Ingested Poisons

8/13/2019 Ingested Poisons

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VcManuel A. Mabayo


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Poison? A substance that, when introduced into or

absorbed by a living organism, causes death orinjury, esp. one that kills by rapid action.

Poisoning occurs when any substance interfereswith normal body functions after it is swallowed,

inhaled, injected, or absorbed. The branch ofmedicine that deals with the detection andtreatment of poisons is known as toxicology.


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A poison is any substance that, when ingested,inhaled, absorbed, applied to the skin, orproduced within the body in relatively smallamounts, injures the body by its chemical

action.


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History Egyptians are said to have studied many

poisons as early as 3000BC.

Susrutha (350BC) described as how poisonswere mixed with food and drink, medicines,snuff, etc..

Orfila-(1787-1853) was first to attempt asystemic correlation between the chemical andbiologic information of the poisons knownthen.


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Poisonings are a common occurrence. About 10million cases of poisoning occur in the United States

each year. In 80% of the cases, the victim is a childunder the age of five. About 50 children die each yearfrom poisonings. Curiosity, inability to read warninglabels, a desire to imitate adults, and inadequatesupervision lead to childhood poisonings.

The elderly are the second most likely group to bepoisoned. Mental confusion, poor eyesight, and theuse of multiple drugs are the leading reasons why thisgroup has a high rate of accidental poisoning. A

substantial number of poisonings also occuras suicideattempts or drug overdoses.
http://medical-dictionary.thefreedictionary.com/Suicidehttp://medical-dictionary.thefreedictionary.com/Suicidehttp://medical-dictionary.thefreedictionary.com/Suicide


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Poisons are common in the home and workplace,

yet there are basically two major types. One groupconsists of products that were never meant to beingested or inhaled, such as shampoo, paintthinner, pesticides, houseplant leaves, and carbon

monoxide. The other group contains products thatcan be ingested in small quantities, but which areharmful if taken in large amounts, such aspharmaceuticals, medicinal herbs, or alcohol.


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Other types of poisons include the bacterial toxinsthat cause food poisoning, such as Escherichia coli;heavy metals, such as the lead found in the paint onolder houses; and the venom found in the bites andstings of some animals and insects. The staff at apoison control center and emergency room doctorshave the most experience diagnosing and treatingpoisoning cases.
http://medical-dictionary.thefreedictionary.com/Food+Poisoninghttp://medical-dictionary.thefreedictionary.com/Food+Poisoning


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Poisoning from inhalation and ingestion oftoxic materials, both intentional and

unintentional, constitutes a major healthhazard and an emergency situation.


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Nursing Alert!The local poison control should be called

if an unknown toxic agent has been

taken or if it is necessary to identify anantidote for a known toxic agent.


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Goals:To remove or inactivate the poison

before it is absorbed.

To provide supportive care inmaintaining vital organ function.

To administer a specific antidote to

neutralize a specific poison.To implement treatment that hastens

the elimination of the absorbed poison.


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If swallowed may be corrosive!Alkaline

- lye, drain cleaners, toilet bowl cleaners,

bleach, nonphosphate detergents, ovencleaners, and button batteries (used topower watches, calculators, or cameras).

Acid

- toilet bowl cleaners, pool cleaners,metal cleaners, rust removers, and batteryacid.


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Control of the airway, ventilation, andoxygenation are essential.

Measures are instituted to stabilizecardiovascular and other body functions.


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What to be monitored closely?ECG

Vital Signs

Neurologic Status


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SHOCK may result!

If patient ingested corrosive poison (canbe a strong acid or alkaline substance),can be given WATER or MILK to drink fordilution.


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However, dilution is not attempted if the patienthas acute airway edema or obstruction or if

there is clinical evidence of esophageal, gastric,or intestinal burn or perforation.

The following gastric emptying procedures maybe used as prescribed:

- Syrup of ipecac (never use with corrosivepoisons)

- Gastric lavage

- Activated charcoal- cathartic


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NURSING ALERT!

Vomiting is never induced after ingestion ofcaustic substances (acid or alkaline) or

petroleum distillates.


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General signs and symptomsHypotension & Cardiac Dysrhythmias (possible)

Seizures

Pain Symptoms-odor, sweating, fever, delirium,

convulsions, burns of mouth, blindness, GIsymptoms, abnormal movements, coma.

Signs- miosis, mydriasis, blindness, facialtwitching, dull & mask like expression, pallor,cyanosis, hypothermia, sweating, respiratorysymptoms, CVS symptoms, CNS symptoms.


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Poisoning severity Grades

None(0)- no symptoms or signs/vague

symptoms judged not to be related topoisoning.

Minor(1)- Mild, transient &

spontaneously resolving symptoms.


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Moderate(2)- pronounced orprolonged symptoms.

Severe(3)- severe or life threateningsymptoms.


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Diagnosis of Poisoning Cardiac arrythmias. Tricyclic antidepressants,

amphetamine, aluminium phosphide, digitalis,theophylline, arsenic, cyanide, chloroquin.

Metabolic acidosis. Isoniazid, methanol,salicylates, phenformin, iron, cyanide.

GIT disturbances. Organophosphorus, arsenic,iron, lithium, mercury.

Cyanosis. Nitrobenzene compounds, anilinedyes, and dapsone.


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Basic Management of a poisoned patientAntidotes are available for very few

commonly encountered poisons, and

treatment is usually non-specific andsymptomatic. In such cases managementconsists of emergency first aid andstabilization measures, appropriate

treatment to reduce absorption, measuresto enhance life support followed bypsychiatric counseling.


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Identification of PoisonIdentify the poison by careful history

and helpful clues. Determine what,

when and how much of the poison

was ingested or inhaled. Find the

supporting evidence for yourdiagnosis from the nature of the

symptoms and physical signs.


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Principles of Management Keep the phone numbers of your doctor, hospital &

emergency medical system near the phone. Removal of the patient from the site of poisoning. Initial resuscitation and stabilization. Symptomatic and supportive measures. Removal of unabsorbed poisons- from GI tract or

from skin, eye. Hastening the elimination of absorbed poisons. Use of specific antidote if available Disposition of the patient with advice for

prevention.


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Emergency Stablization Measures The unconscious patient should be transported

in the headdown semiprone position tominimize the risk of inhalation of gastric

contents. A clear airway is established andventilation is maintained. Potentially seriousabnormalities such as metabolic acidosis,hyperkalemia and hypoglcymia may require

correction as a matter of urgency. Neurologicalassessment is made by calculating the GlasgowComa Score (GCS).


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Initial resuscitation stabilization Includes airway- proper positioning head

tilt and chin lift, suction of secretions fromoropharynx, falling back of tongue isprevented by suitable airway tube.

Breathing- oxygen via a mask, whengag/cough reflects is absent- ET tubeinserted. if necessary positive pressureventilation with ABG monitoring,

respiratory stimulants for severerespiratory depression.Circulation- proper IV access, maintenance

of fluid & electrolyte balance, IV drugs fortreatment.


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Removal of Toxin The aim of decontamination procedures is to

reduce the absorption of poison. It can beachieved by:

Eye decontamination. Ocular exposure tosolvents, e.g., hydrocarbons, detergents, andalcohol, or corrosive agents, e.g., acid oralkalis require immediate localdecontamination. This is achieved by copious

irrigation with neutralizing solution (e.g.,normal saline or water) for at least 30minutes. Do not use acid or alkaline irrigatingsolution.


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Dermal decontamination. Absorption oforganophosphorus and related compoundsthrough cutaneous route can prove to be a

fatal as oral route absorption. Cutaneousabsorption depends on several factors suchas lipid solubility, skin condition, location,caustic effect, physical conditions


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Remove all contaminated clothes and irrigate thewhole body including nail, groin, skinfolds with

water or saline as soon as possible after exposure

and continue irrigating for at least 15 minutes.

Water should not be used to decontaminate skin in

exposures to sodium and phosphorus. In certain

cases, specific agents may be indicated for skin

decontamination (e.g., mineral oil for elementalsodium, Neosporin for super glue and calcium

gluconate for hydrofluoric acid).


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Gut decontamination. This includes (i)gastric evacuation; (ii) adsorbent

administration; and (iii) catharsis. Emesis isthe preferred method of emptying thestomach in conscious children. Vomitingcan be induced by (a) tickling the fauceswith a finger, feather or a leafy twig of atree; (b) administration of copiousdraughts of warm water; (c) gurgling withnon-detergent soap; or (d) saline emeticsin warm water. To prevent aspiration insmall children, the head should be keptlow.


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Syrup of ipecac may be used for inducing emesis inchildren older than 6 months in a single dose of 10mL for 6-12 months age, and 15 mL for childrenabove 1 year of age. The dose may be repeated in 20minutes for those more than 1 year of age.

Induction of vomiting is contraindicatied in corrosiveor kerosene poisoning and in comatose patients orthose with absent gag reflex.


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Gastric Lavage. If the vomiting does not occurquickly, gastric lavage should be done promptlyto remove the poison. In a symptomatic butalert patient with minor ingestion, activatedcharcoal alone by mouth is sufficient forgastrointestinal decontamination


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Gastric lavage should not be performed inchildren with poor gag reflex or corrosiveingestion. In kerosene poisoning, lavage maybe done very cautiously if the child has

consumed a large gulp of kerosene and isbrought quickly to the hospital, otherwise it isbetter to avoid stomach wash.


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Adsorbent administrationAn agent capable of binding to a toxic agent in

the GIT is known as adsorbent. Activated

charcoal is the most widely used adsorbent. Itis created by subjecting carbonaceous materiale.g., wood, coal etc. to steam at 600-900degree Celsius and acid.


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For the comatosed patient (Grade 3 or 4) with

potentially serious overdose, gastric lavage isfollowed by administration of activatedcharcoal via an orogastric or nasogastric tubewithin 1-2 hours of ingestion. Dose of activated

charcoal administered should be atleast 10times the dose of ingested toxic material. Inasymptomatic patient presenting early orwithout reliable history, 15-30 gram of charcoalmay be used.


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Catharsis Laxative and purgatives may be given in

poisoning with substances which do not causecorrosive action on gastrointestinal mucosa.

Increased motility of the gut may reduceabsorption. Commonly used cathartics includesorbitol and mannitol (1-2 g/kg), andmagnesium or sodium sulfate (200-300 mg/kg).

Do not give magnesium salt cathartics in caseswith renal failure.


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Supportive TherapyKeep the airway open, give oxygen for

inhalation and be prepared forintermittent positive pressure respiration.Fluid and electrolyte balance ismaintained. Circulatory failure should bemanaged to sustain life. Anemia is treatedwith packed cell transfusion.


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Severe convulsions and statusepilepticus are treated with diazepam

or midazolam. Renal failure is managedas per standard protocol; dialysis maybe needed. Infections are treated withantibiotics. Fever and pain are relived

with antipyretics and analgesics.


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History takingWhat poison was ingested. Time since ingestion. Total amount of poison ingested.Route of exposure. Progression of signs and symptoms since

ingestion. Family history of epilepsy, mental sub

normality, bleeding disorder.Whether the patient is receiving other

medications which may interact with thepoison.


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Ingested Poisons

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