2.

General approach to a
poisoned patient
 Learning objectives
Understand epidemiology of poisoning,
diagnosis of poisoning by history, physical
examination and different investigations.

Understand the basic principles of management of

poisoning.

2
 Epidemiology of poisoning
• Some form of poison directly or indirectly is responsible
for more than 1 million illnesses worldwide annually.

• Nearly 7% of all emergency room visits are the result of

toxic exposures.

• Causes of poisoning
– Civilian and industrial
– Accidental
– Deliberate (Intentional)
 Cont’d…
 Household cleaner, cosmetics, over-the-counter and
prescription drugs and solvents comprise the most
frequent human toxic exposures.

 Young children and elderly are most likely to be

accidentally exposed to drugs/household chemicals
at home.
 Cont’d…
• During adolescence and young adulthood the
exposures are more likely to be intentional.
• Exposures are equally reported in males and females.
However, adult men have been reported to be more at
risk of occupational exposures than adult woman.
 General management of poisoning
• Poisoning is hard to manage and treat
because :-
– Patient may come in unconscious/comatose
condition
– If patient is alert, he is usually uncooperative
and may not admit self poisoning.
– There is an absence of specific sign & symptom

6
 Cont’d…
• The victim's past medical history including
– Drugs prescribed
– Any psychiatric illness
– Occupation and hobbies may also be relevant

• These histories may indicate possible access to

specific poisons.

7
 Cont’d…
• Physical examination of the victim may
indicate
– The poison or class of poison involved.
– The clinical features associated with some
common poisons may be specific.

• Diagnoses other than poisoning must also be

considered. E.g. coma

8
 Cont’d…
• Poisoning with certain compounds may be
misdiagnosed, especially if the victim presents
in the later stages of the episode.
– Hepatitis in paracetamol poisoning
– Cardiorespiratory arrest in cyanide poisoning

9
 Physical examination
• Generally Physical examination should
include
– Vital signs (BP , HR, RR, T˚)
– Evaluation of specific parts of the body

10
 Assessment of patient’s condition
• If patient is in imminent danger (emergency),
initial priority should be to correct immediate
life threatening problems of the
– Airway
– Breathing
– Circulation
– CNS depression.

11
 Level of consciousness
• Assessed via Reed’s classification of comatose patients

Group
Group 0 Arousable
Group Respond to painful stimuli and have intact reflexes
1
Group 2 Don’t Respond to painful stimuli ,most reflexes are
normal
Group 3 Don’t Respond to painful stimuli , most reflexes are
absent
Group 4 Deeply comatose with respiratory and /or
circulatory failure
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 Respiratory status
• Assessed after a clear airway has been
established, by means of arterial puncture
and measurement of blood
– PH
– pCO 2
– Plasma bicarbonate.

13
 Cardiac status
• Done by recording and monitoring pulse,
BP and urinary output.

Bradycardia Tachycardia
Digitali Alcohol
sOpiates Salicylates
Organophosphates Nicotine

14
 Body temperature
• Hypothermia is a common complication in
many poisoned comatose patients.
– When the rectal temperature falls below 35°C
– Some drugs in over dose produce hyperthermia

• If temperature exceeds 42°C, there can be a

serious threat to life.

15
Hypothermia H yperthermia
Anesthetic agents Anticholinergics
Barbiturates Antihistamines
Carbon monoxide Amphetamines
Opiates Salicylates

16
 Pupillary status
• Several drugs produce pupillary changes

Mydriasis
Miosis
Alcohol
Barbiturates
Cyanide
Organophosphates Carbon monoxide
17
 Pupillary changes
Mydriasis Miosis

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 Principle of management
 The airway should be checked, breathing &
circulation should be assessed.

 Then symptomatic & supportive measures are

taken.

 TREAT THE PATIENT NOT THE POISON

19
 Cont’d…
Management has 5 basic elements:
1. Supportive care.
2. Identification of a poison.
3. Prevention of further absorption.
4. Promotion of poison removal.
5. Use of specific antidotes.
1. Supportive care
 Based on the clinical status of the patient.
 Maintenance of respiration and circulation are
primary concern.
 General treatment measures
• Management of respiratory failure
– Institute oxygen, mechanical ventilator
• Management of circulatory failure
– Elevate foot end of the bed
• Management of hypo/hyperthermia
– Warm room/blanket in hypothermia
– Cold bath in hyperthermia
• Control of convulsions
– Diazepam IV, PR (phenytoin is alternative)
21
 Cont’d…
Trendelenburg Ice bath

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2. Poison identification
• In general, specific therapy is only started
when the nature and/or the amount of the
poison(s) involved are known.

• Antidotes are only available for a limited

number of poisons.

• Milk?

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Determination of the ingested substance

 Qualitative & quantitative analysis of biological

specimens.
 From the clinical signs & symptoms.
 Inspection of the area adjacent to the victim and
questioning of any potential witnesses.
 Asking the patient.
 Location of the victim, may also give hints.
3. Prevention of further absorption.
• If the poison has been inhaled, the victim should
first be removed from the contaminated
environment.

• If skin contamination has occurred, contaminated

clothing should be removed and the skin washed
with an appropriate fluid, usually water (Surface
decontamination).

• Helps to minimize blood level of the poison

 Cont’d…

For ingested poison, GI decontaminations:

1. Gastric lavage
2. Induction of emesis
3. Giving activated charcoal
4. Laxatives, and
5. Others
 Gastric lavage (GL)
• Done in alert and conscious patients

• Unconscious patients – insert endotracheal

tube in the airway before trying to wash the
stomach.

27
 Induction of emesis
• Attempted only in alert, conscious patients

• Drug of choice is syrup of ipecac (90%

successful in inducing emesis)

• Less effective alternative is to tickle back of the

throat with finger/spoon handle.

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Activated charcoal

29
 Cont’d…

• Binds non-specifically.
• Interrupt entero-hepatic circulation of a toxicant.
• The absorption of any residue remaining after gastric
lavage can be minimized by leaving a high dose of
activated charcoal in the stomach.

30
 Cont’d…
4. Enhancement of elimination of
toxicants;
 Can be promoted with drugs & non-
pharmacologic techniques.

31
 Principles of toxin eliminations
• Generally, there are 3 main methods of
enhancing elimination of the poison from
the systemic circulation :-
1. Forced diuresis with alteration of urine pH
2. Peritoneal dialysis and hemodialysis
3. Hemoperfusion

32
 Role of antidotes in poisoning
• Antidote – a substance which counteracts
the effects of a poison.

• There are a few poisons for which genuine

antidotes exist but the vast majority are
without such magic remedies.

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 Classification of antidotes
• Mechanical/physical
• Chemical
• Physiological/pharmacological

34
 Mechanical/ physical
• Act by minimizing the absorption of the
poison.
– Activated charcoal in alkaloid poisons.

35
 Chemical antidotes
• Act by chemically forming a non toxic
complex with the poison.
– Acetic acid/vinegar for alkalis
– Magnesium oxide for acids
– Ferric oxide for arsenic

36
 Physiological/pharmacological
• Produce effects which are opposite to
those of the poison.
– Atropine for organophosphates
– Naloxone for morphine

37
 Coma cocktail
• Poisoned patient exhibiting CNS depression
should be given 3 antidotal agents when the
identity of the poison is not known.

• These agents are collectively called the

coma cocktail comprise :-
– Naloxone (2mg)
– Thiamine (100mg)
– Dextrose (50ml of 50% solution)
38
 Rationale behind cocktail
• A significant portion of poisoned comatose
patients are cases of overdose from
– Opiates
– Alcohol
– Hypoglycemic agents.

• Even if a particular case is not due to any of

these causes, administration of these
antidotes is relatively harmless.

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Some antidotes and protective agents

ANTIDOTE INDICATION
Acetylcysteine
Paracetamol Atropine
Organophosphates Deferoxamine
Iron
Methylene blue
Nitrates Physostigmine
Atropine Naloxone
Opioids 40