Вы находитесь на странице: 1из 26

12/23/2011

Poison

A substance, natural
or synthetic, that
causes damage to
living tissues and has
an injurious or fatal
effect on the body

Poison

What makes a poison?

All substances
known to human are
poisons, and only
the dose
determines the
effect

Toxicology

Toxicum:

Poison (Latin)

Toxikom:

Arrow poison (Greek)

Logia:

S i
Science
(L
(Latin)
ti )

Definition: Toxicology is the study of harmful effects to

Accidental poisoning

living organisms from substances which are foreign to them.


The toxins may be naturally occurring in the environment or
synthetic chemicals

exposure to a
poison resulting in
symptoms by an
accidental action
e.g. common in
children or at work
place

12/23/2011

Deliberate poisoning

Occupational poisoning

part of the spectrum


of disorders now
termed as
deliberate selfharm

occurs in context of
employment

Environmental poisoning

Forensic toxicology

exposure resulting
f
from
the
th presence
of a chemical in
air, food or water

It is a discipline which combines analytical


chemistry with essential toxicology
principles in order to deal with medico
legal aspects of toxic effects of drugs &
chemicals on man

How one is poisoned?

10

Scope of Toxicology

A - How it gets in?


D - Where does it go?
M - What happens to it?
E - How do you get rid of it?

How to Kill?

How Much in
Environment?

11

How to
Remedy?

12

12/23/2011

How to Kill?

Toxicology (categories)

Acute Toxicity
Chronic Toxicity
Sub-lethal Effects
Behavioral, Ecological, Physiological, Genetic,
Reproductive, Developmental
Trans-generational Effects
Molecular/Biochemical Modes of Action
Resistance, GMOs (genetically modified organisms)

Acute toxicity: acute toxicity refers to immediate

Chronic toxicity: it refers to the harmful effects of

harmful effects generated by sufficiently large doses


l
long-term
t
exposure to
t relatively
l ti l low
l
d
doses off toxicant
t i
t

Toxicology (effects)

Lethal: resulting in the death of individuals


Sub lethal: other effects not directly resulting in
death

13

Toxicology (damage caused)

14

Toxicology (exposure types)

Physiological damage: reversible / irreversible

damage to the health of the organism

Carcinogenesis: induction of cancer


Mutagenesis: induction of genetic damage /

Teratogenesis: induction of birth defects

mutation(s)

Acute exposure: an acute exposure is

often referred to as being less than 24 hours


duration
Sub acute exposure: describes exposures over a
relatively
l ti l short
h t period
i d off titime, often
ft less
l
than
th one
month
Chronic exposure: describes repeated exposures
for a "significant" portion of an individuals life-span.
(More than three months for mammals)
Sub chronic exposure: describes exposures
shorter than chronic exposures but longer than
subacute (1-3 months is typical for mammals)

15

Toxicology (exposure routes)

How much in the Environment?

Enteral: Mouth, rectum, mucous membranes


Parenteral: Injection, sub cutaneous, I/M, I/V, intra arterial, intra
peritoneal, intra thecal, in bone marrow
Inhalation: Air passages
External application: Skin, wound
Natural orifices: Rectum, vagina, urethra, nose, eyes
Sublingual: Under tongue

Rapidity of absorption in decreasing order


I/V
I/M

inhalation
intraperitoneal
oral
mucous membrane

16

sub-cutaneous
topical
17

Ecosystems
Soil, Water or Air
Seasonal Fluctuations
O
Occupational
ti
l
Workplace Exposures
Epidemiological
Geographic and Industry-wide Patterns
Residential
eg. Lead, Asbestos, Food Residue
18

12/23/2011

How to Remedy?
Dangerous Drug Rules

Clinical
Antidotes, Pharmaceuticals

Hazardous Waste
Bury, Burn, Export

Industrial Ecology
Policy

Drug Act 1976

Regulatory Agencies, Laws, Penalties, NGOs

and

Risk

Dangerous Drug Act 1930

Acceptable Levels
Environmental Justice
19

20

Specific Objectives of Drug Act 1976

Marketed drugs are of required quality


New drugs are adequately tested & evaluated for
safety & efficacy
T
Term
off approvall off any product
d t can b
be modified
difi d or
product can be withdrawn from use after marketing
Medical practitioners are kept fully informed about
properties of the drugs
There is also control over advertising to prevent or
discourage misuse by profession & public

21

Constitution of Central Licensing


Board

22

Standing Drug Committees

Director General Health, Government of Pakistan


Secretary Provincial Health Department, Punjab
Secretary Provincial Health Department, Sindh
1 member from Pharmaceutical Pofession, Frontier
1 member from Drug Administration, Government of
Pakistan (Secretary)

23

Drug Evaluation Committee


National Formulary Committee
Advertisement Control Committee
Any other purpose

24

12/23/2011

Criteria for Drug Dependence

An individual may become compelled to continue


taking drugs (craving)
Amount needed for the intended initial effect may
have to be increased (tolerance)
Discontinuation of the drug may lead to complex
sequence of symptoms (withdrawal symptoms)
Physical & psychological dependence may occur
Social deterioration of the personality of the drug
user may occur

25

Strategic Measures to prevent abuse of


Dangerous Drugs

26

Dangerous Drug Rules

Punishing severely those who indulge in


illegal transportation of such drugs
Providing treatment centres
Restricting availability of such drugs to
those who are predisposed to their use

Rule 2

Names of the Dangerous Drugs

Rule 8

Mode of Sale & Supply of Dangerous


g
Drugs
Prescribes limitations about the
Quantity of Dangerous Drugs

Rule 13
Rule 14
Rule 17

Maintenance of Record of Dangerous


Drugs
Excessive amount of the drugs on
special permission

27

Dangerous Drug Rule 2

28

Dangerous Drug Rule 8

Names of the dangerous drugs


are given in this rule
Opium
Cocaine
Cannabis Indica

Dangerous Drug Rule 8 deals with mode of


sale & supply of these drugs. A licensed
chemist may sell opium alkaloid or coca
derivatives to a medical practitioner known to
him subject to the conditions that:
Medical practitioner should either sign the

register in person or send a written


signed order stating his name, registration
number, address & the name & quantity of
the drugs required.

29

30

12/23/2011

Dangerous Drug Rule 8

Dangerous Drug Rule 8

Licensee shall satisfy himself as to the

genuineness of the signatures &


qualifications of the medical practitioner.

If the
th d
drugs are tto b
be obtained
bt i d b
by post,
t th
they
shall be sent by registered post.
In case of real emergency the drugs may be
supplied on oral message, provided the
licensee is satisfied about the genuineness of the
order & medical practitioner furnishes or assures
to provide written signed order within 24 hours.

The drug may also be supplied to


any person having a prescription
subject to the following conditions

31

Dangerous Drug Rule 8

32

Dangerous Drug Rule 8

Opium alkaloids or coca


derivatives shall be sold in such

quantity only as may be specified in


the prescription.
If the prescription does not bear a
superscription, the dangerous
drugs shall be sold once only & the
prescription shall be retained.

If the prescription bears superscription


as aforesaid, the chemist shall make
entries about the amount of drug
supplied, date of sale & shall sign &
seal in the prescription before returning
it to the holder of the prescription.

33

Dangerous Drug Rule 13

34

Dangerous Drug Rule 13

Dangerous Drug Rule 13 prescribes


limitations about the quantity of

1.
2.

the dangerous drugs, which a medical


practitioner may possess for use in his
practice at any one time.

3.

4.

35

Medicinal hemp
.. 3 ounces.
Medicinal opium .. 3 ounces.
O i
Opium
alkaloid
lk l id derivative
d i i
(excluding prepared opium) ..... 60 grains.
Coca derivative
.. 60 grains.

36

12/23/2011

Dangerous Drug Rule 14

Dangerous Drug Rule 14

Dangerous Drug Rule 14 is about

maintenance of record of
dangerous drugs in separate registers

for each drug or in separate parts of the


same register assigned to each of the
following classes of drugs &
preparations:

Cocaine & preparations containing it.


Medicinal opium.
M hi & preparations
Morphine
i
containing
i i
it.
Morphine derivatives & preparations
containing them.
Extracts or tinctures of Indian hemp

37

Dangerous Drug Rule 14

38

Dangerous Drug Rule 14

Entries in the register shall be

made on the day on which a drug is


received or dispensed.
dispensed
Where a medical practitioner
practices at more than one
premise, a separate account of
drugs kept at each premise shall be
maintained.

Every entry required to be made & every


correction of such an entry shall be made
in ink. No cancellation, obliteration or
alteration
l
shall
h ll be
b made
d off any entry in the
h
register & if any correction of an entry is
made, it shall be made by way of a marginal
note or footnote & the entry shall specify the
date on which the correction is made.

39

Dangerous Drug Rule 14

40

Dangerous Drug Rule 14

The record of dangerous drugs in the possession of a


medical practitioner are open for inspection by
any officer of the Health Department not below
the rank of District Officer Health (DOH) or an Excise
Officer not below the rank of Inspector.
Medical practitioner should submit such information
relating to the transactions in dangerous drugs as
may be demanded from him. All records including
registers & daybooks are being retained for two
years from the date of the last entry therein.
41

A medical practitioner should keep the

dangerous drugs under lock & key. While


carrying such drugs to the house of a patient,
the
h medical
d l practitioner should
h ld take
k full
f ll
precautions for their safe custody & should
report theft or loss of dangerous drugs to the
nearest police station immediately.

42

12/23/2011

Toxicology (history)

Dangerous Drug Rule 17

On special permission of District


Coordination Officer (DCO), some
dispensary or hospital can keep more

amount of the Dangerous Drug

as allowed in Rule No.13

Hecate, Goddess of witchcraft


she was represented as an aspect
of Bendis, a mighty goddess
having power over heaven, earth
and sea
during the middle ages, Hecate
became known as Queen of the
Witches
several poisons and hallucinogens
are linked to Hecate, including
belladonna, hemlock, mandrake,
aconite (known as hecateis), and
opium poppy

43

Toxicology (history)

44

Common Poisons in our Environment

Paracelsus, Philippus
Theophrastus Aureolus
Bombastus von Hohenheim,
the "father of chemistry and
the reformer of materia
medica," the "Luther of
Medicine," the "godfather of
modern chemotherapy," the
founder of medicinal
chemistry, the founder of
modern toxicology
(1493-1591) born in
Switzerland employed as
military surgeon

1- Corrosives

Mineral acids

Organic acids

HCl, H2SO4
oxalic acid, carbolic acid

V
Vegetable
t bl acids
id

HCN

Strong alkalies

NahCO3, NaOH, NH3

2- Irritants

A- Inorganic

Metallic
Non metallic

arsenic, mercury, lead, copper


phosphorus, chlorine, bromine,
iodine

45

Common Poisons in our Environment

B- Organic

Vegetable
Animal

C Metallic
CM t lli

46

Common Poisons in our Environment

castor oil, croton oil, madar

A- Cerebral

snakes, cantharides, insects

diamond, glass, hair

3- Neurotropics

A- Cerebral

i- Somniferous:
ii-Inebriants:

Further classified into,


Somniferous
Inebriants
Delirients

alcohol, anaesthetics
sedatives, hypnotics
fuels
insecticides

iii-Deliriants:

47

opium & alkaloids

Dhatura, cannabis indica, cocaine, belladona

48

12/23/2011

Common Poisons in our Environment

B- Spinal:
C- Peripheral:

nux vomica
curare

4- Cardiac:
5 Asphyxiants:
56- Miscellaneous:

digitalis, oleander, aconite


coall gas, CO
CO, CO2, sewer

analgesic + antipyretic:
antihistamines:
tranquilizers:
anti depressants:
stimulants:
hallucinogens:

aspirin, paracetamol
avil
largectal, reserpine
tricyclic compounds
amphetamines
L.S.D

Corrosives

Irritants

Neuroleptics

Cardiac

Asphyxiants

Miscellaneous

49

Keith Simpsons

1234
45678-

50

Medico legal

Classification

Analgesics:
aspirin, paracetamol
Hypnotics:
chloral aldehyde, barbiturates
Sedatives & Tranquillizers: diazepam, largectal
Anti depressants: tofranil
Anti-depressants:
Narcotics:
opium alkaloid
Stimulants:
amphetamine, cocaine
Abortificient:
purgatives
Industrial gases & Volatile products: SO2, petrolium

Classification

Suicidal:
barbiturates, wheat pills etc
Homicidal: aconite, arsenic etc
Accidental: love
l
philter,
hilt h
household
h ld products
d t etc
Stupefying: dhatura, cannabis indica etc
Abortificient: madar, ergot etc

products

9- Corrosives
10- Irritants
51

Duties of a doctor

52

Clinical duties of a doctor

53

Assess patients condition by paying attention to airway,


breathing, circulation & CNS depression

Try to identify nature of poison, route of exposure, dose


consumed, time elapsed

Obtain any history of allergy or any associated medical problem


or head injury

Assess status of hepatic & renal functions

All necessary investigations

Lay emphasis on supportive measures


54

12/23/2011

Legal duties of a doctor

1- Cant refuse treatment


2- Inform police
3- Arrange for dying declaration
4- Collect & p
preserve specimen
p
p
properly
p y & in
separate containers:
i- stomach wash
iii- urine

Legal duties of a doctor

ii- vomitus
iv- blood

5- Collect all evidence near the patient


iiiiiiiv-

utensils used for poisoning


bottles or containers
food or drink
clothes or bed sheets

6- If death occurs, death certificate must be issued


without mentioning cause of death
7- For medico legal purposes or for autopsy
examination, case referred to medico legal centre (to
Forensic department in case of Faisalabad)
8- All evidence to be handed over to police along with
treatment chart
9- In case of mass poisoning, case must be notified
to public health authorities
Executive Director Health (EDO Health)
District Officer Health (DOH)

55

56

Collection & Preservation of


Viscera /Biological Material

Handling of the Specimen

In Living
Blood
Urine
Gastric Lavage
Vomitus
Left over food
Drinks/tea/water

In Dead
Stomach along with contents
Small intestine with contents
Pieces of liver, Spleen & Kidney

(Saturated solution of Saline used as preservative)

Three anal / vaginal swabs for detection of


semen / grouping (in doubt of sexual assault)
Blood,urine,bile,vitreous & CSF etc;

57

Removing the Stomach

58

Tying the ends of Stomach

59

60

10

12/23/2011

Stomach Contents & Mucosa

Stomach Separated

61

Dissecting the Kidney

62

Dissecting Liver & Spleen

63

64

Labeling the Viscera

Preservation of Viscera for Chemical


Examiner

65

66

11

12/23/2011

Letter to the Bacteriologist

Letter to the Chemical Examiner

67

68

69

70

Report of Chemical Examiner

In Case of Poisoning

Toxicology (action of toxin / poison)

1- What will be the specimen to be


colleted & preserved in living?
2- What will be the specimen to be
collected & preserved in dead?
3- What preservative will be used?
4- To whom the specimen will be sent?

Local

Remote

Direct action on some


part of body

Specific action
Opium alkaloid, digitalis

Local + Remote:
General action:
71

Absorption of poison into


system

Non-specific action
Corrosives by shock

As in oxalic acid
Effects more than one system
72

12

12/23/2011

Recall

123
34567-

Factors influencing toxicity

General categories of toxic agents


General effects of toxic agent
Exposure types of a toxic agent
Exposure routes
CINCAM
Keith Simpsons classification
Medico legal classification of poisons

1- Dose & concentration


2- Composition of toxic agent
3- Condition of stomach
3
4- Routes of administration
5- Metabolism of toxic agent
6- State of health
7- Age & maturity

73

Factors influencing toxicity

74

1- Dose & concentration

8 - Nutritional state & dietary factors


9 - Genetics
10- Sex
10
11- Environmental factors
12- Occupation
13- Living conditions

Toxicity value expressed by LD50

Concentration of chemical required to produce death in 50%


of the animals exposed

Dose

larger dose acts rapidly & severe are the effects but
sometimes vomiting reduces effects e.g. CuSO4

non toxic substances become toxic in larger doses


dose & age e.g. aspirin
diluted & solid form of a drug

75

Toxicity Rating of Poisons


Usual fatal dose

76

2- Composition of toxic agent

Toxicity Rating

a- Physio-chemical composition

Less than 5 mg/kg

6. Supertoxic

5 50 mg/kg
5-50

5 Extremely toxic
5.

50-500 mg/kg

4. Very toxic

500 mg-5 gm/kg

3. Moderately toxic

5-15 gm/kg

2. Slightly toxic

More than 15 gm/kg

1. Practically non-toxic

77

gases act rapidly


fine powders act quicker than coarse
synthetic substances insoluble in gastric
juice but soluble in alkaline medium
small diameter particle will effectively reach
alveoli

78

13

12/23/2011

Recall

Introduction & definitions

Recall

Poison
Toxicology
Manner of poisoning
Forensic toxicology
History

Toxicology

Classification of poisons

Factors affecting toxicity

Categories
Effects
Damage caused
Exposure types
Exposure routes

General classification
Keith Simpsons classification
Medico legal classification

Dose & concentration


Composition of toxic agent

79

80

2- Composition of toxic agent

Boney-M

b- Chemical composition

Chemicals in combination may become inert


AgNO3 + HCl
AgCl + HNO3
Strychnine + Activated charcoal
Chemicals in combination may become poisonous
Cyanide salt in stomach HCl
Barbiturates + Alcohol

(Rasputin)

There lived a certain man in Russia long ago


He was big and strong, in his eyes a flaming glow
Most people looked at him with terror and with fear
But to Moscow chicks he was such a lovely dear
He could preach the bible like a preacher
Full of ecstacy and fire
But he also was the kind of teacher
Women would desire
RA RA RASPUTIN
Lover of the Russian queen
There was a cat that really was gone
RA RA RASPUTIN
Russia's greatest love machine
It was a shame how he carried on

81

Rasputin

82

2- Composition of toxic agent

(1859-1915)

c- Mechanical composition

83

corrosives when diluted with H2O acts as


an irritant
alkaloid with Activated charcoal
arsenic with H2O settles down at bottom so
mix with milk, coffee of same specific
gravity

84

14

12/23/2011

2- Composition of toxic agent

3- Condition of stomach

d- PH
concentrated acid + alkali gives more toxic effect
than diluted one
e- Stability of compound
e
paraldehyde sedative + hypnotic
CNS
depression
arsenic with H2O settles down at bottom so mix
with milk, coffee of same specific gravity
exposure to light + air
decomposes to
acetaldehyde

if stomach is full
S/S delay
fatty food
S/S delay
in phosphorus poisoning
rapid
snake venom harmless by mouth
carbonated beverages the rate of intestinal
absorption by in gastric emptying
all poisons absorbed from small intestine detoxify in
liver by portal circulation positive point of oral route

85

86

Recall

1- How chemical composition of a toxic agent effects


its toxicity
2- How mechanical combination of substances effect
their toxicity
3 Clinical
3Cli i l duties
d ti off a doctor
d t
4- Why taking history is important
5- Legal duties of a doctor
6- Can doctor refuse treatment?
7- Evidence is handed over to?
8- How death certificate is issued?

87

88

Principles of treatment of poisoning

At home

89

Remove victims from contact with chemical or


gaseous fumes as long as you do not put yourself
in danger
Call physician for instructions before giving the
victim anything to eat or drink
Have a bottle of ipecac syrup in the home. Do not
administer ipecac without first contacting the
poison center or your physician
Never give any medications prior to calling your
local poison center or physician for advice
90

15

12/23/2011

At home

At home

(Oral exposures)

rinse the mouth with water


do not try to neutralize a poison by giving raw
eggs, salt water, mustard, vinegar or citrus
fruit juices as an antidote or to cause vomiting
never attempt to induce vomiting by sticking
your fingers anywhere in the patient's mouth
as this procedure can be very dangerous

(Ocular exposures)

eye needs to be rinsed for 15 minutes with


room temperature tap water
this can be done either at the sink using a
pitcher of water or in the shower
it is very important to be sure the eye is held
open during the irrigation

91

At home

92

At home

Inhalation exposures (breathing fumes, gases,

dust, and aerosols)


Immediately remove the person to fresh air
Ventilate that area as soon as possible by opening
windows or directing fans toward the door while
protecting yourself from injury
If the person is unconscious, having difficulty
breathing or not breathing take him to Poison
Control Centre Allied Hospital Faisalabad

Dermal exposures (skin)


Immediately remove any contaminated clothing
and rinse the affected area thoroughly with water
Wash the same area with soap and water to
remove allll remaining
i i chemicals
h i l on th
the skin
ki
Do not use any other medications, ointments,
solutions, or products on the affected area until
advised to do so by the poison center or your
physician

93

General Management

Assessment of Patient

Poisoning case is usually an enigma


in clinical medicine

94

Whether it is an emergency
ABCD of resuscitation

1- Level of consciousness

unconscious state
uncooperative and hostile
absence of specific signs & symptoms

Non-specific resuscitative measures

95

airway, breathing, circulation & CNS depression


Reeds classification of comatose patients

96

16

12/23/2011

Reeds classification

Assessment of Patient

Group 0

Arousable

Group 1

Respond to painful stimuli & intact reflexes

Group 2

Do not respond to painful stimuli most


reflexes are normal

Group 3

Do not respond to painful stimuli most


reflexes are absent

Group 4

Deeply comatose, with respiratory and/or


circulatory failure

2- Respiratory status
After clear airway has been established, by means of arterial
puncture & measurement of blood pH, pCO2 & plasma
bicarbonate
Simple method would be to measure respiratory minute
volume by Wrights spirometer. If its less than 4 litres/min,
respiratory insufficiency is present

3- Cardiac status
By recording & monitoring the pulse, blood pressure &
urinary output

97

Drugs producing changes in blood


pressure
Hypertension

Hypotension

Amphetamines
Cocaine

Antihypertensive
drugs
Antipsychotics

Nicotine

Diuretics

Phencyclidine

Ethyl alcohol

Sympathomimetic
drugs

Opiates
Sedatives &
Hypnotics

98

Drugs producing changes in pulse


rate
Tachycardia

Bradycardia

Alcohol

Aconite

Dhatura

Digitalis

Salicylates

Opiates

Nicotine

Organophosphates

Sympathomimetic
drugs
99

Drugs causing oliguria

100

Assessment of Patient

Barbiturates

4- Body Temperature

Carbolic acid

Cantharidin

Ethylene glycol
Oxalic acid

hypothermia is a common complication


said to be present when rectal temperature
falls below 35oC
ECG will show J or osborne wave

Petroleum derivatives
Salicylates
Sulphonamides
101

102

17

12/23/2011

Drugs producing changes in body


temperature
Hypothermia

Drugs producing pupillary changes

Hyperthermia

Miosis

Mydriasis

Nystagmus

Analgesic drugs

Amphetamines

Barbiturates

Alcohol (constricted

Alcohol

Barbiturates

Anticholinergics

Carbon monoxide

Antihistamines

CNS depressants

Cocaine

Opiates

in coma)

Benzodiazepines

Amphetamines

Barbiturates

Caffeine

Antihistamines

Carbamazepine

Phenothiazines

Carbamates

Carbon
monoxide

Phencyclidine

Salicylates

Carbolic acid
(Phenol)

Cocaine

Pheytoin

103

104

General Treatment Measures

Drugs producing pupillary changes


Miosis

Mydriasis

Parasympathomimetics

Cyanide

M th l d
Methyl
dopa

Dh t
Dhatura

Nicotine

Management of CNS Depression


Coma Cocktail

Ephedrine

Opiates

Dextrose 100 ml of 50% solution, I/V


Thiamine (Vitamin B1) 100 mg, I/V
Naloxone 2mg, I/V

Organophosphates

Atropine is reputed to produce a spasmodic pupil (hippus) i.e alternate constriction


and dilatation

In children, Thiamine is not recommended &


Dextrose is more diluted

100% Oxygen (high flow 8 to 10


litres/min)

105

General Treatment Measures

General Treatment Measures

Management of Respiratory Failure

106

Maintain clear airway


If blood gas analysis shows reduced PO2
level & increasing PCO2 level, patient needs
O2 therapy (assisted ventilation)
Nikethamide administration (2 ml/IV)
Mechanical Respirator in extreme cases

107

Management of Circulatory Failure

Correct acidemia, if present


Elevate foot end of the bed (Trendelenburg position)
Use vasopressors or plasma expanders
Ensure that eyelids are closed to avoid exposure
keratitis

108

18

12/23/2011

General Treatment Measures

Recommended
Vasopressors

Drug

General Treatment Measures

Dose

(microgm/kg/min)

Dopamine

2-20

Epinephrine

1-4

Isoproteronol

0.5-4

Metaraminol

8-15

Norepinephrine

2-8

Phenylephrine

5-20

Management of Hypothermia & Hyperthermia


Hypothermia: Warm room & a blanket. In
severe cases, active re-heating by using warm
water bath

Hyperthermia: Remove clothes & pack the body


with ice or immerse upto neck in cold water bath

109

General Treatment Measures

General Treatment Measures

Correction of fluid & electrolyte imbalances

110

Hyponatraemia (Na<130 mEq/L)

Hypernatraemia (Na>150 mEq/L)

Hypokalaemia (K<3.5 mEq/L)

Hyperkalaemia (K>5.5 mEq/L)

Give 0.9 % NaCl over 15 to 20 min at a time

Correction of fluid & electrolyte imbalances


Hypocalcemia (Ca<4 mEq/L)

Give 0.2 % NaCl over several hours

Give 4 to 6 mEq of K/kg/day orally or in a sol

111

Give sodium bicarbonate I/V at a dose of 1 to 2 mEq/L over


15 20 minutes

Control of Convulsions

In mild cases, give diuretic. In severe cases give 10%


Calcium Gluconate I/V

Give calcium gluconate, 10% I/V

Correction of metabolic acidosis

Drug of choice is DIAZEPAM in a dose of 0.2 to 0.4 mg/kg,


slow I/V upto max of 10 mg at a time

112

General Nursing Care

1- Comatose patients must be turned over


regularly to prevent bed sores
2- Maintenance of adequate airway
3- Adequate bronchial toilet with aspiration of
secretions
4- Physiotherapy
5- Prophylactic antibiotics

113

114

19

12/23/2011

Decontamination

Emesis

In ingested poisons, decontamination is


achieved by evacuation of stomach

emesis

(vomiting)

studies show that syrup of ipecac is very


effective & emesis occurs in more than 90% of
the cases

gastric wash

(stomach lavage)

Only in conscious & alert patient


Ipecac
Source:
Root of a small shrub
Active Principles:
p
Cephaeline,
p
, Emetine
Uses:
1- Induction of emesis
2- Amoebacide
3- Expectorant
Dose:
30 ml (adult), 10-15 ml (child)
Contra-indications:
Coma, infant, advanced
pregnancy, corrosives, severe heart disease, convulsions,
petroleum distillates, foreign body ingestion

115

Gastric lavage

116

Gastric lavage

(stomach wash)

Gastric lavage should not be employed routinely


in the management of poisoned patients
There is no certain evidence that its use improves
clinical
li i l outcome
t
and
d it may cause significant
i ifi
t

Type of tube:

Length of tube inserted:


Procedure:

morbidity

Gastric lavage should not be considered unless a


patient has ingested a potentially life-threatening
amount of a poison and the procedure can be
undertaken within 60 minutes of ingestion

Adult 30 gauge Jaques tube


Child Ryles tube
50 cm (adult) & 25 cm (child)
* Lubericate with g
glycerine
y
& pass
p
* Use mouth gag
* 300 ml of warm water (380C) or
saline is poured (100ml in child)
* This is continued until clear fluid
returns

117

Gastric lavage

KMNO4 ((1:5000))
Tannic acid
Iodinated water

Gastric lavage

(lavage fluid)

1- Warm water
2- Saline (0.9% or 0.45%)
3- Oxidizing silutions

118

These are preferred in alkaloidal poisons or salicylates

4- Soldium thiosulphate, for cyanide


5- Desferrioxamine, for iron
6- Castor oil & warm water, for carbolic acid
7- Calcium gluconate, for oxalic acid
119

(contraindications)

1- Corrosives (except carbolic acid)


2- Convulsions
3- Foreign body ingestion
4- Petroleum distillates
5- Oesophageal varices
6- Marked hypothermia

120

20

12/23/2011

Gastric lavage

Gastric lavage

(complications)

1- Aspiration pneumonia

2- Laryngospasm

3- Hypoxia and hypercapnia


3

4- Mechanical injury to the throat, esophagus, and stomach

5- Fluid and electrolyte imbalance

6- Combative patients may be at greater risk of complications

Tube

121

Activated charcoal

122

Activated Charcoal

Activated carbon, also called


activated charcoal, activated coal
or carbo activatus, is a form of
carbon that has been processed to
make it extremely porous and thus to
have a very large surface area available
for adsorption or chemical reactions

123

Medical Applications

124

Activated charcoal

Activated carbon is used to treat


poisonings and overdoses following oral
ingestion
Dose is 1 gram/kg of body mass (for
adolescents or adults, give 50100 g),
usually given only once, but depending
on the drug taken, it may be given
more than once.
125

(medicinal charcoal)

Source: Destructive distillation of wood


Uses: Decreases the absorption of various drugs by adsorbing
them on its surface
Indications: Useful in poisoning with salicylates, paracetamol,
barbiturates, anti-depressants
Procedure: Used as a water slurry (4 parts of water added to
desired quantity of activated charcoal) after emesis or gastric
lavage
Dose: 1 gram/kg body weight
Side effects: Almost NIL
Contra-indications: Corrosives, heavy metals & alcohol (its not
useful in any of these)
126

21

12/23/2011

Special Measures

Forced Diuresis

forced diuresis
haemodialysis
haemoperfusion
plasma exchange
exchange transfusion
hyperbaric oxygen

Forced diuresis (increased urine


formation by diuretics and fluid) may
enhance the excretion of certain drugs
in urine and is used to treat drug
overdose or poisoning of these drugs
and hemorrhagic cystitis

127

Haemodialysis

128

Haemodialysable poisons

In medicine, hemodialysis (also


haemodialysis) is a method for
removing waste products such as
creatinine and urea, as well as free
water from the blood when the kidneys
are in renal failure.

Etyhl alcohol

Methaqualone

Arsenic

Ethylene glycol

Methyl alcohol

Barbiturates

Isoniazid

Methyl drops

Bromides

Isopropyl alcohol

Phenytoin

Camphor

Lithium

Salicylates

Copper

Meprobamate

Theophylline

* This list is not complete

129

Hemoperfusion

Amphetamines

130

Plasma Exchange

Hemoperfusion is a medical process


used to remove toxic substances from a
patient'ss blood. The technique involves
patient
passing large volumes of blood over an
adsorbent substance. The adsorbent
substance most commonly used is
activated carbon.
131

Plasmapheresis is the removal,


treatment, and return of (components
of) blood plasma from blood circulation.

132

22

12/23/2011

Exchange Transfusion

Hyperbaric Oxygen

An exchange transfusion is a medical


treatment in which apheresis is used to
remove one person's
person s red blood cells or
platelets and replace them with
transfused blood products. Exchange
transfusion is used in the treatment of a
number of diseases including poisoning.

Hyperbaric oxygen therapy (HBOT)


is breathing 100% oxygen while under
increased atmospheric pressure.
Oxygen Chamber: When a patient is
given 100% oxygen under pressure,
hemoglobin is saturated, but the blood
can be hyperoxygenated by dissolving
oxygen within the plasma

133

Antodote

134

Role of Antidotes

An antidote is a substance which can


counteract a form of poisoning. The
term ultimately derives from the Greek
antididonai, "given against".

In majority of cases, intensive supportive


care is needed
Only few genuine antidotes exist in actual
practice
In appropriate circumstances they can bring
dramatic results
Proper antidote therapy can be life saving

135

Specific Antidotes (modes of action)

136

Specific Antidotes (modes of action)

1- Inert complex formation Some antidotes interact

with poison to form an inert complex which is then


excreted from the body. e.g. chelating agents for
heavy metals
2- Accelerated detoxification Some antidotes
accelerate detoxification of a poison. e.g.
thiosulphate accelerates the conversion of cyanide to
non-toxic thiocyanate

137

3- Reduced toxic conversion Best example is ethanol


which inhibits the metabolism of methanol to toxic
metabolites by competing for same enzyme (alcohol

dehydrogenase)
4- Receptor site competition Some antidotes displace
the poison from specific receptor sites, thus
antagonizing the effects. e.g. naloxone which
antagonizes the effects of opiates at opiod receptor
sites

138

23

12/23/2011

Chelating Agents

Specific Antidotes (modes of action)

5- Receptor site blockade Best examplified by


atropine which blocks the effects of anticholinestrase
agents such as organophosphates at muscarinic
receptor sites
6- Toxic effect bypass e.g. oxygen acts as in cyanide
poisoning

Certain organic compounds are capable


of forming coordinate bonds with
metals through two or more atoms of
the organic compound; such organic
compounds are called chelating agents.
The compound formed by a chelating
agent and a metal is called a chelate.

139

140

Chelating Agents

A chelating agent that has two


coordinating atoms is called bidentate;
one that has three, tridentate; and so
on. EDTA, or
ethylenediaminetetraacetate,
(O2CH2)2NCH2CH2N(CH2CO2)2, is
a common hexadentate chelating agent.

EDTA

141

Chelating Agents

Genuine antidotes

Widely used as specific antidotes against some


heavy metals e.g calcium
Produce a firm non-ionized cyclic complex (chelate)
BAL or Dimercaprol
Di
l or British
B iti h anti-lewisite
ti l i it
EDTA (Sodium Calcium Edetate) great affinity for

lead

Penicillamine (Cuprimine) used in copper

poisoning

142

Desferrioxamine: used in iron poisoning


143

Agent

Indication

Glucose

Hypoglycemia

Haloperidol
p

Psychotic states

Heparin

Hypercoagulability

Lignocaine

Ventricular arrhythmias

Mannitol

Cerebral oedema, fluid retention

Furosemide

Fluid retention, left ventricular


failure

Oxygen

Hypoxia
144

24

12/23/2011

Diagnosis of poisoning in LIVING

1- Onset is usually sudden (except in chronic poisoning) and


occurs after an article of food or drink or medicine
2- Commonest features include vomiting, diarrhea,
convulsions CNS depression and respiratory
convulsions,
difficulty
3- Other people who have partaken of the offending
substance may display similar symptoms
4- If no natural disease can be attributed to the
symptoms, chemical analysis must always be done
on specimens of vomitus, stools, urine or blood

145

Diagnosis of poisoning in DEAD

146

Diagnosis of poisoning in DEAD

By postmortem examination
1- External Examination

a- Stains or marks of vomitus


a
vomitus, faeces
b- Colour of postmortem lividity

Phosphorus yellowish or brownish


Cyanide Brick red
Carbon monoxide Cherry red

c- Odour, especially around mouth & nose


d- Injection marks
e- Extent of putrefaction: Some poisons
e
retard putrefaction as arsenic,
organophosphates

147

Diagnosis of poisoning in DEAD

Diagnosis of poisoning in DEAD

By postmortem examination
2- Internal Examination

148

3- Chemical Analysis

a- Odour: Always open skull first alcohol,


a
alcohol
cyanide, phenol
b- Evidence of inflammation: softening,
corrosion, perforation of GIT mucosa
c- Contents of GI tract: poison may still be
present
149

a- Stomach with contents


b- Liver, spleen & kidney
cc- Piece of intestine
d- 5 ml of blood & urine
e- Sample of preservative

(saturated saline)

3- Histopathological Examination: To see

degenerative changes brought by certain poisons

150

25

12/23/2011

Thanks !

151

26