YL7
ACUTE CARE [MEDICINE]
GENERAL PRINCIPLES IN THE EMERGENCY MANAGEMENT
OF AN ACUTELY POISONED PATIENT
What are the 6 PRINCIPLES in the approach to the poisoned
patient?
 Toxicology is an exaggeration of pharmacology
GENERAL APPROACH
I. Emergency Stabilization
II. Clinical Evaluation
III. Decontamination
IV. Elimination of Absorbed Substance
V. Administration of Antidotes
VI. Supportive Therapy and Observation
NOTE! The 6 principles also comprise the OUTLINE of this lecture.
I.
Emergency Stabilization
When should you NOT give oxygen to a poisoned patient?
What is the IV fluid of choice in treating poisoned patients?
 Maintain adequate airway
 Provide adequate oxygenation/ventilation
- Exceptions: watusi, paraquat
- Paraquat is a herbicide; forms oxygen radicals that destroy
lung tissue; the more oxygen, the more lung tissue destroyed
- watusi contains yellow phosphorous; smoking stool sign; do
not give O2 because it ignites in body temperature
 Maintain adequate circulation
- Starting fluids: NSS in adults, 0.3 NaCL in children
- NSS: if BP is low, give isotonic fluids to bring up the blood
pressure
- D5 LR: can also be used. But poisoned patients are usually
acidotic, you shouldn’t give lactose
If a previously well patient has seizures, he has no history of epilepsy,
what medication can be given as a therapeutic trial apart from the
usual anticonvulsants?
A. Treat convulsions
 Diazepam 5mg IV
- Do NOT mix with D5 containing solutions—the diazepam
will crystallize
- Aspirate until you get blood, then inject the diazepam, then
push with plain NSS
 Seizures of unknown origin—pyridoxine (80-120 mg/kg)
- because Isoniazid is an over the counter drug, can cause
convulsions by inhibition of GABA throuh inhibition of
pyridoxine production
- pyridoxal phosphate is essential for GABA production
What is appropriate dose of naloxone in patients presenting with
what appears to be a metabolic coma in the ER?
B. Treat coma
 D50-50
- The single most common cause of decreased sensorium
- Hypoglycaemia is LIFE-THREATENING!
Group 08
06 March 2012
Allan R. Dionisio, MD
 Naloxone 2 mg IV (pedia 0.1 mg/kg)
- Textbooks will tell you to give 0.2 mg IV – good for pure
agonists but NOT EFFECTIVE for mixed agonist/antagonists
- .4 mg dose is usually given to morphine-like opiates, for pure
agonists
- for mixed agonist-antagonist: 2 mg
 Thiamine 100 mg IV
- To treat or prevent Wernicke’s encephalopathy
 Correct metabolic abnormalities
- Electrolytes
- Acid-base abnormalities
II.
Clinical Evaluation
A. Time of Exposure
 Tell whether to decontaminate or not
 Most ingestions beyond 2 hours are not worth decontamination
 Clinical effectiveness of gut decontamination appears to be
insignificant beyond 1 hour post-ingestion
 Exceptions:
- Meds that slow down gut motility—ex. Loperamide
- Slow release meds—ex. Verapamil SR
- Enteric coated preparations—ex. Enteric coated aspirin
B. Mode of exposure
 tells what to decontaminate
 must know the route of contamination
C. Intake of other substances
 Always keep co-ingestants in the back of your mind
 Look for incongruences between ssx and hx
 more often than not, a patient can come with different toxicants,
must look at history and presentation
D. Circumstances prior to poisoning
 Get MULTIPLE testimonies
 Collaborate with at least 2 sources, get as many sources as you
can
E. Current medications and past medical of PATIENT and FAMILY
 Most suicidals get anything within reach
 Most children get anything within reach
 best place to look at is medicine box/cabinet
F. Any home remedies taken
 Milk makes lipophilic toxicants get absorbed faster (ex.
Benzodiazepines)
 Egg yolk enhances watusi/firecracker absorption
 Aspiration pneumonia is frequent in kerosene/hydrocarbon
ingestions given household emetics
- Caustic agents: can severely burn patient if patient vomits
and aspirates
- Paroxysms of coughing can most likely point to inhalation to
lungs
LENSbello KEESHduyongco anne gomez ross groves GIAN gutierrezJANINA musicoCORRINE sisoncaly tongson
Page 1 of 4
GENERAL PRINCIPLES IN THE EMERGENCY MANAGEMENT OF AN ACUTELY POISONED PATIENT
G. Odors
 One can use sense of smell to determine poison
 Bitter almonds—cyanide
 Fruity odor—DKA, isopropyl alcohol
 Oil of wintergreen—methylsalicylate
 Rotten eggs—sulphur dioxide, hydrogen sulfide
 Garlic—arsenic, zinc phosphide (rat poison), watusi
 Mothballs—camphor
H. Colors
 Red skin—rifampicin, anticholinergics
- Rifampicin: orange urine, sweat, tears, saliva if overdosed
- Anticholinergics: “Red as a beet”
- Aside from antihistamines, an interesting poision is Angel’s
Trumpet which also has an anticholinergic effect
 Gray gums—lead, mercury
- Other toxic effects: Abdominal colic, Gingival lines
 Green urine—formaldehyde
 Blue skin and lips—methemoglobin
- Turns the blood dark because cells cannot carry oxygen
 Cherry red lips—carbon monoxide
NOTE: Pay Attention to Autonomic SSx!
I.
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Hypertension
MNEMONIC: CT SCAN
Cocaine
Theophylline
Sympathomimetics
Caffeine
Anticholinergics
Nicotine
J.
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Hypotension
MNEMONIC: CRASH
Clonidine
Reserpine and other antihypertensives
Antidepressants
Sedative-hypnotics
Heroin and other opiates
K. Bradycardia
 MNEMONIC: PACED
 Propanolol and other beta blockers
 Anticholinesterases
- E.g. malathione
 Clonidine, calcium channel blockers
 Ethanol
 Digitalis
L.

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Mydriasis
MNEMONIC: AASIA
Antihistamines
Antidepressants
Sympathomimetics
Isoniazid
Anticholinergics
Group08
MEDICINE
M. Miosis
 MNEMONIC: COPS
 Cholinergics, clonidine
 Opiates, organophosphates
 Phenothizines, pilocarpine
 Sedative-hypnotics
N. Toxidrome
1. Anticholinergics
- Dry as a Bone
- Hot as a Hare
- Mad as a Hatter
- Red as a Beet
- Blind as a Bat
2. DUMBELS (anticholinesterases)
- Diarrhea, diaphoresis
- Urinary incontinence
- Miosis, muscle fasciculations
- Bradycardia, bronchoconstriction
- Emesis
- Lacrimation
- Salivation
 use of malathione
 you will have a very “wet” patient
 manifestations of “acetylcholine gone wild!”
3. Isoniazid
- Seizures
- Coma
- Acidosis
4. Aspirin
- Mixed metabolic acidosis and respiratory alkalosis in an
unknown poisoning
- Tinnitus
- Tachycardia
O. Lab Exams
 5-10 ml heparinized blood
 5-10 mlclotted blood
 100 ml urine
 Gastric aspirate
 All poisoning patients are potentially medico-legal, hence the
importance of laboratory exams
 Seal the samples with candle wax
III. Decontamination
A. External Decontamination
 Dermal: Discard clothing, bathe with alkaline soap
 Eye: Irrigate with free flowing water for 30 minutes
 Avoid neutralizing solutions in caustic exposures
 Protect yourself!
 Correct dose of activated charcoal and sodium sulfate
 Exothermic reaction happens if you try to put base in a caustic
reaction by acid
 Always use protective gloves in contaminating
LENSbello KEESHduyongco anne gomez ross groves GIANgutierrezjaninamusicoCORRINEsisoncaly tongson
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MEDICINE
GENERAL PRINCIPLES IN THE EMERGENCY MANAGEMENT OF AN ACUTELY POISONED PATIENT
B. Gastric Decontamination
 Insert NGT;Trendelenburg position
 Lavage with NSS
 NOTE these DOSAGES!
(1) Activated charcoal
Adults: 100 GRAMS in 200ml water
Children: 1g/kg as a slurry
(2) Sodium Sulfate
Adults: 15 GRAMS in 100 ml water
Children: 250mg/kg as a 10% solution in water
 Contraindications to NGT/lavage
- Caustics, kerosene less than 1 ml/kg, frank convulsions
 Charcoal
- NOTE: Not effective for alcohol, cyanide, iron, lithium,
pertroleum distillates
- Contraindicated in watusi and caustics
 Sodium Sulfate is contraindicated in:
- Caustics
- Ileus
- Electrolyte imbalance
- Patients with heart failure
- Patients with kidney failure
NOTE: Alternative to sodium sulfate is sorbitol 1-2 g/kg
 Note that you are inducing diarrhea in sodium sulfate
 Do not give in patients with heart failure due to sodium content
 Sodim sulfate is osmotic and will induce diarrhea; should not be
given in patients with ileus
 Sorbitol, which is usual a suppository, can be given orally as an
alternative for sodium sulfate
 Do not give charcoal for heavy metals (not effective) and caustics
and watusi (you will only fuel the flame)
C. Multiple Dose Activated Charcoal
 Adults: 50 g in 150 ml water retained in stomach q6h PO or per
NGT x 48h
 Children: 0.5g/kg as a slurry q6h PO or per NGT x 48 hr
 Give sodium sulfate every morning to evacuate the charcoal
 Use half the dose of activated charcoal for multiple dosing
 When charcoal is given, water is reabsorbed; charcoal becomes a
“brick” if sodium sulfate is not given
Toxicants Eliminated by Multiple Dose Activated Charcoal
 NOTE those in BOLD. These are only the common ones which
cover for 8% of the cases that we see.
 These toxicants undergo enterohepatic circulation
 Salicylates
 Quinine
 Methamphetamine and
 Theophylline
ecstasy
 Amitryptilline
 Diazepam and other
 Dextropropoxyphene
benzodiazepines
 Digitoxin and digoxin
 Phenobarbital
 Disopyramide
 Digoxin
 Nadolol
 Carbamazepine
 Phenybutazone
 Dapsone
 Phenytoin
Group08
 Phenobarbital
 Piroxicam
 Sotalol
D. Urine PH Manipulation
 Alkalinize for weak acids:
- Salicylates, Barbiturates , INH (isonicotinic acid hydrazide)
- To alkalinize–Sodium Bicarbonate 1 meq/kg/dose until urine
pH >7.5
 Acidify for weak bases
- Amphetamines, phenytoin, theophylline
- To acidify – ascorbic acid 1g (pedia 20mg/kg) IV q6h until
urine pH <5.5
 No need to memorize; just NOTE the target pH
 Check the pKAs to determine if it is a weak acid or a weak base
 Usually, those with “amines” are basic
E. Dialysis
 When do you dialyze? (includes pharmacokinetic parameters
which say that dialysis is possible)
1. Low volume distribution
- Low Vd means that the chemical is mostly found in the blood
2. Low protein binding
3. Toxin is dialysable
4. Benefit outweighs risks of dialysis
 Dialyzable Toxicants (NOTE!)
- Barbiturates
- Ethylene glycol
- INH
- Lithium
- Ethanol, methanol, isopropanol
- Salicylates
IV. ANTIDOTES
A. Pyridoxine (Vitamin B6)
 Specific antidote for INH poisoning
 Give IV bolus dose equal to amount of INH ingested
 If dose of INH is not known, give 120 mg/kg of pyridoxine and
repeat as necessary to control seizures
 As much as 52g has been given safely
 Maintain on 10 mg/kg/d in 3dd x 6 weeks
 If vitamin B1/B6 combination do not give more than 1 g Vit B1 at
any one bolus; repeat every 5 minutes until total required B6is
given
B. Atropine
 Physiologic antidote for cholinesterase inhibitors
 1-2 mg (pedia 0.01mg/kg) IV q q15 min until:
- HR > 100
- Pupils >4 mm
- Dry oral mucosa
- Hypoactive bowel sounds
 Once full atropinized, gradually increase intervals—speed of
downloading the dose depends on whether carbamate or
organophosphate
 WOF: hyperpyrexia, tachyarrhythmias, hallucinations, flushing.
Stop atropine and hydrate patient until symptoms wear off.
LENSbello KEESHduyongco anne gomez ross groves GIANgutierrezjaninamusicoCORRINEsisoncaly tongson
Page 3 of 4
GENERAL PRINCIPLES IN THE EMERGENCY MANAGEMENT OF AN ACUTELY POISONED PATIENT
MEDICINE
C. Naloxone
 Specific antidote for opiate poisoning
 2 mg IV initially. Repeat q 5 min until awake or until max of 10
mg total given
 Once awake, give 2/3 of the wake up dose as a drip every hour
D. Flumazenil
 Specific antidote for benzodiazepine overdose
 Anexate 0.5 mg/5 ml
- 0.1 mg in 4 ml D5W IV over 15 seconds q 1 min; max of 2 mg
 Maintain on 0.1-0.2 mg/hour as IV drip
 QUICK REVIEW!
(1) Pyridoxine: INH Poisioning
(2) Atropine: Cholinesterase Inhibitors
(3) Nalozone: Opiate poisoning
(4) Flumazenil: Benzodiazepine overdose
V. SUPPORTIVE THERAPY AND OBSERVATION
 80% of poisoned patients survive with aggressive supportive
therapy alone
 Your management is NOT COMPLETE unless you address the
PSYCHOSOCIAL factors leading to poisoning
 For suicidals: Counseling, co-management with psychology
- If no mental health professional, you should be that
professional
 Patients who attempt suicide deserve compassion, not ridicule or
condemnation
 For accidental poisoning TOXICOVIGILANCE (home, workplace,
community)
VI. ASIDE: SPIRAL CURRICULUM
 go to the same stuff, learn more about it in a deeper way
 same slides but with variation
Group08
LENSbello KEESHduyongco anne gomez ross groves GIANgutierrezjaninamusicoCORRINEsisoncaly tongson
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