Recent recommendations in general management of acute poisoned

patient

American Academy of Clinical Toxicology(AACT) , the European Association of Poison Centres and Clinical Toxicologists guidelines(EAPCCT)

Haifa Alshwikh

“Alle Dinge sind Gift und nichts ist ohne Gift, allein die Dosis macht es, dass

ein Ding kein Gift ist.”—

 Paracelsus 

"All things are poison and nothing is without poison; only the dose makes a thing not a

poison“.

even water and oxygen—can be toxic if too much is taken, drunk, or absorbed

STATISTICS:

2 to 5 million poisonings and drug overdoses occur annually in the United States

poison exposures account for 5 to 10 percent of all emergency department visits and greater than 5 percent of adult intensive care unit (ICU) admissions

The annual incidence of poisoning is increasing, with a 4.6 percent increase in cases noted between 2000 and 2001

Approach to poisoned patient

ABCDE

RAPID FIRST LOOK: EXAMINATION, MONITORING, AND TESTING  (vital signs, mental status , pupil size)

DIAGNOSIS(history , examination, investigations)

MANAGMENTGIT decontamination

(emesis , activated charcol, gastric lavavge , whole bowel irrigation , Endoscopy/surgery)Enhanced elimination

(multiple activated charcol, forced diuresis, hemodialysis) Antidote therapy

Supportive treatment

 FIRST PRIORITIES

THE ABCDE APPROACH

The steps are organized according to the issues that pose the most immediate life threats and consist of

airway, breathing, circulation, disability (neurologic stabilization), and exposure .

Problems are managed immediately in the order encountered

the resuscitation leader should ensuring the safety of health care workers

( A single patient contaminated with a highly potent toxin (eg, a radioactive isotope or nerve agent such as sarin) can disable an entire emergency department (ED))

 is a routine use of coma cocktail still warranted ?The so-called “coma cocktail” of dextrose, naloxone, and thiamine , flumazenil is an outdated concept and has been replaced by selective use of each component as necessary

-if there's a doubt about whether hypoglycemia is present, then glucose should be empirically administered .

-Naloxone should be used only for those cases in which a narcotic overdose appears likely .

-Similarly thiamine administration should be limited to patients suspected of chronic alcohol abuse and who exhibit at least one of the three symptoms of WE

-Flumazenil should not be used, even when benzodiazepine causing toxicity is suspected, because it can precipitate benzodiazepine withdrawal, seizures.

http://www.ncbi.nlm.nih.gov/pubmed/12483195

The theory that thiamine must be given prior to dextrose to avoid precipitating Wernicke's encephalopathy is largely unsupported .

(Uptake of thiamine into cells is slower than that of dextrose and withholding dextrose until the administration of thiamine is complete may prove

detrimental to those with actual hypoglycemia)

DIAGNOSIS OF POISONING

History

routine and toxicological laboratory evaluations

physical examination

History When the patient is unable or unwilling to give a reliable history , information should be sought from paramedics, police, and the patient's employer, family, friends, primary care clinician, and pharmacist.

environment should be conducted for -pill bottles

-suicide note -Knowledge of drugs prescribed for the patient or the patient's

family or friends to which (s)he could have had access-Unknown pills or chemicals may be identified by consultation with a

regional poison control center, computerized poison identification system, or product manufacturer (eg, material data safety sheet)

Physical examination

The mental status, vital signs, and pupillary examination are the most useful elements and allow classification of the patient into either a state of CNS excitation or depression

Several classes of toxins manifest as characteristic combinations of symptoms and signs (so called “toxidromes”). The “toxidrome-oriented” physical

examination consists of :

vital signs level of alertness pupil size and position mucous membranes skin temperature and moisture

presence or absence of bowel sounds

 

Toxidrome FlowChart Diagnosishttps://en.wikipedia.org/wiki/Toxidrome

laboratory studies

glucose Urine REserum electrolytes

BUN, creatinineliver function tests

calciumArterial blood gaspregnancy testing is strongly recommended in all women of childbearing ageMeasurements of serum osmolalityserum lactate may be necessary in patients with acid-base, cardiovascular, neurologic, or respiratory disturbancespresence of an anion gap metabolic acidosis may be the first clue to a toxic ingestion and should prompt measurement of serum salicylates, ethylene glycol, and methanol and examination of the urine for oxalate crystals; serum creatinine, glucose, ketones, and lactate also should be measured to detect other causes of the high gap acidosis.

Measurement of isopropyl alcohol concentration in blood should be obtained in patients with an elevated osmolal gap without metabolic acidosis

DOES THE TOXIC SCREEN IN BLOOD , URINE RECOMMENED IN POISONED PATIENT AND DOES IT AFFECT OVERALL MORTALITY? comprehensive qualitative toxic screening of urine, blood, or other body fluids (commonly by liquid and gas chromatography and mass spectrometry) is

expensive, commonly requires six hours for results, often does not predict or define the severity of poisoning, detects unsuspected drugs in only a minority of patients, rarely leads to changes in patient management and disposition, and is

unlikely to affect patient outcome

Thus, comprehensive toxic screening should be performed on blood and urine only in patients with severe or unexplained toxicity

Toxic screens

Other investigations

Electrocardiography (cardiotoxic agents)

Radiographic studies — Imaging studies are not required in every patient but may be useful in several situations:

Certain radiopaque toxins (summarized by the mnemonic "CHIPS") may be visualized by plain film radiographs

C Calcium salts H Heavy metals I Iodinated compounds (eg, thyroxine) P Psychotropics (eg, phenothiazines, lithium, cyclic antidepressants)

S Salicylates , Sustained released preparations Noncardiogenic pulmonary edema and/or the acute respiratory distress syndrome due to exposure to certain toxic agents may be suggested by the appearance of the chest radiograph

Abdominal radiograph showing radiopaque iron (ferrous sulfate) tablets visualized in the stomach of an intentional overdose patient

(arrow).

Courtesy of Michael J Burns, MD.

Abdominal radiograph showing radiopaque drug packets ingested by a

"body packer ".

Drug Duration of delectability in urine

Amphetamines 2 to 3 daysCocaine 2 to 3 daysMarijuana 1 to 7 days (light use); 1 month with

chronic moderate to heavy useOpiates 1 to 3 daysPhencyclidine 7 to 14 days

Drugs of abuse" immunoassay screens can be used to detect opiates, benzodiazepines, cocaine metabolites, barbiturates, tricyclic antidepressants, tetrahydrocannabinol, and phencyclidine in urine

POISONING MANAGEMENT

Treatment variably includes :

GIT DecontaminationEnhanced elimination techniques

Antidotal therapySupportive care

GIT decontamination

Activated charcol

Gastric lavage

Syrup of ipecac

Whole bowel

irrigationEndoscopy or surgery

The decision to perform GI decontamination is based upon: -type of poison

-time from ingestion to presentation -predicted severity of poisoning

The various methods of GI decontamination can be used alone or in combination

GIT decontamination

Activated charcolGastric

Gastric lavavgesyrup of

ipecac (SOIWhole bowel

irrigationEndoscopy/

surgery— 

Dose : ( 1g/kg) , 25-100 g usually needed in adult mixed with water

Technique:Trendelenburg

position , 200-300ml tap water and continue till clearance of the content ( up to 5 L )

Formula ( alkaloid ( emetine & cephaline )Induce emesis in 20 min Dose:

30 ml / mouth in water

Technique—  polyethylene

glycol (PEG-ELS) electrolyte lavage solution ( mouth or NGT)

rate 2 L /h in until the rectal effluent clear ,(5 to 50 L)

Fluid and electrolyte abnormalities generally do not occur with WBI

life-threatening intoxicant has been ingested which cannot be effectively removed by less invasive means

Eg: heavy metals, refractory to whole bowel irrigation or gastric lavage , drug pakers with int obstruction

C/I : bowel obstruction and perforation, corrosives , unprotecetd airway , HC

C/I: corrosives , HC ,

l.o.cComplications:

Aspiration , electrolyte imbalance,arrythmia , pulm lavavge , laryngospasm, perforation and

bleeding

C/I : depressed mental status , corrosives , HC

C/I: depressed mental status , bowel obstruction or perforation , masssive GI bleeding

Enhanced elimination techniques

multiple-dose activated ch

arcoal ,

forced diuresis

Forced alkaline diuresis

Forced acid diuresis

hemodialysis, hemoperfusion, hemofiltration

General indications for enhanced elimination techniques include:

1-Ingestion of a poison whose elimination can be enhanced2-Failure of a patient to respond to maximal supportive care

3-The clinical course is predicted to be complicated

In all cases, the expected benefits of the use of an enhanced elimination technique must be carefully balanced with the risk of

potential complications associated with the technique

Multiple activated charcol

Forced alkaline diuresis

Forced acid diuresis HEMODIALYSIS AND HEMOPERFUSION

dose :

1 g/kg of activated charcoal with sorbitol followed by 0.5 to 1 g/kg of activated charcoal in aqueous suspension every2-4 hours is recommended

achieve a urine pH of 7.5

IV bolus of 1-2 mEq/kg of 8.4 percent sodium bicarbonate, followed by continuous infusion of sodium bicarbonate. (150 mEq Nahco3 into 1 L of 5 % dextrose )

C/I : renal failure, pulmonary oedema and cerebral oedema ,heart disease

complications:

Hypokalemiahypocalcemia

urine pH < 5.5

giving ammonium chloride orascorbic acid

used to treat intoxications with weak basessuch as amphetamines, quinidine or phencyclidine

Hemodialysis (HD)

Hemoperfusion refers to the circulation of blood through an extracorporeal circuit containing an adsorbent such as

activated charcoal 

Agents responsive for MDAC

ABCD

A antimalarialB barbituratesC carbamazipineD dapsone

Toxins accesible for hemodialysis

I STUMBLE

I isoprenalineS salicylates

T theophyllineU uremiaM methanolB barbituratesL lithiumE ethylene glycol

ANTIDOTES THERAPYAntidotes dramatically reduce morbidity and mortality in certain intoxications, but they are unavailable for most toxic agents and therefore are used in only about 1 percent of cases

Supportive care:

Hypotension (intravenous fluids)

Hypertension ( 1st line: nonspecific sedatives such as a benzodiazepine

2nd line: phentolamine ,labetalol ,or nitroprusside .

The use of beta-blockers alone for patients with sympathetic hyperactivity (eg, cocaine intoxication) is not recommended

because it may result in unopposed alpha-adrenergic stimulation and intensified vasoconstriction

Sodium bicarbonate is first line therapy for ventricular tachycardias (TCAs)

Bradyarrhythmias (in patients with calcium channel blocker or beta blocker intoxication, the administration of calcium and glucagon may obviate the need for further measures)

Seizures generally are best treated with benzodiazepines Seizures caused by certain agents may require specific antidotes for their successful termination (eg, pyridoxine for isoniazid toxicity, glucose for hypoglycemic agents)

Criteria for ICU admission of poisoned patient

The presence of any of these 9 clinical criterias predicted a complicated hospital course that could be best managed in an ICU:

-PaCO2 >45 mmHg -need for emergency intubation

-The presence of seizures- Unresponsiveness to verbal stimuli ( GCS < 7 )-Second- or third-degree atrioventricular block

-Systolic blood pressure less than 80 mmHg-QRS duration ≥0.12 seconds

-Need for whole bowel irrigation to enhance GI elimination of poison -Need for emergency hemodialysis, hemoperfusion, hemofiltration

American Academy of Clinical Toxicology and the European Association of Poison Centres and Clinical Toxicologists recommendations

Position paper update: gastric lavage for gastrointestinaldecontamination

B. E. BENSON 1 , K. HOPPU 2 , W. G. TROUTMAN 1 , R. BEDRY 2 , A. ERDMAN 1 , J. H Ö JER 2 , B. M É GARBANE 2, R. THANACOODY 2 , and E. M. CARAVATI 1

1 American Academy of Clinical Toxicology, McLean, VA, USA2 European Association of Poisons Centres and Clinical Toxicologists, Brussels, Belgium

Benefit from GI decontamination is most likely when it can be performed within one hour of poison ingestion , most adults do not present to emergency departments until a mean of three to

four hours after a toxic ingestion, GI decontamination is unlikely to affect patient outcome in most clinical circumstances

Regardless of the method employed, efficacy decreases with greater delay between ingestion and treatment .

Routine use of gastric lavage in the management of poisoned patients is not recommended by the American Academy of

Clinical Toxicology or the European Association of Poison Centres and Clinical Toxicologists

Clinical studies have failed to show that gastric lavage improves the severity of illness

For the vast majority of patients, especially those that present late or are asymptomatic on presentation, gastric lavage is not likely

to add benefit

The use gastric lavavge in patients who present more than one hour following ingestion is exclusive in the agents that are highly toxic

and not bound well by AC or cause delay in gastric emptying.

Gastric lavage is less effective than activated charcoal (AC) in reducing the absorption of simulated toxins but is roughly

equivalent in efficacy to ipecac . 

In 2003, the American Academy of Pediatrics advised against the continued routine use of ipecac in the home and also

recommended disposal of any ipecac that remained in homes

Ipecac should NOT be administered routinely in the management of poisoned patients since there is no evidence from clinical

studies that it improves important outcomes.

Clinical Toxicology (2013), 51, 140–146Copyright © 2013 Informa Healthcare USA, Inc.

Activated charcol is The only GI decontamination measure needed to treat an overdose , its a first-line agent for the treatment of poisonings, especially if more than several hours have passed

since ingestion.

AC appears superior to syrup of ipecac or gastric lavage alone for preventing the absorption of ingested intoxicants , Gastric

lavage followed by or preceded and followed by AC may be more effective than AC alone at preventing drug absorption

WBI is probably more effective than gastric lavage or ipecac but probably less effective than AC in preventing poison absorption when the

intoxicant can be bound by charcoal.

Whole bowel irrigation is reserved primarily for patients who have ingested toxic foreign bodies (eg, drug packets), sustained-release or

enteric-coated drugs, or toxic materials not bound by activated charcoal (eg, heavy metals) .

hemodynamically stable and cooperative patients are best candidate for WBI intensive cathartic treatment

Concurrent use of WBI and AC is not advisable as PEG-ELS may reduce the binding capacity of AC

In most toxicological emergencies, effective antidotes are not Available , Symptomatic treatment and supportive care are still

the primary approach to treatment

The administration of antidotal therapy, when indicated, should not be delayed by attempts at decontamination. Some antidotes may

be bound or removed by agents used during decontamination

Urinary acidification has been abandoned, as efficacy has not been established and iatrogenic toxicity (severe acidosis) can occur.

Conclusion:stabilization of the patient is being considered as the main stay Of management of poisoning emergencies.

There has been a major change in the treatment of poisoned patients, especially in the area of gastric decontamination. The trend is away from the use of ipecac, except in limited situations.

activated charcoal has attained a prominent role, not only as an adjunct either with ipecac or gastric lavage but also as the sole decontamination agent .

Gastric lavage still plays an important role if it can be performed early, or if drugs are involved that may delay gastric emptying .

Whole–bowel irrigation is safe and effective in limited situations such as iron, lithium, or sustained release medications, and for body packers .

Antidotes play an important role in specific situations. Review PaperRecent Advances in the Management of Poisoning Cases

*Dasari Harish, **K H Chavali,**Amandeep Singh, ** Ajay Kumar