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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.
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Contraindications of Gastric Lavage
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 Lavage
Contraindications of Gastric Lavage
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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.
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Complications of Gastric
Complications of Gastric
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Complications of Gastric
Lavage
Complications of Gastric
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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Complications of Gastric
Complications of Gastric
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Complications of Gastric
Lavage
Complications of Gastric
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.
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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.
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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.
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Surgical removal
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Surgical removal
Drug-filled condoms
Intact tablets
Tablet concretions
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