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Recent Advances in Clinical Management of Acute Human Poisonings

Recent Advances in Clinical Management of Acute Human Poisonings. Mahdi Balali-Mood, M.D., Ph.D. Visiting Professor of Newcastle University, UK. Professor of Medicine and Clinical Toxicology. Director, Medical Toxicology Research Center, Imam Reza Hospital, Faculty of Medicine,

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Recent Advances in Clinical Management of Acute Human Poisonings

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  1. Recent Advances in Clinical Management of Acute Human Poisonings Mahdi Balali-Mood, M.D., Ph.D. Visiting Professor of Newcastle University, UK. Professor of Medicine and Clinical Toxicology. Director, Medical Toxicology Research Center, Imam Reza Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.

  2. Introduction (1) • Any chemical, drug or a natural toxin may induce acute human poisoning • A health problem in many parts of the world, particularly in developing countries with poor controls on drugs and chemicals • Nanomaterials are generally more toxic than normal xenobiotics, which will soon be a new health concern

  3. Introduction (2) • Acute human poisoning is a medical emergency • Accidental, occupational, environmental, suicidal, or even criminal act as well as in the war and terrorism • Establishment of CLINICAL TOXICOLOGY FELLOWSHIP • Updated knowledge to deal with the appropriate clinical management

  4. Management Overview • History & assessment of vital signs A, B, C, D... • Any concerns: Consult senior staff • Consider the toxidromes • Supportive care (O2, IV Fluids) • Prevent absorption • Increase elimination • Antidotes • PSYCHOLOGICAL ASSESSMENT

  5. Decontamination • Based on the route of exposure (inhalation, oral ingestion, skin and the eyes) • In case of toxic gas exposure, the rescuer(s) should be protected • The exposed persons must be first removed from the polluted area • Remove clothes • Decontaminate based on the poison and severity of toxicity (running water and or soap, saline or Ringer solution)

  6. History – Questions to be Answered • What? • When? • How much? (mg/kg) • What else? • Why? • Previous health condition? • Medications? • Drug Abuse?

  7. Toxic Syndromes or Toxidromes • Sedatives and Hypnotics • Cholinergic • Anticholinergics • Serotonin • Malignant • Narcotics • Withdrawal

  8. Initial Examination and Management • Vital signs • Airway • Breathing • Circulation • Disability – Coma, Respiratory and Pupils • Gastric aspiration (sample) and lavage • Activated Charcoal • Blood samples before IV treatment – Glucose • Treat problems as you find them!

  9. Investigations • All Poisoned Patients • Glucose, BUN • Urine & Electrolytes • Urine toxicology screen • Quantification: Acetaminophen, Phenobarbital, Salicylate • As indicated • LFT • Co-ag / INR • CK • ABG / VBG • ECG • CXR • Others

  10. Reduce absorption • Emesis – No role • Activated charcoal within 1 hour • Gastric lavage – rarely • Whole bowel irrigation – rarely • Skin and eye wash • Do Not try to Neutralize

  11. Syrup of Ipecac? Soapy water? Don’t use: Finger gag Salt water Copper sulfate Induce vomiting?

  12. Easy to perform, but Not very effective Contraindicated: Comatose/convulsing Ingested corrosive or hydrocarbon Rapid-acting CNS agent Ipecac is no longer used Ipecac-induced emesis?

  13. Finely divided powdered material Huge surface area Binds most drugs/poisons Exceptions:- Iron- Lithium - Other metals Activated charcoal

  14. Increase elimination • Multi-dose Activated Charcoal • Urinary Alkalinisation • Haemodialysis • Haemoperfusion • Haemofiltration • Plasma exchange • Forced alkaline diuresis and acid diuresisare no longer recommended

  15. Mechanical flush Balanced salt solution with PEG No net fluid gain/loss Good for: Iron Lithium Sustained-release pills, foreign bodies Whole bowel irrigation

  16. Antidotal Therapy • Effective specific antidotes for <10% of poisonings • Administered as clinically indicated • Simple cheap medications: sodium bicarbonate, magnesium sulfate • Bio-scavengers: fresh frozen plasma, albumin

  17. Antidotes • Opiates – naloxone, nalmephen • Acetaminophen – NAC, methionin • Beta-blockers – atropine, glucagon • Insulin – glucose • Iron – desferrioxamine • Lead/Mercury – Succimer, BAL, CaNa2EDTA • Carbon monoxide – oxygen • Methanol – ethanol, fomepizol • Valporic acid – L-carnitine • (Benzodiazepines – flumazenil)

  18. Intravenous Fat Emulsions • Intravenous fat emulsion (IFE) as a source of parenteral nutrition for over 40 years • As a diluent for intravenous drug delivery of highly lipophilic xenobiotics such as propofol and liposomal amphotericin • IFE as an antidote for local anesthetic (bupivacaine) toxicity • Proposed for lipophilic drugs such as calcium channel blockers, cyclic antidepressants, clomipramine and beta adrenergic antagonists

  19. Summary and Conclusion • Acute Human Poisonings are Common • Vital signs monitoring and support care using: A B C D ... • Consider the toxidromes • Early senior help / Early ITU referral • Supportive Care • Antidotes • Psychological assessment and treatment

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