08.acute Poisoning
08.acute Poisoning
08.acute Poisoning
POISONING
The First Teaching Hospital of Zhengzhou
University
Chao Lan
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Poisoning is defined as “to injure or kill
organism”.
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Acute Poisoning in the
Emergency Department
• Common - 3-5% of ED attendances
• 2000 Deaths per year
• Some of the highest rates of deliberate
poisoning in Europe
• Often multiple drugs
• DON’T FORGET ALCOHOL !!
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The general approach to the poisoned
patient may be divided into seven
phases 。
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(1) emergency management,
(2) clinical evaluation,
(3) eliminating poison from the gastrointestinal
tract, skin, and eyes or removal from the site
of exposure in inhalation poisoning,
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(4) administering an antidote,
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1. Emergency Management.
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1. Emergency Management.
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2. Clinical evaluation.
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• Use all your senses, search for the clues
• LOOK
– Track Marks
– Pupil Size
• FEEL
– Temperature, Sweating
• SMELL
– Alcohol
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2. Clinical evaluation
( 1 ) Any patient presenting with
multisystem involvement should be
suspected of poisoning until proved
otherwise. A thorough history and
physical examination are essential.
( 2 ) A patient with acute poisoning
often presents with coma, cardiac
arrhythmia, seizures , metabolic acidosis,
and/or gastrointestinal disturbances, either
together as symptom complexes or as
isolated events.
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2. Clinical evaluation
( 3 ) Hepatic, renal, respiratory, and
hematologic disturbances are generally
delayed manifestation of poisoning.
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3. Elimination of Poison.
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Inhaled Poisons
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Absorbed Poisons
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Dilute / Irrigate / Wash
• Use soap, shampoo for hydrocarbons
• No need for chemical neutralization - heat
produced by reaction could be harmful
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Eye Irrigation
• Wash for 15 minutes
• Use only water or balanced salt solutions
• Remove contact lenses
• Wash from medial to lateral
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Ingested Poisons
Objective
Remove from GI tract before
absorption occurs
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3. Elimination of Poison
The majority of poisoning occurs via the
gastrointestinal tract. Gastric decontamination
is indicated to reduce absorption of the
poisonous substance. Principal modalities in
historical order include induced vomiting,
gastric lavage, activated charcoal, and whole-
bowel irrigation.
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3. Elimination of Poison
a. Induced vomiting.
– This is may be recommended if the time
since ingestion of the poison is less than
30 minutes.
– (a) digital stimulation (b) Syrup of
ipecac
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Ipecac
• RARELY used anymore
• If used, has to have been initiated within 30
minutes after ingestion
• Vomiting in 20-30 minutes
• Only removes about 32% of contaminate
• Many contraindications
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Ipecac
• Dose
– 15 cc if 12 months to 12 years old
– 30 cc if >12 years old
• Follow with 2-3 glasses of water
• Keep patient ambulatory if possible
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Ipecac
• If no vomiting after 20 minutes, repeat
• When emesis occurs, keep head down
• Collect, save vomitus for analysis
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Ipecac
• Contraindications
– Comatose or no gag reflex
– Seizing or has seized
– Caustic (acid or alkali) ingestion
– Late term pregnancy
– Severe hypertension, cardiovascular
insufficiency, possible AMI
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3. Elimination of Poison
b. Gastric lavage
– Gastric lavage is contraindicated in
patients who have ingested corrosives or
petroleum distillate hydrocarbons because
of the risk of aspiration-induced
hydrocarbon pneumonitis and
gastroesophageal perforation.
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Lavage
• Commonly used in ED’s
• Removes about 31% of substance
• Helps get activated charcoal in patient,
especially if patient is unconscious
• Not helpful for sustained release tablets
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3. Elimination of Poison
c. Activated charcoal
– Activated charcoal ,as a suspension in
water either alone or with a cathartic ,is
given orally via a nippled bottle(for
infants), or via a cup ,straw,or small-bore
nasogastric tube.
– The recommended dose is 1 to 2g/kg body
weight.
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Activated Charcoal
• Adsorbs compounds, prevents movement
from GI tract
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Activated Charcoal
• Inactivates Ipecac
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3. Elimination of Poison
d. Whole-bowel irrigation
- Whole-bowel irrigation is performed by
administering a bowel-cleansing
solution containing electrolytes and
polyethylene glycol orally or by gastric
tube.
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4. Antidotes.
a. Naloxone for all morphine-like drugs
b. Atropine sulphate and pralidoxime, for
anticholinesterase poisoning.
c. Desferrioxamine for iron poisoning
d. Methionine or N-acetyl cysteine in severe
paracetamol poisoning.
e. Nikethamide for alcohol or barbiturate.
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5.Elimination of Absorbed Substance.
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Conscious level
• GradeⅠ Drowsy, confused, responds to
command, reflexes brisk.
• GradeⅡ. Unconscious, does not respond to
command, responds to minimal painful
stimulus.
• GradeⅢ Deeper, responds only to severe
stimulus, respiration depressed
• GradeⅣ Coma, no responses, hypotension
severe respiratory depression or apnea
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6. Supportive Therapy.
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Carbon monoxide
Poisoning
The First Teaching Hospital of
Zhengzhou University
Chao Lan
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Carbon monoxide
• Colourless, odourless tasteless non-irritant
gas from incomplete combustion of organic
materials
• 1-2% COHb in non-smokers, 5-6% in
smokers.
• Approx. 1,000 people die /year from CO
poisoning. Less now natural gas has replaced
coal gas.
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Toxicity
• Main cause of death in children
• Common sources
– car exhausts (lethal in closed garage in
<10 min)
– Unserviced heating systems
– Fires - all sorts
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Physiology
• Binds to Hb with an affinity 200-250 times that of
oxygen.
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Clinical manifestations
• Varied
• Depends on
– CO concentration
– length of exposure
– general health of exposed person
• Infants, elderly, anaemia, lung disease at risk
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Chronic exposure to low
concentrations
• Headache, fatigue, dizziness, difficulty in
concentration, chest pain, palpitations, visual
disturbances, nausea, diarrhoea, abdominal
pain.
• Can easily be mistaken for other illnesses.
• Should be considered in vague presentations.
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Acute poisoning
• Clinical findings do NOT correlate well with
CO concentrations
• <10% - asymptomatic
• 10-30% - headache, mild dyspnea, “gastro-
enteritis”.
• Coma, cardiorespiratory arrest if >60%
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Treatment
• Remove from source
• 100% O2 by close-fitting facemask-intubate and
ventilate EARLY if unconscious as high
incidence of regurgitation.
• Dissociation from Hb occurs readily-elimination
t1/2 <50 min with 100%O2.
• Hyperbaric treatment at 2.5 bar reduces this to
22 minutes and dissolves enough O2 to meet
needs of body without HB.
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Results of hyperbaric therapy
• First used successfully in Glasgow in 1960s.
• Reduces morbidity from 43% to <5%.
• Can even be used in late-presenting cases
with high CO levels.
• Early treatment associated with better
outcomes
• General support also necessary.
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