Emergency Medicine | Principles of Management of Acute Poisoning | Made Easy by Dr. Rupak Bhandari

A video by:
Dr. Bharat KC ( MBBS 2014, BPKIHS)

PRINCIPLES OF MANAGEMENT OF ACUTE Poisoning
Rupak Bhandari, MD
Assistant Professor
Dept. of General Practice and Emergency Medicine, BPKIHS, Dharan
Nepal Chair: WONCA Spice Route Young Doctor’s Movement

Poison centre (Nepal) : +977-9851038490

Poison
Any substance that can cause severe damage or death if ingested, breathed in, injected into the body or absorbed through the skin.

Scenario in Nepal

Organophosphates are the most common form of poisoning
Majority of intentional poisoning occur in the female housewives & students of younger age group
More common in age group 15-24 years

APPROACH TO MANAGEMENT OF ACUTE POISONING
Stepwise approach to management of acute poisoning
1. Emergency stabilization
2. Supportive therapy
3. Clinical evaluation
4. Limiting absorption of poison
5. Enhanced elimination of poison
6. Administration of antidote
7. Appropriate disposition

Emergency Stabilization(Resuscitation)

Airway
Airway interventions
Clear oropharyngeal secretions
Sniffing position
Head-down, left-lateral position

Evaluate gag/cough reflex

Timely Intubation

Breathing

Determine if respirations are adequate
Give supplemental oxygen
Check oxygen saturation, ABG
Assist with bag-valve-mask ventilation

Auscultate lung fields
Bronchospasm: salbutamol nebulization
Bronchorrhea: Atropine
Stridor: Determine need for immediate intubation

Circulation

IV access

Evaluate the hemodynamic status

Obtain blood samples for work-up

Continuous ECG monitoring

Assess for arrhythmias, treat accordingly

Hypotension treatment:
Normal saline fluid challenge, 20 mL/kg
Re-assessment and repeat bolus if required
Vasopressors if still hypotensive

Hypertension treatment:
Nitroprusside, beta blocker, or nitroglycerin

Disability
Focused neurological assessment:
AVPU / GCS
Pupillary reaction

Exposure with environmental control

Remove clothing and change with a new set
Examine patient for any trauma
Prevent Hypothermia

SUPPORTIVE MEASURES
Monitor vital signs
Maintenance IV fluids
Intensive nursing care (Nasogastric tubes, foley’s catheter, eye care)
Monitor fluid input and output
Temperature charting
Prevention of Hypo-/ Hyperthermia
Control of seizure and agitation
Benzodiazepines, Barbiturates
CLINICAL EVALUATION

History

Agent and amount
Time and location of exposure
Route of exposure
Intake of other substances
Circumstances of exposure
Current medications
Past medical history
Pre-hospital treatment

Physical Examination

Check clothing for objects or substances
Assess general appearance of patient - Agitation, confusion, drowsy
Exam skin for bruising, cyanosis, flushing
Exam eyes for pupils size, reactivity, lacrimation
Oropharynx for increase salivation or excessive dryness

Cardiovascular: tachy-/brady-cardia, hypo-/hypertension, conduction defects and arrhythmias

Respiratory: bronchorrhea, wheezing, ventilatory failure

Neurological: agitation, delirium, seizure

Extremities: fasciculation, tremors

Metabolic: hyper-/hypoglycemia, electrolyte imbalance, acidosis, alkalosis

Toxidromes
A toxidrome is a combination of signs and symptoms which, when taken collectively, characterize a suspected toxicant

Bradypnea
Bradycardia
Hypotension Opioids
Hypothermia
Miosis

Diarrhea/diaphoresis Urination
Miosis
Muscle fasciculations Organophosphate Poisoning
Bradycardia/bronchorrhea
Emesis
Lacrimation
Salivation

Tachycardia
Hyperthermia
Dry skin
Mydriasis
Decreased bowel sounds Anticholinergics
Urinary retention
Delirium
Agitation

Hypertension
Tachycardia
Mydriasis Amphetamine/ Cocaine
Agitation

Laboratory Tests

Electrolytes
Glucose
Urea and creatinine
LFT, PT/INR
Electrocardiogram
Arterial blood gas
Urinalysis
Chest X-Ray
Pregnancy test (for female of reproductive age-group)

Specific lab testing
Acetaminophen
Salicylates
Urine drug screen
Alcohol screen

Electrocardiogram

Prolonged QRS
Tricyclic Antidepressants
Calcium channel blockers

Sinus bradycardia/AV block
Beta-blockers
Calcium channel blockers
Digoxin
Organophosphates

Ventricular tachycardia
Cocaine, amphetamines
Digoxin
TCAs

LIMITING ABSORPTION OF POISON
Decontamination
External
Internal

Gastric Lavage
A method of evacuating stomach contents by inserting a nasogastric tube, administration of normal saline then subsequent aspiration of fluid, bringing with it the ingested poison.

It should NOT be considered unless :
Patient has ingested a potentially life-threatening amount of poison
Patient presents within 1 hour of ingestion
Patient is either fully awake or intubated

Contraindications:
Unprotected airway
Hydrocarbon or Corrosive ingestion
Esophageal pathology

Complications:
Aspiration leading to hypoxia, pneumonia
Perforation (Throat, Esophagus, Stomach)
Laryngospasm
Epistaxis

Music credit:
Aakash Gandhi - lifting dreams

@DIP -Medical Videos | 2020
#poisoning #emergencymedicine #bpkihs

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