Management of Acute Poisoning : General approaches RPh Adilah - - PowerPoint PPT Presentation

Management of Acute Poisoning : General approaches

RPh Adilah Mohamed Ariff

National Poison Centre Universiti Sains Malaysia

Introduction

• Basic knowledge and practices in managing acute

poisoning.

• Understanding this basic and general approaches is

vital for healthcare provider in facilitating decisions of diagnosis, risk assessment and treatment plan of specific type of poisoning.

• Pharmacist should identify their important roles in the

management flow regardless their setting of practice.

• Other healthcare providers are part of the important

team members in managing poisoned patient.

Scenarios: Pharmacist may encounter

 A doctor call the pharmacist National Poison Centre (NPC) to get information on how to manage a poisoning case recently admitted to the ED  A mother of a 2 yo boy called a community pharmacist asking whether 50 tablets of Vitamin C is toxic to her child or not.  A public walk into your retail pharmacy asking whether the TCM product he took contains any poison.  A doctor called a pharmacist in hospital DIS asking about dosing, dilution and preparation of ethanol to treat methanol poisoning  A doctor contacted a pharmacist in hospital TDM enquiring about procedure on measuring carbamazepine level in an overdosed patient.  A doctor/pharmacist from NPC called a pharmacist in a community/hospital pharmacy to get assistance on identifying an unknown tablet that was taken overdose by a patient.

Competencies for Pharmacist

• Good history taking – consider various circumstances in

poisoning

• Able to understand and correlate the signs and symptoms

with suspected agent

• Understand lab findings
• Able to choose and search in relevant reference sources
• Able to evaluate risk of the patient
• Able to deliver relevant information which is individualized

to the patient.

• Good in handling drug-related enquiries eg antidote, drug

dosing, dilution etc.

Drug overdose Chemical accident Envenomation Occupational exposure Environmental contaminant Adverse reaction

GE GENE NERAL AL AP APPR PROA OACH CH

• 1. Eme

mergenc ency y st stabiliz lization ation

• 2. Cl

Clinical cal ev evaluation uation

• 3. Li

Limi mitin ting g abso sorpti rption

• n of

f poiso son

• 4. Enhance

anced d el elimi mination ation of f poiso son

• 5. Adm

dministration stration of an f antidote dote

• 6. Support

pportive ive ther erapy apy

• 7. Appropria

propriate te di disp spositi sition

• n

Em Emergency gency St Stabili bilization zation

ma maintenance enance of

• f ade

dequate uate airway way ade dequate uate ox

• xygenation

enation and d ve ventilation ation ade dequate uate circulation culation treat eat convu vulsi lsion

• ns

correction ection of met f metabol bolic ic abnormalitie malities ma manage e com

• ma

GE GENE NERAL AL AP APPR PROA OACH CH

• 1. Eme

mergenc ency y st stabiliz lization ation

• 2. Cl

Clinical cal ev evaluation uation

• 3. Li

Limi mitin ting g abso sorpti rption

• n of

f poiso son

• 4. Enhance

anced d el elimi mination ation of f poiso son

• 5. Adm

dministration stration of an f antidote dote

• 6. Support

pportive ive ther erapy apy

• 7. Appropria

propriate te di disp spositi sition

• n

CLIN INICA ICAL EV EVAL ALUATION UATION

• A. Hi

Hist story ry taki king ng C.

• C. Toxicologic

cological al sc scree eenin ing B.

• B. Physic

sical l ex exami mination ation

CLIN INICA ICAL EV EVAL ALUATION: UATION: A.

• A. Histor

tory y Ta Taking ng

agen ent t and d amo mount nt route te of f ex exposure sure intake ke of f other er su subst stances ances circums cumstances tances of ex f exposure sure current rent me medi dication ations past st me medi dical al hist story ry preh ehospital spital trea eatment tment time me & location ation of f ex exposure sure

CLIN INICA ICAL EV EVAL ALUATION: UATION: B.

• B. Phys

ysical ical Ex Examination ination

gen ener eral status us look at the e skin smel ell the e br brea eath listen en to the lu e lungs ev evaluate te the e hea eart rt ex examine e the e abd bdomen en per erform rm neu euro rologi logical cal ex exam

• May need to remove clothing for thorough exam
• Check clothing for objects or substances
• Assess general appearance of patient - Agitation, confusion, or
• btundation
• Exam skin for bruising, cyanosis, flushing
• Exam eyes for pupils size, nystagmus, reactivity, dysconjugate

gaze, increased lacrimation

• Oropharynx for increase salivation or excessive dryness
• Heart: rhythm, rate, regularity
• Lungs: bronchorrhea or wheezing
• Abdomen: bowel sounds, tenderness or rigidity
• Extremities: fasiculations, tremor
• Neuro: CNS, reflexes, muscle tone coordination, cognition, ability to

ambulate

CLIN INICA ICAL EV EVAL ALUATION: UATION: Phys ysica ical l Ex Examination ination

Ab Abdome domen

hypoac activ tive : anti tichol choliner inergics gics hyperacti ractive :

• rgan

anop

• phosph

hosphates ates

Neuro urologic logic Ex Exam

co coma :

• pioid
• id , i

iso soni niazi azid paralysis alysis : sn snake ke bite te aniso isoco coria ria : eth thylene lene glyco col blin indness dness : meth than anol

• l

Glasgow Coma Scale (E, M, V) Measure conscious state: Eye opening Best motor response Best verbal response Scoring MILD = 13 - 15 MODERATE = 9 - 12 SEVERE = 3 - 8

CLIN INICA ICAL EV EVAL ALUATION: UATION: B.

• B. Phys

ysical ical Ex Examination ination

A A toxi xidro drome is a combinatio nation n of signs gns and d symptoms toms which, h, when n taken en co collec ective tively, ly, ch charac acterize terize a sus uspec ected ted toxi xica cant nt

Organopho hosp spha hates/ tes/car carbam bamates ates

Diarrhea arrhea/d /diaphore iaphoresis sis Urinat natio ion Miosi

• sis/musc

/muscle le fascic ciculations ulations Bradycard dycardia ia/bronc bronchorrhea horrhea Emesis is Lacrim rimatio ation Sali livat vatio ion n Com

• ma

Respira iratory tory depressio ssion Mios

• sis

is/myd mydriasi riasis

• pioids

ds

CLIN INICA ICAL EV EVAL ALUATION: UATION: B.

• B. Phys

ysical ical Ex Examination ination

Poisons

• ns with

th de delay ayed ed signs ns an and sym d symptom toms:

et ethyle ylene e glyc ycol

• l : 6

6 hours rs

• rg

rganop anophosphat hosphate e : 6-12 2 hours rs parace racetamo tamol : 36 hours rs paraq raquat uat : 4 48 hours rs met ethanol anol : 48 hours rs thyroxi yroxine ne : 4 4 wee eeks

CLIN INICA ICAL EV EVAL ALUATION: UATION: B.

• B. Phys

ysical ical Ex Examination ination

As Asymp mpto toma matic tic or mild d initial ial condi dition tion not nece cessarily ssarily warr rrant ant go good d progno

• gnosis

sis

CLIN INICA ICAL EV EVAL ALUATION: UATION: C. To Toxicolog cologica ical l screening ening

• Specime

imen n collection ection

• Timing of

f sampling

• Manner

er of s f sampling

• Type of

f bi biologic fl fluid d

Availab ilability ility of specif ecific ic lab inv nvestig stigatio ation n in n Malaysia laysia

• Urine

ine paraquat aquat

• Rapid

pid urine ne test st for

• r su

substan stance ce of

• f abuse

se

• Blood
• od methanol

hanol, etha hano nol l

• Pseudocholi

udocholines nesterase terase (no not RBC C cho holine linesteras sterase)

• Ca

Carbox rboxyHe yHemogl moglob

• bin

in (CO COHb Hb)

In the e acute e care e set etting, ng, toxi xicology gy screenin ing g is is very limited ed and do d does not contri ribu bute te signifi ficantly antly

CLIN INICA ICAL EV EVAL ALUATION: UATION: C.To Toxicological xicological screening eening

Radio dio-opaque

• paque Dr

Drugs s (C (CHI HIPS) S)

Chloral loral hydr drate ate Heavy y metals ls Ir Iron and d Io Iodi dides des Ps Psychotr hotropi pics cs (TCA) A) Enteric ric-coated coated salic icylates ylates Ther ere e are varying ing radi dio-opa pacity ity among g di differ erent ent medi dications tions and d even for the same medi dication tion from m di differ erent ent manufac acturer turers

GE GENE NERAL AL AP APPR PROA OACH CH

• 1. Eme

mergenc ency y st stabiliz lization ation

• 2. Cl

Clinical cal ev evaluation uation

• 3. Li

Limi mitin ting g abso sorpti rption

• n of

f poiso son

• 4. Enhance

anced d el elimi mination ation of f poiso son

• 5. Adm

dministration stration of an f antidote dote

• 6. Support

pportive ive ther erapy apy

• 7. Appropria

propriate te di disp spositi sition

• n

LIMITI ITING NG AB ABSOR ORPTION TION OF OF POI OISON ON

A. . De Deconta tamina mination tion (e (ext xtern ernal al an and in d inte ternal) al)

A1

• A1. Sk

Skin de decontam tamination ination A2

• A2. Eye de

deco contamination tamination A3

• A3. In

Indu duce emesis is A4

• A4. Gastric

tric lavage ge / Gastri stric aspira iration tion

• B. Adsorbent (Activated charcoal, Fuller’s Earth)
• C. Cat

. Cathar arti tics

• D. Wh

. Whole le bowel el ir irrig igatio ation

Principles of Decontamination

• External

– Protect yourself and others – Remove exposure – Irrigate copiously with water or normal saline

• Internal

– Patient must be fully awake or intubated – Most common complication is aspiration – Gastric lavage/aspiration

• A1. Skin

– Protect yourself and other HC workers – Remove clothing – Flush with water or normal saline – Use soap and water if oily substance – Chemical neutralization can potentiate injury – Corrosive agents injure skin and can have systemic effects

LIMITI ITING NG AB ABSOR ORPTION: TION: A.

• A. Dec

econtam ntaminat ination ion (e (ext xter ernal al)

• A2. Eyes

– Remove contact lens – Flush copiously with water or normal saline – Use local anesthetic drops – Continue irrigation until pH is normal – Slit lamp and fluorescein exam

LIMITI ITING NG AB ABSOR ORPTION: TION: A.

• A. Dec

econtam ntaminatio ination n (i (inter erna nal) l)

A3. . In Induc duction tion of

• f em

emesi esis

Us Use of f syr yrup up of f ipecac c is NO NO LON ONGER GER recomme

• mmended

nded in th n the mana nagement gement of po f poisoned soned patients tients be because: use:

• it can

n caus use prolon longed ged vomiting iting

• can

n delay y administ nistration ration of f activate vated d charcoal coal

• its

s pote tent ntial ial complicati plication

• ns

s inc ncluding uding pul ulmonary monary aspiration ration

In Induce duce of

• f em

emes esis is with ith

• t
• ther

her met ethods hods ar are e ge genera erally lly not

• t

rec ecommended

• mmended too
• o.

LIM IMITI ITING NG AB ABSOR ORPTION TION: : A.

• A. Decont

ntaminatio amination A4 A4. . Ga Gastric tric lavage ge is a m method hod of f evacua uating ting stomach mach cont ntent nts s by by ins nserting erting a na nasogastric

• gastric or orograstric
• grastric tub

ube and nd sub ubseque equent nt administ inistration ration then n aspirat iration ion of f small l volum umes es of li f liquid uid, , br bringi nging ng with h it the ing ngested ested poison. son.

It t sh should d not t be be co consi sidered dered UNLESS SS :

• pa

pati tient ent ha has s ingeste ested d a po pote tentiall tially y life fe-thr threaten eatening ing amount t of f po poiso son

• pr

proce cedure dure ca can be pe perfo formed med with thin n 1 1 ho hour of i f ingesti estion

• n .
• pati

tient ent is fu s fully y awake ke or intu tuba bate ted It t ca can be of b f benef efit it up to p to 4 4 ho hours s in pa pati tien ents ts who ho inges ested ted su subst stances nces th that fo t form co concret cretion ions s in th the st stomach ch or th those se th that t marke kedly dly de decr crease ase gast stric c moti tilit ity. y.

Head Down Left Lateral Decubitus In Awake Patient

• Contraindications of Gastric Lavage:

– Unprotected airway – Hydrocarbon or Caustic ingestion – Esophageal pathology

• Complications of Gastric lavage:

– Aspiration  Hypoxia, Pneumonia – Kinked Orogastric Tube – Perforation (Throat, Esophagus, Stomach) – Laryngospasm, Epistaxis, Great Discomfort

LIMITI ITING NG AB ABSOR ORPTION: TION: A.

• A. Dec

econtam ntaminat ination ion (I (Inter ernal nal)

Ga Gastr stric ic lava vage ge

LIMITI ITING NG AB ABSOR ORPTION: TION: A.

• A. Dec

econtam ntaminat ination ion (I (Inter ernal nal)

LIMITI ITING NG AB ABSOR ORPTION TION: : B. Ad Adsorb rben ent

Ac Activated ated ch charcoal coal

• very

y fine partic ticles les with h increased eased surfac ace e area that able to accumulates ates poison ison on its surfac ace e (ads dsorption

• rption not absorption
• rption)
• prepa

epare re slur urry ry from m AC AC powder der

• charcoal

coal tablet t not useful l for ads dsorbing

• rbing poiso

ison Fuller’s Earth

• Comm

mmon

• nly

ly us used d in paraqua quat poisoning soning since ce paraq aqua uat be beco come me de deact ctiv ivated ated after er contac act t with h soil/c il/clay lay Be Bento tonite nite clay

• another alternative to Fuller’s Earth

DOS OSAGE: AGE: Ch Children dren 0.5 0.5-1 1 g/k /kg Ad Adolescents lescents and nd adul ults ts 25 25-100 100 g Mini

nimum mum di diluti tion

• n fo

for sl slurry: y: 30 30 gram in 24 240m 0mls ls Normally ally given n as s si single le do dose se orally lly

• r via NG/O

/OG G tu tube be

LIMITI ITING NG AB ABSOR ORPTION: TION:

• B. Abs

Absorb rben ent: t: Ac Activate ated d Charcoal rcoal

Co Contr traindicat aindication ions s to to act ctivate ted d ch charco coal al

• Gast

strointest intestin inal al tr tract ct not a t anato tomical mically ly inta tact ct

• Unpr

prote tect cted ed airway

• Prese

sence nce of i f inte testin stinal al obst struct ction ion

• Ingestio

stion n of c f corrosiv sive e su subst stanc nces es It t is n s not t eff ffect ctive ve in th the fo follo lowing wing su subs bsta tances: nces:

• Al

Alco coho hol l

• Cy

Cyanide ide

• Iron
• Lith

thium um

• Hydr

droca carbons rbons

• Meta

tals ls

LIMITI ITING NG AB ABSOR ORPTION: TION:

• B. Abs

Absorb rben ent: t: Ac Activate ated d Charcoal rcoal

LIMITI ITING NG AB ABSOR ORPTION: TION: C. Catharti hartics cs

Cathartics are intended to decrease the absorption of poison by accelerating the expulsion of the poison from the GI tract.

* Cathartics have NO ROLE in the management of a poisoned patient when used ALONE. * Based on available data, the routine use of a cathartic in combination with activated charcoal is not endorsed. If a cathartic is used, it should be limited to a single dose in order to minimize adverse effects.

The two general types of osmotic cathartics used in poisoned patients are :

• saccharide cathartics (sorbitol)
• saline cathartics (magnesium citrate, magnesium sulfate, sodium sulfate).

LIMITI ITING NG AB ABSOR ORPTION: TION:

• D. Whole

e Bowel el Irr rrigation tion

WB WBI uti tilize izes s po polyet ethylene hylene glyco col-elect electrolyte rolyte so soluti tion

• n and

d is s use sed d to to expe pel l : * po poiso sons ns th that t are po poorly y abso sorbed bed by act ctivate ted d ch charco coal al * su sust stain ined ed-release release dr drugs * pa pack cked d dr drugs s in th the body dy (body dy pa pack ckers) rs) WB WBI indu duce ce liquid id st stool – po poorly y to tolerat ated, ed, ca cause se di disc scomf mfor

• rt,

t, co compl plic icat ations ions The here e are no est stablished lished indi dicati cations

• ns to

to th the use se

• f WBI

f WBI, n nor are th there co concl clusive usive evide denc nces es sh showing ng th that t th this s pr proce cedu dure re impr proves es pa pati tien ent t outc tcome e in po poiso soning ning ca case ses. s.

GE GENE NERAL AL AP APPR PROA OACH CH

• 1. Eme

mergenc ency y st stabiliz lization ation

• 2. Cl

Clinical cal ev evaluation uation

• 3. Li

Limi mitin ting g abso sorpti rption

• n of

f poiso son

• 4. Enhance

anced d el elimi mination ation of f poiso son

• 5. Adm

dministration stration of an f antidote dote

• 6. Support

pportive ive ther erapy apy

• 7. Appropria

propriate te di disp spositi sition

• n

EN ENHANCE ANCED D EL ELIM IMINATION INATION OF OF POI OISON ON

• Does the patient need it?

– Severe intoxication with a deteriorating condition despite maximal supportive care – Usual route of elimination is impaired – A known lethal dose or lethal blood level – Underlying medical conditions that can increase complications

• Methods:
• A. Multiple Dose Activated Charcoal
• B. Ion trapping technique – Urine alkalinization/acidification
• C. Extracorporeal elimination
• D. Forced diuresis (mannitol) - no longer recommended, no clinical evidence

to support its effectiveness

ENHAN ANCED CED ELIMINATION NATION OF OF POI OISON ON: A.

• A. Multipl

iple e Dose e Ac Activate ated d Charcoal rcoal

• Opt

ptimum m do dose se is s unkn known

• wn. Af

Afte ter initial tial do dose se (25 25-10 100g 0g in adu dult) t), give at a t a rate te less ss th than 12 12.5g 5g/hour /hour

• Ba

Base sed d on expe perimental rimental and d cl clinical ical st studi dies, s, MDAC AC sh should d be be co consi sidered dered only y in pa pati tien ent t who ho ingeste ested d life fe-th threat reatening ening amount nt of - carba

bamazep azepine ne, , da dapsone, , phenoba barbi rbitol tol, , theophylline ine, , quinine, e, phenytoin

Comp mplic lications ations of MD MDAC AC

• Thi

hick cken ening ing of c f cha harco coal al in th the gut

• Gut o

t obst struct ction ion/p /per erfora forati tion

• n
• Bo

Bowel infa farction rction

• Pulmona
• nary

ry asp spirat ration ion

ENHAN ANCE CED D ELIMINATION NATION OF OF POI OISON ON

• B. Ion tra

rappi ping ng tec echnique ique

• No longe

ger r reco comm mmen ended ded be beca caus use e it ca can produ

• duce

ce me metabo bolic ic aci cidos dosis is, , rhab abdomyolys domyolysis is and d renal al failure. ure.

• Vi

Vitamin min C t titra rated ed to acidi dic urine e pH

• 2. Ur

Urin ine e ac acid idification ification

• Sa

Salic icylate ylates, , pheno nobar arbital, bital, chlorp

• rpropamid

ropamide, , pheno noxy xyac acetate etate herbic icides. ides.

• IV

IV So Sodi dium m bicarbona rbonate te 1-2 ampules es or 1 mEq/kg/dose kg/dose to titrate ate urine ine pH within hin 7.5-8.5 8.5

• Contra

ntraindic indication ation – estab ablished lished or incipi pient ent renal al failu lure re

• 1. Ur

Urin ine e al alka kali linization nization

ENHAN ANCE CED D ELIMINATION NATION OF OF POI OISON ON:

• C. Ext

xtra racorpore corporeal al Elimination ation

• Severe poisoning
• Reserve for specific agent (life treatening) that

amenable to removal by this method:

• Hemodialysis (HD), Hemoperfusion (HP),

Hemofiltration (HF), Plasmapheresis, Exchange transfusion

• Clinical efficacy – difficult to differentiate from

concomitant effect of other mechanism of metabolism and excretion (renal, liver)

Drug Preferred method Carbamazepine HP Ethylene glycol HD Lithium HD Methanol HD Methotrexate HF Phenobarbital HP Procainamide HF Salicylate HD or HP Theophylline HP or HD Valproic acid HD or HP Remember: *Consider pharmacokinetics and known behavior of the drug (Vd, protein binding, T1/2, MW) *What clinical evidence is there for benefit with enhanced removal?

Hemoperfusion

Uses hemodialysis machine - but runs blood directly through a charcoal- or sorbent-containing filter

Blood from patient

ARTERY

• r

VEIN VEIN

Return to patient

GE GENE NERAL AL AP APPR PROA OACH CH

• 1. Eme

mergenc ency y st stabiliz lization ation

• 2. Cl

Clinical cal ev evaluation uation

• 3. Li

Limi mitin ting g abso sorpti rption

• n of

f poiso son

• 4. Enhance

anced d el elimi mination ation of f poiso son

• 5. Adm

dministration stration of an f antidote dote

• 6. Support

pportive ive ther erapy apy

• 7. Appropria

propriate te di disp spositi sition

• n

AN ANTI TIDOT OTES ES

MECHANIS ANISMS MS:

• 1. Iner

ert compl plex ex form rmatio ation

• 2. Ac

Accel elera erate ted d de detoxi xificat fication ion

• 3. Red

eduction tion in convers ersion ion to more re t toxic xic compo pound unds

• 4. Compe

peti titiv tive e inhibi biti tion

• n at re

recep epto tor r site

• 5. Byp

ypassi sing ng ef effec ects ts of poison

• n
• 6. An

Antibo bodi dies es Inter eract acting ing with Poison

• n

Common antidotes Antidotes Poison N-acetylcysteine Paracetamol Atropine & Pralidoxime Organophosphate/ carbamate Vitamin K1 Anticoagulants Pyridoxine Isoniazid Thiamine Alcohol Antidotes Poison Deferoxamine Iron Naloxone Opioids Flumazenil Benzodiazepines Ethanol or Fomepizole Methanol, Ethylene glycol Calcium chloride/ gluconate Calcium channel blocker, Hydrofluoric acid

AN ANTI TIDOT OTES ES

GE GENE NERAL AL AP APPR PROA OACH CH

• 1. Eme

mergenc ency y st stabiliz lization ation

• 2. Cl

Clinical cal ev evaluation uation

• 3. Li

Limi mitin ting g abso sorpti rption

• n of

f poiso son

• 4. Enhance

anced d el elimi mination ation of f poiso son

• 5. Adm

dministration stration of an f antidote dote

• 6. Support

pportive ive ther erapy apy

• 7. Appropria

propriate te di disp spositi sition

• n

SU SUPP PPOR ORTIV TIVE E TH THER ERAP APY Y

IV IVF fo for repla lacement cement and nd maintena ntenance nce of f adequat uate e circulating culating bl blood

• od volume

ume fr freque quent nt monit nitoring

• ring of

f ur urine ne pH dur uring ng alkalinizati linization

• n therapy

rapy int ntensive ensive nu nursing ing care (ET ET tub ubes, s, ul ulcers) rs) address ress metabolic bolic distu turb rbances nces monit nitor

• r vital

al signs ns monit nitor

• r fl

flui uid d inp nput ut and nd out utpu put mana nage ge un underly rlying ing illnesses nesses

GE GENE NERAL AL AP APPR PROA OACH CH

• 1. Eme

mergenc ency y st stabiliz lization ation

• 2. Cl

Clinical cal ev evaluation uation

• 3. Li

Limi mitin ing g abso sorpti rption

• n of

f poiso son

• 4. Enhance

anced d el elimi mination ation of f poiso son

• 5. Adm

dministration stration of an f antidote dote

• 6. Support

pportive ive ther erapy apy

• 7. Appropria

propriate te di disp spositi sition

• n

AP APPR PROPRIA OPRIATE TE DIS ISPO POSIT SITION ION

Short rt per eriod d obs bser ervatio ation n ver ersus adm dmission

• n

Psyc ychiatric atric ev evaluation tion Rule e out child d abu buse e / n neg eglec ect Family y counsel seling ng and d ed education tion

Consult the National Poison Centre Office Hours: +604-657 0099 (Monday-Friday: 8.10am-5.10pm) After Office Hours: +6012-430 9499 (including weekends and public holidays

Thank You

Transforming Higher Education For A Sustainable Tomorrow