Fakhr Zohair Al-Ayoubi, Msc

Clinical Pharmacist in: CCU & Cardiology Department

Poison Information CenterKKUH May 2010

Introduction• Poisoning is an important public health problem

• In 2009, 2 million human poison exposures were

reported to all poison centers in the US.

• Deaths from Poisoning:

– Total 19,269

– Unintentional14,078

– Suicide 5,191

• Medical costs is estimated at $3 billion in the USClinical Toxicology 1999, Vol. 37, No. 7Miller and Lestina, CDC, 1997

Definition of Poisoning• Toxicology

–The basic since of poisons (old)–The study of the adverse effects of

chemical agents on biological system (new)

• Poison –Any substance that causes injury or

illness or death of a living organism

Definition of Overdose

• Overdose “dose too heavily”

– Ingestion or application of a drug or other

substance in quantities ↑↑ than recommended

or generally practiced.

– Its considered harmful & dangerous, & it can

result in death.

Definition of Overdose

• Overdose “dose too heavily”

– This mean that there is a common safe

dosage & usage for the drug; therefore, the

term is only applied to drugs, not poison

though it should be noted that even certain

poisons are harmless at a low enough

dosage.

Types of Poisoning/Overdose• Accidental “Self-harm”

– Many are this type – Pediatric (most common)– Usually the result of either irresponsible

behavior or the misreading of product labels.

• Intentional “Suicide”– Throughout the ages– The act of deliberately killing oneself murder,

causing your own death suicide & execution.

Type of Poisons

Prescription drug

Over The Counter drugs (OTC)

Herbal medications or preparations

Household chemicals

Industrial chemicals

What do pharmacist provide in the center?

• immediate action real time answer ( for

health care & public)

• Expert & accessible ( coaching)

• Promoting education for all (awareness)

• Registry , statistic : (paracetamol child

resistance caps)

Clinical Pharmacist Role in Poising Management

• Identification of the poison

• Pharmacokinetic / Toxokinetic

• Antidotes dosing & update

• Patient treatment plans

• Monitoring outcomes

• Improving health care & Lay

public awareness

Am J Health-Syst Pharm,2006

Poison Resources

• Primary resources: – Journals

• Secondary resources– Poisondex– Iowa system

• Tertiary resources:– Text books:– Clinical Toxicology

Am J Health-Syst Pharm,2006

Poison Resources

•GUIDE TO POISONOUS AND TOXIC PLANTS  From US Army Center for Health Promotion and Preventive Medicine

•Common Antidote Chart  Common Antidote Chart From California Poison Control

•Management of Poisoning - A handbook for health care workers By World Health Organization

Poison Resources

• American Association of Poison Control Centers (AAPCC) The AAPCC provides a forum for poison centers and interested individuals to promote the reduction of morbidity and mortality from poisonings through public and professional education and scientific research. It also sets voluntary standards for poison center operations.

Poison Resources

• Basic Analytical Toxicology - WHO By World Health Organization

Guidelines for poison control - WHO By World Health Organization. Contains antidote information for drug poisoning.

Clinical Toxicology - Paddock Labs Clinical Toxicology published by Paddock Lab of Canada. Includes current and practical information on the management of various types of poisoning and overdose emergencies.

Poison Resources• Diseases and Disorders links pertaining to poisoning 

A list of links compiled by Karolinska Institutet (a medical university in Sweden), covering topics from bites and stings, to poisoning related to foods, gas, lead, iron, plant, arsenic, mercury, cadmium, nickel, and permanganate, drug toxicity, and hazardous substances.

TOXNET From the National Library of Medicine in the U.S., this site is a collection of of databases on toxicology, hazardous chemicals, and related areas.

Arizona Poison and Drug Information Center Home Provides accessible poison and medication-related emergency treatment advice, referral assistance and comprehensive information on poisons and toxins, poison prevention, and the safe and proper use of medications.

Poison Resources

• Poisons Information Monographs International Programme on Chemical Safety Poison monographs of: Chemical, Pharmaceuticals, Animals, Plants, Bacteria and Fungi

Toxic Exposure Treatment Guides IPCS International Programme on Chemical Safety

AACT - American Academy of Clinical Toxicology An organization uniting scientists and clinicians in the advancement of research, education, prevention and treatment of diseases caused by chemicals, drugs and toxins.

Poison Resources

• EXTOXNET - The Extension Toxicology Network Provides info. on various types of pesticide toxicology and environmental chemistry. These include: discussions of toxicological issues of concern (TICs); toxicology newsletters; other resources for toxicology information; toxicology fact sheets; Pesticide Information Profiles (PIPs); and Toxicology Information Briefs (TIBs).

Consumer Products Safety - Health Canada 

General Management

• Decontamination• Supportive care.• Prevent further exposure to the

poison.• Removal of the unabsorbed poison

from the stomach.• Inactivation of the poison remaining

in the stomach.• Enhancement of excretion.• Administration of an antidote.• Symptomatic treatment.

General Management

• General

– Absorption

– Elimination

– Specific antidotes

Absorption

• Gastric lavage

– Indications include coma or impending coma,

seizures, or a depressed gag reflex.

– Only if within 1 hour & life-threatening amount

– Oro-gastric tube should be used.

– Should be done only in older children.

– Never for corrosives & chronic cases

Absorption.... Cont.

• Activated charcoal

– Has no real contraindications and is the treatment of

choice to prevent absorption of the poisoning when

the patient is in the emergency room.

– It is ineffective against cyanides, heavy metals, Na, K,

Cl, ethanol, acids, and bases.

– 50 g single or repeated dose ( elimination)

Absorption.... Cont.

• Cathartic

– Decrease absorption by increasing the rate of

excretion

– Mg Sulphate should not be used if the patient has

renal failure

– Sorbitol

Elimination

• Multiple dose activated charcoal– Quinine, phenobarbitone, Carbamazepine

• Charcoal haemoperfusion– Barbiturates, theophylline

• Diuresis

– may be done using hemodialysis,

hemoperfusion, & peritoneal dialysis.

Elimination....Cont.

• Exchange transfusion

– Only if the patient is unresponsive to

appropriate care.

• Urinary alkalinization

• Whole Bowel Irrigation

Physiological Antidotes Classifications

• Antagonists:– Stimulate where the poisons depressed & vise

versa e.g:

• Diazepam in strychnine poisoning.• Atropine in organophosphorous (antagonize muscarinic

action).• Pilocarpine antagonize peripheral action of atropine.

Physiological Antidotes Classifications.... Cont..

• Chelators:– Antidotes forms chelates which are less toxic &easily excreted

through the kidneys e.g.:

– BAL (British anti-lewisite) in arsenic poisoning.

– EDTA (Ethylene Diamine Tetra-Acetate) in heavy metals poison.

– Desferrioxamine (Desferal) chelator in cases of iron poisoning.

– Penicillamine used as oral chelator in lead poisoning.

Physiological Antidotes Classifications.... Cont..

• Competitors:

– Compete with the poisons at the sites of their

action.

– Naloxone in morphine poisoning but recently used

as a narcotics antidote with no CNS depressant

action.

– Ethyl alcohol in cases of methanol poisoning.

Telephone Protocol For Handling Poison Calls

• I .Initial assessment – Substance– Symptoms – What has been done

• II. History– Basic information– Substance– Amount– Symptoms

• III. Assessment– Toxicity of the substance– Circumstances of exposure– Competency of the caller

Telephone Protocol For Handling Poison Calls

• IV. Treatment plan (one of the following)– No treatment– First aid and observe at home– Syrup of ipecac and observe at home– Refer t o MD, ER,etc

• V. Follow up Made at 0.5 hr,2-4hrs,12hrsor 24hrs

– Has the victim remained asymptomatic– Were instructions followed– Was treatment effective– Poison prevention teaching12– Referral

I .Initial assessment

a) Substance involved:

1) Toxic substance

b) Are symptoms present?

1) irritated, discolored or swollen lips, gums, tongue; coughing, convulsions, acting unusual, can't wake up,

c) What has been done?

1) is immediate first aid necessary e.g. dilution, washing area.

2) has incorrect first aid been done e.g. salt water as emetic.

3) is immediate ER referral indicated?

II. History

A. Basic Information:

1) Name of caller relationship of caller to victim - parent, friend, babysitter, MDRN.

2) Name and age of victim.

3) Weight of victim

4) Phone number.

5) Time of exposure how long has it been?

6) Route of exposure ingestion, inhalation, percu taneous, occular.

II. History

B. Substance:

1) Brand name and other identification form

2) Medication: read prescription label. is there a drug imprint code? what was it supposed to do?

3) Plant has it recently been sprayed?

4) Is it possible anything else involved look around for any other bottles, broken plants

C. Amount:

1) Describe situation tell me exactly what happened? did you see him/her swallow?

2) Extract quantitative details how many/much was there originally? count/measure how much is left when was it purchased? used often?

II. History

D. symptoms: Present Medical condition. does he/she take any medicineregularly? has he/she been sick lately?

II. History

III. Assessment:

A. Toxicity of substance. Poisindex

Reference texts and articles. Manufacturer emergency number Consultants and experts.

III. Assessment

B. Circumstances of Exposure Suicide

Accidental occupational Environmental Drug abuse.

III. Assessment

C. Competency of caller. will they be able to carry out instructions and make

observations?

How important does caller consider exposure to be?

IV. Treatment Plan:

A. No treatment necessary

1) Will they be available for follow-up? 2) Do they understand what to watch for?

B. First aid and observe at home .

1) Is syrup of Ipecac available? 2) Is caller competent and calm home. 3) Will they be available for follow-up? 4) Do they understand what to watch for?

C. Syrupe of Ipecac

1) Arrange transportation 2) Call ahead. 3) Have they bring container, plant with them

D. Refer to MD, ER, clinicin the following situations

highly toxic substance; unknown substance; , unknown amount; signs plant, etc. symptoms not obvious, e.g. EKG changes; unstable situation.

V. Follow-up:

1) Anything at all unusual? 2) Sleeping, eating, etc. normally?

A. Has the victim remained asymptomatic?

1) How much Ipecac did you give2) Did you give water afterward? 3) How long did you wash the eye?

B. Were instructions followed?

1) Did victim vomit? 2) How many times? 3) Were pill fragments present? 4) Is he/she eating all right now?

C. Was treatment effective?

1) Education and first aid .. 2) Poison proof now-low the odds of a repeat.

D. Poison prevention teaching

1) Public health nurse 2) Workers clinic 3) Suicide prevention

E. Referral