Toxicology
Short Description
Download Toxicology ...
Description
PHARMACOLOGY Toxicology Dra Dando 12 February 2008 Joyce “,. POISONING •
•
•
Overdose of drugs, medicaments, chemicals and biological substances “acute” poisoning versus “chronic’ poisoning Acute: 24 -48 hrs of exposure Chro Chroni nic: c: week weeks, s, mont months hs,, year years s of exposure Father of toxicology: Paracelsus
GENERAL PRINCIPLES Emergency Emergency stabilization o First thing to do Clinical evaluation o Include good Hx taking & thorough PE Elimination of the poison Excretion Excretion of the absorbed substance Administration Administration of antidotes o Important for certain specific poisons or drugs Supportive therapy and observation Disposition EMERGENCY STABILIZATION Maintain adequate Airway o Remove obstructions o Condition Conditions s wherein wherein suction cannot cannot be done: caustic substances (causes ulceration of GI mucosa) hydr hydroc ocar arbo bons ns (cau (cause ses s aspi aspira rati tion on)) Ensure adequate Breathing/Ventilation o Nasal cannula, intubation Maintain adequate Circulation (put IV lines, fluids) Treat convulsions (e.g Diazepam) o Diaze Diazepam pam:: 1st lin line of Tx for for acti active ve seizures and status epilepticus Correct metabolic abnormalities (E (Electrolytes, glucose, acid-base) o Base ase: used for for severe metabo taboli lic c acidosis (Tx: Na, bicarbonate) o Glucose: Glucose: for hypoglyc hypoglycemia emia (Dextr (Dextrose ose 50-50 concentration) Treat coma (e.g Flumazenil) o Flumazenil: 1) Tx for for BZD BZD (dia (diazep zepam) am) overd overdose ose 2) Tx for for coma coma (bu (butt not not as firs firstt line line agent) - coma due to overdose overdose of valium valium
COMMON CAUSE OF HYPOXIA Alcohol Cyanide o In silver jewelry cleaners Organophosphates o In pesticies apriL jat
aLLain bambi
madeL erika
yna jen
raLph roche
Carbon monoxide
Opiates (Morphine, Novaine, Heroin, Codeine) Quinine o Anti-protozoal
RECOMMENDED IV FLUIDS Hypotensive Hypotensive patients NSS Adult for maintenance NSS D5 Acetated Ringer’s solution
Pediatric Pediatric for maintenance D5 0.3% NaCl (hypo)
POISO SON N COMMONLY ASSOCIA CIATED WITH CONVULSIONS Aminophylline Amphetamines Carbon monoxide Cocaine Cyanide Ethylene glycol Hypoglycemic Hypoglycemic agents Isoniazid – triad of coma, metabolic acidosis, intractable seizures Lead MAO inhibitors Mefe Mefena nami mic c Acid cid (usu (usual al side side effe effect ct:: GI irritation; overdose: seizures) seizures) Opioids Organophosphates Phenothiazines Salicylates (Aspirin) Strychnine Theophylline Tricyclic antidepressants Withdrawal Withdrawal of narcotics, diazepam or ethanol Signs of ethanol withdrawal o Irritable o Agitated o Seizure CAUSE SES S OF CONVULSION IN POISONED NED PATIENTS Direct convulsant effect of the poisons Cer Cerebral ral hypox poxia from from respirat irato ory or cardiovascular cardiovascular depressive effect of drugs Hypoglycemia Seve evere muscle cle spasm pasm due to spina pinall o periph riphe eral ral effe ffects cts on the the mec mechani hanis sm controlling muscle tone Withdrawal Withdrawal reactions in patients with physical dependence on abused drugs Decrease Decreased d seizure seizure threshol threshold d in an epilepti epileptic c patient TREATMENT TREATMENT OF CONVULSION
tLe bam
jovs aLex
pao anna
cess sheen a
xtian jam
abi pau
edward eagleman
banana jeff
car toni
PHARMACOLOGY:
Toxicology – Dra. Dando Page 2 of 8
•
•
•
•
Diazepam o Adult: 5mg IV o Children:0.3mg/kg o Only compatible fluid is blood (direct) Lorazepam (Ativan) o Adult: 2.5-10mg IV o Children: 0.05-1 mg/dose o Withd Withdraw rawn n from from the marke marked d d/t its associated side effects o Short acting, long duration Phenytoin o LD: 15-20mg/kg IV o Adult: 50mg/min o Children: 1mg/kg/min o Inducer of CYP450 o Maintenance Maintenance drug Pyridoxine (B6) o Adult: 5g IV o Children: 80-120mg/kg o For INH poisoning o Tx of convu convulsi lsions ons due to unkno unknown wn etiology Hypothermia Alcohol Barbiturates Carbon monoxide General anesthetics Opioids Phenothiazenes Sedative-hypnotics Tricyclic antidepressants
Hyperthermia
Antihistamines Amphetamines Isoniazid Phenytoin Salicylates Xanthines Anticholinergics: Atropine Cocaine Phenothiazines Quinidine Sulfonamides
•
•
Thiamine (vit B1) 100mg IV o Tx Tx of Werni ernick cke e Korsa orsako koff ff Synd Synd in alcoholic px Glucose Adult: 50-100ml D50-50 o o Children:2ml/kg Children:2ml/kg d10 o Most pts present with hypoglycemia esp. in alcoholic intoxication o Wernicke-Korsakoff syndrome d/t sever B1 deficiency admi admini nist ster er B1 firs firstt befo before re giving glucose Naloxone o Adult: 2mg IV every 3-5mins o Children: 10mcg/kg o For opiate overdose (coma) o Expensive o Given Given to newb newbor orns ns whose whose mothe mothers rs unde underwe rwent nt CS causin causing g resp respirat iratory ory difficult in their babies
COMPLETE CLINICAL EVALUATION •
Good Good hist history ory taki taking ng (d/t (d/t vuln vulner erab abil ilit ity y children)
Time exposure Needs to be very specific e.g.: N-acetylcysteine, N-acetylcysteine, antidote for paracetamol overdose; effective only in the first 6 hrs after ingestion
•
• • • • •
e.g. lavage of poison is only good for the 1st 24hours Mode exposure Rectal Transplacental Oral Etc Intake of other substances Circumstances Circumstances prior to poisoning Current medications Past medical history Any home remedies taken *Organophosphate/carbamat *Organophosphate/carbamate e poisoning: manifests with DUMBEL
POISONS WITH DELAYED MANIFESTAIONS Ethylene glycol 6 hours o Prese resent nt in anti anti-12 hours freeze 36 hours Salicylates 48 hours Paracetamol 48 hours Paraquat Methanol 4 weeks o Toxic Toxic alcohol Thyroxine *Vodka - among alcohols, alcohols, has the highest alcohol alcohol content - converts ethylene glycol and methanol to less toxic form - amount to be given needs to be computed
TREATMENT OF COMA OF UNKNOWN ETIOLOGY •
•
of
INFORMATION TO BE ELICITED DURING HISTORY
COMPLETE CLINICAL EVALUATION Complete physical examination examination Evaluate general status Examine skin Characterize odor of patient’s breath Auscultate the lungs Listen to patient’s heart Check the abdomen Do a complete neurologic exam Skin changes in poisoning Bullae: barbiturates, CO Diaphoresis: OP, salicylate, amphetamine Jaundice: paracetamol Dry and warm: atropine, anticholinergic
alco alcoho hol, l,
Oil of wintergreen: methylsalicylate Rotte Rotten n eggs: eggs: sul sulfur fur dioxid dioxide, e, hydr hydroge ogen n sulfide Pears: chloral hydrate Garlic: arsenic, OP
Mothballs: camphor (like the one in vicks)
Flus Flushe hed: d: anti antich chol olin ine ergic rgics, s, cyanide, atrophine odors Brerath odors Bitter: almonds, cyanide Fruity: DKA, isopropanol
Bradycardia
Tachycardia
PHARMACOLOGY:
Toxicology – Dra. Dando Page 3 of 8
Propranolol
Iron
Anticholinesterase
CO, cyanide
Clonidine, codeine, Ca-channel blocker
Organophocphate
Phenothiazine
Ethanol
Digitalis
Ethanol thanol,, glycol
Antihistamines
Antidepressants
Sympathomimetics
Isoniazid
Anticholinergics
COND CONDIT ITIO ION N OR AGEN AGENTS TS PRED PREDIS ISPO POSI SING NG TO METABOLIC ACIDOSIS OR ELEVATED ANION GAP Methanol •
Anticholinergics
Antihistamines
•
Ethylene gycol
Amphetamines
•
Theophylline, heophylline, toluene
Sympathomimetics
•
Alcoholic ketoacidosis
Salicylates, solvents
•
Lactic acidosis
•
Theopylline
Aminoglycosides
•
Cyanide, CO
•
Isoniazid, Iron
•
Diabetic ketoacidosis
•
Grand Mal seizures
•
Aspirin (salicylate)
•
Paraldehyde, phenformin
Miosis
Cholinergics, clonidine
Opiates, Organophosphate
Phenothiazines, pilocarpine, pontine bleed Sedative-hypnotics
*Triad of opiate overdose: Coma Respiratory depression Pinpoint pupils Clinical Evaluation: Check for Toxidromes Signs Signs and symptoms taken collectively collectively can characterize a suspected toxicant These groups of manifestations are observed to occur consistently with particular poisons o Intr Intrac acttable able seiz seizur ure es + Com Coma + Metabolic acidosis = INH Poisoning *Intractable seizures despite administration of diazepam
Anticholinergic / Antidepressant T Toxidrome oxidrome Hyperthermia: Hyperthermia: “hot as a hare” Dry mucosa: “dry as a bone” Flushed skin: “red as a beet” Dilated pupils: “blind as a bat” Confusion / delirium: “mad as a hatter”
ELIMINATION OF THE POISON •
•
•
Cholinergic Toxidrome (S&Sx of organophosphate and carbamate poisoning) Diarrhea, diaphoresis
Urination
Miosis, muscle fasciculations
Bradycardia, bronchoconstriction bronchoconstriction
Emesis
Lacrimation
Salivation
SUBSTANCES WITH RECIRCULATION Aspirin Cyclosporine Digoxin Meprobamate Paracetamol Phenothiazine Phenytoin Salicylate TCAD Anticoagulants Carbamazepine Dapsone Gluthetimide Methamphetamine •
• • • • • • • • • • •
Opiates / Narcotics
External Decontamination Decontamination – bathing of pt with alkaline soap e.g perla, ivory, dove Emptying the stomach o Emesis – only in adults *pediatrics have risk for aspiration o Gastric lavage – H20, NSS, Na Bicarbonate, activated charcoal Limiting GI absorption o Activated charcoal o Demu Demulc lcen ents ts (wat (watus usi) i) / neut neutra rali lizi zing ng agen agents ts (raw (raw egg egg whit white: e: to prev preven entt absorption)
SUBST SUBSTANC ANCES ES NOT ABSORB ABSORBED ED BY ACTIV ACTIVA ATED CHARCOAL Alcohol – rapid absorption Cyanide Iron o Lavage with NaHCO3 Lithium - dialysis Petroleum distillates (hydrocarbons) Caustic agents
•
Miosis Bradycardia Hypotension Hyperventilation Coma
ethyle ethylene ne
Free-base cocaine
Sympathomimetics
Mydriasis
Mydriasis Tachycardia Hypertension Hyperthermia Seizures
•
EXTRAHEPATIC
PHARMACOLOGY:
Toxicology – Dra. Dando Page 4 of 8
• • • • •
Phencyclidine Phenobarbital Piroxicam Theophylline Organochlorines
o
o
*Formalin ingestion: No antidote Give H2 blockers
Reductio ction n compounds Ethanol o For For tx of metha methanol nol and ethylene ethylene glycol poisoning Competitive inhibition at receptor site
Surgery (cut the part with ulceration)
ENHANCEMENT OF ELIMINATION OF ABSORBED SUBSTANCES Forced diuresis o Mannitol 20% - osmotic diuretic o Furosemide – loop diuretic Alkalinization therapy Sodium Sodium bicarbon bicarbonate ate – for weak weak acids: acids: o INH poisoning Acidi cidifi fica cati tion on ther therap apy y (for (for weak weak base bases: s: • Methamphetamine/shabu) o Ascorbic acid o Ammonium chloride Dialysis and hemoperfusion Multiple dose activated charcoal •
Atro Atropi pine ne (phy (physi siol olog ogic ic anti antido dote te)) – for for organoph organophosph osphate/c ate/carbam arbamate ate poisoning; poisoning; inhibits the enzyme acetylcholinesterase) acetylcholinesterase) Pralidoxime Pralidoxime (pharmacologic antidote) Bypassing the effects of the poison Oxygen for CN poisoning
•
Pyridoxine Pyridoxine for INH poisoning Antibody interacting with poison
•
Digoxin Digoxin antibody antibody fragment fragments s (Digibin (Digibind) d) – not available locally *Locally: nadia-nadia
Snake antivernin (available in RITM) spec specie ies s of Phi Phili lipp ppin ine e cobr cobra a caus cause e paralysis Tx: acti activ vate ated char charc coal oal
•
INDICATIONS FOR DIALYSIS •
•
•
• •
Aman Amanit ita a phal phallo loid ides es (mus (mushr hroo oom) m) – very very dangerous and lethal causing renal failure Antifreeze (glycol type) o Tx: Tx: ethan thanol ol e.g. .g. vodk odka via via NGT; prevents conversion to more toxic from Heavy metals in soluble compounds o Tx with EDTA or chelators Heavy metals after chelation Methanol
ANTI ANTIDO DOTE TES S FO FOR R PATIEN TIENTS TS WITH WITH COMA COMA OF UNKNOWN ETIOLOGY ETIOLOGY Naloxone Glucose Thiamine • • •
ANTID ANTIDOTE OTE FOR PATIENTS TIENTS WITH WITH SEIZUR SEIZURE E OF UNKNOWN ETIOLOGY ETIOLOGY •
Pyridoxine (Vitamin B6)
(Fe3+) stat state e, result sultin ing g in the inability to transport oxygen and carbon dioxide) Sodium Sodium Thiosu Thiosulfa lfate te:: binds binds with with cyanide-methemoglobin cyanide-methemoglobin complex to detoxify Used in PGH, a raw material that is comp compou ound nded ed and and prep prepar ared ed whenever it is needed in con conversio rsion n to more ore toxic
SUPPORTIVE THERAPY Essential for poisoning patients, especially for critically ill Problems Problems in the critically ill poisoned patients o Depressed sensorium o Impaired ventilation o Impaired cough reflexes o Prone to aspiration o Immobility o Fluid, Fluid, electro electrolyte lyte and other other ,metabol ,metabolic ic problems Intr Intrav aven eno ous flu fluids ids: replace lacem ment and and maintenance Frequent blood and urine pH determination: acidification and alkalinization therapy Prevention Prevention of aspiration Prevention of decubitus Ulcer Tre Treatm atment ent of electr electroly olytes tes,, metab metaboli olic c and temperature problems Monitoring of vital signs Monitoring of input and output •
•
•
•
• •
USE OF ANTIDOTES Mechanisms: Inert Complex Formation Chelating agents (DMSA, NAPA) o Tx of heavy metal poisoning DMSA: suximer? NAP NA PA: N-ac N-acet etyl yl-p -pen enic icil illa lami mic c acid acid mercury, arsenic, lead Accelerated detoxification
• •
• •
–
GOOD GOOD SUPP SUPPOR ORTI TIVE VE AN AND D NURS NURSIN ING G CARE CARE IS IMPORTANT
Cyanid Cyanide e antido antidote te kit – availa available ble in US only Sodium nitrite and sodium thiosulfate o Sodium nitrite: Induce methemoglobinemia (a condition in which the iron within hemoglobin is oxidized from the ferrous ferrous (Fe2+) state to the ferric
DISPOSITION Observation at the emergency room: atleast 24hrs may be warranted Frequent reevaluation Psychiatric evaluation: suicidal patients and substance abusing patients Childhood Childhood poisonin poisoning g: evaluate evaluate for possible possible • child abuse or neglect Family counseling and education •
• •
•
PHARMACOLOGY:
Toxicology – Dra. Dando Page 5 of 8
• •
Physical or sexual abuse among women Domestic violence
TOP TEN POISONS (All Ages) IN-PATIENT STATISTICS National Poison Control and Information Service UPPGH YEAR 2006 (N=847) NUMBER PERCENTAGE 1. Ethanol – alcohol 95 1 1 .2 withdrawal pts 2. Kerosene (Gaas) 87 1 0 .3 3. Sodiu odium m Hypoc ypoch hlori lorite te 62 7 .3 (Zonrox) 4. Mercury (thermometer) 45 5 .3 5. Jewelry Cleaner (Cyanide) 35 4 .1 6. Hydrochloric acid (Muriatic) 27 3 .2 7. Methamphetamine (Shabu) 19 2 .2 8. Paracetamol 16 1 .9 9. Mixed Pesticides (Baygon) 15 1 .8 10. Jathropa seeds (cause 15 1 .8 hemorrhagic gastritis)
Acetic acid Benzalkonium chloride Pathology: Coagulation necrosis Others
Phenol (e.g. Lysol)
Cyanide salts: Silver jewelry cleaner - mixed with Na Hydroxide
PHARMACEUTICAL AGENTS Paracetamol Toxic dose: 150-200mg/kg Toxic xic meta metabo boli lite te:: NAPQ NA PQII (N-a (N-ace cety tyll-ppbenzoquinone imine) GI, liver and renal damage (4 stages) Antidote: N-Acetylcysteine
*Na Hydroxide: Liquid sosa
TOP TEN POISONS (All Ages) TELEPHONE REFERRALS National Poison Control and Information Service UPPGH YEAR 20 2006 (N (N=2,682) NUMBER PERCENTAGE 1. Kerosene 192 7 .2 2. Sodium Hypochlorite 131 4 .9 3. Mixed Pesticides (Baygon) 118 4 .4 4. Elemental Mercury 90 3 .4 5. Paracetamol 64 2 .4 6. Silica gel (sho es es) – 62 2 .3 nontoxic, causes mild GI manifestation 7. Jewelry Cleaner 57 2 .1 8. Ferrous Sulfate 53 2 .0 9. Hydrochloric acid 48 1 .7 10. Isoniazid 42 1 .6
HYDROCARBONS
Kerosene (Gaas) Chemical pneumonitis o Presents with cough cyanosis seizures Aspiration pneumonia
Treatment: Pen G or other beta-lactams (for pneumonia) No antidote Easily absorbed
CAUSTIC AGENTS
Alkali (ph > 7)
Strong alkali: ph >10
No antidote (only supportive): H2 blockers, PPI Sodium hypochlorite Sodium hydroxide (e.g liquid sosa) “LIhiya” (pang-green ng suman) Main Tx: surgical Pathology: liquefaction necrosis (esophagus and intestine)
Acids (ph < 7) Strong acid: ph 2 >2 y/o y/o Permethrin - anti-pediculosis and scabies: cause seizure
Small-scale mining practices = residue after panning operation where most of the water are removed = no personal protective device is provided = route of entry is skin
Coumatetralyl bleeding (Tx: vitamin K)
Herbicides Chemical pneumonitis
Mercury in Thermometer Thermometer “Ther “There e is appro approxim ximate ately ly 1 gram gram of merc mercury ury in a typical fever thermometer. This is enough mercury to contaminate a lake with a surface area of about 20 acres, to the degree that fish would be unsafe to eat”
MIIXED PESTICIDES (e.g. Baygon) Carbamates Propoxur
Orga Organi nic: c: cont contam amin inat ated ed wate waters rs from from indu indust stri rial al wast waste e prod produc ucts ts,, air, air, soil soil (methylmercury)
Pyrethroid Cyfluthrin Transfluthrin S/Sx: DUMBELS Treatment: Atropine, Activated Charcoal
*Mercury is not actually absorbed if GI is intact but can cross BBB after 24-48 hrs *Tx: cathartics
Organic Chemicals: Methylmercury Methylmercury
Effects of Pesticides: - Endoc Endocrin rine e dis disrup ruptio tion n (cause (cause probl problems ems in reproduction and immune system) Neurode odevelop lopmen mental tal effe ffects (e. (e.g auti autism sm,, cerebral palsy, mental retardation) Immu Immune ne sys syste tem m (can (can cau cause se can cance cer) r) NON-PHARMACEUTICALS
Silica gel – gastric irritant
Chinese Chinese herbal herbal meds (e.g. (e.g. Ma-Hu Ma-Huang ang – has pseudoe pseudoephe phedrine drine and ephedrin ephedrine: e: precurs precursor or of methamphetamine) Button batteries in 1.5 5 cm can can obst obstru ruct ct trac trache hea, a, pyl pylor oric ic sph sphin inct cter er endo endosc scop opy y is is don done e to to get get it manu manual ally ly Watusi
Yel Yello low w phos phosph phor orus us – most most dang danger erou ous s (protoplasmic: (protoplasmic: cause severe hypotension and hypoxia)
dynam dynamite ite and
Trin Trinitr itroto otolue luene ne (pres (present ent in bombs) Potassium nitrate Potassium Potassium chlorate Moth balls
Naphthal Naphthalene ene – causes causes hemolytic hemolytic anemia in G6PD deficiency pts
Camphor – most toxic
Paraara-di dich chlo loro robe benz nzen ene e Albatross)
–
deod deodor oriz izer er
(e.g (e.g..
toxic, causes - least toxic, slight gastric irritation
*Mercury vapor – amalgam fillings are chief sources of exposure to mercury vapor Minamata Minamata Disease Disease (d/t (d/t high high leve levels ls of meth methyl yl mercury in big fishes, e.g. tuna) In 1932, Nippon Chisso Hiyu started to operate an acetaldeh acetaldehyde yde acetic acetic venyl venyl chloride chloride manufactu manufacturing ring plant plant using using mercury mercury as a cataly catalyst. st. The plant plant had been directly directly discharg discharging ing its industria industriall waste waste into Mina Minama mata ta Bay for for 36 year years s with ith no adeq adequa uate te facilities. In 1958, Chisso redirected the outlet drainage canal from from Minam inamat ata a Bay into into the the trib tribu utary tary of the the Minamata River which resulted in the contamination of a wider area of Yatshushiro Sea. Increase in number of vaccines recommended for routine use in infants
HEAVY METALS
Mercury (a.k.a Asoge) Sources: Elemental: “quicksilver” metal, cinnabar ore ore, dental ntal amal amalg gam, am, app apparat aratu us, thermometers Inorganic: (merthiolate)
antiseptics,
vaccines
Potential increased exposure of infants to mercury from thimerosal in vaccines Ethyl Mercury
PHARMACOLOGY:
Toxicology – Dra. Dando Page 7 of 8
= in childre children n receivin receiving g thimeros thimerosal al in vaccines vaccines,, the half-life of ethyl mercury in blood was 7-10 days or 1/7 to 1/5 as long as that of methyl mercury = a WHO advisory committee recently concluded that it is safe to continue using thimerosal in vaccine Mercury (Pink Disease) Acrodynia Acrod crodyn ynia ia is a rar rare idio idiopa path thic ic chr chronic onic toxi toxic c reaction reaction to element elemental al or inorganic inorganic mercury mercury expo exposu sure re,, whic which h occu occurs rs main mainly ly in youn young g children children.. It is character characterized ized by by pain in the extr extrem emit itie ies s and and oink oink disc discol olor orat atio ion n with with desquamation of the skin
Cyanogen-containing plants Linamarin in cassava cake – associated Sxs: DUMBELS
Cyanide salts
Uncommon Syndrome “Pink Disease”
Pain in the extremities Pinkish discoloration and desquamation Hypertension Sweating Insomnia, irritability, apathy Considered Considered as idiosyncratic reaction
Adverse Effects of Mercury Elemental acut acute e necr necrot otiz izin ing g bron bronch chit itis is pneu pneumo moni niti tis, s, insomn ins omnia, ia, forget forgetful fulne ness, ss, loss loss of appeti appetite, te, tremor, erethism, renal toxicity Inorganic corr corros osiv ive e effect effects: s: GI ulcer ulcerat atio ion, n, perf perfor orat atio ion, n, hemorrhage, acrodynia, renal toxicity Organic - CNS: paresthesia, ataxia, muscle spasticity Infa Infant nts: s: psych psychom omot otor or retar retarda dati tion on,, blin blindn dnes ess, s, deafness, seizure, cerebral palsy Beha Behavi vior oral al and lear learni ning ng dela delays ys:: defi defici cits ts in language, attention and memory
Lead (a.k.a tingga) Pregn regnan antt women omen and and thei theirr deve develo lopi ping ng fetuses are at high-risk because lead readily crosses the placenta For every 10mcg/dl increase in BLL, children’s IQ dropped by 4-7 points
A higher higher proporti proportion on of learning learning disabilit disabilities ies was found among school-aged children with biological parents who ere lead poisoned as children 50 years previously Source: paints, lipstick, gasoline, hair dyes
CYANIDE inhi inhibi bits ts cyto cytoch chro rome me oxida xidase se CNS Effec Effects: ts: shock shock,, prof profoun ound d lactic lactic acidos acidosis is Toxic oxic bloo blood d lev level el:: >0. >0.5 5 mcg mcg/m /mll
Metal polishing (jewelry cleaners)
Cyanide Antidote Kit Amy Amyl nitri itritte, sodiu odium m thiosulfate
Amne Amnesi sic c or poisoning Domoic acid
Paralytic shellfish poisoning
Brevetoxin
Department of Health Criteria for Detecting PSP Ataxia + Additional 2 Motor Distrubances + Dysphagia Inability to to st stand Vomiting Dyspnea Paralysis Additional 2 Sensory Disturbances Dizziness Headache Lightheadedness Paresthesias Dysthesia Hot flashes Numbness
PLANT TOXINS Jathropa Seeds Contents: toxalbumins = ricin (toxic content causing hemorrhagic gastritis), curcin, tannic acid
Effects: Effects: abdomina abdominall pain, pain, nausea, nausea, vomiting, vomiting, hepatic hepatic injury, injury, muscle muscle twitchin twitching, g, weakness weakness,, salvation, sweating, dehydration, hemorrhagic hemorrhagic gastritis Tx: activated charcoal
shel shellf lfis ish h
Neurotoxic shellfish poisoning (NSP)
Keratotic lesions cancerous Patients from Bangladesh dig a well
ence enceph phal alop opat athi hic c
Saxitoxin and gonyautoxin (GTX)
Arsenic Poisoning
sodiu odium m
RED TIDE POISONING Diarrheic shellfish poisoning Okadaic acid (OA) and its derivatives
nitri itrite te,,
Specific Treatment
PHARMACOLOGY:
Toxicology – Dra. Dando Page 8 of 8
With known or suspected toxin
(-) Respiratory Distress
Give Give raw raw egg egg whit whites es in case cases s of corr corros osiv ive e ingestion 8-12 egg whites (adult) 4-6 egg whites (children)
Give Give 1-5% 1-5% baking baking soda soluti solution on in cases cases of shellfish and iron poisoning 1 teaspoon + 100mL water
(+) Respi Distress
Observe for 24 hrs
Asymptomatic Respi Failure
(-) Respi Failure
(+) PREVENTIVE MEASURES Wash vegetables / fruits thoroughly Support integrated pest management Avoid use of mercury thermometers Flush cold water tap before use Dispose chemical containers properly Promote healthy lifestyle: “Say no to drugs” Do regular inventory of drugs and chemicals in the house Proper storage or labels • •
Discharge hrs x 24h
NaHCO3 q 5 hr
NaHCO3 q 5
• • •
Observe x 24 hrs
•
Ventilatory support
•
Respi Distress
Test dose of
•
edrophonium
Nati Nation onal al Pois Poison on Mana Manage geme ment nt and and Cont Contro roll Center UPCM – Philippine General Hospital Hotl Hotlin ine e Numb Number ers: s: 5241 524107 078 8 or 5218 521845 450 0 loc. loc. 2311 Public Health Issues Reporting to DOH Shellfish / Fish Advisory Monitoring of other possible patients Monitoring of levels of toxins in the area (BFAR) SUBSTANCE ABUSE Sedatives Diazepam (Valium) Lorazepam (Ativan) Flunitrazepam (Rohypnol) Sleeping Pills (Stinox, Unisom) *Ecstasy - side effect: bruxism - causes seizure, severe dehydration - more toxic than shabu Smoking and Alcohol FIRST AID MANAGEMENT OF POISONING CASES GOAL OF TREATMENT: to limi limitt abs absor orpt ptio ion n of of poi poiso son n remo remove ve from from to toxic xic env envir iron onme ment nt deco decont ntam amin inat atio ion n Mane Maneuv uve ers REMEMBER THE DONT’S:
Do not not indu induce ce vomi vomiti ting ng in the the foll follow owin ing g situations: drow drowsy sy and and com comat atos ose e pat patie ient nts s poor gag reflex inge ingest stio ion n of cor corro rosi sive ve and and hyd hydro roca carb rbon on if the the inges ingesti tion on has has occur occurrred for for more more than than one hour late late pre pregna gnancy ncy (last (last 3 mont months hs of pregn pregnanc ancy) y) pres presen ence ce of hear heartt dise diseas ase e Do not give milk or vinegar :milk is not a universal antidote
View more...
Comments
