Universal Medical and Business College
POISONING
Minelik II Comprehensive Specialized Hospital
Attachment Clerkship
Seminar Presentation
July ,2022 DEPARTMENT OF CLINICAL PHARMACY: Emergency Ward
Compiled by
2
Andualem Kibatu
Addisalem Kebede
Bamlak Knife
Bethlehem Chane
Biruktawit Aklilu
Contents
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INTRODUCTION
EPIDEMIOLOGY
DIAGNOSIS
DESIRED OUTCOMES
CLASSIFICATION
MANAGEMENT
ANTIDOTES
REFERENCES
INTRODUCTION
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Poisoning represents the harmful effects of accidental or
intentional exposure to toxic amounts of any substance.
The exposure can be by ingestion, inhalation, injection, or
through skin.
The effects may occur immediately or several hours or even
days after the exposure.
The damage could be local or systemic.
EPIDEMIOLOGY
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Poisonings account for approximately 52,000 deaths.
Approximately 0.2% of poisoning deaths involve children younger
than 5 years.
Of emergency department visits for drug-related poisoning,
typically 1.1 million visits.
One-fourth of emergency department visits for drug-related
poisonings were hospitalized.
Organophosphorus more prevalence than others
Dipiro JT, et. al. Pharmacotherapy, A pathophysiologic approach. 10th page 301
RISK FACTOR
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Individuals Relationship
• Previous suicide attempt • Adverse childhood
• Mental illness, such as depression experiences such as child
• Social isolation abuse and neglect
• Criminal problems • Bullying
• Financial problems
• Impulsive or aggressive tendencies
• Family history of suicide
• Job problems or loss • Relationship problems such
• Legal problems as a breakup, violence, or
• Serious illness loss
• Substance use disorder • Sexual violence
DIAGNOSIS
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Random blood sugar
CBC
BUN and creatinine,
Electrolytes
Liver function tests
Chest X-ray for possible aspiration pneumonia
Toxicological analysis of identified substance (e.g. Gastric
aspirate) or from serum
CLASSIFICATION
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ORGANOPHOSPHATES
Rat poison, malathion
ENVIROMENTAL POLLUTANTS
CO, Sulfur dioxide, Nitrogen dioxide
FOOD POISIONG
HOUSE HOLD CLEANING AGENTS
Bleach , Detrol
DRUG OVER DOSE
PCM, benzodiazepines, heparin , isoniazid, opiates, tricyclic
antidepressants and other.
ORGANOPHOSPHATES
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Organophosphates is potent cholinesterase inhibitors capable of causing
severe cholinergic toxicity.
Following cutaneous exposure, inhalation, or ingestion.
Examples
Insecticides – Malathion, parathion, diazinon, fenthion
Nerve gases – Soman, sarin, tabun
Ophthalmic agents – Echothiopate, isoflurophate
Anthelmintics – Trichlorfon
Herbicides – Tribufos (DEF), merphos
Industrial chemical (plasticizer) – Tricresyl phosphate
CONT…
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Thus, organophosphate toxicity can result from
Household or occupational exposure
Military or terrorist action
Iatrogenic mishap.
Exposure to organophosphates is also possible via intentional
or unintentional contamination of food sources.
CLINICAL PRESENTATION
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Muscarinic effects Nicotinic effects CNS effects
Bradycardia ,hypotension Muscle fasciculation Anxiety
Bronchospasm Cramping Confusion
Nausea, vomiting, Abd pain Weakness Seizures
Urinary incontinence Mydriasis Coma
Blurred vision, miosis HTN Restless
Increased lacrimation Tachycardia
TREATMENTS
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Treatment begins with decontamination.
Airway control and oxygenation are paramount.
The mainstays of pharmacological therapy include atropine,
pralidoxime (2-PAM), and benzodiazepines (e.g., diazepam).
Initial management must focus on adequate use of atropine.
Optimizing oxygenation prior to the use of atropine is
recommended to minimize the potential for dysrhythmias.
Atropine, iv, 1-3 mg, every 3-5 minutes
Until pulmonary secretions are dry
CARBON MONOXIDE
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Carbon monoxide is common where there is incomplete
combustion of charcoal.
Acute poisoning results in headache, nausea and vomiting,
mental confusion and agitation.
Severe toxicity causes confusion, impaired thinking, and may
progress to coma, convulsions, and death.
Mechanism of poisoning
Interact with Hgb-bound oxygen
Rx
Transferring to fresh air
Oxygen administration 100% via face
FOOD POISONING
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An illness caused by the consumption of food or water
contaminated with bacteria and/or their toxins, or with
parasites, viruses, or chemicals.
The most common pathogens are norovirus, escherichia coli,
salmonella, clostridium perfringens, campylobacter, and
staphylococcus aureus.
Abdominal pain, vomiting, diarrhea, headache, fever, bloating,
More serious cases of food poisoning can result in life-
threatening neurologic, hepatic, and renal syndromes leading
to permanent disability or death
Treatment
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Support care
Adequate rehydration and electrolyte supplementation
Vomiting (eg, isotonic sodium chloride solution, lactated ringer solution)
Patients should avoid milk, dairy products, and other lactose-containing
foods during episodes of acute diarrhea
Antidiarrheals:
absorbents (eg, attapulgite, aluminum hydroxide); antisecretory agents
(eg, bismuth subsalicylate); antiperistalsis (eg, opiate derivatives such as
diphenoxylate with atropine, loperamide)
Antibiotics
eg, ciprofloxacin, norfloxacin, TMX/SMP, doxycycline.
Selection of antibiotic depends on clinical setting and guided by
microbiology and blood culture sensitivity results
Alcohol intoxication
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Maladaptive pattern of alcohol use leading to clinically significant
impairment or distress, manifested.
Dyspepsia, gastritis, elevated liver enzyme levels, glucose intolerance,
sleep disorders, vague abdominal complaints, Anxiety, depressed mood
Alcohol Detoxification: Inpatient protocol
Give Librium chlordiazepoxide 50 mg po qid and diazepam
10 mg po tid for 24 hrs.
And then give chlordiazepoxide 25 – 100mg po Q6 hrs with
symptoms and signs of alcohol withdrawal
Give thiamine 100mg po bid to tid.
DRUG OVER DOSE
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DOD Poisoning happens when a person takes too much of the
X medicine
Drugs are special drug monitor needs
DOD
When children get access to medicine and take too much
When people take 2 or more of these medicines
People take too much they want to kill themselves.
PCM
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May occur following a single acute ingestion or through the
repeated ingestion of supratherapeutic amounts.
Manifest symptoms
Signs of hepatic injury or failure, such as nausea, vomiting, jaundice, abdominal pain,
renal injury, coagulopathy (eg, gastrointestinal bleeding), hepatic encephalopathy,
cerebral edema, or hypotension.
The management of the acetaminophen-poisoned patient may
include stabilization, decontamination, and administration of N-
acetylcysteine, a specific antidote.
PHENOBARBITONE
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Depression of the CNS, coma, hypotension, loss of reflexes,
hypothermia, respiratory arrest, and death.
Overdose is the persistence of the pupillary light reflex.
Non-pharmacologic
Mechanical ventilation required in severe cases
Hemodialysis
Pharmacologic
Activated charcoal plus alkaline diuresis
NSAIDs
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Alterations in mental status, seizure, metabolic acidosis, or
renal insufficiency and Anaphylaxis may occur
Management
Secure airway, breathing,
Gastrointestinal decontamination if patient presents within two hours of
acute ingestion: activated charcoal, 1 g/kg (maximum dose 50 g).
There is no antidote for NSAID poisoning.
Therapeutic Range for Commonly Monitored Drugs
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Amikacin 20–30 μg/mL
Carbamazepine 4–12 μg/mL
Digoxin 0.5–2 ng/mL
Gentamicin 5–10 μg/mL
Lidocaine 1–5 μg/mL
Lithium 0.6–1.4 mEq/L
Phenytoin 10–20 μg/mL
Procainamide 4–10 μg/mL
Quinidine 1–4 μg/mL
Theophylline 10–20 μg/mL
Tobramycin 5–10 μg/mL
Valproic acid 50–100 μg/mL
Vancomycin 20–40 μg/mL
Desired Outcomes
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Maintain airway, breathing and circulation
Reduce absorption and enhance elimination
Antagonize or neutralize the effects
Relieve symptoms
Prevent organ damage or impairment
NON PHARMACOLOGICAL
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Supportive care
Airway protection
Treatment of hypoxia
Correct hypotension/arrhythmia
Treatment of seizures
Correction of temperature abnormalities
Correction of metabolic derangements
Pharmacologic and other cares
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Prevention of further poison absorption
Gastric lavage
Should be done within an hour of ingestion
Contraindicated in patients with unprotected airway, corrosive and
hydrocarbon poisoning
Decontamination of eye
Skin decontamination
Activated charcoal
Enhancement of elimination
Multiple-dose activated charcoal
Hemodialysis
Urinary PH alkalization
Hyperbaric oxygenation
CONT…
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Administration of anti-dotes
Neutralization by antibodies
Metabolic antagonism
Physiologic antagonism
Prevention of re-exposure
Child-proofing
Psychiatric referral
N.B-Induction of vomiting is contraindicated in patients who ingested
caustic or corrosive substances and hydrocarbons, comatose patients and
those with seizures.
ANTIDOTES
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Poison Antidote(s) Dose for adults
Co Oxygen High-flow O2 by tight-fitting facemask or ventilator
Benzodiazepines Flumazenil Initial dose: 0.1-0.2mg IV over 30-60 sec, repeat 0.1-
0.2mg IV every minute up to 1mg
Acetaminophen N-acetylcysteine Initial : 140mg/kg, then 70mg/kg q 4h x 17 doses
Heparin Protamine sulfate 1 mg neutralizes 90-115 U heparin; initial dose: 1
mg/min to total dose 200mg in 2 h
Isoniazid Pyridoxine (vitamin B6) Initial dose: 1 gm pyridoxine for every gm INH
ingested or empiric 5gm IV over 10 min
Tricyclic Sodium bicarbonate Initial dose: 1-2 ampules (50-100meq) IV push, then
antidepressants IV infusion to maintain blood ph 7.45-7.55
Op Atropine Initial dose: 0.5-2.0mg IV; repeat q 3-5 min until sweat
and secretions clear
Initial dose: 1 gm IV over 15 min, then IV infusion of
Carbamates Pralidoxime 3-4mg/kg/h for 24-72 hrs
ANTIDOTES
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Poison Antidote(s) Dose for adults
Cyanide Hydroxocobalami 70 mg/kg as a single infusion; maximum dose: may repeat a
poisoning n 2nd dose of 70 mg/kg (max dose: 5,000 mg/dose)
Botulism Heptavalent 20ml vial
Digoxin Digoxin immune 20 vial
Fab
Iron Deferoxamine 1gm initially and then 500mg Q4hr for 2 dose
Lead Edetate calcium 1 g/sq.meter IV/IM
disodium
Opioids Naloxone 0.4 -2 mg IV/IM/SC ;repeat Q2-3 min PRN Max dose 1omg
Radioactive Potassium iodide 130 mg po qDAY not to exceed 1 dose/24hr
iodine
Reference
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1. Dipiro JT, et. al. Pharmacotherapy, A pathophysiologic
approach. 10th page 300-345, 2022
2. Ernest H, et at , A textbook of modern toxicology 3th page
54- 60 2004
3. Standard treatment guideline for general hospitals in
Ethiopia 4th edition page 714 – 721,2021
