ACUTE POISONING (Pr. V. DANEL)
Worksheet n°1
Vocabulary
Think ABC — Airway, Breathing, Circulation and Disability. Move
quickly through Airway and Breathing to begin chest compressions to restore circulation.
ABCD:
Activated charcoal:
Charcoal that has been heated to increase its absorptive capacity.
Activated charcoal is sold as an over-the-counter (OTC) product to help relieve intestinal gas.
It is also used to absorb poisons (as in gas mask filters), neutralize poisons that have been
swallowed, and filter and purify liquids.
Alcoholism
Altered mental status:
Mental status is the clinical state of emotional and
intellectual functioning of the individual. Emergency physicians seldom perform the same
aspects of mental status examination as general psychiatrists. The mental status evaluation
may be divided into six categories: (1) appearance, behavior and attitude; (2) disorders of
thought; (3) disorders of perception; (4) mood and affect; (5) insight and judgement, and (6)
sensorium and intelligence (see table 1). Testing the mental status is done both formally and
informally during patient evaluation. (Zun and Howes 1988) Currently no standardized testing
is done in most emergency departments.The higher mental or cognitive functions need
specific tests for assessment; screening tests are described in the following section. (J.
Stephen Huff, MD, FACEP - Associate Professor - University of Virginia, Charlottesville,
VA)
Antagonists:
In biochemistry, an antagonist acts against and blocks an action. For
example, insulin lowers the level of glucose (sugar) in the blood, whereas another hormone
called glucagon raises it; therefore, insulin and glucagon are antagonists.
An antagonist is the opposite of an agonist which stimulates an action. Antagonists and
agonists are key players in pharmacology and in the chemistry of the human body.
Antidote
Attempted homicide
Arterial blood gases:
The sampling of the blood levels of oxygen and carbon
dioxide within the arteries, as opposed to the levels of oxygen and carbon dioxide in venous
blood. Typically the acidity, or pH, of the blood is measured simultaneously with the gas
levels in ABG sampling.
Arrhythmias
Assisted ventilation
Behavior
Blistering
Blood sugar
Breath smell
Carboxyhaemoglobin levels
Cardiac arrest
Chemicals
Cognition
Coma
1
ACUTE POISONING (Pr. V. DANEL)
Comprehensive toxicology screens: A toxicology screen refers to various tests to
determine the type and approximate amount of legal and illegal drugs a person has taken.
How the test is performed
Toxicology screening is most often done using a blood or urine sample. However, it may be
done soon after swallowing the medication, using stomach contents that are obtained through
gastric lavage or after vomiting.
Why the test is performed
This test is often done in emergency medical situations. It can be used to evaluate possible
accidental or intentional overdose or poisoning. It may help determine the cause of acute drug
toxicity, to monitor drug dependency, and to determine the presence of substances in the body
for medical or legal purposes. If the test is used as a drug screen, it must be done during a
certain time period after the drug is taken or while forms of the drug can still be detected in
the body. Examples are below:
Alcohol: 3 to 10 hs
Codeine: 1 to 2 days
Amphetamines: 24 to 48 hs
Heroin: 1 to 2 days
Barbiturates: up to 6 wks
Methadone: 2 to 3 days
Cocaine: 2 to 4 days; up to 10 to 22 days
Morphine: 1 to 2 days
with heavy use
Consciousness
Convulsion
CPR
Delirium: A sudden state of severe confusion and rapid changes in brain function,
sometimes associated with hallucinations and hyperactivity, in which the patient is
inaccessible to normal contact. Symptoms may include inability to concentrate and
disorganized thinking evidenced by rambling, irrelevant, or incoherent speech. There may be
a reduced level of consciousness, sensory misperceptions and illusions, disturbances of sleep,
drowsiness, disorientation to time, place, or person, and problems with memory.
Delirium can be due to a number of conditions that derange brain metabolism, including
infection, brain tumor, poisoning, drug toxicity or withdrawal, seizures, head trauma, and
metabolic disturbances such as fluid, electrolyte, or acid-base imbalance, hypoxia,
hypoglycemia, or hepatic or renal failure.
Dementia: Significant loss of intellectual abilities such as memory capacity, severe
enough to interfere with social or occupational functioning. Criteria for the diagnosis of
dementia include impairment of attention, orientation, memory, judgment, language, motor
and spatial skills, and function. By definition, dementia is not due to major depression or
schizophrenia. Alzheimer's disease is the most common cause of dementia. There are many
other causes of dementia, including (in alphabetical order): AIDS (due to HIV infection),
alcoholism (the dementia is due to thiamine deficiency), brain injury, brain tumors,
Creutzfeldt-Jakob disease, dementia with Lewy bodies (tiny round structures made of proteins
that develop within nerve cells in the brain), drug toxicity, encephalitis, meningitis, Pick
disease (a slowly progressive deterioration of social skills and changes in personality leading
to impairment of intellect, memory, and language), syphilis, thyroid disease (hypothyroidism)
and vascular dementia (damage to the blood vessels leading to the brain).
Depression
Drug-overdose
2
ACUTE POISONING (Pr. V. DANEL)
EKG = ECG:
The electrocardiogram is a noninvasive test that is used to reflect
underlying heart conditions by measuring the electrical activity of the heart. By positioning
leads on the body in standardized locations, information about many heart conditions can be
learned by looking for characteristic patterns on the EKG.
How is an ECG (EKG) performed?
EKG leads are attached to the body while the patient lies flat on a bed or table. Leads are
attached to each extremity (four total) and to six pre-defined positions on the front of the
chest. A small amount of gel is applied to the skin, which allows the electrical impulses of the
heart to be more easily transmitted to the EKG leads. The leads are attached by small suction
cups, Velcro straps, or by small adhesive patches attached loosely to the skin. The test takes
about five minutes and is painless. In some instances, men may require the shaving of a small
amount of chest hair to obtain optimal contact between the leads and the skin.
What is measured or can be detected on the ECG (EKG)?
1. The underlying rate and rhythm mechanism of the heart.
2. The orientation of the heart (how it is placed) in the chest cavity.
3. Evidence of increased thickness (hypertrophy) of the heart muscle.
4. Evidence of damage to the various parts of the heart muscle.
5. Evidence of acutely impaired blood flow to the heart muscle.
6. Patterns of abnormal electric activity that may predispose the patient to abnormal
cardiac rhythm disturbances.
When is an ECG (EKG) performed?
- As part of a routine physical examination or screening evaluation.
- As part of a cardiac exercice stress test.
- As part of the evaluation of symptoms of chest pain, shortness of breath, dizziness or
fainting, palpitations, or
- As part of the preoperative workup for surgery in patients who may be at an age where
heart disease could potentially be present.
Endotracheal intubation
Glasgow coma scale:
A scale for measuring level of consciousness, especially after a
head injury, in which scoring is determined by three factors: amount of eye opening, verbal
responsiveness, and motor responsiveness.
Eye Opening
E
spontaneous
4
to speech
3
to pain
2
no response
1
Best Motor Response
M
To Verbal Command:
3
ACUTE POISONING (Pr. V. DANEL)
obeys
6
To Painful Stimulus:
localizes pain
5
flexion-withdrawal
4
flexion-abnormal
3
extension
2
no response
1
Best Verbal Response
V
oriented and converses
5
disoriented and converses
4
inappropriate words
3
incomprehensible sounds
2
no response
1
E + M + V = 3 to 15






90% less than or equal to 8 are in coma
Greater than or equal to 9 not in coma
8 is the critical score
Less than or equal to 8 at 6 hours - 50% die
9-11 = moderate severity
Greater than or equal to 12 = minor injury
Coma is defined as: (1) not opening eyes, (2) not obeying commands, and (3) not uttering understandable
words.
Head trauma
Hemodialysis
Household chemicals
Hyperglycaemia
Hypotension
Hypotensive
Hypoglycemia
Inhalation of vomitus
Judgement
Occupational hazard
Occupational history
Opiates
Opioid addict
Perception
Poison
Poisoning
Post-ictal state
Protective clothing
Psychiatric assessment
Psychiatric disorder
Psychiatric referral
Pulmonary oedema
4
ACUTE POISONING (Pr. V. DANEL)
Rhabdomyolysis:
From the Greek roots rhabdo-, striped (striated) + -myo-, muscle
+ -lysis, breakdown = the breakdown of striated muscle (skeletal muscle).
A condition in which skeletal muscle cells break down, releasing myoglobin (the oxygencarrying pigment in muscle) together with enzymes and electrolytes from inside the muscle
cells. The risks with Rhabdomyolysis include muscle breakdown and since myoglobin is toxic
to the kidneys.
Respiratory depression
Schizophrenia:
One of several brain diseases whose symptoms that may include loss of
personality (flat affect), agitation, catatonia, confusion, psychosis, unusual behavior, and
withdrawal. The illness usually begins in early adulthood.
Seizures:
Uncontrolled electrical activity in the brain, which may produce a physical
convulsion, minor physical signs, thought disturbances, or a combination of symptoms.
The type of symptoms and seizures depend on where the abnormal electrical activity takes
place in the brain, what its cause is, and such factors as the patient's age and general state of
health. Seizures can be caused by head injuries, brain tumors, lead poisoning,
maldevelopment of the brain, genetic and infectious illnesses, and fevers. In fully half of the
patients with seizures, no cause can yet be found.
Self-harm
Self-poisoning
Stroke:
The sudden death of some brain cells due to a lack of oxygen when the blood
flow to the brain is impaired by blockage or rupture of an artery to the brain. A stroke is also
called a cerebrovascular accident or, for short, a CVA.
Suicide attempt
Supportive treatment ≠
Specific treatment
Tachycardia
Tachypnea:
Abnormally fast breathing. A respiratory rate that is too rapid. The
normal rate of respirations (breaths per minute) depends on a number of factors, including the
age of the individual and the degree of exertion.
The prefix tachy- means swift or rapid; it comes from the Greek word tachys, meaning
"swift." The word ending -pnea denotes a relationship to breathing; it comes from the Greek
pnoia, meaning breath.
Terrorist
A head-to-toe examination
Urinalysis
Venomous stings, bites
Vomiting
Warfare (Chemical)
Withdrawal symptom
5
ACUTE POISONING (Pr. V. DANEL)
Worksheet n°2
Matching definitions
Suicide attempt — Poisoning — Post-ictal state — Comprehensive toxicology screens —
Tachypnoea — Overdose — Supportive treatment — Glasgow Coma Scale — Assisted
ventilation — Stroke — Rhabdomyolysis — Arterial blood gases — Hypotensive — Seizures
— Blister
Poisoning: Taking a substance that is injurious to health or can cause death.
Overdose: accidental or intentional use of a drug or medicine in an amount that is higher
than is normally used.
Suicide attempt: the act of deliberately taking one's own life.
Supportive care: Treatment given to prevent, control, or relieve complications and side
effects and to improve the patient's comfort and quality of life.
Assisted ventilation: the depth of spontaneous ventilation is augmented by the anesthetist,
as by squeezing the rebreathing bag.
Tachypnoea: Abnormally fast breathing.
Hypotensive: Having abnormally low blood pressure.
Glasgow Coma Scale: a quick, practical standardized system for assessing the degree of
consciousness in the critically ill and for predicting the duration and ultimate outcome of
coma, primarily in patients with head injuries.
Seizures: Uncontrolled electrical activity in the brain, which may produce a physical
convulsion, minor physical signs, thought disturbances, or a combination of symptoms.
Blister: A collection of fluid underneath the top layer of skin
Rhabdomyolysis: A condition in which skeletal muscle cells break down, releasing
myoglobin (the oxygen-carrying pigment in muscle) together with enzymes and electrolytes
from inside the muscle cells.
Arterial blood gases: The sampling of the blood levels of oxygen and carbon dioxide
within the arteries, as opposed to the levels of oxygen and carbon dioxide in venous blood.
Post-ictal state: Following a seizure
Comprehensive toxicology screens: refers to various tests to determine the type and
approximate amount of legal and illegal drugs a person has taken.
Stroke: The sudden death of some brain cells due to a lack of oxygen when the blood flow
to the brain is impaired by blockage or rupture of an artery to the brain. Also called a CVA.
6
ACUTE POISONING (Pr. V. DANEL)
Worksheet n°3
Label the following diagram.
7
ACUTE POISONING (Pr. V. DANEL)
Worksheet n°4
Answer the following questions
What is acute poisoning?
Taking a substance that is injurious to health or
can cause death. Poisoning is still a major hazard to children, despite child-resistant (and
sometimes adult-resistant) packaging and dose-limits per container.
How often does it occur?
French Data:
- There are 10 Control Poison Center (CPC) in France;
- There is a "Toxicovigilance" Center in Grenoble.
- Each CPC receive 200,000 calls / year; 50% of them are about children;
- 200,000 people are hospitalized each year; and
- 2,000 die each year.
- A regular student in medicine usually thinks that women are more suicidal than men; 2
women for 1 men;
- Women kill themselves with drugs.
- In reality, 2 men kill themselves for 1 woman.
- Men kill themselves with gunshot and hanging.
- Poisoning is the 1st cause of non traumatic coma for people btw 15-45y/o.
It has been estimated that in the UK and USA over 10% of all acute adult medical admissions to
hospital are due to acute poisoning.
-
About 4000 adults and <20 children die each year in the UK from acute poisoning.
65% of drugs involved are prescribed to the patient, a relative or friend
30% of self-poisonings involve multiple drugs
50% of drug-overdose also involve alcohol
Hence question witnesses or family about ANY access to drugs or ANY bottles found.
What are the 4 types of acute poisoning?
Deliberate:
o Overdose as self-harm or suicide attempt
o Child abuse ± Munchausen’s syndrome by proxy
o Third party (attempted homicide, terrorist, warfare)
Accidental:
o Most episodes of paediatric poisoning.
o Dosage error:
o Recreational use Plants
o Food
o Venomous stings/bites
Environmental:
o Chemicals
o Heavy metals
Industrial exposures
8
ACUTE POISONING (Pr. V. DANEL)
What’s the process for resuscitation? (CPR)
Airway:
Open, suction, maintain and intubate as necessary.
Breathing:
- Assess work and effectiveness of ventilation.
- Give oxygen ± assisted ventilation (avoid mouth-to-mouth).
- Respiratory depression
- Tachypnoea
Circulation:
- Attach a cardiac monitor; assess pulse, blood pressure and perfusion. Establish
intravenous access.
Disability:
- Assess consciousness level (Glasgow Coma Scale).
- Coma may suggest benzodiazepines, alcohol, opiates, tricyclics, or barbiturates.
- Check pupils and eye movements:
o Large - consider anticholinergics, tricyclics.
o Small - consider opiates or cholinergics.
o Unreactive - causes include barbiturates, carbon mmonoxide, hydrogen
sulphide, cyanide/cyanogens, head injury/hypoxia.
o Unequal - slight variation can be normal - but consider head injury.
o Strabismus - can be seen with carbamazepine overdose.
- Papilledema - associated with methanol, carbon monoxide and glutethimide.
- Check blood glucose - if hypoglycaemic give 50 ml 50% dextrose IV (children: 5
ml/kg of 10% dextrose IV).
o Hyperglycemia or Hypoglycemia
- Seizures: Many drugs can induce seizures including tricyclics, theophylline, opiates,
cocaine and amphetamines.
General examination.
-
cardiovascular, respiratory, abdominal and neurological examination;
Vital signs (pupils etc);
Temperature: hypothermia or hyperthermia;
Muscle rigidity;
Skin examination: blistering and rhabdomyolysis;
Breath smell;
Mouth examination: perioral acneiform lesions, dry mouth, hypersalivation.
Investigations
-
12 lead electrocardiogram.
Arterial blood gases.
Drug levels (at appropriate interval)
Comprehensive toxicology screens
Carboxyhaemoglobin levels if carbon monoxide poisoning suspected.
9
ACUTE POISONING (Pr. V. DANEL)
-
Urinalysis
CXR if pulmonary oedema/aspiration suspected.
CT brain may be needed to exclude other causes of alterations in conscious level.
Differential diagnosis?
-
Head trauma (especially, in the ethanol-intoxicated patient)
Stroke / SAH
Meningitis
Metabolic abnormalities (such as hypoglycemia, hyponatremia, or hypoxemia)
Liver disease
Post-ictal state
Treatment.
-
-
Decontamination if appropriate:
o Avoid contaminating yourself and wear protective clothing.
o Ensure area is well-ventilated.
o The patient should remove soiled clothing and wash him/herself if possible.
o Put soiled clothing in a sealed container.
o Wash all contaminated skin/hair with liberal amounts of warm water ±soap.
Decrease absorption:
o
-
-
-
(Gastric emptying: no more used)
o Activated charcoal (oral, naso-gastric tube)
o Whole bowel irrigation
Increase elimination:
o Haemodialysis
o Multiple doses of activated charcoal
Supportive:
o Maintain ABCDs
o Observation and treatment of late complications (e.g. liver failure)
Specific antidote:
o See individual articles for relevant antidotes and antagonists.
Referral
-
Medical/Paediatric - for continued support/antidote administration, observation,
cardiac monitoring.
Psychiatric - for all deliberate self-poisonings, those with suicidal ideation and if
the country's Mental Health Act has been employed to detain/treat.
Psychiatric assessment
-
Was the act planned? Did the patient seek help afterwards? Does the patient think
the method was dangerous? Was there a final act (e.g. suicide note)?
What problems led to the act: do they still exist?
Was the act aimed at someone?
Is there a psychiatric disorder (depression, alcoholism, personality disorder,
schizophrenia, and dementia)?
10
ACUTE POISONING (Pr. V. DANEL)
-
What are his resources (friends, family, work, personality)?
Present intentions and suicide risk. The following factors increase the chance of
future suicide:
o Original intention was to die
o Present intention is to die
o Presence of psychiatric disorder
o Poor resources
o Previous suicide attempts
o Socially isolated
o Unemployed
o Male
o Over 50yrs old
Prevention
-
Adult education.
Double-check dosage before administration.
Vigilance by health professionals to recognise the early signs of abuse and
potential suicide.
Put all medicines and household chemicals in a locked child-proof cupboard.
Safely dispose of medicines, chemicals which are not needed or out of date.
Keep all medicines and chemicals in their original containers
Worksheet n°5
Doctor-patient interview
History
This may be unreliable but include the following:
- What was taken, how much, when, and by what route?
- Was alcohol consumed too?
- Any vomiting since ingestion?
- Past medical history, current medications and allergies.
- Was a suicide note left?
- Is the patient pregnant?
- Histories from others including: family, friends, paramedics, police and observers.
Obtain past medical notes if possible.
11