بسم الله الرحمن الرحيم Principles of Management of Poisoned Patient

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: Patient with normal mental status or alert patient (Stable). Patient with altered mental status or coma(Unstable).

3. Dr Abdelmonem G. Madboly

4. 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

5. B = Breathing: How to know: • Clinical exam. (Resp. rate, Cyanosis………..) • Perform arterial blood gas )ABG) analysis to monitor: • The adequacy of oxygenation by measuring PO2 (normal : 75-100 mmHg or 10-13.3 Kpa “kilopascal”) and O2 saturation (normal: 95-100% or 4.8-6.1 KPa) • The adequacy of alveolar ventilation by measuring PCO2 (normal values are 36-46 mmHg). Pulse oximetry :مهمممم • Not reliable in patients with methemoglobinemia or carbon monoxide poisoning.

6. Methods of O2 administration: • Mouth to mouth. • AMBU bag (Bag valve mask). • Nasal cannula. • Nasal musk. • Mechanical ventilation (ventilator). • + ttt of Cause: (respiratory arrest, bronchospasm, pulmonary aspiration, or noncardiogenic pulmonary edema).

7. C = Circulation: • Cause of abnormal circulation: • Hypotension & shock……………. • Dysrhythmias……………………… • Bleeding & hemorrhage………… • How to know: • Measure pulse and blood pressure • Estimate tissue perfusion (urinary output, skin signs, pH). • Insert an intravenous line, and draw blood samples. • How to treat (hypotension)

8. ttt of Hypotension & shock: • Position & Warming of patient . • IV fluids (up to 2 L in adults or to a systolic blood pressure of 100 mmHg). • Vasopressors (dopamine or dobutrex). • Continuous ECG monitoring: antiarrhythmic agents such as lidocaine or phenytoin • Cardiopulmonary resuscitation (CPR) for cardiac arrest. • ttt of cause(antidote). • ttt ofppt factors “arrhythmogenic factors”: (hypoxia, met. acidosis, dysrhythmias& hypokalemia)

9. Depression (D) or Excitation (E): ttt of Coma (Coma cocktail): DONT • ttt of depression (Coma cocktail): =dextrose, oxygen, thiamine & naloxone • Excitation= seizures: • Diazepam • Phenobarbital • Phenytoin • General anaesthesia • Drug elimination by haemodialysis. • Treatment of violent patient (Agitati =Benzodiazepines & haloperidol. ttt of seizures (Convulsions): ttt of violent patient (Agitation)

10. II- Initial Therapy (Empiric Antidote ) DONT (Coma cocktail)

11. Def.: drugs which should be used as diagnostic or therapeutic agents for the comatose patient. • Drugs: DON’T • Dextrose (Hypertonic)0.5 to 1 g/kg of 50% dextrose in water (D50W) for an adult, or D10W or D25W for a child. • Oxygen 100% • Naloxone (Narcan),2 mg (5 ampoules, each 0.4 mg) intravenous for adults and children. • Thiamine,100 mg intravenous for an adult (usually unnecessary for a child).

12. Emergent therapy: • Some urgent manifestations: • Coma ……………………………. • Convulsions …………………… • Pulmonary edema ………….. • Cerebral edema …………….. • Metabolic Acidosis …………. • Some specific antidotes.