POISONINGPOISONING

Dr. M.L.SiddarajuDr. M.L.Siddaraju

HistoryHistory

• Egyptians are said to have studied many poisons Egyptians are said to have studied many poisons as early as 3000BC.as early as 3000BC.

• Among vedas- Atharvana veda (1500BC) Among vedas- Atharvana veda (1500BC) describes poisons.describes poisons.

• Susrutha (350BC) described as how poisons were Susrutha (350BC) described as how poisons were mixed with food and drink, medicines, snuff, etc..mixed with food and drink, medicines, snuff, etc..

• Italians brought the art of poisoning to its zenith Italians brought the art of poisoning to its zenith prior to 6prior to 6thth century AD. century AD.

• Orfila-(1787-1853) was first to attempt a Orfila-(1787-1853) was first to attempt a systemic correlation between the chemical and systemic correlation between the chemical and biologic information of the poisons known then.biologic information of the poisons known then.

• Others who worked are Marsh, Magendie, Others who worked are Marsh, Magendie, Ambrose, Scheelle, Robert Christison and Rudolf Ambrose, Scheelle, Robert Christison and Rudolf Kobert.Kobert.

POISONING IN CHILDRENPOISONING IN CHILDREN

• Poison is a substance that causes Poison is a substance that causes harm if it gets into the body.harm if it gets into the body.

• The poisoning in children could occur The poisoning in children could occur due to diverse causes and could be due to diverse causes and could be classified asclassified as– accidental,accidental,– homicidal orhomicidal or– suicidal.suicidal.

• Erroneous administration of Erroneous administration of overdosage of drugs by the parents overdosage of drugs by the parents or by the medical staff is also or by the medical staff is also frequent.frequent.

• Acute exposure is a single contact that Acute exposure is a single contact that lasts for seconds, minutes or hours, or lasts for seconds, minutes or hours, or several exposures over about a day or several exposures over about a day or less. Chronic exposure is contact that less. Chronic exposure is contact that lasts for many days, months or years.lasts for many days, months or years.

• A poison may get into the body A poison may get into the body through ingestion, inhalation (gas, through ingestion, inhalation (gas, vapors, dust, fumes, smoke, spray), vapors, dust, fumes, smoke, spray), skin contact (pesticides), or injection skin contact (pesticides), or injection (bites and stings, drug injection(bites and stings, drug injection

• Accidental poisoning in children is a Accidental poisoning in children is a global problem. The relative importance global problem. The relative importance of poisoning as a cause of childhood of poisoning as a cause of childhood morbidity and mortality increases when morbidity and mortality increases when malnutrition and infections are brought malnutrition and infections are brought under control. under control.

• Accidental poisoning is the twelfth Accidental poisoning is the twelfth leading cause of admissions in pediatric leading cause of admissions in pediatric wards in India and accounts for about wards in India and accounts for about one percent of the hospitalized one percent of the hospitalized patients. Most cases of accidental patients. Most cases of accidental poisoning are preventable. Continuing poisoning are preventable. Continuing morbidity and mortality due to morbidity and mortality due to accidental poisoning is serious accidental poisoning is serious challenge to the pediatricians and challenge to the pediatricians and public health officials. public health officials.

Pattern of poisoningPattern of poisoning

• Chemical products, most often Chemical products, most often swallowed by children include household swallowed by children include household cleaners (bleach, detergents) fuel cleaners (bleach, detergents) fuel (kerosene, paraffin), cosmetics, (kerosene, paraffin), cosmetics, medicines, paints and products for medicines, paints and products for household repairs and household household repairs and household pesticides.pesticides.

• Bites and stings of animals and insects, Bites and stings of animals and insects, and ingestion of poisonous plants and and ingestion of poisonous plants and seeds also considerably account for seeds also considerably account for outdoor poisoning in children.outdoor poisoning in children.

• Carbon monoxide poisoning can Carbon monoxide poisoning can happen when fires, stoves, happen when fires, stoves, heaters or ovens are used in heaters or ovens are used in rooms, huts which do not have rooms, huts which do not have proper ventilation to let the gas proper ventilation to let the gas out.out.

Ecology of poisoningEcology of poisoning

• Interaction between the host and the environment Interaction between the host and the environment (including easy access to the poisonous (including easy access to the poisonous substances) determines the magnitude of the substances) determines the magnitude of the problem.problem.

• Age. About 40% of all cases of accidental Age. About 40% of all cases of accidental poisoning in children are reported in the second poisoning in children are reported in the second year of life; about 12% of the cases occur in the year of life; about 12% of the cases occur in the first and 20% in the third year. As the children first and 20% in the third year. As the children start crawling and walking around 1 year, they start crawling and walking around 1 year, they become very active and try to explore unfamiliar become very active and try to explore unfamiliar objects by putting these into their mouth and objects by putting these into their mouth and testing these. Thus they expose themselves to testing these. Thus they expose themselves to accidental poisoning. Hyperactive male children accidental poisoning. Hyperactive male children are more prone to accidental poisoningare more prone to accidental poisoning..

• Large families:Large families:In large families In large families mother is often too occupied with mother is often too occupied with household chores, is easily fatigued household chores, is easily fatigued and often careless in storage of and often careless in storage of potentially poisonous household potentially poisonous household substances.substances.

• Small accommodationSmall accommodation

• EnvironmentEnvironment: Lead poisoning is : Lead poisoning is common in children living in areas were common in children living in areas were there are workshops for automobile, lead there are workshops for automobile, lead storage batteries or for manufacture of storage batteries or for manufacture of lead typesets for printing presses. lead typesets for printing presses. Caustic soda poisoning used to be Caustic soda poisoning used to be observed frequently in children of observed frequently in children of families, which prepared washing soap families, which prepared washing soap for domestic or commercial purposes in for domestic or commercial purposes in their own houses. Insecticides, their own houses. Insecticides, medicines, naphthalene balls and medicines, naphthalene balls and kerosene are common household things kerosene are common household things which are potential hazards. which are potential hazards.

• Rural or Urban areas:Rural or Urban areas:• The pattern of poisoning varies in rural The pattern of poisoning varies in rural

and urban areas due to exposures to and urban areas due to exposures to different types of potential poisons. different types of potential poisons. Snakebites are more common in those Snakebites are more common in those wandering in fields.Also pesticides are wandering in fields.Also pesticides are more common in rural set up. The poor more common in rural set up. The poor are driven by starvation to experiment on are driven by starvation to experiment on roots and fruits thus leading to poisoningroots and fruits thus leading to poisoning..

•Time relationshipTime relationship::

• . Accidental poisoning is likely . Accidental poisoning is likely when normal routine in the when normal routine in the house is disturbed such as house is disturbed such as during periodic house painting, during periodic house painting, packing and unpacking at the packing and unpacking at the time of change of residence, time of change of residence, going for vacation etc. going for vacation etc.

Classification of poisonsClassification of poisons

Based on the chief symptoms they Based on the chief symptoms they produceproduce

1.1. Corrosives- strong acids, strong Corrosives- strong acids, strong alkalis, metallic salts.alkalis, metallic salts.

2.2. Irritants- organic, inorganic.Irritants- organic, inorganic.3.3. Systemic- cerebral, spinal, peripheral, Systemic- cerebral, spinal, peripheral,

CVS, asphyxiants.CVS, asphyxiants.4.4. Miscellaneous- food poisoning & Miscellaneous- food poisoning &

botulism.botulism.

Non toxic common household Non toxic common household agentsagents

• Shampoos, toothpaste, lipstick, Shampoos, toothpaste, lipstick, creams, shaving cream, toilet creams, shaving cream, toilet soaps, cosmetics, hair dye/oil.soaps, cosmetics, hair dye/oil.

• Antacids, house lizards, non Antacids, house lizards, non nitrate fertilizers, newspaper, nitrate fertilizers, newspaper, adhesives, water colors, chalk, adhesives, water colors, chalk, ink (ball point/ fountain pen), ink (ball point/ fountain pen), candles.candles.

Important causes of child Important causes of child poisoning in Indiapoisoning in India• Kerosene and other hydro carbons(8-55%)Kerosene and other hydro carbons(8-55%)• Household products-insecticides, rodenticides, Household products-insecticides, rodenticides,

phenol, alkalis, turpentine, camphor, phenol, alkalis, turpentine, camphor, naphthalene, neem oil, alcohol(14-30%).naphthalene, neem oil, alcohol(14-30%).

• Drugs- iron salts, barbiturates, Drugs- iron salts, barbiturates, anticonvulsants, antihypertensives, aspirin, anticonvulsants, antihypertensives, aspirin, antiseptics(16-30%).antiseptics(16-30%).

• Plant and plant products- Dhatura, castor Plant and plant products- Dhatura, castor seeds(6-32%).seeds(6-32%).

• Food poisoning(7-15%).Food poisoning(7-15%).• Venomous bites & stings(7-11%).Venomous bites & stings(7-11%).

History takingHistory taking

• What poison was ingested.What poison was ingested.• Time since ingestion.Time since ingestion.• Total amount of poison ingested.Total amount of poison ingested.• Route of exposure.Route of exposure.• Progression of signs and symptoms since Progression of signs and symptoms since

ingestion.ingestion.• Family history of epilepsy, mental sub Family history of epilepsy, mental sub

normality, bleeding disorder.normality, bleeding disorder.• Whether the patient is receiving other Whether the patient is receiving other

medications which may interact with the medications which may interact with the poison.poison.

General signs and General signs and symptomssymptoms

• Symptoms-odor, sweating, fever, Symptoms-odor, sweating, fever, delirium, convulsions, burns of mouth, delirium, convulsions, burns of mouth, blindness, GI symptoms, abnormal blindness, GI symptoms, abnormal movements, coma.movements, coma.

• Signs- miosis, mydriasis, blindness, Signs- miosis, mydriasis, blindness, facial twitching, dull & mask like facial twitching, dull & mask like expression, pallor, cyanosis, expression, pallor, cyanosis, hypothermia, sweating, respiratory hypothermia, sweating, respiratory symptoms, CVS symptoms, CNS symptoms, CVS symptoms, CNS symptoms. symptoms.

Poisoning severity GradesPoisoning severity Grades

•None(0)- no symptoms or None(0)- no symptoms or signs/vague symptoms signs/vague symptoms judged not to be related to judged not to be related to poisoning.poisoning.

•Minor(1)- Mild, transient & Minor(1)- Mild, transient & spontaneously resolving spontaneously resolving symptoms.symptoms.

•Moderate(2)- pronounced or Moderate(2)- pronounced or prolonged symptoms.prolonged symptoms.

•Severe(3)- severe or life Severe(3)- severe or life threatening symptoms. threatening symptoms.

Diagnosis of PoisoningDiagnosis of Poisoning

• Cardiac arrythmias. Tricyclic Cardiac arrythmias. Tricyclic antidepressants, amphetamine, antidepressants, amphetamine, aluminium phosphide, digitalis, aluminium phosphide, digitalis, theophylline, arsenic, cyanide, theophylline, arsenic, cyanide, chloroquin.chloroquin.

• Metabolic acidosis. Isoniazid, methanol, Metabolic acidosis. Isoniazid, methanol, salicylates, phenformin, iron, cyanide.salicylates, phenformin, iron, cyanide.

• GIT disturbances. Organophosphorus, GIT disturbances. Organophosphorus, arsenic, iron, lithium, mercury.arsenic, iron, lithium, mercury.

• Cyanosis. Nitrobenzene compounds, Cyanosis. Nitrobenzene compounds, aniline dyes, and dapsone.aniline dyes, and dapsone.

Basic Management of a Basic Management of a poisoned patientpoisoned patient

• Antidotes are available for very few Antidotes are available for very few commonly encountered poisons, and commonly encountered poisons, and treatment is usually non-specific treatment is usually non-specific and symptomatic. In such cases and symptomatic. In such cases management consists of emergency management consists of emergency first aid and stabilization measures, first aid and stabilization measures, appropriate treatment to reduce appropriate treatment to reduce absorption, measures to enhance absorption, measures to enhance life support followed by psychiatric life support followed by psychiatric counseling.counseling.

Identification of PoisonIdentification of Poison

• Identify the poison by careful Identify the poison by careful history and helpful clues. history and helpful clues. Determine what, when and how Determine what, when and how much of the poison was ingested or much of the poison was ingested or inhaled. Find the supporting inhaled. Find the supporting evidence for your diagnosis from evidence for your diagnosis from the nature of the symptoms and the nature of the symptoms and physical signs. Some common physical signs. Some common toxidromes based on certain signs toxidromes based on certain signs and symptoms :and symptoms :

PupilsPupils RespResp ConsConsciousciousnessness

Possible agentPossible agent Other Other associationsassociations

Pinpoint Pinpoint ComaComa

ComaComa

ComaComa

OrganophosphoruOrganophosphorus insecticides, s insecticides, carbamatescarbamates

OpioidsOpioids

Phenothiazines Phenothiazines

Cholinergic: Cholinergic: bradycardia, bradycardia, wheeze, wheeze, salivationsalivation

Hypotension, Hypotension, hypothermiahypothermia

Cardiac Cardiac arrhythmiaarrhythmia

DilateDilated d

Agitation, Agitation, hallucinationhallucination

ComaComa

ComaComa

Agitation, Agitation, hallucinationhallucination

AtropineAtropine

Tricyclic Tricyclic antidepressantantidepressants s

Sedatives, Sedatives, barbiturates barbiturates

Theophylline, Theophylline, amphetaminesamphetamines

AnticholineAnticholinergic; fever, rgic; fever, dry mucous dry mucous membranemembranes, flushing, s, flushing, urinary urinary retentionretention

Cardiac Cardiac arrhythmia, arrhythmia, seizureseizure

,hypotensio,hypotensionn

HypotensioHypotension, n, hypothermihypothermia,hyporeflea,hyporeflexiaxia

Seizures, Seizures, tachcardia, tachcardia, hypertensihypertension, acidosison, acidosis

NormNormalal

ComaComa

ComaComa

UremiaUremia

SalicylatesSalicylates

Acidosis, Acidosis, hyperkalemhyperkalemiaia

Tinnitus, Tinnitus, agitation, agitation, diaphoresis, diaphoresis, alkalosis alkalosis followed by followed by acidosisacidosis

Principles of ManagementPrinciples of Management

• Keep the phone numbers of your doctor, Keep the phone numbers of your doctor, hospital & emergency medical system near the hospital & emergency medical system near the phone.phone.

• Removal of the patient from the site of Removal of the patient from the site of poisoning.poisoning.

• Initial resuscitation and stabilization.Initial resuscitation and stabilization.• Symptomatic and supportive measures.Symptomatic and supportive measures.• Removal of unabsorbed poisons- from GI tract Removal of unabsorbed poisons- from GI tract

or from skin, eye.or from skin, eye.• Hastening the elimination of absorbed poisons.Hastening the elimination of absorbed poisons.• Use of specific antidote if available Use of specific antidote if available • Disposition of the patient with advice for Disposition of the patient with advice for

prevention. prevention.

Emergency Stablization Emergency Stablization MeasuresMeasures

• The unconscious patient should be The unconscious patient should be transported in the headdown semiprone transported in the headdown semiprone position to minimize the risk of inhalation of position to minimize the risk of inhalation of gastric contents. A clear airway is established gastric contents. A clear airway is established and ventilation is maintained. Potentially and ventilation is maintained. Potentially serious abnormalities such as metabolic serious abnormalities such as metabolic acidosis, hyperkalemia and hypoglcymia may acidosis, hyperkalemia and hypoglcymia may require correction as a matter of urgency. require correction as a matter of urgency. Neurological assessment is made by Neurological assessment is made by calculating the Glasgow Coma Score (GCS).calculating the Glasgow Coma Score (GCS).

• Many drugs and poisons can cause grand mal Many drugs and poisons can cause grand mal convulsions, which, if repeated, should be convulsions, which, if repeated, should be controlled with intravenous diazepam. controlled with intravenous diazepam. Hypotension with peripheral circulatory Hypotension with peripheral circulatory failure is treated first by correction of failure is treated first by correction of hypoxia and acidosis, and by elevation of the hypoxia and acidosis, and by elevation of the foot end of the bed. If adequate perfusion is foot end of the bed. If adequate perfusion is not restored by these measures, the not restored by these measures, the circulating volume should be increased by circulating volume should be increased by administration of a plasma expander administration of a plasma expander intravenously. Cardiac arrhythmias are often intravenously. Cardiac arrhythmias are often improved or abolished by correction of improved or abolished by correction of hypoxia, acidosis and electroyte imbalance hypoxia, acidosis and electroyte imbalance

Initial resuscitation Initial resuscitation stabilizationstabilization• Includes airway- proper positioning head tilt Includes airway- proper positioning head tilt

and chin lift, suction of secretions from and chin lift, suction of secretions from oropharynx, falling back of tongue is oropharynx, falling back of tongue is prevented by suitable airway tube.prevented by suitable airway tube.

• Breathing- oxygen via a mask, when Breathing- oxygen via a mask, when gag/cough reflects is absent- ET tube gag/cough reflects is absent- ET tube inserted. if necessary positive pressure inserted. if necessary positive pressure ventilation with ABG monitoring, respiratory ventilation with ABG monitoring, respiratory stimulants for severe respiratory stimulants for severe respiratory depression.depression.

• Circulation- proper IV access, maintenance Circulation- proper IV access, maintenance of fluid & electrolyte balance, IV drugs for of fluid & electrolyte balance, IV drugs for treatment. treatment.

Symptomatic & supportive Symptomatic & supportive ManagementManagement

• Hemodynamic support- elevation of foot Hemodynamic support- elevation of foot end of the bed, oxygen administration, end of the bed, oxygen administration, IV fluids, blood products.IV fluids, blood products.

• Cardiac dysrrhythmias- correction of Cardiac dysrrhythmias- correction of hypoxia, acidosis, hypokalemia, ECG, hypoxia, acidosis, hypokalemia, ECG, treatment with antiarrhythmic drugs.treatment with antiarrhythmic drugs.

• Convulsions- correction of Convulsions- correction of hypoglycemia/hypocalcemia/hypoxia/cerhypoglycemia/hypocalcemia/hypoxia/cerebral edema and other metabolic ebral edema and other metabolic defects, anticonvulsant therapy.defects, anticonvulsant therapy.

Continued…Continued…

• Management of hypothermia- cover Management of hypothermia- cover with a blanket, thermo neutral with a blanket, thermo neutral environment maintenance, pre environment maintenance, pre warmed IV fluids and inspired gases.warmed IV fluids and inspired gases.

• Management of pulmonary edema- Management of pulmonary edema- administer 100% oxygen, intermittent administer 100% oxygen, intermittent positive pressure ventilation, IV positive pressure ventilation, IV aminophylline(5-8mg/kg), IV aminophylline(5-8mg/kg), IV frusemide(1-2 mg/kg). frusemide(1-2 mg/kg).

Continued…Continued…

• Management of stress ulcers- NG Management of stress ulcers- NG intubation, cold saline wash, intubation, cold saline wash, administration of antacids, H2- administration of antacids, H2- receptor antagonists.receptor antagonists.

• Management of pain- analgesics Management of pain- analgesics (preferably- narcotics). (preferably- narcotics).

Removal of ToxinRemoval of Toxin

• The aim of decontamination procedures The aim of decontamination procedures is to reduce the absorption of poison. It is to reduce the absorption of poison. It can be achieved by:can be achieved by:– Eye decontaminationEye decontamination. Ocular exposure to . Ocular exposure to

solvents, e.g., hydrocarbons, detergents, solvents, e.g., hydrocarbons, detergents, and alcohol, or corrosive agents, e.g., acid and alcohol, or corrosive agents, e.g., acid or alkalis require immediate local or alkalis require immediate local decontamination. This is achieved by decontamination. This is achieved by copious irrigation with neutralizing solution copious irrigation with neutralizing solution (e.g., normal saline or water) for at least 30 (e.g., normal saline or water) for at least 30 minutes. Do not use acid or alkaline minutes. Do not use acid or alkaline irrigating solution.irrigating solution.

– Dermal decontaminationDermal decontamination. . Absorption of organophosphorus Absorption of organophosphorus and related compounds through and related compounds through cutaneous route can prove to be a cutaneous route can prove to be a fatal as oral route absorption. fatal as oral route absorption. Cutaneous absorption depends on Cutaneous absorption depends on several factors such as lipid several factors such as lipid solubility, skin condition, location, solubility, skin condition, location, caustic effect, physical conditionscaustic effect, physical conditions

• Remove all contaminated clothes and Remove all contaminated clothes and irrigate the whole body including nail, irrigate the whole body including nail, groin, skinfolds with water or saline as soon groin, skinfolds with water or saline as soon as possible after exposure and continue as possible after exposure and continue irrigating for at least 15 minutes. Water irrigating for at least 15 minutes. Water should not be used to decontaminate skin in should not be used to decontaminate skin in exposures to sodium and phosphorus. In exposures to sodium and phosphorus. In certain cases, specific agents may be certain cases, specific agents may be indicated for skin decontamination (e.g., indicated for skin decontamination (e.g., mineral oil for elemental sodium, Neosporin mineral oil for elemental sodium, Neosporin for super glue and calcium gluconate for for super glue and calcium gluconate for hydrofluoric acid).hydrofluoric acid).

• Gut decontaminationGut decontamination. This includes (i) . This includes (i) gastric evacuation; (ii) adsorbent gastric evacuation; (ii) adsorbent administration; and (iii) catharsis. Emesis is administration; and (iii) catharsis. Emesis is the preferred method of emptying the the preferred method of emptying the stomach in conscious children. Vomiting can stomach in conscious children. Vomiting can be induced by (a) tickling the fauces with a be induced by (a) tickling the fauces with a finger, feather or a leafy twig of a tree; (b) finger, feather or a leafy twig of a tree; (b) administration of copious draughts of warm administration of copious draughts of warm water; (c) gurgling with non-detergent water; (c) gurgling with non-detergent soap; or (d) saline emetics in warm water. soap; or (d) saline emetics in warm water. To prevent aspiration in small children, the To prevent aspiration in small children, the head should be kept low.head should be kept low.

• Syrup of ipecac may be used for inducing Syrup of ipecac may be used for inducing emesis in children older than 6 months emesis in children older than 6 months in a single dose of 10 mL for 6-12 in a single dose of 10 mL for 6-12 months age, and 15 mL for children months age, and 15 mL for children above 1 year of age. The dose may be above 1 year of age. The dose may be repeated in 20 minutes for those more repeated in 20 minutes for those more than 1 year of age.than 1 year of age.

• Induction of vomiting is contraindicatied Induction of vomiting is contraindicatied in corrosive or kerosene poisoning and in corrosive or kerosene poisoning and in comatose patients or those with in comatose patients or those with absent gag reflex.absent gag reflex.

• Gastric Lavage. If the vomiting Gastric Lavage. If the vomiting does not occur quickly, gastric does not occur quickly, gastric lavage should be done lavage should be done promptly to remove the promptly to remove the poison. In a symptomatic but poison. In a symptomatic but alert patient with minor alert patient with minor ingestion, activated charcoal ingestion, activated charcoal alone by mouth is sufficient for alone by mouth is sufficient for gastrointestinal gastrointestinal decontaminationdecontamination

• The child is kept in the left lateral The child is kept in the left lateral position with the head hanging over position with the head hanging over edge of the table and the face down. A edge of the table and the face down. A large single lumen tube with multiple large single lumen tube with multiple distal ports is necessary. A restraint is distal ports is necessary. A restraint is required for most children and mouth required for most children and mouth gag is placed in the mouth before the gag is placed in the mouth before the procedure. The catheter is passed procedure. The catheter is passed gently and free end is dipped under gently and free end is dipped under water to make sure that the catheter water to make sure that the catheter is not in the airway. is not in the airway.

• Generally tap water is used for lavage Generally tap water is used for lavage and four or five washes are done. The and four or five washes are done. The volume of each aliquot should be at volume of each aliquot should be at least 10-15 mL/kg. After the fluid has least 10-15 mL/kg. After the fluid has been instilled, it should be removed by been instilled, it should be removed by gravity drainage or tube suction. gravity drainage or tube suction. Catheter is pinched before it is finally Catheter is pinched before it is finally withdrawn or suction is maintained withdrawn or suction is maintained during withdrawal to prevent during withdrawal to prevent aspiration.aspiration.

• Gastric lavage should not be Gastric lavage should not be performed in children with poor performed in children with poor gag reflex or corrosive ingestion. gag reflex or corrosive ingestion. In kerosene poisoning, lavage may In kerosene poisoning, lavage may be done very cautiously if the be done very cautiously if the child has consumed a large gulp of child has consumed a large gulp of kerosene and is brought quickly to kerosene and is brought quickly to the hospital, otherwise it is better the hospital, otherwise it is better to avoid stomach wash.to avoid stomach wash.

Adsorbent administrationAdsorbent administration

• An agent capable of binding to a An agent capable of binding to a toxic agent in the GIT is known as toxic agent in the GIT is known as adsorbent. Activated charcoal is adsorbent. Activated charcoal is the most widely used adsorbent. It the most widely used adsorbent. It is created by subjecting is created by subjecting carbonaceous material e.g., wood, carbonaceous material e.g., wood, coal etc. to steam at 600-900 coal etc. to steam at 600-900 degree Celsius and acid. degree Celsius and acid.

• For the comatosed patient (Grade 3 or For the comatosed patient (Grade 3 or 4) with potentially serious overdose, 4) with potentially serious overdose, gastric lavage is followed by gastric lavage is followed by administration of activated charcoal administration of activated charcoal via an orogastric or nasogastric tube via an orogastric or nasogastric tube within 1-2 hours of ingestion. Dose of within 1-2 hours of ingestion. Dose of activated charcoal administered activated charcoal administered should be atleast 10 times the dose of should be atleast 10 times the dose of ingested toxic material. In ingested toxic material. In asymptomatic patient presenting early asymptomatic patient presenting early or without reliable history, 15-30 gram or without reliable history, 15-30 gram of charcoal may be used.of charcoal may be used.

CatharsisCatharsis

• Laxative and purgatives may be given in Laxative and purgatives may be given in poisoning with substances which do not poisoning with substances which do not cause corrosive action on cause corrosive action on gastrointestinal mucosa. Increased gastrointestinal mucosa. Increased motility of the gut may reduce motility of the gut may reduce absorption. Commonly used cathartics absorption. Commonly used cathartics include sorbitol and mannitol (1-2 g/kg), include sorbitol and mannitol (1-2 g/kg), and magnesium or sodium sulfate (200-and magnesium or sodium sulfate (200-300 mg/kg). Do not give magnesium salt 300 mg/kg). Do not give magnesium salt cathartics in cases with renal failure. cathartics in cases with renal failure.

Specific Antidotal Specific Antidotal TherapyTherapy• The antidotes may be physiological, The antidotes may be physiological,

chemical or physical. Chemical antidotes chemical or physical. Chemical antidotes combine with the poison and render it combine with the poison and render it innocuous. Physiological antidotes innocuous. Physiological antidotes counteract the effects of the poison on the counteract the effects of the poison on the metabolism and physiological functions of metabolism and physiological functions of the body and thus prevent its harmful the body and thus prevent its harmful effects. Physical antidotes prevent the effects. Physical antidotes prevent the contact of the poisonous substance with the contact of the poisonous substance with the target organ or adsorb the toxic target organ or adsorb the toxic components, thus preventing their toxicity.components, thus preventing their toxicity.

• Specific antidotes may be life saving but Specific antidotes may be life saving but unfortunately they are not often available unfortunately they are not often available and are effective for less than 5% of and are effective for less than 5% of poisoning cases. When obtainable, they poisoning cases. When obtainable, they must be given without delay for maximum must be given without delay for maximum protective action. protective action.

• Antidotes now considered obsolete include Antidotes now considered obsolete include universal antidote for ingested poisons, universal antidote for ingested poisons, acetazolamide for modification of urinary acetazolamide for modification of urinary pH, ascorbic acid for methemoglobinemia, pH, ascorbic acid for methemoglobinemia, castor oil as cathartic, nalorphine for castor oil as cathartic, nalorphine for opiates, sodium chloride for emesis and opiates, sodium chloride for emesis and tannins for alkaloids.tannins for alkaloids.

Promotion of Excretion of Promotion of Excretion of ToxinToxin

• The efficiency of regimens for The efficiency of regimens for enhancement of drug elimination enhancement of drug elimination from the body can be predicted to a from the body can be predicted to a large extent if the physio-chemical large extent if the physio-chemical properties, disposition and properties, disposition and pharmacokinetics of the substance pharmacokinetics of the substance are known. The fluid intake is are known. The fluid intake is increased to promote glomerular increased to promote glomerular filtration and excretion of poison filtration and excretion of poison through the urine.through the urine.

• Forced diuresisForced diuresis:Diuresis alone has relatively :Diuresis alone has relatively little effect on drug elimination because at best little effect on drug elimination because at best the renal clearance is only proportional to the the renal clearance is only proportional to the urine flow rate. In the case of drugs which are urine flow rate. In the case of drugs which are weak organic acids and bases, a much greater weak organic acids and bases, a much greater effect on clearance can be obtained by effect on clearance can be obtained by manipulation of the urine Ph. The lipid solubility manipulation of the urine Ph. The lipid solubility and hence tubular reabsorption of such acidic and and hence tubular reabsorption of such acidic and basic drugs is decreased in alkaline and acid basic drugs is decreased in alkaline and acid urine respectively. Theoretically for each change urine respectively. Theoretically for each change of one unit in urine pH, the renal clearance could of one unit in urine pH, the renal clearance could change by a factor of 10. Urine pH is therefore change by a factor of 10. Urine pH is therefore much more important than urine flow rate.much more important than urine flow rate.

• In practices, forced alkaline diuresis is In practices, forced alkaline diuresis is restricted largely to poisoning with restricted largely to poisoning with phenobarbitone and salicylate, although phenobarbitone and salicylate, although much of the effect in lowering plasma much of the effect in lowering plasma salicylate concentrations result from salicylate concentrations result from haemodilution rather than increased urinary haemodilution rather than increased urinary excretion. Raise the urinary pH to 7.5 for excretion. Raise the urinary pH to 7.5 for weak acids (e.g., barbiturates, salicylates) weak acids (e.g., barbiturates, salicylates) with 1.4 percent sodabicarb. Maintain with 1.4 percent sodabicarb. Maintain urinary pH to 5.5-6.5 (forced acidic diuresis) urinary pH to 5.5-6.5 (forced acidic diuresis) in poisoning with weak bases e.g., tricyclic in poisoning with weak bases e.g., tricyclic antidepressant and pheytoin, with antidepressant and pheytoin, with ammonium chloride 4 g administered every ammonium chloride 4 g administered every two hourly through Ryle’s tube two hourly through Ryle’s tube

• Any form of forced diuresis is Any form of forced diuresis is potentially dangerous. Forced diuresis potentially dangerous. Forced diuresis is contraindicated in patients with is contraindicated in patients with cardiac and renal impairment; cardiac and renal impairment; complications include water complications include water intoxication, disturbances of acid-base intoxication, disturbances of acid-base and electrolyte balance, left ventricular and electrolyte balance, left ventricular failure with pulmonary oedema and failure with pulmonary oedema and cerebral oedema.cerebral oedema.

• Hemodialysis, hemo-perfusion and Hemodialysis, hemo-perfusion and peritoneal dialysis. Drugs which peritoneal dialysis. Drugs which can be removed reasonably can be removed reasonably effectively by hemoperfusion and effectively by hemoperfusion and haemodialysis include haemodialysis include barbiturates, carbamazepine, barbiturates, carbamazepine, salicylates, theophylline, dapsone, salicylates, theophylline, dapsone, most antibiotics, lithium, chloral most antibiotics, lithium, chloral hydrate, methanol and ethylene hydrate, methanol and ethylene glycol. glycol.

• In general, hemoperfusion with In general, hemoperfusion with coated charcoal or exchange coated charcoal or exchange resins is more preferred for resins is more preferred for simultaneous correction of acid-simultaneous correction of acid-base and electrolyte balance (e.g., base and electrolyte balance (e.g., in salicylate poisoning). in salicylate poisoning). Hemodialysis is also the method of Hemodialysis is also the method of choice for removal of methanol, choice for removal of methanol, ethylene glycol and lithium.ethylene glycol and lithium.

• Peritoneal dialysis is much less effective Peritoneal dialysis is much less effective and it is used rarely. It has the advantage and it is used rarely. It has the advantage that is does not require special facilities that is does not require special facilities but may be complicated by fluid and but may be complicated by fluid and electrolyte abnormalities, perforations, electrolyte abnormalities, perforations, peritonitis and adhesions.peritonitis and adhesions.

• Dialysis is not useful in poisoning with Dialysis is not useful in poisoning with digitalis, antihistaminics, belladonna digitalis, antihistaminics, belladonna alkaloids, opiates, etc.alkaloids, opiates, etc.

Supportive TherapySupportive Therapy

• Keep the airway open, give Keep the airway open, give oxygen for inhalation and be oxygen for inhalation and be prepared for intermittent prepared for intermittent positive pressure respiration. positive pressure respiration. Fluid and electrolyte balance is Fluid and electrolyte balance is maintained. Circulatory failure maintained. Circulatory failure should be managed to sustain should be managed to sustain life. Anemia is treated with life. Anemia is treated with packed cell transfusion. packed cell transfusion.

• Severe convulsions and status Severe convulsions and status epilepticus are treated with epilepticus are treated with diazepam or midazolam. Renal diazepam or midazolam. Renal failure is managed as per standard failure is managed as per standard protocol; dialysis may be needed. protocol; dialysis may be needed. Infections are treated with Infections are treated with antibiotics. Fever and pain are antibiotics. Fever and pain are relived with antipyretics and relived with antipyretics and analgesics.analgesics.

Prevention of PoisoningPrevention of Poisoning

• Protection of the child from the Protection of the child from the poisonous substances. The poisonous substances. The poisonous substances should be poisonous substances should be kept in secure places out of reach kept in secure places out of reach of the child. The poisonous of the child. The poisonous substances should be replaced in substances should be replaced in their proper place. Potential their proper place. Potential household poisons should not be household poisons should not be transferred to empty containers transferred to empty containers otherwise used for innocuous food otherwise used for innocuous food or beverages. or beverages.

• Drugs should be dispensed in the Drugs should be dispensed in the original container. The word poison original container. The word poison should be exhibited prominently on should be exhibited prominently on the containers of potential poisonous the containers of potential poisonous substances. Kerosene oil and caustic substances. Kerosene oil and caustic soda should not be stored in tumblers soda should not be stored in tumblers or beverage bottles. The containers or beverage bottles. The containers should not be left on the ground. should not be left on the ground. Kerosene bottles and stoves should be Kerosene bottles and stoves should be kept out of reach of the children in the kept out of reach of the children in the kitchen.kitchen.

• Education of parents about potential Education of parents about potential household poisons.household poisons.

• Need for parental supervision of Need for parental supervision of toddler’s behavior should be toddler’s behavior should be emphasized.emphasized.

• Safety regulations by the State should Safety regulations by the State should be enforced.be enforced.

• Establishment of poison control centers Establishment of poison control centers to collect, compile and disseminate to collect, compile and disseminate information on poisons and their information on poisons and their management. These should promote management. These should promote research on prevention and treatment.research on prevention and treatment.

Some Specific Poisons and Some Specific Poisons and AntidotesAntidotes

KEROSENE POISONINGKEROSENE POISONING

• EpidemiologyEpidemiology

• Clinical featuresClinical features

• InvestigationInvestigation

• TreatmentTreatment

EpidemiologyEpidemiology

• Accidental – 33 to 60% in India & Accidental – 33 to 60% in India & other other developing countriesdeveloping countries

• Reasons for high incidenceReasons for high incidence

1.1. Extensive use for cooking & Extensive use for cooking & lighting in low socioeconomic lighting in low socioeconomic statusstatus

2.2. Stored in soft drink bottles, beer Stored in soft drink bottles, beer bottles within reach of childrenbottles within reach of children

Clinical featuresClinical features

• Age – 1 to 3 years Age – 1 to 3 years more than 70% symptomatic within more than 70% symptomatic within

10 hours10 hours

SYMPTOMSSYMPTOMS

RSRS – breathlessness, cough – breathlessness, coughCNSCNS – convulsions, coma – convulsions, coma GPEGPE – fever, restlessness, cyanosis – fever, restlessness, cyanosisGIGI – vomiting, diarrhea – vomiting, diarrhea

Lab InvestigationsLab Investigations• Blood – LeukocytosisBlood – Leukocytosis

X – Ray changesX – Ray changes

Changes appear within one hourChanges appear within one hour - commonly right basal infiltrates- commonly right basal infiltrates - emphysema- emphysema - pleural effusion- pleural effusion - pneumatocoeles- pneumatocoeles

Severity scoreSeverity score

PARAMETERSPARAMETERS ABSENTABSENT PRESENTPRESENT OTHERSOTHERS

FEVER FEVER 00 11 00

SEVERE SEVERE MALNUTRITIONMALNUTRITION

00 11 00

RESP. DISTRESSRESP. DISTRESS 00 22 44

CNS SYMPTOMS CNS SYMPTOMS 00 22 44

• >4 – Significant• <7 – Likely to survive• >8 –– Risk of death is increased

ManagementManagement

• Avoid emeticsAvoid emetics• Avoid gastric lavage – In case of massive Avoid gastric lavage – In case of massive

amount use a cuffed endotracheal tubeamount use a cuffed endotracheal tube• After lavage leave magnesium or sodium After lavage leave magnesium or sodium

sulphate in the stomachsulphate in the stomach• Oxygen may be usefulOxygen may be useful• Assisted VentilationAssisted Ventilation• Antibiotics - Penicillin G 50000/Kg/24 hrs Antibiotics - Penicillin G 50000/Kg/24 hrs

IV qid IV qid • Kanamycin – 10-15mg/Kg/24 hrs - IM bdKanamycin – 10-15mg/Kg/24 hrs - IM bd• Steroids – Not helpfulSteroids – Not helpful

ComplicationsComplications

• PneumothoraxPneumothorax• PneumatocoelesPneumatocoeles• Pleural effusionPleural effusion• BronchopneumoniaBronchopneumonia• ComaComa

Organophosphorus Organophosphorus (insecticides and (insecticides and pesticides) Poisoningpesticides) Poisoning• Organic phosphate insecticides Organic phosphate insecticides

cause irreversible inhibition of the cause irreversible inhibition of the enzyme cholinesterase. As result enzyme cholinesterase. As result acetylcholine accumulates in acetylcholine accumulates in various tissues. Excessive various tissues. Excessive parasympathetic activity occurs. parasympathetic activity occurs. These agents are absorbed by all These agents are absorbed by all routes including skin and mucosa. routes including skin and mucosa.

• Symptoms manifest quickly usually Symptoms manifest quickly usually within a few hours and include within a few hours and include weakness, blurred vision, headache, weakness, blurred vision, headache, giddiness, nausea, and pain in chest. giddiness, nausea, and pain in chest. These patients have excessive secretion These patients have excessive secretion in the lungs and they sweat profusely. in the lungs and they sweat profusely. Salivation is marked. Pupils are Salivation is marked. Pupils are constricted and papilledema may occur. constricted and papilledema may occur. Muscle twitching, convulsions and coma Muscle twitching, convulsions and coma occur in severe cases. Reflexes are occur in severe cases. Reflexes are absent and sphincter control is lost.absent and sphincter control is lost.

TreatmentTreatment

• If the insecticide was in contact with If the insecticide was in contact with skin or eyes, these are thoroughly skin or eyes, these are thoroughly washed. Stomach wash is done.washed. Stomach wash is done.

• Atropine sulphate: 0.03 to 0.04 mg/kg IV Atropine sulphate: 0.03 to 0.04 mg/kg IV (atropine sulphate is usually available in (atropine sulphate is usually available in ampules 1 in 1,000 or 1 mg/mL). Other ampules 1 in 1,000 or 1 mg/mL). Other strengths may also be available. Repeat strengths may also be available. Repeat half the dose in 15 minutes and if half the dose in 15 minutes and if necessary every hour (until signs of necessary every hour (until signs of toxicity appear), subject to a maximum toxicity appear), subject to a maximum of 1 mg/kg in 24 hours.of 1 mg/kg in 24 hours.

• Pralidoxime (PAM) is given in dose of Pralidoxime (PAM) is given in dose of 25-50 mg/kg IM or IV over 30 min 25-50 mg/kg IM or IV over 30 min infusion. The dose may be repeated in infusion. The dose may be repeated in 1-2 hours, then at 6-12 hour intervals 1-2 hours, then at 6-12 hour intervals as needed. Monitor for hypertension. as needed. Monitor for hypertension. Never inject morphine, theophylline, Never inject morphine, theophylline, aminophylline or chlorpromazine. aminophylline or chlorpromazine. Intravenous fluids should only be Intravenous fluids should only be given with caution. No oral given with caution. No oral tranquilizers are administered. tranquilizers are administered. Artificial respiration may be Artificial respiration may be necessary to sustain life.necessary to sustain life.

Iron IntoxicationIron Intoxication

• Ingestion of a number of tablets of Ingestion of a number of tablets of ferrous sulphate may cause acute ferrous sulphate may cause acute poisoning. Lethal dose is 300 mg/kg of poisoning. Lethal dose is 300 mg/kg of iron. Severe vomiting and diarrhea iron. Severe vomiting and diarrhea occur. These may contain blood due to occur. These may contain blood due to extensive gastrointestinal bleeding. extensive gastrointestinal bleeding. The child may go into severe shock, The child may go into severe shock, hepatic and renal failure within a few hepatic and renal failure within a few hours or after a latent period of 1 to 2 hours or after a latent period of 1 to 2 days days

TreatmentTreatment

• Vomiting should be induced and Vomiting should be induced and stomach should be washed with stomach should be washed with sodium bicarbonate solution. Shock is sodium bicarbonate solution. Shock is corrected by infusion of fluids corrected by infusion of fluids parenterally. Three mL of 7.5 percent parenterally. Three mL of 7.5 percent sodium bicarbonate solution per kg of sodium bicarbonate solution per kg of body weight are diluted with 3 times body weight are diluted with 3 times its volume of 5 percent glucose its volume of 5 percent glucose solution and injected intravenously solution and injected intravenously for treatment of acidosis. This dose for treatment of acidosis. This dose may be repeated after an hour if may be repeated after an hour if acidosis is persisting. acidosis is persisting.

• Iron salts are chelated with Iron salts are chelated with desferrioxamine IV at 15mg/kg/hour desferrioxamine IV at 15mg/kg/hour until the serum iron is <300 mg/dL or until the serum iron is <300 mg/dL or till 24 hours after the child has till 24 hours after the child has stopped passing the characteristic stopped passing the characteristic ‘vin rose’ colored urine. Presence of ‘vin rose’ colored urine. Presence of ‘vin rose’ color to urine indicates ‘vin rose’ color to urine indicates significant poisoning.significant poisoning.

Salicylate PoisoningSalicylate Poisoning

• Ingestion of 150 mg/kg of salicylates Ingestion of 150 mg/kg of salicylates causes intoxication. Salicylate level of causes intoxication. Salicylate level of 50-80 mg/dL causes moderate 50-80 mg/dL causes moderate symptoms. Severe symptoms are symptoms. Severe symptoms are associated with blood levels above 80 associated with blood levels above 80 mg/dL.mg/dL.

• Initially, there is a respiratory alkalosis, Initially, there is a respiratory alkalosis, because of hyperventilation induced by because of hyperventilation induced by sensitization of the respiratory center sensitization of the respiratory center by salicylates. Kidneys compensate for by salicylates. Kidneys compensate for this alkalsis by increasing the excretion this alkalsis by increasing the excretion of sodium and potassium bicarbonate of sodium and potassium bicarbonate

• Metabolic acidosis supervenes Metabolic acidosis supervenes quickly due to disturbances of quickly due to disturbances of oxidative phosphorylation and oxidative phosphorylation and reduction of hepatic glycogen reduction of hepatic glycogen with resultant ketonemia. The with resultant ketonemia. The patients are treated with patients are treated with adequate replacement of fluids adequate replacement of fluids to restore renal function. to restore renal function.

• Urine is alkalinized by administering Urine is alkalinized by administering 1-2 mEq/kg of sodium bicarbonate 1-2 mEq/kg of sodium bicarbonate at half hourly intervals for 4 hours at half hourly intervals for 4 hours to promote excretion of urine, to promote excretion of urine, because in alkaline urine, because in alkaline urine, salicylates do not diffuse back into salicylates do not diffuse back into the tubular cells from the lumen. the tubular cells from the lumen. Potassium salts should be given (3-Potassium salts should be given (3-5 mEq/kg/day) to replace the 5 mEq/kg/day) to replace the potassium losses potassium losses

Acetaminophen (paracetamol)Acetaminophen (paracetamol)

• It is safe in pharmacological doses. It is safe in pharmacological doses. Overdosage may cause hepatic Overdosage may cause hepatic damage. Acetaminophen damage. Acetaminophen overdosage is treated with overdosage is treated with acetylcysteine to be used orally acetylcysteine to be used orally within 16 hours after ingestion in a within 16 hours after ingestion in a loading dosage of 140 mg/kg loading dosage of 140 mg/kg diluted to 5 percent solution orally diluted to 5 percent solution orally followed by 70 mg/kg q 4h for followed by 70 mg/kg q 4h for another 16 doses.another 16 doses.

Hydrocarbon PoisoningHydrocarbon Poisoning

• These may be divided into These may be divided into aliphatic or aromatic compounds. aliphatic or aromatic compounds. Aliphatic hydrocarbons include Aliphatic hydrocarbons include kerosene, turpentine, lubricating kerosene, turpentine, lubricating oils, tar and have greatest risk of oils, tar and have greatest risk of aspiration and pulmonary aspiration and pulmonary symptoms. Aromatic compounds symptoms. Aromatic compounds have mainly neurological and have mainly neurological and hepatic toxicity and include hepatic toxicity and include benzene compounds. benzene compounds.

• Type of toxicity with a Type of toxicity with a hydrocarbon depends on its hydrocarbon depends on its volatility, viscosity or surface volatility, viscosity or surface tension. The lower is viscosity, tension. The lower is viscosity, more is the risk of pulmonary more is the risk of pulmonary aspiration. Mineral spirit, kerosene aspiration. Mineral spirit, kerosene and furniture polish have both low and furniture polish have both low volatility and viscosity and thus volatility and viscosity and thus carry a higher risk of aspiration carry a higher risk of aspiration pneumonia.pneumonia.

• Benzene derivates, toluene and xylene Benzene derivates, toluene and xylene are components of various solvents and are components of various solvents and degreasers. These are highly volatile degreasers. These are highly volatile but have low viscosity. Inhalation is the but have low viscosity. Inhalation is the primary route of toxicity which primary route of toxicity which manifests with CNS symptoms. Gasoline manifests with CNS symptoms. Gasoline and naphtha are constituents of lighter and naphtha are constituents of lighter fuel and lacquer diluent and primarily fuel and lacquer diluent and primarily cause depression of the central nervous cause depression of the central nervous system (CNS).system (CNS).

• Turpentine oil is highly volatile but has low Turpentine oil is highly volatile but has low viscosity also. Toxicity results from viscosity also. Toxicity results from inhalation and gastrointestinal absorption. inhalation and gastrointestinal absorption. They can also cause CNS toxicity.They can also cause CNS toxicity.

• Halogenated hydrocarbons are used as Halogenated hydrocarbons are used as solvents and spot removers. Freon is used solvents and spot removers. Freon is used as a refrigerant.as a refrigerant.

• Toxic exposure to hydrocarbons may result Toxic exposure to hydrocarbons may result in cardia, gastrointestinal, neurological, in cardia, gastrointestinal, neurological, pulmonary, renal, hepatic, metabolic and pulmonary, renal, hepatic, metabolic and hematological manifestations.hematological manifestations.

• Induced emesis or gastric lavage is Induced emesis or gastric lavage is contraindicated for kerosene oil contraindicated for kerosene oil poisoning. It is done only when large poisoning. It is done only when large quantities of turpentine have been quantities of turpentine have been ingested or the hydrocarbons product ingested or the hydrocarbons product contains benzene, toluene, contains benzene, toluene, halogenated hydrocarbons, heavy halogenated hydrocarbons, heavy metals, pesticides or aniline dyes. metals, pesticides or aniline dyes. Other specific modalities including Other specific modalities including steroids and antibiotics are not steroids and antibiotics are not efficacious.efficacious.

Carbon Monoxide PoisoningCarbon Monoxide Poisoning

• Carbon monoxide poisoning results from Carbon monoxide poisoning results from inhalation of fire smoke, automobile inhalation of fire smoke, automobile exhaust, fumes from faulty gas stoves exhaust, fumes from faulty gas stoves and ingestion of paint and varnish and ingestion of paint and varnish removers. Clinical manifestations include removers. Clinical manifestations include headache, cyanosis, convulsions, and headache, cyanosis, convulsions, and coma. Patients are administered 100 coma. Patients are administered 100 percent oxygen and if carboxyhemoglobin percent oxygen and if carboxyhemoglobin levels are above 40 percent, hyperbaric levels are above 40 percent, hyperbaric oxygen therapy is considered.oxygen therapy is considered.

Pyrethrin PoisoningPyrethrin Poisoning

• Pyrethrin is an active ingredient of Pyrethrin is an active ingredient of various mosquito and fly repellant various mosquito and fly repellant strips. These insecticides quickly strips. These insecticides quickly inactivate the insect. Mammals are inactivate the insect. Mammals are relatively resistant to these agents and relatively resistant to these agents and most cases of toxicity with these agent most cases of toxicity with these agent occur because of allergic reactions. occur because of allergic reactions. Ingestion of these repellant strips does Ingestion of these repellant strips does not lead to significant symptoms.not lead to significant symptoms.

Lead PoisoningLead Poisoning• Exposure to lead occurs from old lead Exposure to lead occurs from old lead

based deteriorated house paint (in old based deteriorated house paint (in old houses) and dust and soil contaminated houses) and dust and soil contaminated with lead such as from leaded gasoline, with lead such as from leaded gasoline, lead electrode plates from old lead electrode plates from old automobile batteries, adultered food, automobile batteries, adultered food, folk remedies, broken lead typesets folk remedies, broken lead typesets scattered around old printing scattered around old printing establishments. Food may be establishments. Food may be adulterated with colored metallic salts adulterated with colored metallic salts or the black collyrium used as surma or the black collyrium used as surma may contain a proportion of black oxide may contain a proportion of black oxide of lead.of lead.

Lead PoisoningLead Poisoning• Chronic lead intoxication occurs Chronic lead intoxication occurs

usually in children who eat non-usually in children who eat non-edible substances (pica) and edible substances (pica) and manifests as pain in abdomen manifests as pain in abdomen and resistant anemia. Lead is and resistant anemia. Lead is deposited in the bones. Acute deposited in the bones. Acute infections may mobilize lead infections may mobilize lead from storage areas in bones and from storage areas in bones and cause acute lead poisoning cause acute lead poisoning leading to acute lead leading to acute lead encephalopathy. encephalopathy.

• In these cases the child may be left In these cases the child may be left with neurological sequelae. Lead with neurological sequelae. Lead inhibits sulfhydryl enzymes and inhibits sulfhydryl enzymes and formation of heme. Heme precursors formation of heme. Heme precursors such as porphyrins accumulate in the such as porphyrins accumulate in the blood and are excreted in the urine. blood and are excreted in the urine. Screening for lead intoxication is Screening for lead intoxication is done by measuring zinc done by measuring zinc protoporphyrin or blood lead levels.protoporphyrin or blood lead levels.

TreatmentTreatment

• In symptomatic children, therapy is In symptomatic children, therapy is usually started with dimercapol (BAL) usually started with dimercapol (BAL) (75 mg/m2 every 4 hourly IM). BAL (75 mg/m2 every 4 hourly IM). BAL may be stopped after 48 hours, while may be stopped after 48 hours, while calcium disodium edetate is used for calcium disodium edetate is used for another 3 days but at a lower dosage another 3 days but at a lower dosage of 50 mg/kg or 1000 mg/M2 per 24 of 50 mg/kg or 1000 mg/M2 per 24 hours by continuous IV infusion. hours by continuous IV infusion.

• Maximum daily dose should not exceed Maximum daily dose should not exceed 500 mg/kg. Stop BAL when blood lead 500 mg/kg. Stop BAL when blood lead level falls below 60 microgram/dL. Give level falls below 60 microgram/dL. Give a second course of edetate alone if a second course of edetate alone if blood lead rebounds to 45-69 blood lead rebounds to 45-69 microgram/dL. A second course of microgram/dL. A second course of edetate in combination with BAL is edetate in combination with BAL is recommended for rebound lead level of recommended for rebound lead level of >70 microgram/dL. Wait for 5-7 days in >70 microgram/dL. Wait for 5-7 days in between the two courses. between the two courses.

Barbiturate PoisoningBarbiturate Poisoning

• Clinical features include hypoxia, Clinical features include hypoxia, depression of respiration, depression of respiration, pulmonary complications and pulmonary complications and kidney failure. Peripheral kidney failure. Peripheral vascular bed is dilated; shock vascular bed is dilated; shock which may sometimes be which may sometimes be delayed may occur delayed may occur

TreatmentTreatment

• Hypoxia is managed by oxygen Hypoxia is managed by oxygen inhalation and maintenance of open air inhalation and maintenance of open air way. Circulatory collapse is treated way. Circulatory collapse is treated with fluids and plasma. Patients do not with fluids and plasma. Patients do not respond to epinephrine.respond to epinephrine.

• Urine is alkalinized to facilitate Urine is alkalinized to facilitate excretion of barbiturates. Mannitol is excretion of barbiturates. Mannitol is given. This causes osmotic diuresis. In given. This causes osmotic diuresis. In severe cases peritoneal dialysis may severe cases peritoneal dialysis may be necessary to remove barbiturates. be necessary to remove barbiturates.

Alcohol PoisoningAlcohol Poisoning

• Ethyl alcohol 0.75-1 mL/kg is Ethyl alcohol 0.75-1 mL/kg is given IV followed by 0.5 mL/kg given IV followed by 0.5 mL/kg every 4 hours. Three mL of 7.5% every 4 hours. Three mL of 7.5% sodium bicarbonate solution sodium bicarbonate solution diluted 1 in 4 is given IV. Dialysis diluted 1 in 4 is given IV. Dialysis should be done.should be done.

• Cyanide PoisoningCyanide Poisoning• Sodium nitrite 2.5 to 5 mL of Sodium nitrite 2.5 to 5 mL of

3.5 percent solution is given IV 3.5 percent solution is given IV every minute followed by every minute followed by sodium thiosulfate 2.5 mL of sodium thiosulfate 2.5 mL of 25 percent solution every 25 percent solution every minute subject to a maximum minute subject to a maximum of 50 mL. Amylnitrite capsules of 50 mL. Amylnitrite capsules (10mg/kg) may be inhaled.(10mg/kg) may be inhaled.

• Opium (Morphine) PoisoningOpium (Morphine) Poisoning• Respiratory depression occurs and Respiratory depression occurs and

pupils are constricted; patients are pupils are constricted; patients are excessively drowsy.excessively drowsy.

• Treatment:-Treatment:-Stomach wash is done. Stomach wash is done. Specific antidote for opium poisoning Specific antidote for opium poisoning is naloxone given IV in a dose of 0.03 is naloxone given IV in a dose of 0.03 mg/kg/dose. If there is no response in mg/kg/dose. If there is no response in 2 minutes the same dose may be 2 minutes the same dose may be repeated. Naloxone can also be given repeated. Naloxone can also be given by continuous infusion (20-40 by continuous infusion (20-40 microgram/kg/h). Analeptics may be microgram/kg/h). Analeptics may be used and oxygen is administered by used and oxygen is administered by inhalation.inhalation.

• Dhatura (Belladonna) PoisoningDhatura (Belladonna) Poisoning

• Accidental ingestion of dhatura Accidental ingestion of dhatura seeds causes delirium, seeds causes delirium, confusion, visual disturbances, confusion, visual disturbances, photophobia, dilated sluggishly photophobia, dilated sluggishly reacting pupils, dryness of skin reacting pupils, dryness of skin and mouth, fever, tachycardia and mouth, fever, tachycardia and urinary retention.and urinary retention.

• Treatment is by gastric lavage Treatment is by gastric lavage and physostigmine in a dose and physostigmine in a dose 0.02 mg/kg (maximum 2 mg) IV 0.02 mg/kg (maximum 2 mg) IV slowly. Dose may be increased slowly. Dose may be increased and repeated after 20 minutes.and repeated after 20 minutes.

• Isoniazid (INH) IntoxicationIsoniazid (INH) Intoxication• Toxic effects of INH may be (i) Toxic effects of INH may be (i)

directly due to the drug i.e., directly due to the drug i.e., jaundice, SLE, arthralgias, altered jaundice, SLE, arthralgias, altered sensorium, hemolysis and sensorium, hemolysis and hypersensitivity reactions; or (ii) hypersensitivity reactions; or (ii) due to pyridoxine depletion i.e., due to pyridoxine depletion i.e., convulsions, peripheral neuropathy, convulsions, peripheral neuropathy, demyelination and inhibition of demyelination and inhibition of phenytoin metabolism. Lethal doses phenytoin metabolism. Lethal doses are>50 mg/kg. are>50 mg/kg.

• Gastric lavage is indicated. Patients Gastric lavage is indicated. Patients are given 1 g of pyridoxine (vit. B6) are given 1 g of pyridoxine (vit. B6) for each gram of INH ingested. If for each gram of INH ingested. If amount of ingested INH is not known, amount of ingested INH is not known, administer 70 mg/kg of pyridoxine administer 70 mg/kg of pyridoxine intravenously. The dose may be intravenously. The dose may be repeated if seizures recur. Use repeated if seizures recur. Use diazepam or phenobarbitone to diazepam or phenobarbitone to control seizures. In severe cases with control seizures. In severe cases with seizures not responding to treatment seizures not responding to treatment hemodialysis may be necessary to hemodialysis may be necessary to save life.save life.

PreventionPrevention

• Parental educationParental education

• Keep away from reach of childrenKeep away from reach of children

• Properly capped containersProperly capped containers

• Avoid storage in beverage bottles or Avoid storage in beverage bottles or colorful containers which attract childrencolorful containers which attract children

• Immediately seek medical careImmediately seek medical care

Preventing childhood poisoningPreventing childhood poisoning

• Education is the major component of Education is the major component of any poison prevention programme.any poison prevention programme.

• Keep medicines, insecticides, etc… Keep medicines, insecticides, etc… out of the reach and sight of your out of the reach and sight of your children.children.

• Never store food & cleaning Never store food & cleaning products together. Store medicine products together. Store medicine and chemicals in original containers.and chemicals in original containers.

• The label should be read before using The label should be read before using the drug. No drug should be given or the drug. No drug should be given or taken in the dark. Drugs after their taken in the dark. Drugs after their expiry date should be disposed in a expiry date should be disposed in a safe manner. Avoid taking medicine safe manner. Avoid taking medicine in your child’s presence. Never in your child’s presence. Never suggest that medicine is candy.suggest that medicine is candy.

• Children should be taught not to eat Children should be taught not to eat plants or berries.plants or berries.

Laws on poisonLaws on poison

The Drugs and Cosmetics act, 1940.The Drugs and Cosmetics act, 1940.1.1. To control the quality, purity & strength of To control the quality, purity & strength of

drugs.drugs.

2.2. Any patent/proprietary medicine should Any patent/proprietary medicine should display on the label or container & the list of display on the label or container & the list of ingredients contained in it.ingredients contained in it.

The Pharmacy Act-1948The Pharmacy Act-1948The object of this act is to allow only the The object of this act is to allow only the

registered pharmacists to prepare, mix or registered pharmacists to prepare, mix or dispense any medicine on prescription of a dispense any medicine on prescription of a medical practitioner.medical practitioner.

The Drugs and Magic remedies The Drugs and Magic remedies Act-1954.Act-1954.

To ban advertisements procuring To ban advertisements procuring abortion/increase of sexual abortion/increase of sexual potency/treatment of veneral potency/treatment of veneral diseases/correction of menstrual diseases/correction of menstrual disorders.disorders.