management of poisoned patients

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Toxicology

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PHARMACOLOGY PRESENTATION

10.Tuba Hasaan Qureshi 10692

1.Afshan Mushtaq 10597

2.Ammarah Shaikh 10604 3.Asra ALVI 10611

Syeda Kinza Mehmood 10682Sualeha Batool Baig 10681

Group Members (No. 7)6.Hira Akbar 10634

4.Erum Akhter 10617

7.Huma Ilyas 10635

5.Halima Sadia 10628

MANAGEMENT OF POISONED PATIENTS

Common Terms Used In Toxicology

Initial Management Of Poisoned PatientsMONITERINGAirwayShould be cleared of vomitus or any other obstruction & an oral airway or endotracheal tube inserted if needed.The initial management of a patient with coma, seizures or otherwise altered mental status should follow the same approach regardless of poisoned involved. Attempting to make a specific toxicological diagnosis only delays the application of supportive measures

CirculationShould be assed by continuos monitering of pulse rate, blood pressure, urinary output & evaluation of peripheral perfusion.

BreathingShould be assessed by observation and if in doubt, by measuring arterial blood gases. Patients with respiratory insufficiency should be inttubated & mechanically ventilated.

History & Physical ExaminationHistory: Oral Statement about the amount and even the type of drug ingested in toxic emergencies but it may be unreliable.

The Figure Shows Different Routes Of Administration Of Drug In Management Of Poisoned Pts10% 6% 8% Ingestion Inhalation Dermal 76% Others

PHYSICAL EXAMINATIONVital Signs Abdomen

Eyes

Mouth

Skin

Nervous System

Hypertension And Tachycardia Hypotension And Bradycardia Are Characteristic Feature Of Overdose WithHypotension With Tachycardia Is Common With Rapid Respiration Are Typical With Hyperthermia May Be Associated With Hypothermia

Amphetamines, Cocaine And Anti Muscarinic Drugs

Ca Channel Blockers, Beta Blockers, Clonidine And Sedative Hypnotics.

TCAS ,Trazodone , Quetiapine , Vasodilators Ans Beta Agonist.

Salicylates, Carbon Mono Oxide

Sympathomimetics, Anti Cholinergics , Salicylates And Drug Producing Seizures Or Muscular Ragidity

CNS Depressants

The eyes are a valuable source of toxicologic information.Miosis Constriction of pupil is typical of opioids, clonidine, phenothiazines, and cholinesterase inhibitors

Mydriasis Dilation of pupil is common with amphetamines , cocaine, LSD and atropine & other anti cholinergic drugs.

MOUTH: The mouth may show signs of burns due to corrosive substances or soot from smoke inhalation. Typical odours of alcohol, hydrocarbon,solvents ,or ammonia may be noted.poisoning due to cyanide can be recognized by some examiners.

SKIN The skin often appears flushed, hot and dry in poisoning with atropine and other antimuscuranics. Excessive sweating occurs in organophosphates, nicotine,and sympathomimitic drugs.

Abdominal examination may reveal ILEUS, which is typical of poisoning with Antimuscuranic, Opioids,and Sedative Drugs.Abdominal cramping, and diarrhea are common in organophosphates,iron, arsenic theophylline.

Sualeha batool baigLaboratory and imaging procedure

Arterial Blood Gas:An arterial blood gas (ABG) test measures the acidity (pH) and the levels of oxygen and carbon dioxide in the blood from an artery. This test is used to check how well your lungs are able to move oxygen into the blood and remove carbon dioxide from the blood.

Electrolyte tests are typically conducted on blood plasma or serum, urine, and diarrheal fluids.

Measure the acid-base level in the blood of people who have heart failure, kidney failure,uncontrolled diabetes, sleep disord ers, severe infections, or after a drug overdose.

Electrolytes are positively and negatively charged molecules, called ions. The concentrations of these ions in the bloodstream remain fairly constant throughout the day in a healthy person. Changes in the concentration of one or more of these ions can occur during various acute and chronic disease states and can lead to serious consequences.

Sodium, potassium, chloride, and bicarbonate should be measured. The anion gap is then calculated by subtracting the measured anions from cations: anion gap = (Na+K) (HCo3+ Cl)

Drug that may induce an elevated anion gap metabolic acidosis include aspirin, metformin, methanol, ethylene glycol, isoniazid and Iron.

Examples of drug-induced anion gap acidosis:

TYPE OF ELEVATION OF THE ANION GAP

AGENTS

ORGANIC ACID METABOLITE

Methanol, ethylene glycol, diethylene glycol.Cyanide,carbonmo noxide,ibuprofen,is oniazide,metformi n,salicylates,valproi c acid

LACTIC ACIDOSIS

Renal function tests :

Some toxins have direct nephrotoxic effects; in other cases, renal failure is due to shock or myoglobinuria. Blood uria nitrogen and creatinine levels should be measured and urine analysis performed. Elevated serum creatine kinase (CK) and myoglobin in the urine suggest muscle necrosis due to seizures or muscular rigidity. Oxylate crystals in the urine suggest ethylene glycol poisoning.

Serum osmolality:

The calculated serum osmolality is dependent mainly on the serum sodium and glucose and the blood urea nitrogen This calculated value is normally 280290mOsm/L.

The measured osmolality should not exceed the predicted by more than 10 mOsm/kg. A difference of more than 10 mOsm/kg is considered an osmolal gap. Causes for a serum osmolal gap include mannitol, ethanol, methanol, ethylene glycol and other compounds in very high concentration, usually small molecules and often toxins.

IMAGING FINDINGS:

A plane film of the abdomin may be useful because some tablets, particularly Iron and potassium may be radiopaque.Chest radiographs may reveal aspiration pneumonia, hydrocarbon pneumonia , or pulmonary edema. When head trauma is suspeted,a computed tomography(CT) scan is recommended.

TOXICOLOGY SCREENING TEST

A toxicology screen refers to various tests to determine the type and approximate amount of legal and illegal drugs a person has taken.

Toxicology screening is most often done using a blood or urine sample. However, it may be done soon after swallowing the medication.

This test is often done in emergency medical situations. It can be used to evaluate possible accidental or intentional overdose or poisoning. It may help determine the cause of acute drug toxicity, to monitor drug dependency, and to determine the presence of substances in the body for medical or legal purposes.

RISKSRisks associated with having blood drawn are slight but may include:

Excessive bleeding Fainting or feeling lightheaded

Hematoma (blood accumulating under the skin)Infection (a slight risk any time the skin is broken)

DECONTAMINATION

Decontamination procedures should be undertaken simultaneously with initial stabilization, diagnostic assessment, and laboratory evaluation. Decontamination involves removing toxins from the skin or gastrointestinal tract.

GI DECONTAMILNATIONGastric lavage:

- Used with moderate to severe overdoses within an hour of ingestion.

-Lavage is contraindicated with ingestion of corrosives.

GI DECONTAMINATION CONTD..

Activated charcoal: Purported to be superior to lavage

- Used in toxic ingestions within an hour of the ingestion.

- Dosed as 1g/kg or 10:1 ratio of charcoal to poison

- Given as single dose or multiple dose.

GI DECONTAMINATION CONTD..Cathartics:- Given

with charcoal to enhance elimination

- Unproven efficacy when used alone. Whole bowel irrigation:-Used for body stuffers/packers

Common toxic syndromes

Acetaminophen Acetaminophen is one of the drugs commonly involved in suicide attempts and accidental poisonings. A highly toxic metabolite is produced in the liver.

Toxic dose (children)

More than 150-200mg/kg

Toxic dose(adult)

7gm

Initially,the patient is asymptomatic or has mild GI upset(nausea vomiting)

After 24-36hrs,evidence of liver injury appear,with elevated aminotransferase levels &hypoprothrombinemia.

In severe cases ,fulminant liver failure occur,leading to hepatic encephalopathy &death.renal failure

the antidote of acetaminophene is Nacetylcystein

Amphetamine & other stimulants A major toxic effect of amphetamine in humans at higher doses,restlessnes,agitation,acute psychsis,seizures,hyperthermia,rhabdomylosis .hyperthermia can cause brain damage,hypotension ,coagulopathy & renal failure. There is no specific antidote.

ANTICHOLINERGIC AGENTS:Examples of classes of medications with anticholinergic properties include: antihistamines (eg, diphenhydramine), tricyclic antidepressants (eg, amitriptyline), sleep aids (eg, doxylamine), cold preparations, scopolamine, and tainted illicit street drugs (eg, heroin "cut" with scopolamine). TREATMENT: Agitated patients may require sedation with a BDZ or an antipsychotic agents(haloperidol).The specific peripheral & central anticolinergic syndrome is physostigmine

Antidepressant Tricyclics have a narrow therapeutic index. Ingestion of more than 1 gm of a tricyclic is considered potentially lethal. TREATMENT: Endotracheal intubation & assisted ventilation may be needed.intravenous fluid s are given for hypotension. Monoamine oxidase inhibitor (tranylcypramine,phenelzine)

Antipsychotic: Include phenothaizine &butyrophenones as well as newer atypical drugs. Some can cause QT prolongation. The potent dopamine D2blocker are also associated with parkinsonian movement disorder. TREATMENT: of antipsychotic overdose includes supportive care of the comatose patient, effective gast

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