Poisoning & Accidents

1. Poisoning & Accidents DR. Sanjeev

2. Poisoning & Accidents • Poison: A poison is a substance that causes harm if it gets into the body • Poisoning Severity Grades: • None (0): No symptoms or signs • Minor (1): Mild, transient and spontaneously resolving symptoms • Moderate (2): Prolonged symptoms • Severe (3): Severe or life threatening symptoms

3. Initial Management of the poisoned patient (ABCD’s) • First, the airway should be cleared of vomitus or any other obstruction and an oral airway or endotracheal tube inserted if needed. • Breathing should be assessed by observation and oximetry and, if in doubt by measuring arterial blood gases patients with respiratory insufficiency should be intubated and mechanically ventilated • Circulation should be assessed by continuous monitoring of pulse rate, blood pressure , urinary output. An intravenous line should be placed and blood drawn fro serum glucose and other routine determinations • Dextrose to treat hypoglycemia (0.5gm/kg)

4. History & Physical Exam • Lab and Imaging procedures: • Arterial Blood Gases • Electrolytes: Sodium, Potassium, Chloride, Bicarbonate • Renal Function Tests: Blood Urea, Creatinine • Electrocardiogram

5. Decontamination • Decontamination procedure should be undertaken simultaneously with initial stabilization, diagnostic assessment and lab evaluation • Decontamination involves removing toxins from the skin or GIT

6. A) Skin • Contaminated clothing should be completely removed and double bagged to prevent illness in health care providers and for possible lab analysis • Wash contaminated skin with soap and water

7. B) GIT • Emesis: Emptying of stomach in conscious children • Syrup: Ipecac (6-12 months 10 ml single dose and >1 yr 15 ml) *repeated in 20 mins for those more than 1 yr. • Gastric Lavage: • 0.9% saline , Left Lateral position • Activated Charcoal • Catharsis: Laxative and purgatives • Mannitol (1-2 gm/kg) • Magnesium or sodium sulfate (200-300 mg/kg) * Specific Antidotes*

8. Methods of enhancing elimination of toxins • Dialysis procedures • Peritoneal dialysis • Hemodialysis: useful in overdose cases • Forced Diuresis and urinary PH Manipulation Prevention of poisoning • Protection of the child from the poisonous substances • Education of parents about the potential household poisons • Parental supervision • Safety Regulation

9. Organo-Phosphorus • Absorbed through: Skin, Bronchial Mucosa and GUT • Inhibit Cholinesterase, causing accumulation of Ach. at nerve endings and neuro-muscular junctions • Irreversible binding of cholinesterase develops after some mins or hrs

10. Clinical Features • Minor exposure to organophosphates may cause subclinical poisoning with decrease cholinesterase levels, but no symptoms or signs • Symptoms may be delayed by 12-24 hrs after skin exposure

11. Muscarinic findings • Diarrhea, urination, miosis, bradycardia, bronchorrhea, bronchospasm, emesis, lacrimation and salivation (DUMBELS) • Wheezing and/or bronchoconstriction • Pulmonary edema • Increased pulmonary and oropharyngeal secretions • Sweating • Abdominal cramping and intestinal hypermotility

12. Nicotinic findings • Muscle fasciculations (twitching) • Fatigue • Paralysis • Respiratory muscle weakness • Diminished respiratory effort • Tachycardia (nicotinic ACh receptors are present in both sympathetic and parasympathetic ganglia. These ganglionic effects in the sympathetic system may contribute to tachycardia) • Hypertension

13. CNS findings • Anxiety • Restlessness • Confusion • Headache • Slurred speech • Seizures • Coma • Central respiratory paralysis • Altered level of consciousness and/or hypotonia

14. Management • Wear protective clothing and avoid getting yourself contaminated • Give supportive treatment as needed • Clear the airway and remove bronchial secretions • Give 02 if necessary • Prevent further absorption by removing soiled clothing and washing the skin, or by gastric lavage after ingestion in the previous 1 hr • Take blood for cholinesterase

15. Manage. (contd.) • If there are profuse bronchial secretion and/or bronchospasm, give • Atropine IV 0.02 mg/kg, repeated every 10-30 mins until there is improvement or obvious signs of Atropinization • Atropinization means Dry mouth, Tachycardia, Dilated Pupils • Very large quantities may be needed

16. Manage. (contd.) • In moderate or severe poisoning give: • Pralidoxime mesylate (also called P2s) 30 mg/kg IV over 5-10 mins, repeated if necessary every 4 hrs • Improvement is usually apparent within 30 mins - Give Diazepam to decrease agitation and control convulsion • 30 days to 5 years: 0.2-0.5 mg IV slowly q2-5min until symptoms resolve; not to exceed 5 mg>5 years: 1 mg IV slowly q2-5min until symptoms resolve; not to exceed 10 mg

17. Carbon Monoxide Poisoning • CO: tasteless and odourless • May occur from: car exhaust, fire smoke, faulty gas heaters • CO decrease O2 carrying capacity of the blood by binding Hb to form CoHb • Impairs O2 delivery from blood to the tissues and also inhibits cytochrome oxidase, blocking O2 utilization • Cause severe tissue hypoxia

18. Clinical Features • Early features: Headache, Malaise, Nausea, Vomiting • In severe poisoning: • There is coma with hyperventilation, hypotension, Increase Muscle Tone, Increase reflexes and convulsions and extensor plantars (Babinski response) • Cherry Red coloring of skin (Fatal CO Poisoning) • Pulmonary Oedema, MI and cerebral oedema

19. Management • Remove from exposure • Clear the airway and maintain ventilation with as high a concentration of O2 as possible: for a conscious patient use a tight fitting mask with an O2 reservoir, but if unconscious intubate and provide IPPV (Intermittent Positive Pressure Ventilation on 100% O2) • Record ECG and monitor heart rhythm (for arrhythmias and sings of acute MI) • Check ABG • Check COHb levels • Correct metabolic acidosis by ventilation and O2 • Consider mannitol if cerebral oedema is suspected