Internal Diseases and Therapy · MU Sofia

123. Treatment of acute exogenous poisoning

Covers the main clinical syndromes of acute poisoning, from cerebrotoxic to gastrotoxic, then the basic resuscitation approach and the reversible causes of peri-arrest. It goes on to general principles: limiting absorption, enhancing elimination with forced diuresis or haemodialysis, giving specific antidotes and preventing re-exposure. It also lists initial and further investigations and a table-style list linking common symptoms to likely culprit drugs, followed by example antidotes such as naloxone, fomepizole and acetylcysteine.

Inside: 2 sections · 16 flashcards · 3 min

Topic 124 of 139 in the MU Sofia syllabus for Internal Diseases and Therapy (Medicine, Years 4 and 5). The free AceMed note covers it in 2 sections, about 330 words (3 min of reading), with 16 flashcards.

In this note

  1. Treatment of acute exogenous poisoning
  2. Treatment principles in poisoning

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

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