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بسم الله الرحمن الرحيم Principles of Management of Poisoned Patient

بسم الله الرحمن الرحيم Principles of Management of Poisoned Patient. د/ عبد المنعم جودة مدبولى دكتوراة الطب الشرعي و السموم الإكلينيكية, مدرس الطب الشرعي و السموم الإكلينيكية, استشاري علاج التسمم بمستشفى بنها الجامعي. Objectives (ILOs):. = treat patient, not poison.

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بسم الله الرحمن الرحيم Principles of Management of Poisoned Patient

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  1. بسم الله الرحمن الرحيمPrinciples of Management of Poisoned Patient د/ عبد المنعم جودة مدبولى دكتوراة الطب الشرعي و السموم الإكلينيكية, مدرس الطب الشرعي و السموم الإكلينيكية, استشاري علاج التسمم بمستشفى بنها الجامعي DrAbdelmonem G. Madboly

  2. Objectives (ILOs): = treat patient, not poison General management of poisoned patient: WITH SPECIAL CONCENTRATION ON: Active methods of detoxification (Decontamination)

  3. Treatment • Stable • Proper clinical • evaluation. • 2. Decontamination & • Enhanced Elimination. • 3. Antidote. • 4. Sympt. (Supportive) ttt. • 5. Discharge & follow up. • 6- Prevention re-exposure Unstable 1- Emergency stabilization ABCDEs. 2- Initial therapy (Empiric antidote) 3. Emergent therapy. +تكمل من رقم 1 فى alert = Treat the patient, not the poison Dr Abdelmonem G. Madboly

  4. DecontaminationDefinition: Removal of toxin from patient. Or Removal of patient from toxin.

  5. DecontaminationTypes: External: - For poisons outside the body (non ingested poison): • Environment = Inhalation(gaseous poisons) • Clothing…………………...(toxins ??????) • Skin = Dermal ……… (toxins ??????) • Ocular……………… (toxins ??????) Internal: - For poisons inside the body: • GIT (Gut Decontamination). • Parental (SC, IV)…….. (how.?????) • Blood & tissues = Enhanced elimination.

  6. GIT Decontamination: • Emesis. • Gastric lavage. • Endoscopic removal (surgical). ------------------------------------------- • Activated charcoal. • Local antidote. ------------------------------------------- • Cathartics. • WBI

  7. I- Emesis: • Definition: (DD Vomiting).

  8. EXCEPT: > 6 hours • Sustained released tablets (Salicylates). • Enteric coated tablets (Cach. blockers). • Drug concretion (lumps or mass) bezoars: (salicylates, iron, sedatives, Bromide) • Drugs slow gastric empting: (anticholinergic, salicylates, morphine, ..) • Entero-entric circulation: (morphine, nicotine, theophylline, HMs (Hg, As)…). • Entero-hepatic circulation: (Digitalis, TCAs, ..) Dr/ Abdelmonem G. Madboly

  9. II- Gastric lavage: • It is done by inserting a tube in to the stomach, washing it with water or harmless solvent to remove the unabsorbed poison. • Useful for as long as 3-6 hrs. after ingestion. • It should not be employed routinely in the management of poisoned pt, but it should be considered only if a pt. has ingested a life- threatening amount of toxic sub. • A cuffed endo-tracheal tube has been inserted before lavage to avoid pulmonary complication in cases of C.N.S. depressants.

  10. Procedure of gastric lavage: • The pt. In left lat. Decubitus position. • Remove dentures or foreign body from mouth. • Use endotracheal or nasotracheal intubation before gastric lavage in: a- unconscious. b- seizures. c- Pt. With absent gag R. • Lubricant QY gel …………………….. • Swallowduring introducing. • Confirmation position: (ALERT & COMA). • Sample of gastric contents (for analysis) • 200 ml for adults & 50-100 ml for children of warm H2O • Before removal: • Charcoal & Cathartic should be instilled. • The tube is firmly nipped and removed, to avoid aspiration.

  11. Uses of Ryle tube: • Suction of secretions. • Gastric lavage. • Giving activated charcoal. • Feeding of comatosed patient. • Hematemesis.

  12. Contraindication: • Non- live threatening ingestions & non- toxic ingestions. • Pills that are known not to fit into the holes of the gastric lavage tube. • Any pt. whose air integrity is not assured. • CORROSIVESexcept…………. • Toxic ingestions with more pulmonary than G.I.T Toxicity e.g. kerosene (to avoid aspiration). Complication: • Insertion of the tube in to the trachea obstructing it. • Aspiration pneumonitis, • Esophageal or gastric perforation. • Decreased oxygenation during the procedure.

  13. III- Activated charcoal (AC): • AC is considered the best methodof gastric decontamination. • It is produced by the destructive distillation of various organic materials(i.e. wood, coal, petroleum) and then treated at high temperatures and steam: 600- 900 C, which produces great surface area & Surface binding area = 900- 1500 m2/g. • Super-activated charcoal: 3 folds surface area of AC due to increase its adsorbent capacity.

  14. T T T A. Charcoal T Mechanism of action: • It adsorbs the toxin within the gut lumen, making the toxin less available for absorption in to the blood tissues thus it enhances elimination (GIT dialysis). • It can bind the drug in the bile, interrupting the enterohepatic circulation. Single- dose A.ch.: • l g/ kg b.w. (adult & children) • must be freshly prepared. • A.ch + 4 parts water slurry (given by mouth or through G. tube). • Must not be given until the syrup of ipecac has evoked emesis. • Given with cathartic to reduce G.I.T transit time

  15. Indications: • All suspected toxic ingestions. • Ingestion of any sub. Known to adsorb to it • After unknown ingestion by pts. With protected airways. Contraindication: • Poorly adsorbed poisons to AC (such as iron, lithium, ethanol or Bead). • Prior to Corrosive ingestions (not only ineffective but also may be accumulated in burned areas interfering with endoscopy). • The presence of diminished bowel sounds, iIleus, bowel obstruction Complication: • Rare risks: aspiration, intra-luminal impaction in pts. With abnormal gut motility.

  16. IV- Cathartics: Type & dose: • The most commonly used are osmotic cathartics • As 70% Sorbitol sol (I g/kg) or 10% sol of mg citrate or sulfate (250 ml/kg for adult 4 ml/kg for children). Indications: • With activated charcoal to enhance elimination ( - - - transit time). • Same indications as A charcoal.

  17. V- Whole bowel irrigation:بتاع الحاجات الصعبة Definition: A rapid catharsis by mechanically forcing ingested substances through the bowel at a rapid rate, without the risk of serious fluid and electrolyte disturbances. Technique: • Installation of (2L/h in adult, 500 mL/h in children). • Either by mouth or through a gastric tube of isotonic polyethylene glycol (CoLyte, GoLYTELY) lavage solution that neither causes fluid nor electrolyte shifts. • The end point is clear rectal effluent.

  18. VI- Surgical GIT decontamination: Indications: 1- Ing. of drug-containing packets bowl obs. or bowel ischemia. 2- Rupture of packets containing large amount of cocaine. 3- Poisons that form large masses or adhere to the GIT wall & are not removed medically as aspirin , bromide or iron.

  19. VII- Local antidote: • Neutralization therapy. xxxxxxx • Milk or water. • A charcoal. • Universal antidote.

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