lecture of clinical toxicology dr.hossam kandeel

1. DR/ HOSSAM KANDEEL

2. ‫عن‬‫قـال‬ ‫عنه‬ ‫هللا‬ ‫رضي‬ ‫هريرة‬ ‫أبي‬:
‫صلى‬ ‫هللا‬ ‫رسول‬ ‫قال‬‫عليه‬ ‫هللا‬‫وسلم‬
(‫ثالث‬ ‫من‬ ‫إال‬ ‫عمله‬ ‫انقطع‬ ‫العبد‬ ‫مات‬ ‫إذا‬:
‫صالح‬ ‫ولد‬ ‫أو‬ ، ‫به‬ ‫ينتفع‬ ‫علم‬ ‫أو‬ ، ‫صدقةجارية‬
‫له‬ ‫يدعو‬)

10. Our rules

16. • General :
- Emergency ABCD approach for unconscious pt
- Diagnosis
- steps of treatment
• Special :
- Most common toxins

18. A-Airway
• Ensure patent air way , if not :
 open :
- Triple maneuver
- Tubes
 clean :
- finger sweep
- suction

19. Triple maneuver

20. 2- Tubes
• Oropharyngeal
• Cuffed endotracheal
• Tracheostomy

21. Oropharyngeal tubes

22. Tubes “endotracheal “

23. Tracheostomy

24. Clean
- finger sweep
- suction

25. Sweep

26. Suction

27. Suctioning

28. Don’t forget
• Ensure patent air way , if not :
 open :
- Triple maneuver
- Tubes
 clean :
- finger sweep
- suction

29. Breathing
• Ensure adequate breathing by
Look
Feel
Listen
Give O2 mask

30. Look listen and feel

31. Circulation
• Pulse  if no pulse start CPR
• 2 wide bore cannula avoid hypotension
• shock : - elevate lower limb
- saline

32. Treatment of shock

33. Disability
• Convulsion 
One fit : nothing is done
More than one fit : neuril amp (diazepam )
- dose  ampule slowly IV
- repeat it in need  not more than 3 times

34. Convulsions

36. 2- diagnosis
• History taking
• Clinical picture
• Investigation
• Differential diagnosis

38. First question

39. 2nd question

40. 2- diagnosis
• History
• Clinical picture “and rapid examination “
• Investigation
• Differential diagnosis

41. Clinical picture “
and
rapid examination “

42. Check vital signs
• Blood pressure
• Pulse
• Temperature
• Respiratory rate
level of conscious
• Glasgow coma scale

43. 2- diagnosis
• History
• Clinical picture
• Investigation
• Differential diagnosis

44. Investigations
• Routine :
- Blood
- Biochemical : Rft . Lft
- Others “ ECG – x-rays “
• Specific :
- According to the drug

45. Rapid investigations if needed
• Random blood glucose why ?
• ABG
• ECG

46. 2- diagnosis
• History
• Clinical picture
• Investigation
• Differential diagnosis

49. 5 minutes discussion
What about your goals

51. •If you don’t want
,you will find an
excuse .

52. In order to succeed your
desire for success should
be greater than your fear
of failure

53. Steps of treatment
• Decontamination
• Elimination
• Supportive and symptomatic

54. Decontamination
• Emesis
• Gastric lavage
• Local antidote

55. Emesis
Types
• Mechanical :
- gag reflex
• Chemical
- Central : apomorhine
- Peripheral
- Mixed
Indications ???

56. Gag reflex

57. Induction of vomiting XXXXXX

58. Emesis
• The rule in emesis is
“emesis is indicated to be contraindicated “
Hossam kandeel

60. Decontamination
• Emesis
• Gastric lavage
• Local antidote

61. Gastric lavage
not used routinely nowadays
• Indications :
- Failure of emesis
- Drugs which are sustained release
- To administrate activated charcoal
- Tricyclic antidepressant
• Contraindications :
- Corrosive except phenol ?
- Kerosene
- Chronic poisoning
- Time passed more than 6 hours except …,….

62. Method of gastric lavage

63. Method of gastric lavage

64. Decontamination
• Emesis
• Gastric lavage
• Local antidote

65. Local antidote
• Activated charcoal
• Demulcent
• NB : precipitation is a local antidote mechanism
“Nablion”

66. Activated charcoal
• Give it to all toxins except

67. Method of administration
• Dose : 1gm /kg
• Method : dose + water or juice + cathartics + antiemetic
• You can repeat it again
• Very useful in gut dialysis

68. Activated charcoal

69. Eucarbon = charcoal tablets
10.5LE

70. Demulcent
• What do you think about it ?

71. Elimination
• Diuresis and dialysis
• Specific antidote
• Special for each toxin

72. Supportive ttt
• Hypotension : elevate leg + saline
• Convulsions : neuril amp. Slowly IV
• Hyperthermia : cold fomentation + paracetamol
• Hypothermia : warming
• Urine retention : catheterization

75. Special types of toxins
“most common cases “
1. Organophosphate
2. Hydrocarbon ingestion
3. Primperan toxicity
4. Carbon monoxide
5. Opioid
6. Paracetamol and aspirin
7. Naphthalene
8. Zinc phosphide
9. Snake bite

76. Organophosphate
• Mechanism :
increase ACH via inhibition of ACHE enz.
how ?
• History :
- farmer
- suicidal attempt

78. Clinical picture
• Clinical picture : DUMBBELS  increase all secretions
D Diarrhea  GIT  Nausea- vomiting- colic
U Uremia  Bladder incontinence of urine
M Moises  Pin- point- pupil
B Bronchi  Bronchospasm and wheezes -Branchorrhea
B Bradycardia, hypotension
E Emesis
L Lacrimation
S Salivation .
Sever cases vomiting , diarrhea Metabolic acidosis

79. Clinical pic. Cont………..
 Due to nicotinic action
- Stimulation: TMF  Tremors – Muscle cramps-
Fasciculation
- Inhibition : Muscle  wasting  paralysis
 Due to centeral action:
- Stimulation CNS  Restlessness- irritability –
agitation
- Inhibition CNS  Stupor-coma-R.C depression

80. Treatment
• As general steps
ABCD  corner stone in treatment
• If skin is exposed  wash the skin
• Antidote :
- atropine 2amp IV every 10minutes
Till
Dryness of chest secretion
- Oximes 1gm  in hospital

81. Hydrocarbon
• History : ……..
• Clinical picture :……………….
• Treatment :
- O2 inhalation
- Zantac amp
- Solucortef vial 3.5 ?????????
- Penicillin ??????
No emesis or gastric lavage

82. Kerosene poisoning

83. Primpran
• Clinical picture : ………
• Treatment :
Stop it
According to the age :
- Less than 2ys  ½ amp “avil- solucortef “
- More than 2ys  1amp “avil – solucortef “

84. Carbon monoxide
• History :………………..
• Clinical picture :…………
• Treatment :
-as general
- O2 , O2
- hyperbaric O2

85. Mode of poisoning

87. Opioid + tramadol 
• History ………
• Clinical triad :
coma
RC depression
 pin point pupil
• Treatment
As general
 lavage and charcoal
Antidote :
Naloxone amp : 18LE  amp +200cc water
for 1hour

88. Pinpoint pupil

89. Analgesic
• Paracetamol :
 history
Clinical picture
Treatment : general + lavage +18doses of oral NAC
• Aspirin : 0.3gm / kg
 history  
Clinical picture : tinnitus ???
Treatment  

90. Others
• Naphthalene balls :
• Zinc phosphide :
• Snake bit :who was the most famous personhe/shedead
byitsuicidal?.
• Corrosive

91. Naphthalene ball

92. Snake bites
• In Egypt most of snakes not toxin
• Hernid viper vs copra
• Management
At scene:
1-Calm pt and try to identify snake
2-Splint in fractures→ immobilize the bitten limb.
3-Apply tourniquet proximal to site of bite and released for (30seconds) every
15 minutes’.
4-Suction over bits marks→ batter than incisions to prevent infection to wound
by incised instrument.

93. Tourniquet ??

94. - At hospital: →
1. support→ monitor vital signs
2.Analgesic
3.Antibiotics.
4.Anti-tetanus
5.Anti-venoum
→ preparation: prepared on hors
→ types : Monovalent-pentavalent
→Action: neutralize toxin
→ Dose - Mild→5vials
- Moderate→10vials
- Sever→15 vials

95. Suction of toxin

97. Poisonous and non

99. Feed back
• Lecture
-information
- duration
- interruption
- Presentation
• Lecturer
- Speed
- Management of lecture
- Your participation with me