PHARMACOLOGY -DRUG POISONING -QUESTIONS !!!!

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1.ACUTE IRON TOXICITY

• Accidental ingestion of iron tablets seen almost exclusively in children.

• Rare in adults

LETHAL DOSE:

• 10-20 tablets or equivalent of the liquid preparation (> 60 mg/ kg iron)

SYMPTOMS:

• Vomiting
• Abdominal pain
• Bloody diarrhoea
• Shock
• Lethargy
• Cyanosis
• Dyspnoea
• Severe metabolic acidosis
• Coma
• Death – within 6 hours

COMPLICATIONS :

• Necrotizing enteritis
• Hepatic necrosis
• Brain damage

TREATMENT:

• To prevent further absorption of iron from gut

• Gastric lavage using HCO3 – to render iron insoluble.
• Egg yolk and milk orally – to complex iron.
• Activated charcoal doesn’t bind with iron, thus ineffective in iron poisoning.
 • To bind and remove already absorbed iron
• Desferroxamine (an iron chelating agent)
• i.m. 0.5 -1g repeated 4-12 hours (50mg/kg in children)
• DTPA or Calcium edetate – can be used if Desferroxamine is not available.
• BAL- contraindicated because its iron chelate is also toxic
• Supportive measures
• Maintain fluid and electrolyte balance
• To reverse acidosis if present with i.v. infusion.
• Respiration and BP may need support.
• Diazepam (i.v.) to control convulsions, if present.
• Prevent further absorption.
• Bind and remove already absorbed iron.

2. ACUTE MORPHINE POISONING

Accidental, suicidal or seen in drug abusers.

DOSE:

In non-tolerant adult – 50 mg i.m. produces serious toxicity

Human lethal dose – 250 mg

MANIFESTATONS:

• Stupor or coma
• Flaccidity
• Shallow and occasional breathing
• Cyanosis
• Pinpoint pupil
• Fall in BP
• Shock
• Convolutions may be seen
• Pulmonary edema occurs at terminal stage
• Death due to respiratory failure

TREATMENT:

• Respiratory support
• Maintenance of BP
• Gastric lavage with KMnO4 to remove unabsorbed drug.
 • Lavage is indicated even when morphine has been injected.
• Specific antidote: naloxone 0.4 – 0.8 mg i.v. every 2 – 3 minutes till respiration

3. ACUTE BARBITUATE POISONING

Mostly suicidal or accidental

MANIFESTATIONS:

• patient is flabby and comatose with shallow and failing respiration

• fall in BP
• cardiovascular collapse
• renal shut down
• pulmonary complications
• bullous eruptions

TREATMENT:

there is no specific antidote

• Gastric lavage – suspension of activated charcoal

• Supportive measures – patent airway, assisted respiration, maintenance Of blood
volume by infusion
• Alkaline diuresis – with sodium bicarbonate 1mEq/kg i.v.
• Haemodialysis and Hemoperfusio

4 . METHANOL POISONING

• A blood level of > 50 mg/dl methanol is associated with severe poisoning.

• Even 15 ml of methanol has caused blindness and 30 ml causes death.
• Fatal dose is 75 – 100 ml.

MANIFESTATIONS:

• Vomiting
• Headache
• Epigastric pain
• Uneasiness
• Disorientation
• Tachypnoea
• Bradycardia
• Hypotension
 • Acidosis causes retinal damage
• Blurring of vision, congestion of optic disc followed by blindness
• If left untreated, death is due to respiratory failure.

TREATMENT:

The patient should be kept in dark, quiet room protect the eyes from light.

• Gastric lavage with sodium bicarbonate to be given if the patient is Brought within 2
hours of ingestion of methanol.

• Combat acidosis so as to thus prevent retinal damage by i.v. sodium Bicarbonate

infusion

• Potassium chloride infusion to correct hypokalaemia which occurs due to Alkali

therapy.

• Ethanol is preferentially metabolized by alcohol dehydrogenase over Methanol. At a

concentration of 100mg/dl, it retards alcohol Dehydrogenase metabolism and thus
methanol metabolism is inhibited.

• Ethanol (10% in water) is administered through a nasogastric tube, Loading dose of

0.7 ml/kg, followed by 0.15 ml/kg/hour. Treatment as to Be continued for several
days because methanol will be present for long In the body.

• Haemodialysis – clears methanol and its metabolites, hastens recovery.

• Fomepizole – a specific inhibitor of alcohol dehydrogenase and drug of

Choice in methanol poisoning.

• A loading dose of 15mg/kg infused i.v. over 30 minutes followed by 10 Mg/kg every 12
hours till serum methanol falls below 20 mg/dl.

• Folate therapy: Calcium leucovorin 50 mg is injected 6 hourly reduces Formate

levels by enhancing its oxidation.

5. ACUTE PARACETAMOL POSINING

INCIDENCE:

• Occurs especially in children with low hepatic glucuronide conjugating Ability.

 • If large doses taken (> 150 mg/kg/10g for adult) serious toxicity can occur.
• Fatal for doses > 250mg/kg.
• In chronic alcoholics, 5g taken in one day causes hepatotoxicity because Alcohol
induces CYP2E1 which metabolizes paracetamol to NABQI.

• Paracetamol is not recommended in premature infants (< 2kg) for fear of

Hepatotoxicity.

MANIFESTATIONS:

• Early manifestations
• Nausea
• Vomiting
• Abdominal pain
• Liver tenderness
• After 12-18 hours
• hepatic necrosis accompanied by renal tubules necrosis and hypoglycemia
leading to coma.
• Jaundice starts after two days.
• Fulminating hepatic failure and death are likely if plasma levels are high.

MECHANISM OF TOXICITY:

N-acetyl-p-benzoquinoneimine (NABQI) is a highly reactive minor metabolite of

Paracetamol, which is detoxified in liver by conjugation with glutathione.

TREATMENT:

• Gastric lavage – to induce vomiting.

• Activated charcoal given orally or through tube to prevent further absorption.
• Other supportive measures if needed, to be taken.
• Specific antidote: N-acetylcysteine 150 mg/kg should be infused i.v. n 200 ml

5% glucose solution over 15 minutes followed by same dose i.v. over the next 20 hours.

• Alternatively, 75 mg/kg may be given orally every 4-6 hours for 2-3 days
• . It replenishes the glutathione store of liver and prevents binding of the toxic
metabolite to other cellular constituents.

TREATMENT:

• Gastric lavage – to induce vomiting.

 • Activated charcoal given orally or through tube to prevent further absorption.
• Other supportive measures if needed, to be taken.
• Specific antidote: N-acetylcysteine 150 mg/kg should be infused i.v. n 200 ml

5% glucose solution over 15 minutes followed by same dose i.v. over the next 20 hours.

6.Belladonna poisoning

Occurs due to drug overdose or excess consumption of seeds and berries of Belladonna
or Datura plant.

Symptoms:

→ Dry mouth, difficulty in swallowing and talking.

→ Dry, flushed and hot skin, fever, difficulty in micturition, decreased bowel Sounds. A
scarlet rash may appear.

→ Dilated pupil, photophobia, blurring of near vision, palpitation.

→ Excitement, psychotic behaviour, ataxia, delirium, dreadful visual hallucinations.

→ Hypotension, weak and rapid pulse, cardiovascular collapse with respiratory Depression.

→ Convulsions and coma occur in severe poisoning.

DIAGNOSIS:

Methacholine 5mg or neostigmine 1mg s.c. fails to induce typical Muscarinic effects.

Treatment:

If the poison has been ingested following steps are to be done.

✓ Gastric lavage should be done with tannic acid.

✓ The patient should be kept in dark quiet room.

✓ Cold sponging or ice bags are applied to reduce body temperature.

✓ Physostigmine 1-3mg s.c. or i.v. antagonizes both central and

• Peripheral effects, but have been found to produce Hypotension and

Arrhythmias in some cases. As such it is generally not recommended.
• Neostigmine does not antagonize central effects. Therefore, mostCases are just
treated symptomatically.
✓ Other general measures (maintenance of blood volume, assisted

• Respiration, diazepam to control convulsions) should be taken as Appropriate.

Contraindications:

• Atropinic drugs are absolutely contraindicated in individuals with

• A narrow iridocorneal angle— may precipitate acute congestive glaucoma
• Caution is advocated in elderly males with prostatic hypertrophy .

. Anticholinesterase poisoning

(Most repeated !!!!)

• They are most commonly used as agricultural and household insecticide;

Accidental or suicidal poisoning is more common.

• Local manifestation at the site of infection (skin, eyes) occurs rapidly followed

By systemic effect.

• Irritation of eye, lacrimation, salivation, sweeting, miosis, blurring of vision,

• Bronchospasms, breathlessness.
• Fall in BP. Bradycardia, tachycardia, arrhythmias, respiratory failure.
• Death is usually due to respiratory failure.

Treatment:

• Fresh air to be provided

• Wash the skin and mucous membrane with soap and water
• Gastric lavage according to need
• Maintain airway, BP, control of convulsions with diazepam
• Specific antidotes

▪ Atropine – 2 mg i.v. repeated every 10 minutes till dryness of

Mouth or other signs of atropinization appear.

▪ Cholinesterase reactivators like oximes (pralidoxime…)