Transcript Acute human poisoning is a medical emergency Accidental

Recent Advances in Clinical Management of
Acute Human Poisonings
Mahdi Balali-Mood, M.D., Ph.D.
Visiting Professor of Newcastle University, UK.
Professor of Medicine and Clinical Toxicology.
Director, Medical Toxicology Research Center,
Imam Reza Hospital, Faculty of Medicine,
Mashhad University of Medical Sciences,
Mashhad, Iran.
Introduction (1)
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Any chemical, drug or a natural toxin may induce
acute human poisoning
A health problem in many parts of the world,
particularly in developing countries with poor
controls on drugs and chemicals
Nanomaterials are generally more toxic than
normal xenobiotics, which will soon be a new
health concern
Introduction (2)
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Acute human poisoning is a medical emergency
Accidental, occupational, environmental, suicidal, or even
criminal act as well as in the war and terrorism
Establishment of CLINICAL TOXICOLOGY FELLOWSHIP
Updated knowledge to deal with the appropriate clinical
management
Management Overview
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History & assessment of vital signs
A, B, C, D...
 Any
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concerns: Consult senior staff
Consider the toxidromes
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Supportive care (O2, IV Fluids)
Prevent absorption
Increase elimination
Antidotes
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PSYCHOLOGICAL ASSESSMENT
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Decontamination
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Based on the route of exposure (inhalation, oral
ingestion, skin and the eyes)
In case of toxic gas exposure, the rescuer(s) should
be protected
The exposed persons must be first removed from
the polluted area
Remove clothes
Decontaminate based on the poison and severity of
toxicity (running water and or soap, saline or
Ringer solution)
History – Questions to be Answered
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What?
When?
How much? (mg/kg)
What else?
Why?
Previous health condition?
Medications?
Drug Abuse?
Toxic Syndromes or Toxidromes
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Sedatives and Hypnotics
Cholinergic
Anticholinergics
Serotonin
Malignant
Narcotics
Withdrawal
Initial Examination and Management
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Vital signs
Airway
Breathing
Circulation
Disability – Coma, Respiratory and Pupils
Gastric aspiration (sample) and lavage
Activated Charcoal
Blood samples before IV treatment – Glucose
Treat problems as you find them!
Investigations
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All Poisoned Patients
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Glucose, BUN
Urine & Electrolytes
Urine toxicology screen
Quantification: Acetaminophen, Phenobarbital, Salicylate
As indicated
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LFT
Co-ag / INR
CK
ABG / VBG
ECG
CXR
Others
Reduce absorption
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Emesis – No role
Activated charcoal within 1 hour
Gastric lavage – rarely
Whole bowel irrigation – rarely
Skin and eye wash
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Do Not try to Neutralize
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Induce vomiting?
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Syrup of Ipecac?
Soapy water?
Don’t use:
 Finger
gag
 Salt water
 Copper sulfate
Ipecac-induced emesis?
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Easy to perform, but
Not very effective
Contraindicated:
 Comatose/convulsing
 Ingested
corrosive or hydrocarbon
 Rapid-acting CNS agent
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Ipecac is no longer used
Activated charcoal
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Finely divided powdered material
 Huge
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surface area
Binds most drugs/poisons
 Exceptions:
- Iron
- Lithium
- Other metals
Increase elimination
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Multi-dose Activated Charcoal
Urinary Alkalinisation
Haemodialysis
Haemoperfusion
Haemofiltration
Plasma exchange
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Forced alkaline diuresis and acid diuresis are no longer recommended
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Whole bowel irrigation
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Mechanical flush
Balanced salt solution with PEG
 No
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net fluid gain/loss
Good for:
 Iron
 Lithium
 Sustained-release
 foreign
bodies
pills,
Antidotal Therapy
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Effective specific antidotes for <10% of poisonings
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Administered as clinically indicated
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Simple cheap medications: sodium bicarbonate, magnesium
sulfate
Bio-scavengers: fresh frozen plasma, albumin
Antidotes
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Opiates – naloxone, nalmephen
Acetaminophen – NAC, methionin
Beta-blockers – atropine, glucagon
Insulin – glucose
Iron – desferrioxamine
Lead/Mercury – Succimer, BAL, CaNa2EDTA
Carbon monoxide – oxygen
Methanol – ethanol, fomepizol
Valporic acid – L-carnitine
(Benzodiazepines – flumazenil)
Intravenous Fat Emulsions
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Intravenous fat emulsion (IFE) as a source of parenteral nutrition for
over 40 years
As a diluent for intravenous drug delivery of highly lipophilic
xenobiotics such as propofol and liposomal amphotericin
IFE as an antidote for local anesthetic (bupivacaine) toxicity
Proposed for lipophilic drugs such as calcium channel blockers, cyclic
antidepressants, clomipramine and beta adrenergic antagonists
Summary and Conclusion
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Acute Human Poisonings are Common
Vital signs monitoring and support care using:
A B C D ...
Consider the toxidromes
Early senior help / Early ITU referral
Supportive Care
Antidotes
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Psychological assessment and treatment
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