an approach to a poisoned patient · 2018. 12. 4. · an approach to a poisoned patient muhammad...

An approach to a poisoned patient

Muhammad Darwin Prenggono

Division of Medical Hematology – Oncology Department of Internal Medicine

University of Lambung Mangkurat,School of Medicine / Ulin General Hospital Banjarmasin

South Kalimantan - Indonesia

IntroductionIntroduction

� Apa itu racun?

� Dalam penggunaan umum -racun adalah bahan kimia atauracun adalah bahan kimia atauproduk kimia yang sangatberbahaya bagi manusia

� Lebih tepatnya - racun adalahbahan kimia asing (xenobiotik) yang mampu menghasilkanefek berbahaya pada sistembiologis

Other terminologyOther terminology

Apa itu racun (Toxidrome)?

� Ini awalnya mengacu pada

racun hewan atau tumbuhan asalracun hewan atau tumbuhan asal

� Toksik adalah istilah ilmiah yang

saat ini lebih disukai untuk

semua racun.

Parasympathetic vs. Sympathetic Nervous System

Sistem saraf parasimpatis (PNS) mengontrol homeostasis

dan tubuh saat istirahat dan bertanggung jawab untuk

fungsi "istirahat dan cerna" tubuh.

Sistem saraf simpatik (SNS) mengontrol respons tubuh

terhadap ancaman yang dirasakan dan bertanggung jawab

atas respons "lawan atau lari".

PNS dan SNS adalah bagian dari ANS, atau sistem saraf

otonom yang bertanggung jawab untuk fungsi tubuh

manusia secara tidak sengaja.

Common toxidromesCommon toxidromes

The cholinergic toxidromeThe cholinergic toxidrome

What toxidrome?What toxidrome?

The anticholinergic toxidromeThe anticholinergic toxidrome

Hot as a hare

Dry as a bone

Red as a beet

Mad as a hatter

Blind as a bat

The anticholinergic toxidromeThe anticholinergic toxidrome

Panas seperti kelinci

Kering seperti tulang

Merah sebagai bit

Buta seperti kelelawr

What toxidrome?What toxidrome?

disorientation Amphetamine

hallucinations Cocaine

Hallucinogenic hyperactive bowel Pseudoephedrine

panic Phencyclidine Benzodiazepenespanic Phencyclidine Benzodiazepenes

seizure Ephedrine

Toxidrome Hypertension

Tachycardia

Tachypnea

HallucinogenicHallucinogenicSympathomimetic toxidromeSympathomimetic toxidrome




panic Phencyclidine Benzodiazepenespanic Phencyclidine Benzodiazepenes

seizure Ephedrine


Tachycardia

Tachypnea




panic Phencyclidine Benzodiazepenes

HallucinogenicHallucinogenicSympathomimetic toxidromeSympathomimetic toxidrome

panic Phencyclidine Benzodiazepenes

seizure Ephedrine


Tachycardia

Tachypnea

Sedative/hypnotic toxidromeSedative/hypnotic toxidrome

Opiate toxidromeOpiate toxidrome

Serotonergic syndromeSerotonergic syndrome

Recognition of poisoningRecognition of poisoning

� Mungkin sulit karena gejala yang tidak spesifik

� Indeks kecurigaan yang tinggi - terutama keracunan okultisme

� RIWAYAT PASIEN (AUTO atau ALLO ANAMNESA)� RIWAYAT PASIEN (AUTO atau ALLO ANAMNESA)

� mencari riwayat yang menguatkan – MIS : pil yang hilang, wadah kosong

� Tentu saja racun itu mengalir / CAIR (toxidromes)! - mungkin membantu

� Skrining toksikologi - hanya membantu dalam beberapa KASUS

Clinical manifestationsClinical manifestations

� Sangat beragam dan tergantung pada racunnya

� Pemeriksaan klinis harus difokuskan pada kemungkinan manifestasi dari racun umum di wilayah tsb

Clinical manifestationsClinical manifestations

� Skin and mucosal damage

� Neurotoxic manifestations

Cardiovascular manifestations� Cardiovascular manifestations

� Metabolic consequences

� Eye manifestations

� Hepatic dysfunction

When do you consider ICU?When do you consider ICU?

� Respiratory

� Airway protection

� Respiratory failure

� Cardiovascular

� Hypotension despite fluid challenge

� Heart block, arrhythmias, QTc prolongation as in TCA

When do you consider ICU?When do you consider ICU?

� Neurologic� GCS < 8

� Seizures

� Metabolic� Hypoglycaemia

� Significant electrolyte abnormalities

� metabolic acidosis

� Hepatic failure

� Coagulopathy with bleeding

Assessment & managementAssessment & management

ASSESSMENT & THERAPY should ASSESSMENT & THERAPY should proceed in parallel

Clinical assessmentClinical assessment


� Airway - ensure clear airway, clear secretions, check for cough/gag

� Breathing - check oxygenation, supplemental O2, breathing pattern & adequacy

� Circulation - heart rate, rhythm, blood pressure


� Neurologic - GCS, seizures, agitation, spasms, pupils, autonomic dysfunction

� Miscellaneous - odour, temperature, pallor, cyanosis, jaundice

� Abdomen - rigidity, bleeding, urine output

Laboratory assessmentLaboratory assessment


� Of limited value

� Paracetamol levels, salicylate levels, alcohol, Red cell/pseudocholinesterase, anti-epileptic Red cell/pseudocholinesterase, anti-epileptic drug levels

� Urinary drug screen - opiates, barbiturates, benzodiazepines, amphetamines, cocaine


� Anion gap & Osmolal gap

� Increased anion gap (Normal 12 ± 4 mEq/L)

� Ethylene glycol� Ethylene glycol

� Methanol

� Salicylate poisoning

� Increased osmolal gap (Normal 5 ± 7 m osmol/kg)

� Ethylene glycol

� Methanol

� Acetone, ethanol, isopropyl alcohol, propylene glycol

� (Mahasiswa buat 2 kelompok)


� Electrolytes

� Hypokalemia

� Oduvanthalai poisoning (Clistanthis collinis)

� Diuretics, Methyl xanthine, Toluene

� Hyperkalemia

� Digoxin

� Beta-blocker

� Liver function tests� Acetaminophen, Ethanol, Carbon tetrachloride

� Renal function tests� Ethylene glycol, NSAIDS


� ECG

� Digoxin toxicity

� TCA (Trycyclic Antidepresant))overdose - sinus tachycardia, QT prolongation, increased QRS

� Beta-blockers - conduction abnormalities

� Imaging

� Limited value

Goals of treatmentGoals of treatment

Goals of treatmentGoals of treatment

� Reduce absorption of the toxin (xenobiotic)

� Enhance elimination� Enhance elimination

� Neutralise toxin

Reduce absorption of the toxinReduce absorption of the toxin

Reduce absorptionReduce absorption

� Removal from surface skin & eye

� Emesis induction

� Gastric lavage

Activated charcoal administration & cathartics� Activated charcoal administration & cathartics

� Dilution - milk/other drinks for corrosives

� Whole bowel irrigation

� Endoscopic or surgical removal of ingested chemical


�� Skin decontamination Skin decontamination

�� Important aspect Important aspect –– not to be neglectednot to be neglected

�� Remove contaminated clothingRemove contaminated clothing

�� Wash with soap and water (soaps Wash with soap and water (soaps containing 30% ethanol advocated)containing 30% ethanol advocated)

�� However, no evidence for benefit even in However, no evidence for benefit even in OP poisoningOP poisoning

Decontamination

�� Gastric decontaminationGastric decontamination

�� Forced emesis if patient is awakeForced emesis if patient is awake

�� Gastric lavageGastric lavage�� Gastric lavageGastric lavage

�� Activated charcoal 25 gm 2 hourlyActivated charcoal 25 gm 2 hourly

�� Sorbitol as catharticSorbitol as cathartic


� Gastric lavage

� Bilas lambung penyerapan sd 42% jika dilakukan 20 menit dan dengan 16% jika dilakukan pada 60 menit

Dilakukan dengan terlebih dahulu aspirasi lambung� Dilakukan dengan terlebih dahulu aspirasi lambungdan kemudian berulang-ulang memasukkan cairan

� Posisi lateral kiri lebih baik – penyerapan lebih baik

� Cara paling sederhana, cepat & tidak mahal - corong

� Pilihan cairan adalah air keran - 5-10 ml / kg

� Lebih mudah pada pasien ygmasih sadar

Enhance eliminationEnhance elimination


� Increased elimination is possible only if

� obat didistribusikan terutama di ECF (Extracelluler obat didistribusikan terutama di ECF (Extracelluler fluid

� memiliki ikatan protein rendah

� tingkat eliminasi yang diinduksi lebih cepatdaripada laju normal

� bahaya bila dikerjakan dlm waktu lebih lama karena terpaparnya obat /racun itu berpotensifatal


� Methods

� Pertahankan hasil urin yang baik 150-200 ml / jam

� Alkalinisasi urin - keberhasilan klinis diterimauntuk keracunan salisilat & fenobarbitaluntuk keracunan salisilat & fenobarbital

� Penghapusan extracorporeal

� Hemodialisis - Barbiturat, Salisilat, Asetaminofen, Valproat, Alkohol, Glikol

� Hemoperfusi - theophylline, digitalis, obat yang larut dalam lemak (mengikat protein dlm tubuh atau sulit larut dlm air)

Perbedaan Hemodialisis dan Perbedaan Hemodialisis dan HemoperfusiHemoperfusi

1. Hemodialisis merupakan proses perubahan komposisi terlarut

darah dengan difusi menembus dinding semipermiabel antara

darah dan larutan garam.darah dan larutan garam.

2. Hemoperfusi adalah metode pembuangan obat dan toksin dari

darah, dengan memompakan darah melewati bahan adsorben

dan kemudian disirkulasikan kembali ke dalam tubuh pasien.

Brainly.co.id - https://brainly.co.id/tugas/4686959#readmore

Neutralise toxinNeutralise toxin

Neutralise toxinNeutralise toxin--specific specific antidotesantidotes

Acetaminophen N-acetyl cysteine

Anti-cholinergics Physostigmine

Benzodiazepenes Flumazenil

Ca channel blockers Glucagon, Insulin + dextrose, Calcium

Carbamate Atropine

Cyanide Thiosulphate, nitrate Cyanide Thiosulphate, nitrate

Digoxin Digoxin antibodies

INAH Pyridoxine

Methanol Ethanol, Fomepizole

Glycol Ethanol, Fomepizole

Opioid Naloxone

Oral hypoglycaemics Glucose

Organophosphate Atropine,? P2AM

Warfarin Vitamin K

Neutralise toxinNeutralise toxin--specific specific antidotesantidotes

Iron Desferroxamine

Copper Penicillamine, Dimercaprol, CaEDTA

Lead CaEDTA, Dimercaprol (BAL) Lead CaEDTA, Dimercaprol (BAL)

Mercury DMPS, DMSA, BAL

Arsenic BAL & derivatives

Antimony BAL & derivatives

SummarySummary

� Problem keracunan masalah umum di negara kita

� Indeks kecurigaan yang tinggi diperlukan untuk mendiagnosis

Ketahuilah toxidrome yg sering terjadi� Ketahuilah toxidrome yg sering terjadi

� Jangan panik dan ikuti rencana aksi

� Penurunan penyerapan dlm tubuh

� Meningkatkan eliminasi

� Menetralisir racun

� Hindari Rxs yang berpotensi membahayakan - manfaat vs risiko

Thank youThank you

Organophosphate poisoningOrganophosphate poisoningClinical features

Clinical manifestations

Muscarinic Nicotinic Central receptors

Cardiovascular Bradycardia

Hypotension

Respiratory Rhinorrhea

Bronchorrhea/spasm

Cardiovascular Tachycardia

Hypertension

Musculoskeletal Weakness

Fasciculations

Anxiety

Restlessness

Ataxia

Convulsions

Insomnia

Dysarthria Bronchorrhea/spasm

Cough

Gastrointestinal Increased salivation

Nausea/vomiting

Abdominal pain

Diarrhoea

Fecal incontinence

Genitourinary Urinary incontinence

Ocular Blurred vision/miosis

Increased lacrimation

Fasciculations

Cramps

Paralysis

Tremors

Coma

Absent reflexes

CS respiration

Resp. depression

Circulatory collapse

Neurological manifestations

� Neuromuscular weakness/paralysis� Type I, Type II and Type III paralysis (OPIDP)

� Neuropsychiatric manifestations -COPIND

� Extrapyramidal manifestations� Extrapyramidal manifestations� Dystonia, resting tremor, rigidity, chorea

� Neuro-ophthalmic manifestations� Optic neuropathy, retinal degeneration

� Rarer manifestations� GBS, Ototoxicity, Sphincter involvement

Therapy of organophosphate Therapy of organophosphate poisoning

Management

�� Step I:Step I: Identify the nature of the poisonIdentify the nature of the poison

��OrganophosphateOrganophosphate

��CarbamateCarbamate

��ChlorideChloride

��PyrethroidPyrethroid

��NeonicotinoidsNeonicotinoids

Management

�� Step II: DecontaminationStep II: Decontamination

��Skin decontamination Skin decontamination

�� Important aspect Important aspect –– not to be neglectednot to be neglected

�� Remove contaminated clothingRemove contaminated clothing

�� Wash with soap and water (soaps Wash with soap and water (soaps containing 30% ethanol advocated)containing 30% ethanol advocated)

Management


��Care to be taken by health personnel to Care to be taken by health personnel to avoid contaminationavoid contaminationavoid contaminationavoid contamination

�� Reports of occupational illness in 3 staff caring Reports of occupational illness in 3 staff caring for OP poisoned patientsfor OP poisoned patients

�� Another report 7 of 10 staff who cared for a Another report 7 of 10 staff who cared for a patient developed chest tightness or discomfortpatient developed chest tightness or discomfort

Geller RJ, Singleton KL, Tarantino ML, Drenzek CL, Toomey KE. Nosocomial poisoning associated

with emergency department treatment of organophosphate toxicity – Georgia 2000. J Toxicol Clin Toxicol

2001; 39: 109-11.

Management


��Skin decontamination Skin decontamination –– is there is there evidence for benefit?evidence for benefit?

�� Skin decontamination (15 minutes postSkin decontamination (15 minutes post--VX on the ear) arrested the development VX on the ear) arrested the development of clinical signs and prevented further of clinical signs and prevented further cholinesterase inhibition and death in cholinesterase inhibition and death in experimental animals.experimental animals.

Hamilton MG, Hill I, Conley J, Sawyer TW, Caneva DC, Lundy PM. Clinical aspects of percutaneous

poisoning by the chemical warfare agent VX: effects of application site and decontamination. Mil Med 2004;

169: 856-62.

Management


��Skin decontamination Skin decontamination –– is there is there evidence for benefit?evidence for benefit?evidence for benefit?evidence for benefit?

�� Cholinesterase sponges on surfaces have Cholinesterase sponges on surfaces have been used been used –– called OP scavengerscalled OP scavengers

�� Others have developed lotionsOthers have developed lotions

�� No human evidence for benefit of skin No human evidence for benefit of skin contaminationcontamination

Management


��Gastric decontaminationGastric decontamination

�� Forced emesis if patient is awakeForced emesis if patient is awake�� Forced emesis if patient is awakeForced emesis if patient is awake

�� Gastric lavageGastric lavage

�� Activated charcoal 25 gm 2 hourlyActivated charcoal 25 gm 2 hourly

�� Sorbitol as catharticSorbitol as cathartic


� Gastric lavage

� Gastric lavage decreases absorption by 42% if done 20 min and by 16% if performed at 60 min

� Performed by first aspirating the stomach and then repetitively instilling & aspirating fluid

� Left lateral position better - delays spont. Absorption

� No evidence that larger tube better

� Simplest, quickest & least expensive way -funnel

� Choice of fluid is tap water - 5-10 ml/kg


� Gastric lavage

� Preferrably done on awake patients

� Presence of an ET tube does not preclude aspiration, though preferred if GCS is lowaspiration, though preferred if GCS is low

� No human studies in OP poisoning showing benefit of gastric lavage

Management

�� Step III: Airways and RespirationStep III: Airways and Respiration�� Maintain airwayMaintain airway

�� Ensure adequate oxygenationEnsure adequate oxygenation

�� Watch for intermediate syndrome (diplopia, Watch for intermediate syndrome (diplopia, extraextra--ocular muscle weakness/neck muscle ocular muscle weakness/neck muscle extraextra--ocular muscle weakness/neck muscle ocular muscle weakness/neck muscle weakness)weakness)

�� Monitor respiratory rate/tidal volume/vital Monitor respiratory rate/tidal volume/vital capacitycapacity

�� Blood gas analysisBlood gas analysis

�� Step IV: Cardiac monitoringStep IV: Cardiac monitoring�� Hemodynamic and monitor for arrhythmiasHemodynamic and monitor for arrhythmias

Management

�� Step V: Specific therapyStep V: Specific therapy

�� AtropineAtropine

�� Initiate as soon as diagnosis is suspectedInitiate as soon as diagnosis is suspected

�� Adults 2 mg IV bolus Adults 2 mg IV bolus -- repeat dose very repeat dose very 55--15 minutes till atropinised15 minutes till atropinised

�� Adults 2 mg IV bolus Adults 2 mg IV bolus -- repeat dose very repeat dose very 55--15 minutes till atropinised15 minutes till atropinised

�� children children -- 0.05 mg/kg initially then 0.020.05 mg/kg initially then 0.02--0.05 mg/kg 0.05 mg/kg

�� AtropinisationAtropinisation�� Heart rate about 100/mtHeart rate about 100/mt

�� Pupils mid positionPupils mid position

�� Bowel sounds just heardBowel sounds just heard

�� Clear lung fieldsClear lung fields

RememberRememberSteps I to V occur simultaneously

Role of oximesRole of oximes

Organophosphate poisoningOrganophosphate poisoning

� Are oximes beneficial in human OP poisoning?

� Subject of much debate & literature

� Systematic review & meta-analysis

Organophosphate poisoningOrganophosphate poisoning

OP OP -- why no benefit with PAMwhy no benefit with PAM

� May be a true effect - it is not effective!!

� Type of compound

Poison load & dose� Poison load & dose

� Time of administration

� Ageing of the compound

� Toxicity of the antidote

Conclusions

� The key to successful management in a poisoning is early recognition and appropriate management

Remember common toxidromes� Remember common toxidromes

� OP poisoning very common in our part of the world

� Role of oximes still not established

THANK YOUTHANK YOUTHANK YOUTHANK YOU

Is there a role?- nature of OP compound

�Human poisoning by OP bearing two methoxy groups eg. malathion, paraoxon-methyl, dimethoate and oxydemeton-methyl is generally considered to be rather resistant to considered to be rather resistant to oxime therapy.

� Failure attributed to megadose intoxications and to prolonged time intervals between poison uptake and oxime administration

DimethylphosphorylDimethylphosphoryl--inhibited human cholinesterases: inhibited human cholinesterases: inhibition, reactivation, and aging kinetics. Arch. Toxicol inhibition, reactivation, and aging kinetics. Arch. Toxicol 1999; 73:71999; 73:7--1414

Is there a role?- dose related?

� “Invitro studies (isolated rat diaphragm) and in vivo studies (cats)…. minimum-effective plasma level for oxime therapy 4 mg/l….. higher doses may be required in severe cases of OP poisoning”severe cases of OP poisoning”

� Case reports where even with high dose -course is prolonged

MK Johnson et al. Evaluation of antidotes for poisoning by organophosphorus pesticides. Emergency Medicine (2000) 12:22-37..

Is there a role?- time of administration

�� Electrophysiological Electrophysiological improvements…(present) when improvements…(present) when obidoxime administered within 12 obidoxime administered within 12 hours of poisoning. Minimal or no hours of poisoning. Minimal or no improvement if treatment delayed improvement if treatment delayed improvement if treatment delayed improvement if treatment delayed more than 26 hours.more than 26 hours.

Efficacy of obidoxime in human organophosphorus

poisoning: determination by neuromuscular transmission studies. Besser R et al. Muscle Nerve 1995; 18:15-22

��Vellore Vellore -- in vitro study in vitro study -- rere--activation activation of AChe is poor if P2 AM is of AChe is poor if P2 AM is administered after 12 hours of administered after 12 hours of

Is there a role?- time of administration

� “…Obidoxime was quite ineffective in oxydemetonmethyl poisoning when the time elapsed between ingestion and oxime therapy was longer than 1 day…..when obidoxime was day…..when obidoxime was administered shortly after ingestion (1 h) reactivation was nearly complete…”

Cholinesterase status, pharmacokinetics and laboratory findings during obidoxime therapy in organophosphate poisoned patients. Thiermann H et al (Germany). Hum Exp Toxicol 1997; 16:473-80

Is there a role?- ageing of OP

� “…..believed that 1 day after intoxication with a dimethyl OP insecticide, virtually all the AChe will be in the aged inhibited form, so that oxime therapy will be useless after this oxime therapy will be useless after this time.”

�Ageing characteristics different for di-methyl (half life 3.7 hours) and di-ethyl (half life 33 hours) - therapeutic window five times the half life

MK Johnson et al .Evaluation of antidotes for poisoning by

Is there a role?- toxicity

� Formation of stable phosphoryl oximes (POXs) with high anticholinesterase activity

�Obidoxime and other pyridinium-4-aldoximes form these POXs

The phosphoryl oxime-destroying activity of human plasma. Arch. Toxicol 2000; 74:27-32

Toxicity of oximes - II

� Pralidoxime in a volunteer study -dizziness & blurring

� Rapid administration of PAM - slow & � Rapid administration of PAM - slow & shallow resps

� Cardiac arrhythmias - AF, VT, VFib, AV block

� Liver function abnormalities with obidoxime

High dose oximes cause muscle weakness

an approach to a poisoned patient · 2018. 12. 4. · an approach to a poisoned patient muhammad...

Documents