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14/10/2011Prof Dr Ashraf M. Emara


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Prof in Forensic Medicine and Clinical Toxicology

Department

AND



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OUTLINE OF LECTURE

Definitions and classification of poisons

Phases of poisoning

Factors affecting the severity of poisoning

Diagnosis

Treatment


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DecontaminationDecontamination

1. Removal of the poison from GIT:

Emesis

Gastric Lavage

1. Removal of the poison from GIT:

Emesis

Gastric Lavage

Cathartics

Endoscopy/surgical removal

2. Inactivation of the poison in GIT: Localantidotes e.g. activated charcoal

Cathartics

Endoscopy/surgical removal

2. Inactivation of the poison in GIT: Localantidotes e.g. activated charcoal



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Removal of the unabsorbed poison

If the patient conscious: Emesis.

If the patient unconscious: endotrachealintubation then Gastric lavage.

I t e patient in convu sion: controconvulsion, endotracheal intubation then

gastric lavage.



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EmesisEmesis

1. Mechanical

2. Chemical

1. Mechanical

2. Chemical

yrup o pecac

3. Central

Apomorphine

yrup o pecac

3. Central

Apomorphine



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Indications

Early pre-hospital management of serious

oral poisonings, immediately after ingestion,

when other measures (e.g. activatedcharcoal) are not available with prolonged

.

Ingested agents are not adsorbed by

activated charcoal (e.g. iron, lithium,

potassium). However, whole-bowel irrigationis preferred in these conditions.



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Syrup of ipecac

The emetic of choice in both children over

the age of 6 months and in adults.

Ipecac is the dried root of Cephaelis

ipecaquanha.



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Mechanism of action Direct local irritant action (early) of ipecac on

the peripheral emetic sensory receptors in theproximal small intestine

(late) (chemoreceptor trigger zone).



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Dose 30 ml for adults

15 ml for children under age 5 years

10 mL for children under age 1

Can be repeated after 20 minutes. If the second dose fail, evacuate the stomach

to remove syrup of ipecac then use the

alternative method.



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Contraindications emesis1. Extremes of age (under 6 months and old age).

2. Corrosive

3. Convulsion.

4. Coma.

5. Pregnancy.

6. Bleeding diathesis.7. Excessive vomiting.

8. Serious heart diseases.

9. Sharp solid object.10. Non toxic ingestions.



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Adverse effects

Persistent vomiting may delay administration

of activated charcoal or oral antidotes (e.g.acetylcysteine).

hemorrhagic gastritis.



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It is a method for removing substancesfrom the stomach.

To remove massive overdose within 60

minutes of ingestion, although it may be

useful several hours after ingestion of

agen s a s ow gas r c emp y ng eg,salicylates or anticholinergic drugs).

To administer activated charcoal and

whole-bowel irrigation to patients unwillingor unable to swallow them.



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Efficacy Of Gastric Lavage Depends on:

Time elapsed between ingestion

and lavage

The amount ingested

The rate of absorption.



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Endotracheal intubation should precede

gastric lavage (gag reflex).

The patient is placed on the left lateralposition with the head lower than the level of

e ee o preven regurg a e ma er a rom

entering the respiratory tract.

Dentures if present should be removed.



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POSITION Position the patient in a High Fowlers position.


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INSERTION Lubricate the distal end of the Tube


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INSERTION Instruct the Patient to drink while the tube is

inserted


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CHECKING FOR PLACEMENT Auscultation of air

insufflated through thetube

Immersion of the ProximalImmersion of the Proximalend of in a glass of water.end of in a glass of water.


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If the patient is semiconscious or in coma:Put the ear near the end of the tube,

a hissing sound of the air is heard

when the tube is in the trachea.

confirms.



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If the patient is conscious, sudden

spasmodic cough, dyspnea or cyanosis will

develop when the tube passes into the airpassage.



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CHECKING FOR PLACEMENT

Aspiration of fluid from the tube, with pHtesting of the aspirate.

p <

pH > 6 - Respiratory


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After testing, a sucker is connected to the

tube and aspirate as much as possible. This

sample should be sending for laboratory

diagnosis. Disconnect the sucker and pour 200-300

-

children). and remove by gravity or activesuction. Use repeated aliquots till the

return is clear.



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SECURE THE NG TUBE Anchor the tube securely to the nose and cheek -

keeping it out of the patients field of vision.


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Washing is then repeated until the

returning fluid is clear.

Before extraction of the tube, activated

charcoal is left in the stomach.

Tightly close the external end of the tubeby your finger before withdrawal to prevent

the escape of any fluid from the lower end

into the air passages.


Contraindications of Gastric Lavage



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Contraindications of Gastric LavageContraindications of Gastric Lavage

Ingestion of froth-producingsubstances (liquid soap and shampoo).

Patients with unprotected airway orconvulsing patients (Control of convulsions

and intubation with a cuffed endotracheal

airway).

Ingestion ofsustained-release or enteric-

coated tablets (In such cases, whole-bowelirrigation is preferable)





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Contraindications of Gastric LavageContraindications of Gastric Lavage

Patients with risk of perforation (due topathology or recent operation) or hemorrhage.

Ingestion of a corrosive (except phenol).

Chronic poisoning.

K r n n r l r l m i ill

poisoning.


Complications of Gastric



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Lavage


LavageLaryngospasm.

Vomiting resulting in pulmonary aspirationof gastric contents in an obtunded patient

without airwa rotection.

Complications of tracheal intubation.

Sinus bradycardia.





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Lavage


Lavage Perforation of esophagus.

Hypothermia.

Epistaxis may occur if the lavage

tube is introduced by a nasogastricroute.

Electrolyte disorders



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Gastric LavageGastric Lavage



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Indications Reduce the transit time of poisons especially

that not adsorbed by activated charcoal Hasten passage of charcoal-poison complex

development of charcoal bezoar).

Decrease the constipating effects of activated

charcoal. To hasten passage of iron tablets & non-

adsorbable ingestions.14/10/2011Prof Dr Ashraf M. Emara


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Technique Administer the cathartic of choice (70%

sorbitol, 1 mL/kg) along with activatedcharcoal.

stool after 6-8 hours.


C t i di ti


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Contraindications

Corrosives

Severe diarrhea.

Ileus or intestinal obstruction.

Serious electrol te imbalance.

Recent bowel surgery.

Sodium and magnesium containing

cathartics should not be used in patientswith fluid overload or renal insufficiency,

respectively.



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Complications

.

Abdominal cramping and vomiting.



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Whole bowel irrigation



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Surgical bowel-cleansing solution containsnon-absorbable polyethylene glycol is given

at high flow rate to force the intestinal

contents out.

adult and 0.5 L/ hour in children until rectaleffluent is clear.

It is a useful and rapid method to empty the

gut in 4-6 hours.



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Indications Massive ingestion of amounts of highly

toxic drugs.

Large overdoses ofsustained release orenteric coated preparations.

Large ingestions o poisons poor yadsorbed to activated charcoal (iron,lithium).

Ingestion offoreign bodies or drug-filledpackets or condoms.



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Contraindications

Gastrointestinal pathology or dysfunction

obstruction ileus hemorrha e

perforation) Inadequate airway protection.


Adverse effects


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Adverse effects

Nausea and bloating.

Regurgitation and pulmonary

Activated charcoal may not be as

effective when given with whole-

bowel irrigation.


Surgical removal


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Surgical removal

Drug-filled condoms

Intact tablets

Tablet concretions



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