/ /١٤٤٤ ١٠ ١٣/ /١٤٤٤ ١٠ ١٣ Dr Abdelmonem G. MadbolyDr Abdelmonem G. Madboly 11

الرحمن الله الرحمن بسم الله بسم الرحيمالرحيم

Principles Principles ofof Management of Poisoned Management of Poisoned

PatientPatient

مدبولى/ جودة المنعم عبد مدبولى/ د جودة المنعم عبد ددكتوراة الطب الشرعي و السموم اإلكلينيكية,

مدرس الطب الشرعي و السموم اإلكلينيكية,

استشاري عالج التسمم بمستشفى بنها الجامعي

Objectives (ILOs)Objectives (ILOs)::

General management of poisoned patient:

WITH SPECIAL CONCENTRATION ON:Active methods of detoxification

(DecontaminationDecontamination))

= =treat patient, not treat patient, not poisonpoison

May 3, 2023May 3, 2023 Dr Abdelmonem G. MadbolyDr Abdelmonem G. Madboly 33

TreatmentTreatment

UnstableUnstable 1- Emergency 1- Emergency

stabilization ABCDEs.stabilization ABCDEs.

2- Initial therapy 2- Initial therapy (Empiric antidote)(Empiric antidote)

3. Emergent therapy.3. Emergent therapy.رقم ++ من رقم تكمل من alertalertفى فى 11تكمل

StableStable1.1. Proper clinicalProper clinical evaluation.evaluation.2. Decontamination &2. Decontamination & Enhanced Elimination.Enhanced Elimination.3. Antidote.3. Antidote.4. Sympt4. Sympt. (Supportive) ttt.. (Supportive) ttt.5. Discharge & 5. Discharge & follow up.follow up.6- Prevention 6- Prevention re-exposurere-exposure

== Treat the patient, not the Treat the patient, not the poisonpoison

DecontaminationDecontamination

Definition:Definition: Removal of toxin from patient.Removal of toxin from patient.

OrOr Removal of patient from toxin.Removal of patient from toxin.

DecontaminationDecontamination

TypesTypes::External:External: - - For poisons outside the body For poisons outside the body (non ingested (non ingested poison)poison)::1.1.EnvironmentEnvironment = Inhalation = Inhalation (gaseous poisons)(gaseous poisons)2.2.ClothingClothing…………………...…………………... (toxins ??????)(toxins ??????) 3.3.SkinSkin = Dermal ……… = Dermal ……… (toxins ??????)(toxins ??????)4.4.Ocular……………… Ocular……………… (toxins ??????)(toxins ??????)

Internal:Internal: - - For poisons inside the body:For poisons inside the body:1.1.GIT (Gut Decontamination).GIT (Gut Decontamination).2.2.Parental (SC, IV)…….. Parental (SC, IV)…….. (how.?????)(how.?????)3.3.Blood & tissues = Blood & tissues = Enhanced elimination.Enhanced elimination.

GIT GIT DecontaminationDecontamination:: Emesis.Emesis. Gastric lavage.Gastric lavage. Endoscopic removal (surgical).Endoscopic removal (surgical). -------------------------------------------------------------------------------------- Activated charcoal.Activated charcoal. Local antidote.Local antidote. -------------------------------------------------------------------------------------- Cathartics.Cathartics. WBIWBI

I- EmesisI- Emesis:: Definition:Definition: (DD Vomiting). (DD Vomiting).

EXCEPTEXCEPT: > 6 hours: > 6 hours1.1. Sustained released tablets Sustained released tablets ((Salicylates)..2.2. Enteric coated tablets Enteric coated tablets ((Ca ch. blockers)..

3.3. Drug concretion (lumps or mass) Drug concretion (lumps or mass) bezoars: bezoars: (salicylates, iron, sedatives, Bromide)(salicylates, iron, sedatives, Bromide)

4.4. Drugs slow gastric empting: Drugs slow gastric empting: (anticholinergic, salicylates, morphine, ..)(anticholinergic, salicylates, morphine, ..)

5.5. Entero-entric circulation: Entero-entric circulation: (morphine, (morphine, nicotine, theophylline, HMs (Hg, As)…).nicotine, theophylline, HMs (Hg, As)…).

6.6. Entero-hepatic circulation: Entero-hepatic circulation: (Digitalis, (Digitalis, TCAs, ..)TCAs, ..)

16:1816:18 Dr/ Abdelmonem G. MadbolyDr/ Abdelmonem G. Madboly 88

II- Gastric lavageII- Gastric lavage::- It is done by inserting a tube in to the

stomach, washing it with water or harmless solvent to remove the unabsorbed poison.

– Useful for as long as 3-6 hrs. after ingestion.

– It should notshould not be employed routinely in the management of poisoned pt, but it should be considered only if a pt. has ingested a life- threatening amount of toxic sub.

– A cuffed endo-tracheal tubecuffed endo-tracheal tube has been inserted before lavage to avoid pulmonary complication in cases of C.N.S. depressants.

Procedure of gastric lavageProcedure of gastric lavage:1. The pt. In left lat. Decubitus position.2. Remove dentures or foreign body from mouth.

3. Use endotrachealendotracheal or nasotracheal intubation before gastric lavage in: a- unconscious. b-

seizures. c- Pt. With absent gag R.

4.4. LubricantLubricant QY gel …………………….. QY gel ……………………..5.5. SwallowSwallow during introducing. during introducing.6.6. Confirmation positionConfirmation position: : (ALERT & COMA)(ALERT & COMA).7.7. SampleSample of gastric contents (for analysis)8.8. 200 m200 ml for adults & 50-100 ml 50-100 ml for children of warm

H2O9.9. Before removalBefore removal:

Charcoal & Cathartic should be instilled. The tube is firmly nippedfirmly nipped and removed, to

avoid aspiration.

Uses of Ryle tubeUses of Ryle tube::

Suction of secretions.Suction of secretions. Gastric lavage.Gastric lavage. Giving activated charcoal.Giving activated charcoal. Feeding of comatosed Feeding of comatosed

patient.patient. HematemesisHematemesis..

Contraindication:Contraindication: Non- live threatening ingestions & non-

toxic ingestions. Pills that are known not to fit intonot to fit into the

holes of the gastric lavage tube. Any pt. whose air integrity is not air integrity is not

assuredassured. CORROSIVESCORROSIVES exceptexcept …………. Toxic ingestions with more pulmonarymore pulmonary

than G.I.T Toxicity e.g. kerosene (to avoid aspiration).

Complication:Complication: Insertion of the tube in to the trachea obstructing it. Aspiration pneumonitis, Esophageal or gastric perforation. Decreased Decreased oxygenationoxygenation during the procedure.

III- Activated charcoal (AC)III- Activated charcoal (AC):: AC is considered the best method of

gastric decontamination. It is produced by the destructive

distillation of various organic materials (i.e. wood, coal, petroleum) and then treated at high temperatureshigh temperatures and steamsteam: 600- 900 C, which produces great surface area & Surface binding area = 900- 1500 m2/g.

Super-activated charcoal: 3 folds surface area of AC due to increase its adsorbent adsorbent capacitycapacity.

Mechanism of action:Mechanism of action:1. It adsorbsadsorbs the toxin within the gut lumen,

making the toxin less available for absorption in to the blood tissues thus it enhances elimination (GIT dialysis).(GIT dialysis).

2. It can bind the drug in the bile, interrupting the enterohepatic circulation.

Single- dose A.ch.:Single- dose A.ch.: l g/ kg b.w. (adult & children) must be freshlyfreshly prepared. A.ch + 4 parts water slurry (given by mouth

or through G. tube). Must not be given until the syrup of ipecac has

evoked emesis. Given with catharticcathartic to reduce G.I.T transit timeG.I.T transit time

Indications:Indications: All suspected toxic ingestionsAll suspected toxic ingestions. Ingestion of any sub. Known to adsorb to it After unknown ingestion by pts. With

protected airways.

Contraindication: Contraindication: Poorly adsorbed poisonsPoorly adsorbed poisons to AC (such as iron,

lithium, ethanol or Bead). Prior to CorrosivePrior to Corrosive ingestions (not only

ineffective but also may be accumulated in burned areas interfering with endoscopy).

The presence of diminished bowel soundsdiminished bowel sounds, iIleus, bowel obstruction

Complication:Complication:– Rare risks:Rare risks: aspiration, intra-luminal

impaction in pts. With abnormal gut motility.

IV- CatharticsIV- Cathartics::Type Type & & dose:dose: The most commonly used are osmotic cathartics As 70% Sorbitol Sorbitol sol (I g/kg) or 10% sol of mg citrate or sulfate sulfate (250

ml/kg for adult 4 ml/kg for children).

Indications:Indications: With activated charcoal to enhance enhance

elimination elimination ( - - - transit time). Same indications as A charcoal.

V- Whole bowel irrigationV- Whole bowel irrigation::الصعبة الحاجات بتاع

Definition: A rapid catharsis by A rapid catharsis by mechanicallymechanically forcing forcing

ingested substances through the bowel at a ingested substances through the bowel at a rapid rate, rapid rate, without the risk without the risk of serious fluid and of serious fluid and electrolyte disturbances.electrolyte disturbances.

Technique:Technique: Installation of (2L/h in adult, 500 mL/h500 mL/h in

children). Either by mouth or through a gastric tube of

isotonic polyethylene glycol ((CoLyteCoLyte, , GoLYTELYGoLYTELY) ) lavage solution that neither causes fluid nor electrolyte shifts.

The end point is clear rectal effluent.

VI- Surgical GIT VI- Surgical GIT decontaminationdecontamination::Indications: 1- Ing. of drug-containing packets bowl

obs. or bowel ischemia.

2- Rupture of packets containing large amount of cocaine.

3- Poisons that form large masses or adhere to the GIT wall & are not removed medically as aspirinaspirin , bromidebromide or ironiron.

VII- Local antidoteVII- Local antidote::

Neutralization therapy. Neutralization therapy. xxxxxxxxxxxxxx

Milk or water. Milk or water.

A charcoal.A charcoal.

Universal antidote.Universal antidote.