APPOARCH TO A CASE OF UNKNOWN POISONING

STEP-1:Initial patient Assessment and supportive care STEP 2:History and Examination
History: - Determine Product name
-Check vitalsTPR,BP,SPO2 -GCS, pupils

Symptoms
SIX BASIC TOXIDROMES a) Anticholinergic: Tachycardia,hyperthermia,mydriasis,warm & dry skin,urinary retention,ileus,delirium b) Cholinergic: salivation,lacrimation, defaecation, emesis,GI cramps. c) Nicotinic: mydriasis,tachycardia,weakness,HTN,Hypergly cemia,fasciculations, sweating d) Opiods: Hypoventilation,hypotension,miosis, sedation e) Sympathomimetics : Tachycardia,hypertension,mydriasis,agitation,s eizure, diaphoresis,hyperthermia f) Withdrawal: Tachycardia, HTN, mydriasis, diaphoresis, agitation, restlessness, seizure, hyperreflexia, piloerection, abd cramps.

ABC
-Hypotension: IV fluids, vasopressors -Altered mental status: Naloxone (0.4-2mg)
-Hypoglycemia- Dextrose 50%, 50 ml iv stat
-Thiamine100mg im stat

-Amount -Time since exposure -Route of exposure -Age/Wt -Symptoms -Reason of exposure -Consider poisoning if- abrupt onset, at risk age group (2-4yrs,11-18yrs,>65 yrs), previous history,multiorgan failure, altered mental status

Monitor & Treat-a)Seizure(Diazepam,lorazepam)

b)Hypothermia,Hyperthermia c)Arrythmia d)Fluid & electrolyte imbalance

Examination: -Focus on poison specific symptoms

-Rule out other Medical conditions/trauma -Are signs & symptoms consistent with history?

STEP 3:Poisoning agent Specific Antidote KNOWN Terminate exposure

Poison Antidote Acetaminophen N-acetylcysteine Anticholinergic Physostigmine Benzodiazepines Flumazenil Beta blockers Glucagon CCB Calcium,Glucagon Carbamates Atropine Carbonmonoxide Oxygen Cyanide Na nitrite/Na thiosulphate Ethylene glycol ethanol,fomepizol Heavy metals DMSA,Ca EDTA Methanol ethanol,fomepizol Opiates naloxone Organophosphates-atropine,pralidoxime

UNKNOWN

Depending on route of exposure

-EYE-Flush with NS 15-20 mins -DERMAL-Remove jewelry/clothing -Wash with water 15-20 mins -INHALATION-Move to fresh air -INGESTION-Glass of water to dilute chemicals -INJECTION/BITE-Do not suck -Remove jewelry/clothing

Prevent absorption Activated charcoal- 1gm/Kg-oral/NG tube

-First line therapy -Does not adsorb- Fe, Na, Cyanide, Li, Pb, Hydrocarbons, caustics,alcohol Orogastric lavage - within 1-2 hr of ingestion -For substances not adsorbed by activated charcoal Whole bowel irrigation- Use PEG(polyethylene glycol) -Flushes GI tract -decreases absorption of Fe,Pb,sustained release drugs and FB(body packers)

Enhancing elimination -Multiple dose activated charcoal-Increseases GI clearance - 20-50 gm/4 hours - For dapsone,Phenobarbital, Phenytoin, theophylline -Hemodialysis/Hemoperfusion-for cases with progressive Deterioration despite intensive Supportive care -eg:Phenobarbital,salicylates,alcohol Lithium,Theophylline