POISONING AND TOXIC EXPOSURES TYPES , DIAGNOSIS AND GENERAL PRINCIPLES OF MANAGEMENT

Dr. Neha Kanojia

University College of Medical Sciences & GTB Hospital, Delhi

What is a Poison ?
Poison is a substance ( solid/ liquid or gaseous ), which if introduced in the living body, or brought into contact with any part there of, will produce ill health or death, by its constitutional or local effects or both.

Ref- The Essentials of Forensic Medicine and Toxicology Dr. K. Reddy

Poisoning
The development of dose related adverse effects following exposure to chemicals, drugs or other xenobiotics.

Ref- The Essentials of Forensic Medicine and Toxicology Dr. K. Reddy

EPIDEMIOLOGY
WHO (2004) - 3,46,000 deaths in a year d/t poisoning. In 2005 In India 1,13,914 estimated cases of poisoning with insecticides

Commonest cause in INDIA Pesticides Reasons Agriculture based economy - Easy availability pesticides - Poverty

Types of poisoning
1.

Acute poisoning excessive single dose, or several smaller doses of a poison taken over a short interval of time. Chronic poisoning smaller doses over a period of time, resulting in gradual worsening eg. Arsenic , Phosphorus , Antimony etc.

2.

Nature of poisoning
1.

Homicidal killing of a human being by another

human being by administering poisonous substance deliberately.

2. 3.

Suicidal when a person administer poison himself

to end his/ her life.

Accidental Eg. Household poisons- nail polish

remover , acetone . Depilatories- Barium sulphide

4. Occupational in professional workers. Eg.

insecticides, noxious fumes.

Classification of poisons
According to the chief symptoms produced : Corrosives . Systemic Irritants . Miscellaneous

1.

Corrosives
a) Strong acids- H2SO4 , HNO3 , HCl b) Strong alkalis- Hydrates & Carbonates of Na+ , K+ &
NH3

c) Metallic salts Zinc chloride, Ferric chloride, KCN ,

Silver nitrate, Copper sulphate.

Classification continued.
2.

Irritants
a) Inorganic i) Nonmetallic Phosphorus, Iodine Chlorine. ii) Metallic Arsenic, Antimony, Lead. iii) Mechanical Powdered glass, hair b) Organic Vegetable Abrus precatorius, Castor, Croton, Calotropis. Animal Snake & insect venom, Cantharides

Classification continued.

3. Systemic
a)

Cerebral
CNS depressants Alcohol, opioids, hypnotics, general anesthetics. CNS stimulants Amphetamines, Caffeine Deliriant Datura, Cannabis, Cocaine

b) Spinal Nux vomica c) Peripheral Conium, Curare d) Cardiovascular - Aconite, Quinine, HCN e) Asphyxiants CO, CO2 , H2S

4) Miscellaneous Food poisoning, Botulism.

Routes of administration
Inhalational volatile gas, chemical dust, smoke, aerosol. 2. Injectable a) Intra venous Benzodiazepines, barbiturates,
1.

tricyclic antidepressants etc.

Intramuscular Benzodiazepines, opioids etc c) Subcutaneous Botulinum toxin d) Intra- dermal Local anaesthetics,
b)

organophosphates

3. Oral Corrosives, organophosphorus 4. Through natural orifices- rectum/ vagina/ urethra Abrus precatorius, croton, calotropis 5. Through unbroken skin organophosphorus, Mercury, Lead

Diagnosis of poisoning
History patient witness Circumstantional evidence

suicide note containers & potential toxins at scene of discovery

Physical examination Investigations -Biochemical investigations

-ECG abnormalities -Radiology -Toxicologic screening

History
Patient
If person is conscious , & immediately brought

to the ED, history may be relevant Mostly patient estimates of drug/ nature of substance ingested are inaccurate.

Witness
What substance/ substances ? What route/ routes ? What dose/ doses ? When and for how long? H /O psychiatric illness?

Circumstantial evidence
Unconscious adults Empty drug containers/ wrappers /tablet neraby some sort of poisoning

Tablet particles staining mouth / clothing Suicide note Assumption of poisoning

Following conditions should arouse suspicion of poisoning : Sudden appearance of symptoms after food or drink in an otherwise healthy person Symptoms uniform in character, rapidity Sudden onset delirium, paralysis, cyanosis, collapse etc.

Physical examination
General appearance
Neurological status- conscious, confused, comatose. Glassgow coma scale Pupillary examination Normal Celphos poisoning Miosis Opioids, OP poisoning Mydriasis TCA, Theophylline, Dhatura, Methanol

Convulsions - Ethylene glycol, Lithium, SSRI

Muscular fasciculations OP poisoning

Vital parameters
Cardiorespiratory system PR, BP, RR, Temp

Hypotension with bradycardia :

Beta blockers, Cyanide, Benzodiazepines, Barbiturates, Opioids, Alchohol , OP insecticides

Hypotension with tachycardia :

Beta -2 stimulants, Caffeine ,Theophylline, Amatoxin containing mushroom

Vital parameters contd.

Hypertension with tachycardia : Sympathomimetics, Ergot alkaloids,

Anticholinergics, Alcohol withdrawal

Respiratory depression with failure: Barbiturates,

Benzodiazepines, Opiates, Sedative- hypnotics, Snake venom

Hyperventilation : Amphetamines

, Salicylates, Hallucinogens,

Cyanide, CO, H2S

Vital parameters contd..

Body tempearture

Hypothermia :Benzodiazepines, Ethanol, Opiates, Cyclic antidepressants

Barbiturates,

Hyperthermia :withdrawal, MAO inhibitors, Anticholinergic agents, Salicylates

Amphetamines, Alcohol

Examination of Skin colour and lesions

Colour

Toxin/ poison
Cyanide
Phosphorus ,hepatotoxins (Acetaminophen, mushroom ) Rifampicin Aniline, Nitrites, Methemoglobinemia . .

1.

Pink 2. Yellow ( jaundice)

3.

Red 4. Blue (cyanosis)

Diaphoresis
Salicylate, OP poisoning

Sympathomimetics, serotonin syndrome Phencyclidine, alcohol or sedative withdrawal

Examination of Skin colour and lesions contd.

c. Bruising
Diffuse

d. Needle tracks
I/V

ecchymosis:Anticoagulant poisoning

Rodenticides

abuse :Opiates Amphetamines Cocaine be hidden in groin or interdigital spaces

May

Examination of Skin colour and lesions contd. e. Hair Hair loss Chemotheapuetic agents Thallium

f. Nails Mees lines Arsenic poisoning Thallium

MEES LINES

Odours

Most common odour detected- Alcohol

Odour Toxin

1. Garlic

Arsenic, Phosphorous, Selenium , Thallium , Organophosphorous Ethanol, Chloroform , Nitrites Cyanide

2. Sweet / fruity 3. Bitter almonds

4. Acrid ( pear like )

5. Rotten eggs 6. Fishy / musty 7. solvent/ glue 8. Smoke

Paralydehyde Choral hydrate

Hydrogen sulphide, Mercaptans Zinc phosphide Toulene, Xylene Carbon monoxide

Urine colour
Colour
1. Brown 2. Black 3. Red

Drug/ toxin
Myoglobin, CCL4 , Aniline , Methydopa Naphthalene, Phenols , Cresols Rifampicin, Phenytoin, Phenolphthalein, Desferoxamine Phenols Copper sulphate, Methylene blue

4. Smoky 5. Green / blue

6. Green

Propofol, Indomethacin

Biochemical investigations

Hematologic
CBC, Platelet count, Coagulation profile
Hemolytic anemia- lead, NSAIDS, Quinidine Thrombocytopenia- Aspirin, Phenytoin, Procanamide Coagulopathy- snake venoms, warfarin

Liver function tests

S. bilirubin , enzymes AST,ALT , ALP, coagulation profile
Acetaaminophen, sulfonamides, rifampicin, TCA, INH,

Renal functions tests

Aspirin, lead, barbiturates, alcohol, amphetamines, copper sulphate

Other Abnormalities
Hyperkalemia

Digoxin, Cardiac glycosides, Rhabdomyolysis, K + sparing diuretics Theophylline, Amphetamines, Sympathomimetics

Hypokalemia

Hypernatremia

Uncommon in clinical toxicology Large dose of NaHCO3 for TCA overdose Correction of life threatening metabolic acidosis

Hyponatremia

Rare

Biochemical abnormalities contd

Metabolic acidosis
Acetaaminophen, Ethanol, Methyl alcohol, Toulene

Metabolic alkalosis

Calcium carbonate, Furosemide, Laxative

Anion Gap
Anion Gap = [ Na+ ] { [ Cl] +[ HCO3 ] } Normal 8- 12 mmol/ l Increased anion gap :

Ethylene glycol Methanol Salicylate poisoning

Biochemical abnormalities contd..

Osmolar gap
Detects

the presence of osmotically active susbstances in serum or plasma Calculated osmolality = 2 [ Na+] + [ urea] + glucose 2.8 18
Eg Ethanol - Osmolality =

2 [ Na+] + [ urea] + glucose + Ethanol 2.8 18 4.6

Biochemical abnormalities contd..

Increased osmolar Acetone Ethanol Ethylene glycol Methanol

gap:-

ECG abnormalities

Usually non specific

ECG abnormality 1. Bradycardia & AV Block 2. Ventricular tachyarrhythmias 3. QRS prolongation 4. QT prolongation Drugs/ toxins Barbiturates, - blockers, Antiarrhythmics Cardiac glycosides, Fluorides, Membrane active agents, Sympathomimetics Amantidine , Hyperkalemia Amantadine, Amiodarone, Thallium

Radiological studies

Not particularly helpful in diagnosis. May be useful in confirming :Ingestion of metallic objects. Packets of heroin / cocaine ( body packing) Serial chest X-ray - Aspiration pneumonitis, ARDS

Bio assays of drugs

Acetaminophen Acetone Ethylene glycol Methanol Salicylate Phenobarbital Theophylline Lithium

Toxicologic
Urine

analysis

, blood, gastric contents confirm or rule out suspected poisoning.

Interpretation

requires various methods:-

Thin layer chromatography Acetaminophen Gas liquid chromatography BZD, Amphetamines HPLC- BZD Mass spectrometry- Anticonvulsant Enzyme assays
RBC cholinestrase , serum cholinestrase OP poisoning Pseudocholinestrase levels OP poisoning

Fundamentals of poisoning management

1.

2.
3. 4.

5.
6. 7.

Initial resuscitation and stabilization Removal of toxin from the body Prevention of further poison absorption Enhancement of poison elimination Administration of antidote Supportive treatment Prevention of re - exposure

Management of poisoning contd.

Initial

resuscitation and stabilization I/V access I/V fluids Endo tracheal intubation - to prevent aspiration
Unconscious patients Respiratory depression/ failure

Convulsions- give anticonvulsants of toxin from the body Copious flushing with water or saline of the body including skin folds, hair

Removal

Inhalational exposure Fresh air or oxygen inhalation

Prevention of poison absorption

G I decontamination Performed selectively, not routinely
1.

Gastric lavage
Useful IF DONE BEFORE 3 hr of ingestion of a poison Done with water ( except infants NS), 1:5000 potassium permangnate , 4% Tannic acid, saturated lime water or starch solution Administering & aspirating 5ml/kg through a No. 40 F orogastric tube ( No. 28 F children) or Ewalds tube Position Trendelenburge & left lateral position Performed until clear fluid is obtained or a maximum of 3 L

Prevention of poison absorption contd.

Ewalds gastric tube

Complications
a. b. c.

Aspiration (common) Esophageal / gastric perforation Tube misplacement in the trachea

Prevention of poison absorption contd.

Contraindications
a. b.

c.
d. e.

Corrosive poisoning GE perforation Petroleum distillate ingestants- Aspiration pneumonia Compromised unprotected airway Esophageal / gastric pathology Recent esophageal / gastric surgery Lavage decreases ingestant absorption by an average of :52 % - if performed within 5 mins of ingestion 26 % - if performed at 30 mins 16 % - if performed at 60 mins

Prevention of poison absorption contd.

2. Ipecac Syrup induced emesis

Used for home management of patients with : Accidental ingestions Reliable history Mild predicted toxicity Aministered orally Dose : 30 ml adults 15 ml children 10 ml small infants

MOA
Ipecac irritates the stomach & stimulates CTZ

centre. Vomiting occurs about 20 min after administration Dose may be repeated if vomiting does not occur

Side effects
a.

Protracted vomiting

Contraindications
a.
b. c. d.

Gastric / esophageal tears or perforation Corrosives CNS depression or seizures Rapidly acting CNS poisons ( cyanide, strychnine, camphor )

Prevention of poison absorption contd.

3. Activated charcoal
Greater

efficacy Less invasive Given orally as a suspension ( in water ) or through NG tube Dose 1 g/kg body wt. Charcoal adsorbs ingested poisons within gut lumen allowing charcoal- toxin complex to be evacuated with stool or removed by induced emesis / lavage

Prevention of poison absorption contd

Indications- Barbiturates, Atropine , Opiates,

Strychnine

Contraindications - Mineral acids, alkalis, cyanide,

fluoride ,iron

Side effects
a. b.

Nausea , vomiting, diarrhoea or constipation May prevent absorption of orally administered therapeutic agents

Complications
a. b.

Aspiration vomiting Bowel obstruction

Prevention of poison absorption contd.

4. Whole bowel irrigation Administration of bowel cleansing solution containing electrolytes & polyethylene glycol Orally or through gastric tube Rate 2 L/ hr ( 0.5 L /hr in children) End point- rectal fluid is clear Position sitting

Indication : Slow

or enteric coated medications Packets of illicit drugs Heavy metals Iron , Lithium

Contraindications
Bowel obstruction b. Ileus c. Unprotected airway
a.

Complications: a. Bloating b. Cramping c. Rectal irritation

5. Cathartics

Promote rectal evacuation of GI contents Most effective Sorbitol Dose 1-2 g/kg Salts Disodium phosphate, Magnesium citrate & sulfate, Sodium sulfate Saccharides Mannitol, Sorbitol

Side effects Abdominal cramps, nausea

vomiting

Complications Excessive diarrhoea,

Hypermagnesemia
C/I Corrosives Pre existing diarrhoea

Enhancement of elimination of poison

1.Alkalization of urine
Urine

pH 7.5 Urine output 3-6 ml/kg 5% Dextrose in 0.45 NS containing 20 35 meq /L Of NaHCO3 to an IV solution Uses Chlorpropamide, Phenobarbital, Sulfonamides, Salicylates

C/I :a.
b. c.

Congestive heart failure Renal failure Cerebral edema

2. Acidification of urine

Enhance elimination of weak bases such as Phencyclidine & Amphetamine Not used anymore
S

/E- Metabolic acidosis, Renal damage

3.Extra corporeal removal Dialysis

Acetone, Barbiturates, Bromide, Ethanol, Ethylene

glycol, Salicylates, Lithium Less effective when toxin has large volume of distribution (>1 L/kg), has large molecular weight, or highly protein bound

Elimination of poison contd.

Peritoneal dialysis

Alcohols , long acting salicylates, Lithium

Exchange transfusion Indications

a.
b. c. d.

Fatal , irreversible toxicity Deteriorating despite aggressive supportive therapy Dangerous blood levels of toxins Liver or renal failure Eg. Arsine or Sodium Chlorate poisoning

Elimination of poison contd.

4. Chelation

Heavy metal poisoning Complex of agent & metal is water soluble & excreted by kidneys Eg . BAL, EDTA, Desferrioxamine, DMSA
BAL Arsenic, Lead, Copper, Mercury EDTA- Cobalt, Iron, Cadmium Desferrioxamine Iron DMSA- Lead, Mercury

Administration of Antidotes

Not all poisons have antidotes.

Antidote N - acetylcysteine Dose 140mg/kg. then 70 mg/kg every 4 hrs to total of 18 doses over 72 hrs 0.1mg/min infusion to a total of 1mg 1gm I/M or I/V 2 mg I/V , repeated every half to one min to a total of 20 mg I/V 0.3 g sodium nitrite in 10 ml sterile water iv. 25 g sodium thiosulphate iv slow 2g im 12 hrly or 10- 15 mg/kg/hr not to exceed 80 mg /kg /24 hrs

Poison Acetaaminophen

Benzodiazepine Anticholinergics Opioid Cyanide

Flumazenil Physostigmine Naloxone Thiosulphate , nitrite Desferrioxamine

Iron

Administration of antidotes.
Poison Antidote Dose

OP Poisoning

Atropine , Oximes

Atropine : Loading dose - 2 , 4 , 6 every 5 mins . Maintenance infusion < 3mg/hr PAM 15-30 mg/kg IV to be repeated 6-12 hourly Infusion 20- 40 mg/kg f/b 510mg /kg/h
Ethanol 50% 1 ml/kg every 2 hr for 5 days Fomepizole 15 mg/kg loading dose f/b 10 mg/k every 12 h for 4 days

Methanol

Ethanol , Fomepizole

Supportive care

Hemodynamic support- Hypotension unresponsive

to volume expansion t/t with ionotropes

Correction of temperature abnormalities Hypothermia Rewarming of the patient

Active / passive methods External / internal methods Passive external rewarming- blankets / sleeping bags Active external warming- hot water bottles, heating blankets , forced air warming Invasive core rewarming- peritoneal dialysis, hemodialysis, gastric or rectal lavage

Supportive care contd.

Hyperthermia
Externally immersion in iced saline bath, tepid sponging Internally gastric / peritoneal lavage

Correction of metabolic derangements

Hyperkalemia Calcium gluconate 10% 10-20 ml Insulin 10 units with 50g of 50% dextrose NaHCO3 1mmol/kg , beta-2 agonists

Hypokalemia K < 2.5 mmol/l with symptoms - I/v KCL 20-30 mmol/h K < 3.5 but > 2.5 mmol/l with no symptoms KCL 20-40 mmol every 4-6 hr

Supportive care contd.

Hypernatremia with hemodynamic instability NS saline till I/V vol is corrected. Subsequently replace water with 5% D, or 0.45% NS

Prevention and t/t of secondary complications pulmonary edema , cerebral edema, shock etc. Pulmonary edema Furosemide IV 0.5- 1 mg/kg
Morphine IV 2-4 mg Nitroglycerin SL O2 inhalation / intubation as needed

Cerebral edema Mannitol 1g/kg

Steroids Hydrocortisone, Dexamethasone

Shock crystalloids / colloids

Prevention of re- exposure

Adult education instructions regarding safe use of medications & chemicals Notification of regulatory agencies - in case of environmental or workplace exposure
Psychiatric referral- depressed or psychotic patients should receive psychiatric assessment, disposition & follow-up

Prevention of re- exposure

Child proofing- In house hold
where children live or visit, alcohols, medications, household products ,non edible plants should be kept out of reach or in locked, child proof containers.

Summary
Poisoning a common problem in our country A high index of suspicion required to diagnose For any poisoning the mainstay of treatment is supportive care Follow the A, B, C Dont panic and follow a plan of action

Decreasing absorption Enhancing elimination Neutralising toxins

REFERENCES
1.

2.

3.

4.

5. 6.

Critical care toxicology: Diagnosis and Management of the Critically Poisoned Patient. Jeffery Brent ;2nd edition. Harrisons Principles of Internal Medicine. 16th edition, Vol 2: part 16; Poisoning, Drug overdose, and Envenomation. The Essentials of Forensic Medicine and Toxicology. Dr. K. Reddy , Section II Toxicology; 25th edition International Programme On Chemical Safety, Guidelines On The Prevention Of Toxic Exposure ; WHO 2004 www.biomedcentral.com Official data , D. Gunnell, 2007 Critical Care, Joseph M. Civetta ; 4th edition

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