Dra Dando
Dra Dando
12 February 2008
12 February 2008
Joyce “,.
Joyce “,.
POISONING POISONING •• Overdose of drugs, medicaments, chemicalsOverdose of drugs, medicaments, chemicals and biological substances
and biological substances •
• “acute” poisoning versus “chronic’ poisoning“acute” poisoning versus “chronic’ poisoning
Acute: 24 -48 hrs of Acute: 24 -48 hrs of exposureexposure
ChChroroninic: c: weweekeks, s, momontnthshs, , yeyearars s of of exposure
exposure •
• Father of toxicology: ParacelsusFather of toxicology: Paracelsus GENERAL PRINCIPLES
GENERAL PRINCIPLES
EmergenEmergency cy stabilizationstabilization
o
o First thing to doFirst thing to do
Clinical evaluationClinical evaluation
o
o Include good Hx taking & thorough PEInclude good Hx taking & thorough PE
Elimination of the poisonElimination of the poison
ExcreExcretion of tion of the absorbed substancethe absorbed substance
AdministratAdministration of ion of antidotesantidotes
o
o Important for certain specific poisons orImportant for certain specific poisons or
drugs drugs
Supportive therapy and observationSupportive therapy and observation
DispositionDisposition
EMERGENCY STABILIZATION EMERGENCY STABILIZATION
Maintain adequateMaintain adequate AAirwayirway
o
o Remove obstructionsRemove obstructions o
o CondConditionitions s whewherein suction rein suction canncannot ot bebe
done: done:
-- ccaauussttiic c ssuubbssttaannccees s ((ccaauusseess ulceration of GI mucosa)
ulceration of GI mucosa)
-- hyhydrdrococararbobons ns (c(cauauseses s asaspipiraratitionon))
Ensure adequateEnsure adequate BBreathing/Ventilationreathing/Ventilation
o
o Nasal cannula, intubationNasal cannula, intubation
Maintain adequateMaintain adequate CCirculation (put IV lines,irculation (put IV lines, fluids)
fluids)
Treat convulsions (e.g Treat convulsions (e.g DDiazepam)iazepam)
o
o DiaDiazezepampam: : 11stst lilinne e oof f TTx x fofor r acactitiveve
seizures and status epilepticus seizures and status epilepticus
Correct metabolic abnormalities (Correct metabolic abnormalities (EElectrolytes,lectrolytes, glucose, acid-base)
glucose, acid-base)
o
o BBasasee: : uusseed d fofor r sseevveerre e mmeetatabobolilicc
acidosis (Tx: Na, bicarbonate) acidosis (Tx: Na, bicarbonate)
o
o GlucGlucose: ose: for for hyphypoglycoglycemia emia (De(Dextrxtroseose
50-50 concentration) 50-50 concentration)
Treat coma (e.g Treat coma (e.g FFlumazenil)lumazenil)
o
o Flumazenil:Flumazenil:
1)
1) Tx fTx for Bor BZD (ZD (diadiazepzepam) am) oveoverdrdoseose 2)
2) Tx fTx for coor coma (ma (bubut not not as fit as firsrst lint linee agent)
agent) -
- coma due coma due to overdto overdose of valiose of valiumum COMMON CAUSE OF HYPOXIA
COMMON CAUSE OF HYPOXIA
AlcoholAlcohol
CyanideCyanide
o
o In silver jewelry cleanersIn silver jewelry cleaners
OrganophosphatesOrganophosphates
o
o In pesticiesIn pesticies
Carbon monoxideCarbon monoxide
Opiates (Morphine, Novaine, Heroin, Codeine)Opiates (Morphine, Novaine, Heroin, Codeine) QuinineQuinine o o Anti-protozoalAnti-protozoal RECOMMENDED IV FLUIDS RECOMMENDED IV FLUIDS
HypotensivHypotensive e patientspatients
NSSNSS
Adult for maintenanceAdult for maintenance
NSSNSS
D5 Acetated Ringer’s solutionD5 Acetated Ringer’s solution
PedPediatric for iatric for maintenancemaintenance
D5 0.3% NaCl (hypo)D5 0.3% NaCl (hypo) P
POOIISOSON N CCOOMMMMOONNLLY Y AASSSSOOCICIAATTEED D WWIITTHH CONVULSIONS CONVULSIONS AminophyllineAminophylline AmphetaminesAmphetamines
Carbon monoxideCarbon monoxide
CocaineCocaine
CyanideCyanide
Ethylene glycolEthylene glycol
HypoglycemiHypoglycemic c agentsagents
Isoniazid – triad of coma, metabolic acidosis,Isoniazid – triad of coma, metabolic acidosis, intractable seizures
intractable seizures
LeadLead
MAO inhibitorsMAO inhibitors
MeMefefenanamimic c AAcicid d (u(ususual al siside de efeffefectct: : GIGI irritation; overdose:
irritation; overdose: seizuresseizures)) OpioidsOpioids OrganophosphatesOrganophosphates PhenothiazinesPhenothiazines
Salicylates (Aspirin)Salicylates (Aspirin)
StrychnineStrychnine
Theophylline Theophylline
Tricyclic antidepressants Tricyclic antidepressants
WithdrawaWithdrawal of l of narcotics, diazepam or ethanolnarcotics, diazepam or ethanol
Signs of ethanol withdrawalSigns of ethanol withdrawal
o o IrritableIrritable o o AgitatedAgitated o o SeizureSeizure C
CAAUUSESES S OOF F CCOONNVVUULLSSIIOON N IIN N PPOOIISSOONENEDD PATIENTS
PATIENTS
Direct convulsant effect of the poisonsDirect convulsant effect of the poisons
CeCerreebbraral l hhyypopoxxia ia frfrom om rreessppiriratatoory ry oror cardiovascula
cardiovascular depressive effect of r depressive effect of drugsdrugs
HypoglycemiaHypoglycemia
SSeveveerre e mmuussclcle e sspapasm sm dduue e tto o sspipinanal l oo p
peeririphpheeraral l eeffffeectcts s on on ththe e memecchahaninissmm controlling muscle tone
controlling muscle tone
WithdrawaWithdrawal reactions in l reactions in patients with physicalpatients with physical dependence on abused drugs
dependence on abused drugs
DecrDecreaseeased d seizseizure ure threthresholshold d in in an an epilepileptiepticc patient
patient TREA
TREATMENT OF TMENT OF CONVULSIONCONVULSION
a
apprriiLL aaLLLLaaiinn mmaaddeeLL yynnaa rraaLLpphh ttLLee jjoovvss ppaaoo cceessss xxttiiaann aabbii eeddwwaarrdd bbaannaannaa ccaarr jjaatt bbaammbbii eerriikkaa jjeenn rroocchhee bbaamm aaLLeexx anannnaa shsheeeenn
a a
• • DiazepamDiazepam o o Adult: 5mg IVAdult: 5mg IV o o Children:0.3mg/kgChildren:0.3mg/kg o
o Only compatible fluid is Only compatible fluid is blood (direct)blood (direct) •
• Lorazepam (Ativan)Lorazepam (Ativan) o
o Adult: 2.5-10mg IVAdult: 2.5-10mg IV o
o Children: 0.05-1 mg/doseChildren: 0.05-1 mg/dose o
o WiWithdthdrawrawn n frfrom om the the marmarkeked d d/t d/t itsits
associated side effects associated side effects
o
o Short acting, long durationShort acting, long duration
•
• PhenytoinPhenytoin
o
o LD: 15-20mg/kg IVLD: 15-20mg/kg IV o
o Adult: 50mg/minAdult: 50mg/min o
o Children: 1mg/kg/minChildren: 1mg/kg/min o
o Inducer of CYP450Inducer of CYP450 o
o MaintenancMaintenance e drugdrug
• • Pyridoxine (B6)Pyridoxine (B6) o o Adult: 5g IVAdult: 5g IV o o Children: 80-120mg/kgChildren: 80-120mg/kg o
o For INH poisoningFor INH poisoning o
o Tx Tx of of conconvuvulsilsions ons due to due to ununknoknownwn
etiology etiology H
Hyyppootthheerrmmiiaa HHyyppeerrtthheerrmmiiaa
AlcoholAlcohol
BarbituratesBarbiturates
Carbon monoxideCarbon monoxide GeneralGeneral anesthetics anesthetics OpioidsOpioids PhenothiazenesPhenothiazenes Sedative-hypnoticsSedative-hypnotics Tricyclic Tricyclic antidepressants antidepressants AntihistaminesAntihistamines AmphetaminesAmphetamines IsoniazidIsoniazid PhenytoinPhenytoin SalicylatesSalicylates XanthinesXanthines Anticholinergics:Anticholinergics: Atropine Atropine CocaineCocaine PhenothiazinesPhenothiazines QuinidineQuinidine SulfonamidesSulfonamides TREATMENT OF COMA OF UNKNOWN ETIOLOGY TREATMENT OF COMA OF UNKNOWN ETIOLOGY
•
• Thiamine (vit B1) 100mg IV Thiamine (vit B1) 100mg IV o
o T Tx x of of WWererninickcke e KKororsasakokoff ff SySynd nd inin
alcoholic px alcoholic px • • GlucoseGlucose o o Adult: 50-100ml DAdult: 50-100ml D50-5050-50 o o Children:2Children:2ml/kg ml/kg d10d10 o
o Most pts present with hypoglycemiaMost pts present with hypoglycemia
esp. in alcoholic intoxication esp. in alcoholic intoxication
o
o Wernicke-Korsakoff syndromeWernicke-Korsakoff syndrome
d/t sever B1 deficiencyd/t sever B1 deficiency
adadmimininistster er B1 B1 fifirsrst t bebefoforere giving glucose
giving glucose •
• NaloxoneNaloxone
o
o Adult: 2mg IV Adult: 2mg IV every 3-5minsevery 3-5mins o
o Children: 10mcg/kgChildren: 10mcg/kg o
o For opiate overdose (coma)For opiate overdose (coma) o
o ExpensiveExpensive o
o GivGiven en to to nenewbwbororns ns whwhose ose motmothehersrs
un
undederwerwent nt CS CS caucausinsing g rerespspiratiratoryory difficult in their babies
difficult in their babies COMPLETE CLINICAL EVALUATION COMPLETE CLINICAL EVALUATION
•
• GoGood od hihiststory ory tatakiking ng (d(d/t /t vuvulnlnererababililitity y of of
children) children)
INFORMATION TO BE ELICITED DURING HISTORY INFORMATION TO BE ELICITED DURING HISTORY
•
• Time exposure Time exposure
Needs to be very specificNeeds to be very specific
e.g.: N-acetylcysteinee.g.: N-acetylcysteine, antidote , antidote forfor paracetamol overdose; effective only paracetamol overdose; effective only in the first 6
in the first 6 hrs after ingestionhrs after ingestion
e.g. lavage of poison is only good fore.g. lavage of poison is only good for the 1
the 1stst24hours24hours
•
• Mode exposureMode exposure
RectalRectal Transplacental Transplacental OralOral EtcEtc •
• Intake of other Intake of other substancessubstances
•
• CircumstanceCircumstances prior s prior to poisoningto poisoning •
• Current medicationsCurrent medications •
• Past medical historyPast medical history •
• Any home remedies takenAny home remedies taken *Organopho
*Organophosphate/carbamatsphate/carbamate e poisoning:poisoning: manifests with
manifests with DUMBELDUMBEL
POISONS WITH DELAYED MANIFESTAIONS POISONS WITH DELAYED MANIFESTAIONS Ethylene glycol
Ethylene glycol
o
o PPreresesent nt in in ananti
ti--freeze freeze Salicylates Salicylates Paracetamol Paracetamol Paraquat Paraquat Methanol Methanol o
o T Toxic oxic alcoholalcohol
Thyroxine Thyroxine 6 hours 6 hours 12 hours 12 hours 36 hours 36 hours 48 hours 48 hours 48 hours 48 hours 4 weeks 4 weeks *Vodka *Vodka - among alcohols
- among alcohols, has the , has the highest alcohhighest alcohol contentol content - converts ethylene glycol and methanol to less - converts ethylene glycol and methanol to less toxic form
toxic form
- amount to be given needs to be
- amount to be given needs to be computedcomputed COMPLETE CLINICAL EVALUATION
COMPLETE CLINICAL EVALUATION
Complete physical Complete physical examinatioexaminationn
Evaluate general statusEvaluate general status
Examine skinExamine skin
Characterize odor of patient’s breathCharacterize odor of patient’s breath
Auscultate the lungsAuscultate the lungs
Listen to patient’s heartListen to patient’s heart
Check the abdomenCheck the abdomen
Do a complete neurologic examDo a complete neurologic exam
Skin changes in poisoningSkin changes in poisoning
Bullae: barbiturates, COBullae: barbiturates, CO
Diaphoresis: OP, salicylate, Diaphoresis: OP, salicylate, amphetamineamphetamine
Jaundice: paracetamol Jaundice: paracetamol
Dry and Dry and warm: atropine, anticholinergicwarm: atropine, anticholinergic
FlFlusushehed: d: anantitichchololinineergrgicics, s, alalcocohohol,l, cyanide, atrophine odors
cyanide, atrophine odors
Brerath odorsBrerath odors
Bitter: almonds, cyanideBitter: almonds, cyanide
Fruity: DKA, isopropanolFruity: DKA, isopropanol
Oil Oil of wintergreen: methylsalicylateof wintergreen: methylsalicylate
RoRottetten n egeggs: gs: sulsulfur fur diodioxidxide, e, hyhydrdrogeogenn sulfide
sulfide
Pears: chloral hydratePears: chloral hydrate
Garlic: arsenic, OPGarlic: arsenic, OP
Mothballs: camphor (like the one in vicks)Mothballs: camphor (like the one in vicks) B
PPropranololropranolol
AAnticholinesterasenticholinesterase
CClonidine, codeine,lonidine, codeine, Ca-channel blocker Ca-channel blocker EEthanolthanol DDigitalisigitalis IIronron
CCO, cyanideO, cyanide
OOrganophocphaterganophocphate
PPhenothiazinehenothiazine
EEthathanolnol, , ethethyleylenene glycol
glycol
FFree-base cocaineree-base cocaine AAnticholinergicsnticholinergics AAntihistaminesntihistamines AAmphetaminesmphetamines SSympathomimeticsympathomimetics SSalicylates,alicylates, solvents solvents TTheopyllineheopylline M
Myyddrriiaassiiss MMiioossiiss AAntihistaminesntihistamines AAntidepressantsntidepressants SSympathomimeticsympathomimetics IIsoniazidsoniazid AAnticholinergicsnticholinergics CCholinergics,holinergics, clonidine clonidine OOpiates,piates, Organophosphate Organophosphate PPhenothiazines,henothiazines, pilocarpine, pilocarpine, pontine bleed pontine bleed SSedative-hypnoticsedative-hypnotics *Triad of opiate overdose:
*Triad of opiate overdose:
ComaComa
Respiratory depressionRespiratory depression
Pinpoint pupilsPinpoint pupils Clinical Evaluation: Clinical Evaluation: Check for Toxidromes Check for Toxidromes
SignSigns s and symptoms taken collectiand symptoms taken collectively canvely can characterize a
characterize a suspected toxicantsuspected toxicant
These groups of manifestations are observed These groups of manifestations are observed to occur consistently with particular
to occur consistently with particular poisonspoisons
o
o InIntrtracacttabable le seseizizururees s + + CoComma a ++
Metabolic acidosis = INH Poisoning Metabolic acidosis = INH Poisoning
*Intractable seizures despite *Intractable seizures despite administration of diazepam
administration of diazepam
Anticholinergic /
Anticholinergic / Antidepressant TAntidepressant Toxidromeoxidrome
HypertherHyperthermia: “hot as mia: “hot as a hare”a hare”
Dry mucosa: “dry as a Dry mucosa: “dry as a bone”bone”
Flushed skin: “red as a beet”Flushed skin: “red as a beet”
Dilated pupils: “blind as a bat”Dilated pupils: “blind as a bat”
Confusion / delirium: “mad as a hatter”Confusion / delirium: “mad as a hatter” Cholinergic
Cholinergic TToxidromeoxidrome (S&Sx of organophosphate(S&Sx of organophosphate and carbamate poisoning)
and carbamate poisoning)
DDiarrhea, diaphoresisiarrhea, diaphoresis
UUrinationrination
MMiosis, muscle fasciculationsiosis, muscle fasciculations
BBradycardia, radycardia, bronchoconbronchoconstrictionstriction EEmesismesis LLacrimationacrimation SSalivationalivation S
Syymmppaatthhoommiimmeettiiccss OOppiiaattees s / / NNaarrccoottiiccss
MydriasisMydriasis Tachycardia Tachycardia HypertensionHypertension HyperthermiaHyperthermia SeizuresSeizures MiosisMiosis BradycardiaBradycardia HypotensionHypotension HyperventilationHyperventilation ComaComa CO
CONDNDITITIOION N OR OR AGAGENENTS TS PRPREDEDISISPOPOSISING NG TOTO METABOLIC ACIDOSIS OR ELEVATED ANION GAP METABOLIC ACIDOSIS OR ELEVATED ANION GAP
•
• MMethanolethanol •
• EEthylene gycolthylene gycol •
• TTheophyllineheophylline, , toluenetoluene •
• AAlcoholic ketoacidosislcoholic ketoacidosis •
• LLactic acidosisactic acidosis •
• AAminoglycosidesminoglycosides •
• CCyanide, COyanide, CO •
• IIsoniazid, Ironsoniazid, Iron •
• DDiabetic ketoacidosisiabetic ketoacidosis •
• GGrand Mal seizuresrand Mal seizures •
• AAspirin (salicylate)spirin (salicylate) •
• PParaldehyde, phenforminaraldehyde, phenformin
ELIMINATION OF THE POISON ELIMINATION OF THE POISON
•
• External DecontaminExternal Decontamination – bathing of ation – bathing of pt withpt with
alkaline soap e.g perla, ivory, dove alkaline soap e.g perla, ivory, dove •
• Emptying the stomachEmptying the stomach
o
o Emesis – only in adultsEmesis – only in adults
*pediatrics have risk for
*pediatrics have risk for aspirationaspiration
o
o GGaassttrriic c llaavvaagge e – – HH2200, , NNSSSS, , NNaa
Bicarbonate, activated charcoal Bicarbonate, activated charcoal •
• Limiting GI absorptionLimiting GI absorption
o
o Activated charcoalActivated charcoal o
o DeDemumulclcenents ts (w(watatususi) i) / / neneututraralilizizingng
ag
agenents ts (r(raw aw egegg g whwhitite: e: to to prprevevenentt absorption)
absorption) SUB
SUBSTSTANCANCES ES NOT NOT ABSABSORBORBED ED BY BY ACTACTIVIVAATEDTED CHARCOAL
CHARCOAL
Alcohol – rapid absorptionAlcohol – rapid absorption
CyanideCyanide
IronIron
o
o Lavage with NaHCO3Lavage with NaHCO3
Lithium - dialysisLithium - dialysis
Petroleum distillates (hydrocarbons)Petroleum distillates (hydrocarbons)
Caustic agentsCaustic agents S SUUBBSSTTAANNCCEES S WWIITTH H EEXXTTRRAAHHEEPPAATTIICC RECIRCULATION RECIRCULATION • • AspirinAspirin • • CyclosporineCyclosporine • • DigoxinDigoxin • • MeprobamateMeprobamate • • ParacetamolParacetamol • • PhenothiazinePhenothiazine • • PhenytoinPhenytoin • • SalicylateSalicylate • • TCAD TCAD • • AnticoagulantsAnticoagulants • • CarbamazepineCarbamazepine • • DapsoneDapsone • • GluthetimideGluthetimide • • MethamphetamineMethamphetamine
• • PhencyclidinePhencyclidine • • PhenobarbitalPhenobarbital • • PiroxicamPiroxicam • • Theophylline Theophylline • • OrganochlorinesOrganochlorines *Formalin ingestion: *Formalin ingestion: No antidoteNo antidote
Give H2 blockersGive H2 blockers
Surgery (cut the part with Surgery (cut the part with ulceration)ulceration) ENHANCEMENT OF ELIMINATION OF ABSORBED ENHANCEMENT OF ELIMINATION OF ABSORBED SUBSTANCES
SUBSTANCES •
• Forced diuresisForced diuresis
o
o Mannitol 20% - osmotic diureticMannitol 20% - osmotic diuretic o
o Furosemide – loop diureticFurosemide – loop diuretic
•
• Alkalinization therapyAlkalinization therapy
o
o SodiSodium um bicabicarbonrbonate ate – – for for weaweak k acidacids:s:
INH poisoning INH poisoning
•
• AAcicididifificacatition on ththererapapy y (f(for or weweak ak babaseses:s:
Methamphetamine/shabu) Methamphetamine/shabu)
o
o Ascorbic acidAscorbic acid o
o Ammonium chlorideAmmonium chloride
•
• Dialysis and hemoperfusionDialysis and hemoperfusion •
• Multiple dose activated charcoalMultiple dose activated charcoal INDICATIONS FOR DIALYSIS
INDICATIONS FOR DIALYSIS
•
• AmAmananitita a phphalalloloidides es (m(musushrhroooom) m) – – veveryry
dangerous and lethal causing renal failure dangerous and lethal causing renal failure •
• Antifreeze (glycol type)Antifreeze (glycol type)
o
o T Tx: x: eeththananol ol ee.g.g. . vvododkka a vivia a NNGGT;T;
prevents conversion to more toxic from prevents conversion to more toxic from •
• Heavy metals in soluble compoundsHeavy metals in soluble compounds
o
o Tx with EDTA or chelators Tx with EDTA or chelators
•
• Heavy metals after chelationHeavy metals after chelation •
• MethanolMethanol AN
ANTITIDODOTETES S FOFOR R PPAATITIENENTS TS WIWITH TH COCOMA MA OFOF UNKNOWN
UNKNOWN ETIOLOGETIOLOGY Y • • NaloxoneNaloxone • • GlucoseGlucose • • Thiamine Thiamine ANT
ANTIDIDOTE OTE FOR FOR PPAATIETIENTS NTS WITWITH H SEISEIZURZURE E OFOF UNKNOWN
UNKNOWN ETIOLOGETIOLOGY Y
•
• Pyridoxine (Vitamin B6)Pyridoxine (Vitamin B6)
USE OF ANTIDOTES USE OF ANTIDOTES Mechanisms:
Mechanisms:
Inert Complex FormationInert Complex Formation
Chelating agents (DMSA, NAPA)Chelating agents (DMSA, NAPA)
o
o Tx of heavy metal poisoning Tx of heavy metal poisoning
DMSA: suximer?DMSA: suximer?
NANAPPA: A: N-N-acacetetylyl-p-penenicicilillalamimic c acacid id –– mercury, arsenic, lead
mercury, arsenic, lead
Accelerated detoxificationAccelerated detoxification
CyaCyanidnide e antantidoidote te kit kit – – avaavailailable in ble in USUS only
only
Sodium nitrite and sodium thiosulfateSodium nitrite and sodium thiosulfate
o
o SSooddiiuum m niittrriitten e: : IInndduuccee
methemoglobinemia (a condition methemoglobinemia (a condition iin n wwhhiicch h tthhe e iirroon n wwiitthhiinn hemoglobin is oxidized from the hemoglobin is oxidized from the ferrou
ferrous s (Fe(Fe2+2+) state to the ferric) state to the ferric
(Fe
(Fe3+3+) ) ststatatee, , rreesusultltining g in in tthehe
inability to transport oxygen and inability to transport oxygen and carbon dioxide)
carbon dioxide)
o
o SodSodium ium ThiThiosuosulfalfatete: : binbinds ds witwithh
cyanide-me
cyanide-methemoglobin themoglobin complexcomplex to detoxify
to detoxify
o
o Used in PGH, a raw material thatUsed in PGH, a raw material that
is
is cocompmpououndnded ed anand d prprepeparareded whenever it is needed
whenever it is needed
RReedduuctctioion n in in coconnvveersrsioion n to to mmorore e ttooxxicic compounds
compounds
EthanolEthanol
o
o FoFor r tx tx of of memethathanol nol and ethyland ethyleneene
glycol poisoning glycol poisoning
Competitive inhibition at receptor siteCompetitive inhibition at receptor site
AtAtroropipine ne (p(phyhysisiolologogic ic anantitidodotete) ) – – foforr orga
organophnophosphosphate/cate/carbamarbamate ate poisopoisoning;ning; inhibits the
inhibits the enzyme acetylcholinesteraenzyme acetylcholinesterase)se)
PralidoxPralidoxime ime (pharmacologic antidote)(pharmacologic antidote)
Bypassing the effects of the poisonBypassing the effects of the poison
Oxygen for CN Oxygen for CN poisoningpoisoning
PyridoxinPyridoxine for e for INH poisoningINH poisoning
Antibody interacting with poisonAntibody interacting with poison
DigoDigoxin xin antibantibody ody fragfragmentments s (Dig(Digibinibind) d) –– not available locally
not available locally *Locally: nadia-nadia *Locally: nadia-nadia
Snake antivernin (available in RITM)Snake antivernin (available in RITM)
-- spspececieies of Ps of Phihililippppinine coe cobrbra caa caususee paralysis
paralysis
-- TTx: x: acactitivvatateed d chchararccoaoall SUPPORTIVE THERAPY
SUPPORTIVE THERAPY •
• Essential for poisoning patients, especially forEssential for poisoning patients, especially for critically ill
critically ill •
• ProblemProblems in s in the critically ill the critically ill poisoned patientspoisoned patients
o
o Depressed sensoriumDepressed sensorium o
o Impaired ventilationImpaired ventilation o
o Impaired cough reflexesImpaired cough reflexes o
o Prone to aspirationProne to aspiration o
o ImmobilityImmobility o
o FluiFluid, d, elecelectrotrolyte lyte and and otheother r ,met,metabolabolicic
problems problems •
• InIntrtravavenenoous us flfluuididss: : rreepplalacecemmeennt t anandd maintenance
maintenance •
• Frequent blood and urine pH determination:Frequent blood and urine pH determination: acidification and alkalinization therapy
acidification and alkalinization therapy •
• PrevePrevention of ntion of aspirationaspiration •
• Prevention of decubitusPrevention of decubitus •
• UlcerUlcer •
• T Trereatmatment ent of of eleelectrctrolyolytestes, , memetabtaboliolic c andand temperature problems
temperature problems •
• Monitoring of vital signsMonitoring of vital signs •
• Monitoring of input and outputMonitoring of input and output GO
GOOD OD SUSUPPPPORORTITIVE VE ANAND D NUNURSRSINING G CACARE RE ISIS IMPORTANT
IMPORTANT DISPOSITION DISPOSITION
•
• Observation at the emergency room: atleastObservation at the emergency room: atleast 24hrs may be
24hrs may be warrantedwarranted •
• Frequent reevaluationFrequent reevaluation •
• Psychiatric evaluation: suicidal patients andPsychiatric evaluation: suicidal patients and substance abusing patients
substance abusing patients
•
• ChildChildhood hood poispoisoninoning g : : evalevaluate uate for for posspossibleible
child abuse or
child abuse or neglectneglect •
•
• Physical or sexual abuse among womenPhysical or sexual abuse among women •
• Domestic violenceDomestic violence
TOP TEN POISONS (All Ages) IN-PATIENT STATISTICS TOP TEN POISONS (All Ages) IN-PATIENT STATISTICS National Poison Control and Information Service National Poison Control and Information Service
UP-PGH PGH Y
YEEAAR R 2200006 6 ((NN==884477)) NNUUMMBBEERR PPEERRCCEENNTTAAGGEE 1
1. . EEtthhaannool l – – aallccoohhooll withdrawal pts withdrawal pts 9 955 1111..22 2 2. . KKeerroosseenne e ((GGaaaass)) 8877 1100..33 3
3. . SSododiuium m HHypypocochhloloriritete (Zonrox)
(Zonrox)
6
622 77..33 4
4. . MMeerrccuurry y ((tthheerrmmoommeetteerr)) 4455 55..33 5
5. . JJeewweellrry y CClleeaanneer r ((CCyyaanniiddee)) 3355 44..11 6.
6. HHyyddrroocchhlloorriic c aacciid d ((MMuurriiaattiicc)) 2277 33..22 7
7. . MMeetthhaammpphheettaammiinne e ((SShhaabbuu)) 1199 22..22 8
8..PPaarraacceettaammooll 1166 11..99 9
9. . MMiixxeed d PPeessttiicciiddees s ((BBaayyggoonn)) 1155 11..88 10. Jathropa seeds (cause
10. Jathropa seeds (cause hemorrhagic gastritis) hemorrhagic gastritis)
1
155 11..88
*Na Hydroxide: Liquid sosa *Na Hydroxide: Liquid sosa
TOP TEN POISONS
TOP TEN POISONS (All Ages) TELEPHONE REFERRALS(All Ages) TELEPHONE REFERRALS National Poison Control and Information Service National Poison Control and Information Service
UP-PGH PGH Y YEEAAR 2R 200006 (6 (NN==22,,668822)) NNUUMMBBEERR PPEERRCCEENNTTAAGGEE 1 1..KKeerroosseennee 119922 77..22 2
2. . SSooddiiuum m HHyyppoocchhlloorriittee 113311 44..99 3
3. . MMiixxeed d PPeessttiicciiddees s ((BBaayyggoonn)) 111188 44..44 4
4. . EElleemmeennttaal l MeMerrccuurryy 9900 33..44 5
5..PPaarraacceettaammooll 6644 22..44 6
6. . SSiilliicca a ggeel l ((sshhoeoess) ) –– nontoxic, causes mild GI nontoxic, causes mild GI manifestation
manifestation
6
622 22..33
7
7. . JJeewweellrry y CClleeaanneerr 5577 22..11 8
8. . FFeerrrroouus s SuSullffaattee 5533 22..00 9
9. . HHyyddrroocchhlloorriic c aacciidd 4488 11..77 1
100..IIssoonniiaazziidd 4422 11..66
HYDROCARBONS
HYDROCARBONS
KeroseneKerosene (Gaas)(Gaas)
Chemical pneumonitisChemical pneumonitis
o
o Presents with coughPresents with cough cyanosiscyanosisseizuresseizures
Aspiration pneumoniaAspiration pneumonia
Treatment: Pen G or other beta-lactams (for Treatment: Pen G or other beta-lactams (for pneumonia)
pneumonia)
No antidoteNo antidote
Easily absorbedEasily absorbed
SolventsSolvents
Aliphatic Aliphatic hydrocarbonhydrocarbonss
Aromatic Aromatic hydrocarbonhydrocarbonss
Benzene (ADR: Leukemia)Benzene (ADR: Leukemia)
T Tololueuene ne (A(ADRDR: : KiKidndney ey fafaililurure e dudue e toto chronic exposure)
chronic exposure)
CAUSTIC AGENTS
CAUSTIC AGENTS
AlkaliAlkali (ph > 7)(ph > 7) Strong alkali: ph >10Strong alkali: ph >10
No antidote (only supportive): HNo antidote (only supportive): H22 blockers, PPIblockers, PPI
Sodium hypochloriteSodium hypochlorite
Sodium hydroxide (e.g liquid sosa)Sodium hydroxide (e.g liquid sosa)
“LIhiya” (pang-green ng suman)“LIhiya” (pang-green ng suman)
Main Tx: surgicalMain Tx: surgical
Pathology: liquefaction necrosis (esophagus and Pathology: liquefaction necrosis (esophagus and intestine)
intestine)
AcidsAcids (ph < 7)(ph < 7) Strong acid: ph <4Strong acid: ph <4
Hydrochloric acidHydrochloric acid
Acetic acidAcetic acid
Benzalkonium chlorideBenzalkonium chloride Pathology: Coagulation necrosis Pathology: Coagulation necrosis
OthersOthers
Phenol (e.g. Lysol)Phenol (e.g. Lysol)
Cyanide salts: Silver jewelry cleanerCyanide salts: Silver jewelry cleaner - mixed with Na Hydroxide
- mixed with Na Hydroxide
PHARMACEUTICAL AGENTS
PHARMACEUTICAL AGENTS
ParacetamolParacetamol
Toxic dose: 150-200mg/kg Toxic dose: 150-200mg/kg
T Tooxixic c memetatabobolilitete: : NANAPQPQI I (N(N-a-acecetytyl-l-p- p-benzoquinone imine)
benzoquinone imine)
GI, liver and renal damage (4 stages)GI, liver and renal damage (4 stages)
Antidote:Antidote: N-AcetylcysteineN-Acetylcysteine
PPrreepapararattioionn: : IV IV – – uussuual al rroouute te (e(e..gg.. Hydranap) Hydranap) Oral – in sachet Oral – in sachet Inhalation Inhalation
Average 50-kh man who ingests 15-20 tabletsAverage 50-kh man who ingests 15-20 tablets (500 mg) causes toxic injury
(500 mg) causes toxic injury
IronIron
Toxic Dose: 20mg/kg Toxic Dose: 20mg/kg
GI, CVS, CNS GI, CVS, CNS manifestations (4 stages)manifestations (4 stages)
EGDEGD
Antidote:Antidote: DeferroxamineDeferroxamine
Causes severe bleeding and hypotensionCauses severe bleeding and hypotension
e.g. Flintstones, Gummy bears – contains irone.g. Flintstones, Gummy bears – contains iron which can cause toxicity
which can cause toxicity
Isoniazid (INH)Isoniazid (INH)
Toxic Dose: 80-100mg/kg Toxic Dose: 80-100mg/kg
T Tririad ad of of ININH H totoxixicicityty: : seseizizurureses, , cocomama,, metabolic acidosis
metabolic acidosis
Antidote:Antidote: Pyridoxine (Vitamin B6)Pyridoxine (Vitamin B6)
AspirinAspirin
AcAcetyetylsalsaliclicyliylic c aciacid: d: 100100mg/mg/kg kg (ch(childildreren),n), 200mg/kg(adults)
200mg/kg(adults)
MeMeththylylsasalilicycylalatete: : 5050-5-50000mgmg/k/kg g or or 4m4mll (1.4mg/ml)
(1.4mg/ml)
Vomiting,Vomiting, tinnitustinnitus (first thing to manifest),(first thing to manifest), me
metabtaboliolic c aciacidosdosis, is, seiseizurzureses, , comcoma, a, rerenalnal failure
failure
AcActivtivateated d chacharcrcoal oal / / hehemodmodialialysysis is (ca(causeusess coma, seizure) coma, seizure) PESTICIDES PESTICIDES OrganophosphatesOrganophosphates MalathioneMalathione ChlorpyrifosChlorpyrifos SSx: DUMBELSSSx: DUMBELS CarbamatesCarbamates SSx: DUMBELSSSx: DUMBELS PyrethroidsPyrethroids
DEET DEET (diethyltolbu(diethyltolbutamide)tamide)
-- cacaususes es seseizizurures es esesp ip in cn chihildldreren >n >2 y2 y/o/o
PermethrinPermethrin
- anti-pediculosis and scabies: cause seizure - anti-pediculosis and scabies: cause seizure
RodenticidesRodenticides
Zinc PhosphidesZinc Phosphides
CoumatetralylCoumatetralyl bleeding (Tx: vitamin K)bleeding (Tx: vitamin K)
HerbicidesHerbicides
Chemical pneumonitisChemical pneumonitis MIIXED PESTICIDES
MIIXED PESTICIDES (e.g. Baygon)(e.g. Baygon) CarbamatesCarbamates PropoxurPropoxur PyrethroidPyrethroid CyfluthrinCyfluthrin Transfluthrin Transfluthrin S/Sx: DUMBELSS/Sx: DUMBELS
Treatment: Atropine, Activated Charcoal Treatment: Atropine, Activated Charcoal Effects of Pesticides:
Effects of Pesticides:
--
EnEndocdocrinrine e disdisrupruptiotion n (ca(cause use prprobloblems ems inin reproduction and immune system)reproduction and immune system)
-- NNeeuurrododeevveeloloppmemenntatal l eeffffeeccts ts (e(e..g g auautitismsm,, cerebral palsy, mental retardation)
cerebral palsy, mental retardation) -- ImImmumune sne sysystetem (cm (can can cauause cse canancecer)r) NON-PHARMACEUTICALS
NON-PHARMACEUTICALS
Silica gelSilica gel – gastric irritant– gastric irritant
ChineChinese se herbherbal al medsmeds (e.(e.g. g. MaMa-Hu-Huang ang – – hashas pse
pseudoeudoephephedrine drine and and epheephedrindrine: e: preprecurscursor or of of methamphetamine)
methamphetamine)
Button batteriesButton batteries
-- in <in <7 y/7 y/o, to, the dhe diaiamemeteter of inr of inteteststinine is >e is >1.1.55 cm
cm
-- cacan obn obststruruct tct tracrachehea, pa, pylylororic sic sphphininctcterer -- enendodoscscopopy iy is ds donone te to go get et it it mamanunualallyly
WatusiWatusi
Y Yelellolow w phphososphphororus us – – momost st dadangngererououss (protoplasmic
(protoplasmic: : cause severe hypotension andcause severe hypotension and hypoxia)
hypoxia)
T Trinrinitritrotootolueluene ne (pr(presesent ent in in dydynamnamite ite andand bombs)
bombs)
Potassium nitratePotassium nitrate
PotassiuPotassium m chloratechlorate
Moth ballsMoth balls
NaphNaphthalthalene – ene – causcauses es hemhemolytic anemia inolytic anemia in G6PD deficiency pts
G6PD deficiency pts
Camphor –Camphor – most toxicmost toxic
PParara-a-didichchlolororobebenznzenene e – – dedeododororizizer er (e(e.g.g.. Albatross)
Albatross)
-- least toxicleast toxic, causes, causes slight gastric irritation slight gastric irritation
HEAVY METALS
HEAVY METALS
MercuryMercury (a.k.a Asoge)(a.k.a Asoge)
Sources:Sources:
Elemental: “quicksilver” metal, cinnabarElemental: “quicksilver” metal, cinnabar or
oree, , ddeentntal al amamalalggamam, , apapppararatatuus,s, thermometers
thermometers
IInnoorrggaanniicc: : aannttiisseeppttiiccss, , vvaacccciinneess (merthiolate)
(merthiolate)
OrOrgaganinic: c: cocontntamamininatated ed wawateters rs frfromom in
induduststririal al wawastste e prprododucuctsts, , aiair, r, sosoilil (methylmercury)
(methylmercury) Small-scale mining practices Small-scale mining practices
= residue after panning operation where most of = residue after panning operation where most of
the water are removed the water are removed = no
= no personal protective device is providedpersonal protective device is provided = route of entry is skin
= route of entry is skin Mercury in
Mercury in ThermometeThermometerr “Th
“Therere e is is appapproroximximateately ly 1 1 gragram m of of memercrcury in ury in aa typical fever thermometer.
typical fever thermometer. This is enough This is enough mercury tomercury to contaminate a lake with a surface area of about 20 contaminate a lake with a surface area of about 20 acres, to the degree that fish would be unsafe to eat” acres, to the degree that fish would be unsafe to eat” *Mercury is not actually absorbed if GI is intact but *Mercury is not actually absorbed if GI is intact but can cross BBB after 24-48 hrs
can cross BBB after 24-48 hrs *Tx: cathartics
*Tx: cathartics
Organic Chemicals: Organic Chemicals: MethylmercuMethylmercuryry
*Mercury vapor – amalgam fillings are chief sources *Mercury vapor – amalgam fillings are chief sources of exposure to mercury vapor
of exposure to mercury vapor Minam
Minamata ata DiseDiseasease (d(d/t /t hihigh gh lelevevels ls oof f memeththylyl mercury in big fishes, e.g. tuna)
mercury in big fishes, e.g. tuna)
In 1932, Nippon Chisso Hiyu started to operate an In 1932, Nippon Chisso Hiyu started to operate an acet
acetaldehaldehyde yde acetacetic ic venvenyl yl chlochloride ride manumanufactufacturingring pla
plant usinnt using mercg mercury as a ury as a catcatalyalyst. st. The plaThe plant hadnt had been direct
been directly ly discdischargharging ing its its induindustriastrial l wastwaste e intointo Mi
Minanamamata ta BBay ay fofor r 36 36 yeyearars s wwitith h no no adadeqequauatete facilities.
facilities.
In 1958, Chisso redirected the outlet drainage canal In 1958, Chisso redirected the outlet drainage canal fr
from om MMininamamatata a BBaay y ininto to ththe e trtribibuutatary ry of of ththee Minamata River which resulted in the contamination Minamata River which resulted in the contamination of a wider area of Yatshushiro Sea.
of a wider area of Yatshushiro Sea.
Increase in number of vaccines Increase in number of vaccines recommended for routine use in infants recommended for routine use in infants
Potential increased exposure of infants to mercury Potential increased exposure of infants to mercury
from thimerosal in vaccines from thimerosal in vaccines Ethyl Mercury
=
= in in chilchildredren n recereceiviniving g thimethimerosrosal al in in vaccvaccinesines, , thethe half-life of ethyl mercury in blood was 7-10 days or half-life of ethyl mercury in blood was 7-10 days or 1/7 to 1/5 as long as that of methyl mercury
1/7 to 1/5 as long as that of methyl mercury
= a WHO advisory committee recently concluded that = a WHO advisory committee recently concluded that it is safe
it is safe to continue using thimerosal in vaccineto continue using thimerosal in vaccine Mercury (Pink Disease)
Mercury (Pink Disease) Acrodynia
Acrodynia
-- AAcrcrododynynia is a ia is a rararre e ididioiopapaththic chic chrrononic toic toxixicc reac
reaction tion to to eleelementmental al or or inorinorganic mercuganic mercuryry ex
expoposusurere, , whwhicich h ococcucurs rs mamaininly ly in in yoyounungg child
childrenren. . It is charaIt is charactercterized bized by pain in they pain in the ex
extrtrememititieies s anand d oioink nk didiscscololororatatioion n wiwithth desquamation of the skin
desquamation of the skin
Uncommon Syndrome “Pink Disease” Uncommon Syndrome “Pink Disease”
Pain in the extremitiesPain in the extremities
Pinkish discoloration and Pinkish discoloration and desquamationdesquamation
HypertensionHypertension
SweatingSweating
Insomnia, irritability, apathyInsomnia, irritability, apathy
ConsidereConsidered as d as idiosyncratic reactionidiosyncratic reaction Adverse Effects of Mercury
Adverse Effects of Mercury
ElementalElemental
-- acacutute e nenecrcrototizizining g brbrononchchititis is pnpneueumomoninititis,s, ins
insomnomnia, ia, forforgetgetfulfulneness, ss, losloss s of of appappetietite,te, tremor, erethism, renal toxicity
tremor, erethism, renal toxicity
InorganicInorganic
-- cocorrrrososivive effee effectcts: GI ulcs: GI ulcereratatioion, pen, perfrfororatatioion,n, hemorrhage, acrodynia, renal toxicity
hemorrhage, acrodynia, renal toxicity
OrganicOrganic
--
CNS: paresthesia, ataxia, muscle spasticityCNS: paresthesia, ataxia, muscle spasticity -- InInfafantnts: psys: psychchomomototor retor retarardadatitionon, , blblinindndnesess,s,deafness, seizure, cerebral palsy deafness, seizure, cerebral palsy
-- BeBehahaviviororal and leal and leararnining deng delalaysys: : dedefificicits ints in language, attention and memory
language, attention and memory
LeadLead (a.k.a tingga)(a.k.a tingga)
PPreregngnanant t wwomomen en anand d ththeieir r dedevevelolopipingng fetuses are at high-risk because lead readily fetuses are at high-risk because lead readily crosses the placenta
crosses the placenta
For every 10mcg/dl increase in BLL, children’sFor every 10mcg/dl increase in BLL, children’s IQ dropped by 4-7 points
IQ dropped by 4-7 points
A A highhigher er proproportiportion on of of learlearning ning disadisabilitbilitiesies was found among school-aged children with was found among school-aged children with biological parents who ere lead poisoned as biological parents who ere lead poisoned as children 50 years previously
children 50 years previously
Source: paints, lipstick, gasoline, hair dyesSource: paints, lipstick, gasoline, hair dyes
Arsenic PoisoningArsenic Poisoning
Keratotic lesionsKeratotic lesionscancerouscancerous
Patients from Bangladesh dig a wellPatients from Bangladesh dig a well
PLANT TOXINS
PLANT TOXINS
Jathropa Seeds Jathropa Seeds
Contents: toxalbumins =Contents: toxalbumins = ricinricin (toxic content(toxic content causing hemorrhagic gastritis), curcin, tannic causing hemorrhagic gastritis), curcin, tannic acid
acid
EffeEffects: cts: abdoabdominaminal l painpain, , nausnausea, ea, vomitvomiting,ing, hepa
hepatic tic injurinjury, y, muscmuscle le twitwitchintching, g, weakweaknessness,, s
saallvvaattiioonn, , sswweeaattiinngg, , ddeehhyyddrraattiioonn,, hemorrh
hemorrhagic agic gastritisgastritis
Tx: activated charcoal Tx: activated charcoal
CYANIDE
CYANIDE
-- ininhihibibits ts cycytotochchrorome me ooxixidadasese
-- CNS CNS EfEffecfects: ts: shoshockck, p, profrofounound d laclactic tic aciacidosdosisis -- TToxoxic ic blblooood ld levevelel: >: >0.0.5 m5 mcgcg/m/mll
Cyanogen-containing plantsCyanogen-containing plants
Linamarin in cassava cake – associated Sxs:Linamarin in cassava cake – associated Sxs: DUMBELS
DUMBELS
Cyanide saltsCyanide salts
Metal polishing (jewelry Metal polishing (jewelry cleaners)cleaners)
Cyanide Antidote KitCyanide Antidote Kit
AmAmyyl l nnititririttee, , ssododiuium m nnititriritete, , ssododiuiumm thiosulfate
thiosulfate
RED TIDE POISONING
RED TIDE POISONING
Diarrheic shellfish poisoningDiarrheic shellfish poisoning
Okadaic acid (OA) and Okadaic acid (OA) and its derivativesits derivatives
AmAmnenesisic c or or enencecephphalalopopatathihic c shshelellflfisishh poisoning
poisoning
Domoic acidDomoic acid
Paralytic shellfish poisoningParalytic shellfish poisoning
Saxitoxin and gonyautoxin (GTX)Saxitoxin and gonyautoxin (GTX)
Neurotoxic shellfish poisoning (NSP)Neurotoxic shellfish poisoning (NSP)
BrevetoxinBrevetoxin Department of Health Department of Health
Criteria for Detecting PSP Criteria for Detecting PSP
Ataxia +Ataxia +
Additional 2 Motor Distrubances +Additional 2 Motor Distrubances + -- DDyysspphhaaggiiaa
-- IInnaabbiilliitty ty to so sttaanndd -- VVoommiittiinngg
-- DDyyssppnneeaa -- PPaarraallyyssiiss
Additional 2 Sensory DisturbancesAdditional 2 Sensory Disturbances -- DDiizzzziinneessss -- HHeeaaddaacchhee -- LLiigghhtthheeaaddeeddnneessss -- PPaarreesstthheessiiaass -- DDyysstthheessiiaa -- HHoot t ffllaasshheess -- NNuummbbnneessss Specific Treatment Specific Treatment
Public Health Issues Public Health Issues
Reporting to DOHReporting to DOH
Shellfish / Fish AdvisoryShellfish / Fish Advisory
Monitoring of other possible patientsMonitoring of other possible patients
Monitoring of levels of toxins in the area (BFAR)Monitoring of levels of toxins in the area (BFAR) SUBSTANCE ABUSE
SUBSTANCE ABUSE Sedatives
Sedatives
Diazepam (Valium)Diazepam (Valium)
Lorazepam (Ativan)Lorazepam (Ativan)
Flunitrazepam (Rohypnol)Flunitrazepam (Rohypnol)
Sleeping Pills (Stinox, Unisom)Sleeping Pills (Stinox, Unisom) *Ecstasy
*Ecstasy
- side effect: bruxism - side effect: bruxism
- causes seizure, severe dehydration - causes seizure, severe dehydration - more toxic than shabu
- more toxic than shabu Smoking and Alcohol Smoking and Alcohol
FIRST AID MANAGEMENT OF POISONING CASES
FIRST AID MANAGEMENT OF POISONING CASES
GOAL OF TREATMENT: GOAL OF TREATMENT:
-- to to lilimimit at absbsororptptioion on of pf poioisosonn -- reremomove ve frfrom tom tooxixic ec envnvirirononmementnt -- dedecocontntamamininatatioion n MaManeneuvuveersrs REMEMBER THE DONT’S:
REMEMBER THE DONT’S:
Do Do nonot t ininduduce ce vovomimititing ng in in ththe e fofollllowowiningg situations:
situations:
-- drdrowowsy sy anand cd comomatatosose pe patatieientntss -- ppoooor r ggaag g rreefflleexx
-- iningegeststioion of cn of cororrorosisive ave and hnd hydydrorocacarbrbonon
-- if thif the inge ingesestition haon has occs occururrred foed for morr more the thanan one hour
one hour
-- latlate pe preregnagnancy ncy (la(last st 3 m3 montonths hs of of prepregngnancancy)y) -- prpresesenence ce of of hehearart t didiseseasasee
Do not give milk or Do not give milk or vinegarvinegar :milk is not a
:milk is not a universal antidoteuniversal antidote
GiGive ve raraw w egegg g whwhitites es in in cacaseses s of of cocorrrrososivivee ingestion
ingestion
8-12 egg whites (adult) 8-12 egg whites (adult) 4-6 egg whites (children) 4-6 egg whites (children)
GivGive e 1-51-5% % bakbaking soda ing soda solsolutiution on in in cascases es of of shellfish and iron poisoning
shellfish and iron poisoning 1 teaspoon + 100mL water 1 teaspoon + 100mL water PREVENTIVE MEASURES
PREVENTIVE MEASURES •
• Wash vegetables / fruits thoroughlyWash vegetables / fruits thoroughly •
• Support integrated pest Support integrated pest managementmanagement •
• Avoid use of mercury thermometersAvoid use of mercury thermometers •
• Flush cold water tap before useFlush cold water tap before use •
• Dispose chemical containers Dispose chemical containers properlyproperly •
• Promote healthy lifestyle: “Say no to drugs”Promote healthy lifestyle: “Say no to drugs” •
• Do regular inventory of drugs and chemicalsDo regular inventory of drugs and chemicals in the house
in the house •
• Proper storage or labelsProper storage or labels Na
Natitiononal al PoPoisison on MaMananagegemement nt anand d CoContntroroll Center
Center
UPCM – Philippine General Hospital UPCM – Philippine General Hospital Ho
Hotltlinine e NuNumbmberers: s: 5252414107078 8 or or 5252181845450 0 locloc.. 2311
2311 With known or suspected toxin
With known or suspected toxin
(-)
(-) Respiratory Respiratory Distress Distress (+) (+) Respi Respi DistressDistress
Observe for 24 hrs Observe for 24 hrs
Asymptomatic
Asymptomatic (-) (-) Respi Respi Failure Failure (+)(+) Respi Failure
Respi Failure
Discharge
Discharge NaHCO3 NaHCO3 q q 5 5 hr hr NaHCO3 NaHCO3 q q 55 hrs x 24h hrs x 24h Observe x 24 hrs Observe x 24 hrs Ventilatory support Ventilatory support Respi
Respi Distress Distress Test Test dose dose of of edrophonium
