Treatment of acute exogenous poisoning
Firstly, we need to consider the main clinical manifestations of acute poisoning:
- Cerebro Toxic syndrome
- Cardiotoxic syndrome
- Pulmotoxic syndrome
- Hepatotoxic syndrome
- Renotoxic syndrome
- Epicutaneous syndrome
- Irritative-corrosive syndrome
- Gastrotoxic syndrome
OK, basic principles - ABCDE AND 4Hs 4Ts!
6Hs + 6Ts - the reversible causes of peri arrest
- Hypovolemia
- Hypoxia
- Hydrogen ions (acidosis)
- Hyper/Hypokalemia
- Hypothermia
- Hypoglycemia
- Toxins
- Tamponade
- Tensions pneumothorax
- Thrombosis
- Thromboembolism
- Trauma
We can also say the following about all acute poisoning:
- Prevent additional absorption
- Gastric lavage is mentioned in the lecture, THIS IS NO LONGER COMMON, after 30 mins may make things worse - only attempt in specific cases when recommended by toxbase. Instead, activated charcoal is a more common method for reduction of absorption
- Increase elimination of the poison
- Forced diuresis (infusion of electrolyte and glucose solutions) is a possible treatment, as is haemodialysis (in cases like ethylene glycol, lithium, methanol, phenobarbital, salicylates and sodium valproate)
- Give specific antidote
- Prevent re exposure
So the oxford handbook has this to say:
- ABC, clear airway
- Consider ventilation if RR <8.min, or PaO2<8kPa, when breathing 60% O2, or the airway is at risk (GCS<8)
- Treat shock
- If unconscious, nurse semi prone
Further management
- Hx from patient, friends, family etc
- Try to spot possible cause from symptoms (see box)
- Glucose, U&E, LFT, FBC, INR, ABG, ECG, paracetamol, and salicylate levels. Do urine/serum tox as appropriate
- Monitor sats
- Treat with supportive measures + specific antidotes if possible
Symptoms and their possible cause:
- Fast irregular pulse - salbutamol, antimuscarinics, tricycles, quinine, phenothiazine poisoning
- Hypothermia - phenothiazines, barbiturates
- Hyperthermia - amphetamines, MAOIs, cocaine, ecstasy
- Coma - Benzodiazepines, alcohol, opiates, tricyclics, barbiturates
- Seizures - Recreational drugs, hypoglycemic agents, tricyclics, phenothiazines, theophyllines
- Constricted pupils - opiates, insecticides
- Dilated pupils - amphetamines, cocaine, quinine, tricyclics
- Hyperglycaemia - organophosphates, theophyllines, MAOIs
- Hypoglycaemia - insulin, oral hypoglycemics, alcohol, salicylates
- Renal impairment - salicylate, paracetamol, ethylene glycol
- Metabolic acidosis - alcohol, ethyl glycol, methanol, paracetamol, CO
- Increased osmolality - alcohols, ethylene glycol