Cr & BUN. - Electrolytes. � ECG. 3- Definitive Care: - Correction of the defect caused by the poison. - Drug elimination.

81. General Approach to Anaphylaxis - Causes: 1- Drugs: Antibiotics (penicillins�) Analgesics Hormones (ACTH, insulin�) 2- Diagnostic agents: Iodinated contrast media Sulfobromophthalein Egg-embryo-grown vaccines.

82. 3- Local anesthetics: Procaine Lidocaine 4- Foods: Eggs Milk Nuts Seafood

83. Clinical presentation: - Hypotension, orthostatic dizziness. - Vasodilatation. - Cough, wheeze. - Nasal stiffness or itching. - Dyspnoea. - Skin itching, warmth, urticaria. - Swelling, itching of eyes.

84. Treatment: 1- Initial therapy - Follow APTLS. - Discontinue suspected allergen. - O2 (100%). - If no improvement ? Epinephrine IV or IM with endotracheal intubation.

85. 2- Secondary treatment: - Antihistaminics: Diphenhydramine IV or IM. - Cimetidine IV. - Aminophylline IV (# bronchospasm). - �-adrenergics. - Catecholamines (# hypotension + bronchospasm). - Corticosteroids.

86. General Approach to Alcoholic Patients Alcoholism Tolerance Dependence Clinical Presentation GI complaints Seizures Hypertension Violence Altered mental status

87. Treatment: 1- Primary survey Follow APTLS. 2- Initial treatment - Start with 5% dextrose in normal saline. - All patients with altered mental status ? 50mL 50% dextrose. - IV naloxone. - Mg SO4 IV or IM. - Thiamine IV, IM or PO. - Gastric emptying.

88. 3- Secondary survey: A- Complete history - It deals with the chief complaint. B- Physical examination - Vital signs: tachycardia, hypertension, fever,�. - Neurologic exam. C- Serum ethanol level (Blood alc. conc. [BAC] = 100mg/dL)

89. D- Others - Arterial blood gases. (metabolic acidosis). - Blood glucose (hypoglycemia). - ECG (intoxication or withdrawal ? supraventricular tachycardia). - Urinalysis (crystals ? ethylene glycol intoxication)

90. General Approach to Violent Patient - Causes: *Toxins: Amphetamine Anticholinergics Cocaine Phencyclidine Hallucinogens Phenylpropanolamine Marijuana Ethanol *Organic disorders: - Encephalitis, hypoglycemia, hypoxia.

91. - Treatment: - Follow APTLS. - Additional assistance. - Talk-down approach. - Physical restraint. - Chemical restraint Haloperidol. Diazepam. N.B. - Close monitoring with attention to ? level of consciousness & respiratory failure.

92. General Approach to Ocular Toxicity - Route of exposure: *Splash contamination (most frequent) Lid, conjunctiva & cornea most likely to be exposed. *Vapor contact: Conjunctiva & cornea *Particular matter - Embedded or cause abrasion. - Conjunctiva & cornea.

93. *Systemic exposure - Pupillary dilatation: Atropine, antihistaminics, BB, cocaine, cyanide. - Pupillary constriction: Caffeine, codeine, nicotine, acetone. - Nystagmus: Arsenic, cocaine, cyanide, CO. - Conjunctivitis: Marijuana. - Blurred vision: Atropine, cocaine, insecticides, nicotine. - Lacrimation: Arsenic, thallium, mushrooms. - Pigmented sclera: Carotene, rifampicin, vit.A.

94. Temporal nature of toxic effects: *Immediate effects (require rapid therapy) - Caustics, solvents & surfactants. - Alkali & strong acids. *Delayed effects: - UV light (hrs)? bilateral tearing & sand-like sensation. - Ethylene diamine in vapor form (hrs) ? blurred vision - Chronic industrial exposure of aniline & hydroquinone (years)? corneal discoloration, scarring & distortion.

95. - Treatment: *Immediate treatment: - Irrigation with water or saline (flow from nasal side). - Time of irrigation is the critical point not the volume of irrigant. *alkali? 1-2 hrs continuously (PH<8). *solvents ? 20-30 min.

96. - Ophthalmic anesthetic. - Mydriatics (atropine) & topical antibiotic. - Removal of the particulate matter from the cornea or conjunctive with a toothless forceps. *After immediate treatment: - Visual acuity testing. - Fundoscopic examination (for comparison with follow up exam.)

97. General Approach to Dermatologic Poisoning - It means: absorption of toxins through the skin. - Example of agents in which transdermal absorption causing systemic toxicity: *organophosphate insecticides. *organochlorines. *nitrates. *industrial aromatic hydrocarbons.

98. - Signs of systemic toxicity: Salivation, sweating, bradycardia, hypotension, blurred vision, bronchospasm, abdominal cramps� N.B. They may occur without sensation of burning or itching.

99. Treatment: - Follow APTLS. - Removal of clothes, with washing the skin with warm water, except for chlorosulfonic acid, titanium tetrachloride, CaO (ignition ? toxic fume with water) & phosphorus (insoluble in water). *Organophosphates: ? wash skin with ethyl alc. * Phenols: ? Use undil. Polyethylene glycol or olive oil.

100. * Acids or alkali: ? don't neutralize base with acid (exothermic reaction). * Phosphorus: ? 2% CuSO4 solution * Oxalic acid ? Ca gluconate solution N.B. - In victims with unknown poisoning ? consider the possibility of transdermal entry.