1. Guide –Dr Jyoti Singh

2.  What is a poison?
▪ In common usage - poisons are
chemicals or chemical products
that are distinctly harmful to
human
▪ More precisely - a poison is a
foreign chemical (xenobiotic) that
is capable of producing a harmful
effect on a biologic system

3.  Most common Pediatric Exposure
 Cosmetics and personal care products (13%)
 Cleaning substances (10%)
 Analgesics (7.8%)
 Foreign Bodies (7.4%)
 Topicals (7.4%)
 Cold and Cough Preparations (5.5%)
 Plants (4.6%)
 Pesticides (4.1%)

4.  May be difficult because of non-specific symptoms
 High index of suspicion - especially occult poisoning
▪ history may be unreliable
▪ look for corroborative history - missing pills, empty
container
 Course that a poison runs (toxidromes) ! - may help
 Toxicology screening - helpful only in a few

5. ▪ It is the association of several clinically
recognizable features, signs, symptoms,
phenomena or characteristics which often occur
together, so that the presence of one feature
alerts the physician to the presence of the
others.

10.  S alivation *D iaphoresis/diarrhea
 L acrimation *U rination
 U rination *M iosis
 D efecation *B radycardia/bronchospasm
 G I secrestion/upset *E mesis
 E mesis *L acrimation excess
*S alivation excess

12. Hot as a hare
Dry as a bone
Red as a beet
Mad as a hatter
Blind as a bat
bowel, bladder
lose their tone, &
heart runs alone

13. Hot as a hare
Dry as a bone
Red as a beet
Mad as a hatter
Blind as a bat
bowel , bladder lose
their tone, &
heart runs alone

14. Hot as a hare
Dry as a bone
Red as a beet
Mad as a hatter
Blind as a bat
bowel , bladder
lose their tone,
&heart runs alone

15. disorientation Amphetamine
hallucinations Cocaine
Hallucinogenic hyperactive bowel Pseudoephedrine
panic Phencyclidine Benzodiazepenes
seizure Ephedrine
Toxidrome Hypertension
Tachycardia
Tachypnea

16. disorientation Amphetamine
hallucinations Cocaine
Hallucinogenic hyperactive bowel Pseudoephedrine
panic Phencyclidine Benzodiazepenes
seizure Ephedrine
Toxidrome Hypertension
Tachycardia
Tachypnea

17. disorientation Amphetamine
hallucinations Cocaine
Hallucinogenic hyperactive bowel Pseudoephedrine
panic Phencyclidine Benzodiazepenes
seizure Ephedrine
Toxidrome Hypertension
Tachycardia
Tachypnea

18. disorientation Amphetamine
hallucinations Cocaine
Hallucinogenic hyperactive bowel Pseudoephedrine
panic Phencyclidine Benzodiazepenes
seizure Ephedrine
Toxidrome Hypertension
Tachycardia
Tachypnea

31.  Very diverse and varied - depends on the poison
 Clinical examination should be focused on the
possible manifestations of common poisons in the
geographical area

32.  Skin and mucosal damage
 Neurotoxic manifestations
 Cardiovascular manifestations
 Metabolic consequences
 Eye manifestations
 Hepatic , renal dysfunction
 Multiorgan dysfunction

33.  Respiratory
Airway protection
Respiratory failure
 Cardiovascular
Hypotension despite fluid challenge
Heart block, arrhythmias, QTc prolongation as in TCA

34.  Neurologic
▪ Low GCS
▪ Seizures
 Metabolic
▪ Hypoglycaemia
▪ Significant electrolyte abnormalities
▪ metabolic acidosis
▪ Hepatic failure
▪ Coagulopathy with bleeding

35. ASSESSMENT & THERAPY should
proceed in parallel

37.  Treat the patient, not the poison
 Assess
 General appearance
 Work of breathing
 Circulation
 ABCDs
 IV access and monitors
 High Suspicion

38.  Directed exam (after ABCs)
 mental status
 vital signs
 pupillary size
 skin signs

39.  Airway - ensure clear airway, clear secretions, check for
cough/gag
 Breathing - check oxygenation, supplemental O2,
breathing pattern & adequacy
 Circulation - heart rate, rhythm, blood pressure

40.  Neurologic - GCS, seizures, agitation, spasms, pupils,
autonomic dysfunction
 Miscellaneous - odour, temperature, pallor, cyanosis,
jaundice
 Abdomen - rigidity, bleeding, urine output

42.  Cyanosis
 methemoglobinemia secondary to nitrites,
nitrates, phenacetin, benzocaine-refractory tp
o2
 Red flush
 carbon monoxide, cyanide, boric acid,
anticholinergics
 Joundice – c cl4. paracetamol

43.  Dry
 anticholinergics
 Salivation
 organophosphates, carbamates
 Oral lesions
 corrosives, paraquat
 Lacrimation
 caustics, organophosphates, irritant gases

44.  Anti-histamine
 Anti-depressant
 Anticholinergics (atropine)
 Sympathomimetics
 amphetamine, cocaine, PCP

45.  Cholinergics, Clonidine
 Opiates, Organophosphates
 Phenothiazine, Pilocarpine
 Sedatives (barbiturates, ethanol)

46.  Alcohol
 PCP / marijuana
 LSD
 Anticholinergics
 Sympathomimetics
 Phenothiazines
 Cocaine
 Heroin
 heavy metals

47.  Coma
 alcohols,
 anticholinergics,
 sedative hypnotics,
 opioids,
 carbon monoxide,
 TCAs, salicylates,
 organophosphates
 Weakness/paralysis
 organophosphates, carbamates, heavy metals

48.  Atropine
 Salicylates
 Theophylline
 Cocaine
 TCA

49.  Ethanol
 Narcotics
 Carbon monoxide
 Clonidine

50.  Bradycardia
 digitalis, sedative hypnotics, beta blockers, opioids
 Tachycardia
 anticholinergics, sympathomimetics,
amphetamines, alcohol, aspirin, theophylline,
cocaine, TCAs
 Arrythmias
 anticholinergics, TCAs, organophosphates,
digoxin, phenothiazines, beta blockers, carbon
monoxide, cyanide

51.  OTC cold remedies
 Amphetamine
 PCP
 TCA
 Cocaine
 Diet pills

52.  Calcium channel blockers
 Carbon monoxide
 Cyanide
 Iron
 Narcotics
 Anti-hypertensives
 Met-hemoglobin

53.  Hypoglycemia
 Oral hypoglycemic agents
 Beta-blockers
 Insulin
 Ethanol
 Salicylates

54.  Alcohol
 Narcotics
 Clonidine
 Sedatives

56.  Of limited value
 Paracetamol levels, salicylate levels, alcohol, Red
cell/pseudocholinesterase, anti-epileptic drug levels
 Urinary drug screen - opiates, barbiturates,
benzodiazepines, amphetamines, cocaine

57.  Anion gap & Osmolal gap
 Increased anion gap (Normal 12 ± 4 mEq/L)
▪ Ethylene glycol
▪ Methanol
▪ Salicylate poisoning
 Increased osmolal gap (Normal 5 ± 7 m osmol/kg)
▪ Ethylene glycol
▪ Methanol
▪ Acetone, ethanol, isopropyl alcohol, propylene glycol

58.  Electrolytes
▪ Hypokalemia
▪ Isuline ,oral hypoglysemics
▪ Diuretics, Methyl xanthine, Toluene
▪ Hyperkalemia
▪ Digoxin
▪ Beta-blocker
 Liver function tests
▪ Acetaminophen, Ethanol, Carbon tetrachloride
 Renal function tests
▪ Ethylene glycol, NSAIDS

59.  ECG
Digoxin toxicity
TCA overdose - sinus tachycardia, QT prolongation,
increased QRS
Beta-blockers - conduction abnormalities
Imaging
. CXR- hydrocarbon ingestion
.Abdominal X-ray-- iron ingestion & radioopaque
ingestion.
.Oesophagoscopy -for caustic ingestion.
. Abdominal usg- recently been used as a means of
identifying presence of pharmaceutical material in GIT.

60.  Opiates
 Cocaine metabolite
 Amphetamine
 Benzodiazepines
 Barbiturates
* No urine screen can confirm intoxication, only exposure

63.  Reduce absorption of the toxin
 Enhance elimination
 Neutralise toxin

65.  Removal from surface skin & eye
 Emesis induction
 Gastric lavage
 Activated charcoal administration & cathartics
 Dilution - milk/other drinks for corrosives
 Whole bowel irrigation
 Endoscopic or surgical removal of ingested chemical

66.  Skin decontamination
▪ Important aspect – not to be neglected
▪ Remove contaminated clothing
▪ Wash with soap and water (soaps
containing 30% ethanol advocated)
▪ However, no evidence for benefit even in OP
poisoning

67.  Gastric decontamination
▪ Forced emesis if patient is awake
▪ Gastric lavage
▪ Activated charcoal 25 gm 2 hourly
▪ Sorbitol as cathartic

68.  Gastric lavage
▪ Gastric lavage decreases absorption by 42% if done 20
min and by 16% if performed at 60 min
▪ Performed by first aspirating the stomach and then
repetitively instilling & aspirating fluid
▪ Left lateral position better - delays spont. absorption
▪ No evidence that larger tube better
▪ Simplest, quickest & least expensive way
▪ Choice of fluid is tap water - 5-10 ml/kg

69.  Gastric lavage
▪ Preferrably done on awake patients
▪ Presence of an ET tube does not preclude
aspiration, though preferred if GCS is low
▪ No human studies in OP poisoning showing
benefit of gastric lavage

70.  Single dose activated charcoal
 0.5-1 gm/kg, adolescents 50-100 grams PO;
maximum dose 100 grams
 More benefit if administered within 1 hour of
ingestion, but still good for poison which slows
gastric motility (anticholinergic, opiates,
salicylates)
 Strongly consider for acetaminophen overdose >
4 hours

71.  P – Pesticides, petroleum distillates,
unprotected airway
 H – Hydrocarbons, heavy metals, > 1h delay
in administration
 A – Acids, alkali, alcohol, altered level of
consciousness, aspiration risk
 I – Iron, ileus, intestinal obstruction
 L – Lithium, lack of gag reflex
 S – seizures

72.  Nonabsorbable, isotonic polyethylene glycol
 Toxins “pushed” through GI tract; prevents
absorption
 Concentration gradient created by this
allows absorbed toxin to diffuse back into GI
tract
 Used where toxins NOT absorbed by
charcoal

73.  Recommended for:
 Iron tablets
 Lead paint chips
 Theophylline
 Crack vials/packets
 Button batteries
 Sustained release calcium channel blockers

74.  Bowel perforation
 Bowel obstruction
 Clinically significant gastrointestinal
hemorrhage
 Ileus
 Unprotected or compromised airway
 Hemodynamic instability
 Uncontrollable intractable vomiting

76.  Methods
▪ Keeping a good urine output 150-200 ml/hr
▪ Alkalinisation of urine - clinical efficacy
accepted for salicylate & phenobarbital
poisoning
▪ Extracorporeal removal
▪ Hemodialysis - Barbiturates, Salicylates,
Acetaminophen, Valproate, Alcohols,
Glycols
▪ Hemoperfusion - theophylline, digitalis, lipid
soluble drugs

77.  Plasmapheresis
 Works very well with highly protein (albumin)
bound drugs
 Not a routine methodology, but has been used
to remove theophylline and digoxin/ digibind
complexes
 Exchange transfusion
 Use in smaller infants where vascular access for
extracorporeal techniques can’t be done

78.  Renal failure.
 Congestive heart failure (relative).
 Acute lung injury.
 Persistent CNS disturbance.
 Severe acid-base or electrolyte imbalance,
despite appropriate treatment.
 Hepatic compromise with coagulopathy.
 Salicylate concentration (acute) >100 mg/dL.

80. Acetaminophen N-acetyl cysteine
Anti-cholinergics Physostigmine
Benzodiazepenes Flumazenil
Ca channel blockers Glucagon, Insulin + dextrose, Calcium
Carbamate Atropine
Cyanide Thiosulphate, nitrate
Digoxin Digoxin antibodies
INAH Pyridoxine
Methanol Ethanol, Fomepizole
Glycol Ethanol, Fomepizole
Opioid Naloxone
Oral hypoglycaemics Glucose
Organophosphate Atropine, PAM
Warfarin(rat kill poison) Vitamin K

81. Iron Desferroxamine
Copper Penicillamine, Dimercaprol, CaEDTA
Lead CaEDTA, Dimercaprol (BAL)
Mercury DMPS, DMSA, BAL
Arsenic BAL & derivatives
Antimony BAL & derivatives

82.  Calcium channel blockers: bradycardia and
hypotension; 1 - 10 mg tablet of nifedipine
 Camphor: respiratory depression and seizures; 15
mL of Vicks vapo-rub (700 mg of camphor)
 Clonidine: severe bradycardia; 0.1 mg
 Tricyclic antidepressants: cardiovascular and CNS
toxicity; 10-20mg/kg
 Opioids: CNS and respiratory depression; 2.5 mg of
hydrocodone.

83.  Lomotil: anticholinergic overdose (tachycardia,
seizures, coma); ½ tablet
 Salicylates: cerebral edema, acidosis, coma; ½
teaspoon of wintergreen fatal
 Sulfonylureas: severe hypoglycemia; 1 tablet
 Toxic alcohols: cardiac and CNS depression; 2.9mL
of 95% ethylene glycol has been fatal

84. National Poisons Information Centre (NPIC)
Department of Pharmacology
All India Institute of Medical Sciences
New Delhi, India
 Tel. No.: 26589391, 26593677,
 Fax: 26850691, 26862663
 Email: npicaiims@hotmail.com
provides round-the-clock, 7 days-a-week, 365
days service on telephone.

85.  Poisoning a common problem in our country
 A high index of suspicion required to diagnose
 Know common toxidrome & antidotes
 Charcoal is only given if likely to benefit
 Patients receiving decontamination must have airway protection
 Don’t panic and follow a plan of action
Decreasing absorption
Enhancing elimination
Neutralising toxins
 Avoid potentially harmful Rxs - risk vs benefit