POISONING AND TOXIC EXPOSURES –

TYPES , DIAGNOSIS AND GENERAL

PRINCIPLES OF MANAGEMENT

Department of Pharmacy Practice

Chalapathi Institute of Pharmaceutical Sciences, Guntur
 What is a Poison ?

“Poison is a substance ( solid/

liquid or gaseous ), which if
introduced in the living body, or
brought into contact with any part
there of, will produce ill health or
death, by its constitutional or local
effects or both.”

Ref- The Essentials of Forensic Medicine and Toxicology

Dr. K. Reddy
 Poisoning
“The development of dose
related adverse effects following
exposure to chemicals, drugs or
other xenobiotics.”

Ref- The Essentials of Forensic Medicine and Toxicology

Dr. K. Reddy
EPIDEMIOLOGY
WHO (2004) - 3,46,000 deaths in a year d/t
poisoning.
In 2005 – In India 1,13,914 estimated cases
of poisoning with insecticides

Commonest cause in INDIA – Pesticides

Reasons – Agriculture based economy

- Easy availability pesticides

- Poverty
Types of poisoning

1. Acute poisoning – excessive single

dose, or several smaller doses of a poison
taken over a short interval of time.

2. Chronic poisoning – smaller doses over

a period of time, resulting in gradual
worsening eg. Arsenic , Phosphorus ,
Antimony etc.
 Nature of poisoning
1. Homicidal – killing of a human being by another
human being by administering poisonous substance
deliberately.
2. Suicidal – when a person administer poison himself
to end his/ her life.
3. Accidental – Eg. Household poisons- nail polish
remover , acetone .
Depilatories- Barium sulphide

4. Occupational – in professional workers. Eg.

insecticides, noxious fumes.
 Classification of poisons
According to the chief symptoms
produced :-
Corrosives . Systemic
Irritants . Miscellaneous

1. Corrosives
a) Strong acids- H2SO4 , HNO3 , HCl
b) Strong alkalis- Hydrates & Carbonates of Na+ , K+ &
NH3
c) Metallic salts – Zinc chloride, Ferric chloride, KCN ,
Silver nitrate, Copper sulphate.
 Classification continued….
2. Irritants
a) Inorganic –i) Nonmetallic – Phosphorus, Iodine
Chlorine.
ii) Metallic – Arsenic, Antimony, Lead.
iii) Mechanical – Powdered glass, hair

b) Organic
Vegetable – Abrus precatorius, Castor, Croton,
Calotropis.
Animal – Snake & insect venom, Cantharides
 Classification continued…….

3. Systemic
a) Cerebral
 CNS depressants – Alcohol, opioids, hypnotics,
general anesthetics.
 CNS stimulants – Amphetamines, Caffeine
 Deliriant – Datura, Cannabis, Cocaine

b) Spinal – Nux vomica

c) Peripheral – Conium, Curare
d) Cardiovascular - Aconite, Quinine, HCN
e) Asphyxiants – CO, CO2 , H2S

4) Miscellaneous – Food poisoning, Botulism.

 Routes of administration
1. Inhalational
volatile gas, chemical dust, smoke, aerosol.
2. Injectable
a) Intra venous – Benzodiazepines, barbiturates,
tricyclic antidepressants etc.
b) Intramuscular – Benzodiazepines, opioids etc
c) Subcutaneous – Botulinum toxin
d) Intra- dermal – Local anaesthetics,
organophosphates
3. Oral – Corrosives, organophosphorus
4. Through natural orifices- rectum/ vagina/
urethra
Abrus precatorius, croton, calotropis
5. Through unbroken skin –
organophosphorus, Mercury, Lead
 Diagnosis of poisoning
History
– patient
witness
Circumstantional evidence
 suicide note
 containers & potential toxins at scene of
discovery
Physical examination
Investigations
-Biochemical investigations
-ECG abnormalities
-Radiology
-Toxicologic screening
History
Patient
 If person is conscious , & immediately brought
to the ED, history may be relevant
 Mostly patient estimates of drug/ nature of
substance ingested are inaccurate.

Witness
What substance/ substances ?
What route/ routes ?
What dose/ doses ?
When and for how long?
H /O psychiatric illness?
Circumstantial evidence
Unconscious adults Tablet particles
Empty drug staining mouth /
containers/ clothing
wrappers /tablet Suicide note
neraby ↓
↓ Assumption of
some sort of poisoning
poisoning
 Following conditions should arouse
suspicion of poisoning :-
 Sudden appearance of symptoms after food
or drink in an otherwise healthy person
 Symptoms – uniform in character, rapidity
 Sudden onset delirium, paralysis, cyanosis,
collapse etc.
Physical examination

General appearance

Neurological status- conscious, confused,

comatose.
 Glassgow coma scale

Pupillary examination
 Normal – Celphos poisoning
 Miosis – Opioids, OP poisoning
 Mydriasis – TCA, Theophylline, Dhatura, Methanol

Convulsions - Ethylene glycol, Lithium, SSRI

Muscular fasciculations – OP poisoning

 Vital parameters –
Cardiorespiratory system -
PR, BP, RR, Temp

Hypotension with bradycardia :-

 Betablockers, Cyanide, Benzodiazepines,
Barbiturates, Opioids, Alchohol , OP insecticides

Hypotension with tachycardia :-

 Beta
-2 stimulants, Caffeine ,Theophylline,
Amatoxin containing mushroom
 Vital parameters contd….
Hypertension with tachycardia :-
 Sympathomimetics, Ergot alkaloids,
Anticholinergics, Alcohol withdrawal

Respiratory depression with failure:-

 Barbiturates,
Benzodiazepines, Opiates,
Sedative- hypnotics, Snake venom

Hyperventilation :-
 Amphetamines , Salicylates, Hallucinogens,
Cyanide, CO, H2S
 Vital parameters contd……..

Body tempearture

Hypothermia :-
 Barbiturates,
Benzodiazepines, Ethanol,
Opiates, Cyclic antidepressants

Hyperthermia :-
 Amphetamines, Alcohol withdrawal, MAO
inhibitors, Anticholinergic agents, Salicylates
 Examination of Skin colour and lesions
 Colour Toxin/ poison
1. Pink Cyanide
2. Yellow ( jaundice) Phosphorus ,hepatotoxins
(Acetaminophen, mushroom )
3. Red Rifampicin
4. Blue (cyanosis) Aniline, Nitrites, . .
Methemoglobinemia

 Diaphoresis –
 Salicylate, OP poisoning
 Sympathomimetics, serotonin syndrome
 Phencyclidine, alcohol or sedative withdrawal
Examination of Skin colour and lesions contd….

c. Bruising d. Needle tracks

 Diffuseecchymosis:-  I/Vabuse :-
 Anticoagulant  Opiates
poisoning  Amphetamines
 Rodenticides  Cocaine

 May be hidden in
groin or interdigital
spaces
Examination of Skin colour and lesions contd….

e. Hair
 Hair loss – Chemotheapuetic agents
Thallium

f. Nails
 Mee’s lines – Arsenic poisoning
Thallium
MEE’S LINES
 Odours
 Most common odour detected- Alcohol
Odour Toxin
1. Garlic Arsenic, Phosphorous,
Selenium , Thallium ,
Organophosphorous
2. Sweet / fruity Ethanol, Chloroform ,
Nitrites
3. Bitter almonds Cyanide
4. Acrid ( pear like ) Paralydehyde
Choral hydrate
5. Rotten eggs Hydrogen sulphide,
Mercaptans
6. Fishy / musty Zinc phosphide
7. solvent/ glue Toulene, Xylene
8. Smoke Carbon monoxide
 Urine colour
Colour Drug/ toxin
1. Brown Myoglobin, CCL4 ,
Aniline , Methydopa
2. Black Naphthalene, Phenols ,
Cresols
3. Red Rifampicin, Phenytoin,
Phenolphthalein,
Desferoxamine
4. Smoky Phenols
5. Green / blue Copper sulphate,
Methylene blue
6. Green Propofol, Indomethacin
 Biochemical investigations
 Hematologic
 CBC, Platelet count, Coagulation profile
◦ Hemolytic anemia- lead, NSAIDS, Quinidine
◦ Thrombocytopenia- Aspirin, Phenytoin, Procanamide
◦ Coagulopathy- snake venoms, warfarin

 Liver function tests

 S. bilirubin , enzymes – AST,ALT , ALP, coagulation
profile
◦ Acetaaminophen, sulfonamides, rifampicin, TCA, INH,

 Renal functions tests

◦ Aspirin, lead, barbiturates, alcohol, amphetamines,
copper sulphate
 Other Abnormalities
Hyperkalemia
 Digoxin, Cardiac glycosides, Rhabdomyolysis, K
+
sparing diuretics
Hypokalemia
 Theophylline, Amphetamines, Sympathomimetics
Hypernatremia
 Uncommon in clinical toxicology
 Large dose of NaHCO3 for TCA overdose
 Correction of life threatening metabolic acidosis
Hyponatremia
 Rare
Biochemical abnormalities contd……
Metabolic acidosis
 Acetaaminophen, Ethanol, Methyl alcohol, Toulene

Metabolic alkalosis
 Calcium carbonate, Furosemide, Laxative

Anion Gap
 Anion Gap = [ Na+ ] – { [ Cl] +[ HCO3 ] }
 Normal – 8- 12 mmol/ l
Increased anion gap :-
 Ethylene glycol
 Methanol
 Salicylate poisoning
Biochemical abnormalities contd…..

Osmolar gap
 Detects the presence of osmotically active
susbstances in serum or plasma
 Calculated osmolality =
2 [ Na+] + [ urea] + glucose
2.8 18
Eg Ethanol - Osmolality =
2 [ Na+] + [ urea] + glucose + Ethanol
2.8 18 4.6
Biochemical abnormalities contd…..

Increased osmolar gap:-

 Acetone
 Ethanol
 Ethylene glycol
 Methanol
ECG abnormalities
Usually non specific
ECG abnormality Drugs/ toxins

1. Bradycardia & AV Block Barbiturates, ß- blockers,

Antiarrhythmics
2. Ventricular Cardiac glycosides, Fluorides,
tachyarrhythmias Membrane active agents,
Sympathomimetics
3. QRS prolongation Amantidine , Hyperkalemia
4. QT prolongation Amantadine, Amiodarone,
Thallium
Radiological studies
 Not particularly helpful in diagnosis.
 May be useful in confirming :-
 Ingestion of metallic objects.
 Packets of heroin / cocaine ( body packing)
 Serial chest X-ray - Aspiration pneumonitis, ARDS

Bio assays of drugs

 Acetaminophen
 Acetone
 Ethylene glycol
 Methanol
 Salicylate
 Phenobarbital
 Theophylline
 Lithium
Toxicologic analysis
 Urine, blood, gastric contents – confirm or rule
out suspected poisoning.

 Interpretation requires various methods:-

Thin layer chromatography – Acetaminophen
Gas liquid chromatography – BZD, Amphetamines
HPLC- BZD
Mass spectrometry- Anticonvulsant

Enzyme assays
 RBC cholinestrase , serum cholinestrase – OP poisoning
 Pseudocholinestrase levels – OP poisoning
 Fundamentals of poisoning
management
1. Initial resuscitation and stabilization
2. Removal of toxin from the body
3. Prevention of further poison absorption
4. Enhancement of poison elimination
5. Administration of antidote
6. Supportive treatment
7. Prevention of re - exposure
 Management of poisoning contd….
 Initial resuscitation and stabilization –
 I/V access – I/V fluids
 Endo tracheal intubation - to prevent aspiration
 Unconscious patients
 Respiratory depression/ failure
 Convulsions- give anticonvulsants

 Removal of toxin from the body

 Copious flushing with water or saline of the body
including skin folds, hair

 Inhalational exposure
 Fresh air or oxygen inhalation
 Prevention of poison absorption
G I decontamination
Performed selectively, not routinely

1. Gastric lavage
 Useful IF DONE BEFORE 3 hr of ingestion of a poison
 Done with water ( except infants – NS), 1:5000 potassium
permangnate , 4% Tannic acid, saturated lime water or
starch solution
 Administering & aspirating 5ml/kg through a No. 40 F
orogastric tube ( No. 28 F – children) or Ewald’s tube
 Position – Trendelenburge & left lateral position
 Performed until clear fluid is obtained or a
maximum of 3 L
 Prevention of poison absorption contd….

Ewald’s gastric tube

Complications
a. Aspiration (common)
b. Esophageal / gastric perforation
c. Tube misplacement in the trachea
 Prevention of poison absorption contd….
Contraindications
a. Corrosive poisoning – GE perforation
b. Petroleum distillate ingestants- Aspiration
pneumonia
c. Compromised unprotected airway
d. Esophageal / gastric pathology
e. Recent esophageal / gastric surgery

 Lavage decreases ingestant absorption by an

average of :-
 52 % - if performed within 5 mins of ingestion
 26 % - if performed at 30 mins
 16 % - if performed at 60 mins
 Prevention of poison absorption contd….

2. Ipecac Syrup induced

emesis
Used for home management of
patients with :-
 Accidental ingestions
 Reliable history
 Mild predicted toxicity

Aministered orally
Dose :-
 30 ml – adults
 15 ml – children
 10 ml – small infants
 MOA
 Ipecac irritates the stomach & stimulates CTZ
centre.
 Vomiting occurs about 20 min after administration
 Dose may be repeated if vomiting does not occur

Side effects
a. Protracted vomiting

Contraindications
a. Gastric / esophageal tears or perforation
b. Corrosives
c. CNS depression or seizures
d. Rapidly acting CNS poisons ( cyanide, strychnine,
camphor )
 Prevention of poison absorption contd…….
3. Activated charcoal
 Greater efficacy
 Less invasive
 Given orally as a suspension ( in water ) or
through NG tube
 Dose – 1 g/kg body wt.
 Charcoal adsorbs ingested poisons within gut
lumen allowing charcoal- toxin complex to be
evacuated with stool or removed by induced
emesis / lavage
 Prevention of poison absorption contd…
 Indications- Barbiturates, Atropine , Opiates,
Strychnine

 Contraindications - Mineral acids, alkalis, cyanide,

fluoride ,iron

Side effects
a. Nausea , vomiting, diarrhoea or constipation
b. May prevent absorption of orally administered
therapeutic agents

Complications
a. Aspiration – vomiting
b. Bowel obstruction
Prevention of poison absorption contd….
4. Whole bowel irrigation
 Administration of bowel cleansing solution
containing electrolytes & polyethylene glycol
 Orally or through gastric tube
 Rate – 2 L/ hr ( 0.5 L /hr in children)
 End point- rectal fluid is clear
 Position – sitting

Indication :-
 Slow or enteric coated medications
 Packets of illicit drugs
 Heavy metals
 Iron , Lithium
 Contraindications
a. Bowel obstruction
b. Ileus
c. Unprotected airway

Complications:
a. Bloating
b. Cramping
c. Rectal irritation
5. Cathartics
 Promote rectal evacuation of GI contents
 Most effective – Sorbitol
 Dose – 1-2 g/kg
 Salts – Disodium phosphate, Magnesium citrate &
sulfate, Sodium sulfate
 Saccharides – Mannitol, Sorbitol

Side effects – Abdominal cramps, nausea

vomiting
Complications – Excessive diarrhoea,
Hypermagnesemia
C/I – Corrosives
Pre existing diarrhoea
 Enhancement of elimination of poison
1.Alkalization of urine
 Urine pH ≥ 7.5
 Urine output 3-6 ml/kg
 5% Dextrose in 0.45 NS containing 20 – 35
meq /L Of NaHCO3 to an IV solution
 Uses – Chlorpropamide, Phenobarbital,
Sulfonamides, Salicylates

C/I :-
a. Congestive heart failure
b. Renal failure
c. Cerebral edema
2. Acidification of urine
 Enhance elimination of weak bases such as
Phencyclidine & Amphetamine
 Not used anymore
S /E- Metabolic acidosis, Renal damage

3.Extra corporeal removal

Dialysis
 Acetone, Barbiturates, Bromide, Ethanol, Ethylene
glycol, Salicylates, Lithium
 Less effective when toxin has large volume of
distribution (>1 L/kg), has large molecular weight, or
highly protein bound
 Elimination of poison contd….
Peritoneal dialysis
 Alcohols , long acting salicylates, Lithium

Exchange transfusion
 Indications
a. Fatal , irreversible toxicity
b. Deteriorating despite aggressive supportive therapy
c. Dangerous blood levels of toxins
d. Liver or renal failure
 Eg. Arsine or Sodium Chlorate poisoning
Elimination of poison contd….

4. Chelation
 Heavy metal poisoning
 Complex of agent & metal is water soluble &
excreted by kidneys
 Eg . BAL, EDTA, Desferrioxamine, DMSA
 BAL – Arsenic, Lead, Copper, Mercury
 EDTA- Cobalt, Iron, Cadmium
 Desferrioxamine – Iron
 DMSA- Lead, Mercury
 Administration of Antidotes
Not all poisons have antidotes.
Poison Antidote Dose
Acetaaminophen N - acetylcysteine 140mg/kg. then 70 mg/kg every 4
hrs to total of 18 doses over 72
hrs
Benzodiazepine Flumazenil 0.1mg/min infusion to a total of
1mg
Anticholinergics Physostigmine 1gm I/M or I/V
Opioid Naloxone 2 mg I/V , repeated every half to
one min to a total of 20 mg I/V
Cyanide Thiosulphate , 0.3 g sodium nitrite in 10 ml
nitrite sterile water iv. 25 g sodium
thiosulphate iv slow
Iron Desferrioxamine 2g im 12 hrly or 10- 15 mg/kg/hr
not to exceed 80 mg /kg /24 hrs
Administration of antidotes….
Poison Antidote Dose
OP Poisoning Atropine , Oximes Atropine : Loading dose - 2 , 4 ,
6 every 5 mins .
Maintenance – infusion <
3mg/hr
PAM – 15-30 mg/kg IV to be
repeated 6-12 hourly
Infusion – 20- 40 mg/kg f/b 5-
10mg /kg/h
Methanol Ethanol , Ethanol 50% 1 ml/kg every 2 hr
Fomepizole for 5 days
Fomepizole 15 mg/kg loading
dose f/b 10 mg/k every 12 h for
4 days
 Supportive care
 Hemodynamic support- Hypotension unresponsive
to volume expansion – t/t with ionotropes

 Correction
of temperature abnormalities
 Hypothermia – Rewarming of the patient
 Active / passive methods
 External / internal methods

◦ Passive external rewarming- blankets / sleeping bags

◦ Active external warming- hot water bottles, heating
blankets , forced air warming
◦ Invasive core rewarming- peritoneal dialysis,
hemodialysis, gastric or rectal lavage
Supportive care contd….
 Hyperthermia
◦ Externally – immersion in iced saline bath, tepid sponging
◦ Internally – gastric / peritoneal lavage

 Correction of metabolic derangements

◦ Hyperkalemia –
◦ Calcium gluconate 10% 10-20 ml
◦ Insulin 10 units with 50g of 50% dextrose
◦ NaHCO3 1mmol/kg , beta-2 agonists

◦ Hypokalemia -
◦ K < 2.5 mmol/l with symptoms - I/v KCL 20-30 mmol/h
◦ K < 3.5 but > 2.5 mmol/l with no symptoms – KCL 20-40
mmol every 4-6 hr
 Supportive care contd….
 Hypernatremia with hemodynamic instability-
◦ NS saline till I/V vol is corrected.
◦ Subsequently replace water with 5% D, or 0.45% NS

 Prevention and t/t of secondary complications –

pulmonary edema , cerebral edema, shock etc.
 Pulmonary edema – Furosemide IV 0.5- 1 mg/kg
◦ Morphine IV 2-4 mg
◦ Nitroglycerin SL
◦ O2 inhalation / intubation as needed
 Cerebral edema – Mannitol 1g/kg
◦ Steroids – Hydrocortisone, Dexamethasone
 Shock – crystalloids / colloids
Prevention of re- exposure
Adult education – instructions
regarding safe use of medications &
chemicals

Notification of regulatory agencies -

in case of environmental or workplace
exposure

Psychiatric referral- depressed or

psychotic patients should receive
psychiatric assessment, disposition &
follow-up
Prevention of re- exposure

Child proofing- In house hold

where children live or visit,
alcohols, medications,
household products ,non edible
plants should be kept out of
reach or in locked, child proof
containers.
 Summary
Poisoning a common problem in our
country
A high index of suspicion required to
diagnose
For any poisoning the mainstay of
treatment is supportive care
Follow the A, B, C
Don’t panic and follow a plan of action
 Decreasing absorption
 Enhancing elimination
 Neutralising toxins
 REFERENCES
1. Critical care toxicology: Diagnosis and
Management of the Critically Poisoned Patient.
Jeffery Brent ;2nd edition.
2. Harrison’s Principles of Internal Medicine. 16th
edition, Vol 2: part 16; Poisoning, Drug overdose,
and Envenomation.
3. The Essentials of Forensic Medicine and
Toxicology. Dr. K. Reddy , Section II Toxicology;
25th edition
4. International Programme On Chemical Safety,
Guidelines On The Prevention Of Toxic Exposure ;
WHO 2004
5. www.biomedcentral.com – Official data , D.
Gunnell, 2007
6. Critical Care, Joseph M. Civetta ; 4th edition
THANK YOU