Management of Acute Poisoning : General approaches RPh Adilah Mohamed Ariff National Poison Centre Universiti Sains Malaysia
Introduction • Basic knowledge and practices in managing acute poisoning. • Understanding this basic and general approaches is vital for healthcare provider in facilitating decisions of diagnosis, risk assessment and treatment plan of specific type of poisoning. • Pharmacist should identify their important roles in the management flow regardless their setting of practice. • Other healthcare providers are part of the important team members in managing poisoned patient.
Scenarios: Pharmacist may encounter A doctor call the pharmacist National Poison Centre (NPC) to get information on how to manage a poisoning case recently admitted to the ED A mother of a 2 yo boy called a community pharmacist asking whether 50 tablets of Vitamin C is toxic to her child or not. A public walk into your retail pharmacy asking whether the TCM product he took contains any poison. A doctor called a pharmacist in hospital DIS asking about dosing, dilution and preparation of ethanol to treat methanol poisoning A doctor contacted a pharmacist in hospital TDM enquiring about procedure on measuring carbamazepine level in an overdosed patient. A doctor/pharmacist from NPC called a pharmacist in a community/hospital pharmacy to get assistance on identifying an unknown tablet that was taken overdose by a patient.
Competencies for Pharmacist • Good history taking – consider various circumstances in poisoning • Able to understand and correlate the signs and symptoms with suspected agent • Understand lab findings • Able to choose and search in relevant reference sources • Able to evaluate risk of the patient • Able to deliver relevant information which is individualized to the patient. • Good in handling drug-related enquiries eg antidote, drug dosing, dilution etc.
Drug overdose Chemical accident Envenomation Occupational exposure Environmental contaminant Adverse reaction
CH GE GENE NERAL AL AP APPR PROA OACH 1. Eme mergenc ency y st stabiliz lization ation 2. Cl Clinical cal ev evaluation uation 3. Li Limi mitin ting g abso sorpti rption on of f poiso son 4. Enhance anced d el elimi mination ation of f poiso son 5. Adm dministration stration of an f antidote dote 6. Support pportive ive ther erapy apy 7. Appropria propriate te di disp spositi sition on
zation Em Emergency gency St Stabili bilization ma maintenance enance of of ade dequate uate airway way ade dequate uate ox oxygenation enation and d ve ventilation ation ade dequate uate circulation culation treat eat convu vulsi lsion ons correction ection of met f metabol bolic ic abnormalitie malities ma manage e com oma
CH GE GENE NERAL AL AP APPR PROA OACH 1. Eme mergenc ency y st stabiliz lization ation 2. Cl Clinical cal ev evaluation uation 3. Li Limi mitin ting g abso sorpti rption on of f poiso son 4. Enhance anced d el elimi mination ation of f poiso son 5. Adm dministration stration of an f antidote dote 6. Support pportive ive ther erapy apy 7. Appropria propriate te di disp spositi sition on
UATION CLIN INICA ICAL EV EVAL ALUATION A. Hi Hist story ry taki king ng B. B. Physic sical l ex exami mination ation C. C. Toxicologic cological al sc scree eenin ing
ng CLIN INICA ICAL EV EVAL ALUATION: UATION: A. A. Histor tory y Ta Taking agen ent t and d amo mount nt time me & location ation of f ex exposure sure route te of f ex exposure sure intake ke of f other er su subst stances ances circums cumstances tances of ex f exposure sure current rent me medi dication ations past st me medi dical al hist story ry preh ehospital spital trea eatment tment
ination CLIN INICA ICAL EV EVAL ALUATION: UATION: B. B. Phys ysical ical Ex Examination gen ener eral status us look at the e skin smel ell the e br brea eath listen en to the lu e lungs ev evaluate te the e hea eart rt ex examine e the e abd bdomen en per erform rm neu euro rologi logical cal ex exam
ination CLIN INICA ICAL EV EVAL ALUATION: UATION: Phys ysica ical l Ex Examination May need to remove clothing for thorough exam • Check clothing for objects or substances • Assess general appearance of patient - Agitation, confusion, or • obtundation Exam skin for bruising, cyanosis, flushing • Exam eyes for pupils size, nystagmus, reactivity, dysconjugate • gaze, increased lacrimation Oropharynx for increase salivation or excessive dryness • Heart: rhythm, rate, regularity • Lungs: bronchorrhea or wheezing • Abdomen: bowel sounds, tenderness or rigidity • Extremities: fasiculations, tremor • Neuro: CNS, reflexes, muscle tone coordination, cognition, ability to • ambulate
ination CLIN INICA ICAL EV EVAL ALUATION: UATION: B. B. Phys ysical ical Ex Examination Abdome Ab domen hypoac activ tive : anti tichol choliner inergics gics hyperacti ractive : organ anop ophosph hosphates ates Neuro urologic logic Ex Exam Glasgow Coma Scale (E, M, V) Measure conscious state: co coma : opioid oid , i iso soni niazi azid Eye opening Best motor response paralysis alysis : snake sn ke bite te Best verbal response aniso isoco coria ria : eth thylene lene glyco col Scoring blin indness dness : meth than anol ol MILD = 13 - 15 MODERATE = 9 - 12 SEVERE = 3 - 8
ination CLIN INICA ICAL EV EVAL ALUATION: UATION: B. B. Phys ysical ical Ex Examination A toxi A xidro drome is a combinatio nation n of signs gns and d symptoms toms which, h, when n taken en co collec ective tively, ly, ch charac acterize terize a sus uspec ected ted toxi xica cant nt Com oma opioids ds Respira iratory tory depressio ssion Mios osis is/myd mydriasi riasis Diarrhea arrhea/d /diaphore iaphoresis sis Urinat natio ion Miosi osis/musc /muscle le fascic ciculations ulations Organopho hosp spha hates/ tes/car carbam bamates ates Bradycard dycardia ia/bronc bronchorrhea horrhea Emesis is Lacrim rimatio ation Sali livat vatio ion n
ination CLIN INICA ICAL EV EVAL ALUATION: UATION: B. B. Phys ysical ical Ex Examination Poisons ons with th de delay ayed ed signs ns an and sym d symptom toms: et ethyle ylene e glyc ycol ol : 6 6 hours rs org rganop anophosphat hosphate e : 6-12 2 hours rs As Asymp mpto toma matic tic or mild d initial ial parace racetamo tamol : 36 hours rs condi dition tion not paraq raquat uat : 4 48 hours rs nece cessarily ssarily warr rrant ant go good d met ethanol anol : 48 hours rs progno ognosis sis thyroxi yroxine ne : 4 4 wee eeks
ening CLIN INICA ICAL EV EVAL ALUATION: UATION: C. To Toxicolog cologica ical l screening • Specime imen n collection ection • Timing of f sampling • Manner er of s f sampling • Type of f bi biologic fl fluid d Availab ilability ility of specif ecific ic lab inv nvestig stigatio ation n in n Malaysia laysia • Urine ine paraquat aquat In the e acute e care e set etting, ng, • Rapid pid urine ne test st for or su substan stance ce of of abuse se toxi xicology gy screenin ing g is is • Blood ood methanol hanol, etha hano nol l very limited ed and do d does not • Pseudocholi udocholines nesterase terase (no not RBC C cho holine linesteras sterase) contri ribu bute te signifi ficantly antly • Ca Carbox rboxyHe yHemogl moglob obin in (CO COHb Hb)
eening CLIN INICA ICAL EV EVAL ALUATION: UATION: C.To Toxicological xicological screening Radio dio-opaque opaque Dr Drugs s (C (CHI HIPS) S) Chloral loral hydr drate ate Heavy y metals ls Ir Iron and d Io Iodi dides des Ps Psychotr hotropi pics cs (TCA) A) Enteric ric-coated coated salic icylates ylates Ther ere e are varying ing radi dio-opa pacity ity among g di differ erent ent medi dications tions and d even for the same medi dication tion from m di differ erent ent manufac acturer turers
CH GE GENE NERAL AL AP APPR PROA OACH 1. Eme mergenc ency y st stabiliz lization ation 2. Cl Clinical cal ev evaluation uation 3. Li Limi mitin ting g abso sorpti rption on of f poiso son 4. Enhance anced d el elimi mination ation of f poiso son 5. Adm dministration stration of an f antidote dote 6. Support pportive ive ther erapy apy 7. Appropria propriate te di disp spositi sition on
ON LIMITI ITING NG AB ABSOR ORPTION TION OF OF POI OISON A. . De Deconta tamina mination tion (e (ext xtern ernal al an and in d inte ternal) al) A1 A1. Sk Skin de decontam tamination ination A2. Eye de A2 deco contamination tamination A3 A3. In Indu duce emesis is A4 A4. Gastric tric lavage ge / Gastri stric aspira iration tion B . Adsorbent (Activated charcoal, Fuller’s Earth) C. Cat . Cathar arti tics D. Wh . Whole le bowel el ir irrig igatio ation
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