general lines of management of a case of acute poisoning

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General Lines of Management of Acute Poisoning

The management of acute poisoning follows a structured, stepwise approach regardless of the specific toxin. The framework below is based on Goldman-Cecil Medicine (Chapter 96 — Nelson & Calello).

Management Algorithm for Acute Poisoning

1. Initial Assessment & Diagnosis

History — gather:

Toxicant(s) involved (name, estimated amount, formulation)
Time and route of exposure (ingestion, inhalation, dermal, injection)
Symptoms onset and progression
Treatment already given
Available medications at home (patient's, family's)
Occupational/avocational exposures

The history may be incomplete or inaccurate if the patient is confused or suicidal; corroborate with relatives, EMS, and scene findings.

Physical Examination — focus on:

Vital signs (BP, HR, RR, temperature, GCS)
Eyes (pupils: miosis = opioid/cholinergic; mydriasis = anticholinergic/adrenergic)
Neurologic (level of consciousness, tone, reflexes, seizures)
Cardiopulmonary (arrhythmia, bronchospasm, pulmonary edema)
GI (bowel sounds, vomiting, abdominal pain)
Skin (diaphoresis, flushing, color, burns)

Toxidromes — recognize characteristic clusters:

Toxidrome	Features	Example Agents
Opioid	Miosis, coma, respiratory depression	Heroin, fentanyl, morphine
Anticholinergic	Mydriasis, dry flushed skin, tachycardia, urinary retention, delirium	Atropine, TCAs, antihistamines
Cholinomimetic	SLUDGE (salivation, lacrimation, urination, defecation, GI cramps, emesis) + bradycardia, miosis, bronchospasm	Organophosphates, carbamates
Adrenergic	Mydriasis, hypertension, tachycardia, hyperthermia, diaphoresis	Cocaine, amphetamines
Sedative-hypnotic	CNS depression, slurred speech, ataxia	Benzodiazepines, barbiturates

Laboratory:

Blood glucose (always), ABG/VBG, electrolytes, renal/hepatic function, CBC, coagulation
Anion gap and osmol gap (screen for toxic alcohols)
ECG (QRS widening → TCAs; QTc prolongation → many agents)
Specific levels where indicated (paracetamol, salicylates, digoxin, ethanol, lithium, iron, carbamazepine)
Urine toxicology screen (qualitative, limited specificity)

2. Stabilization (ABC + ALS)

Airway:

Protect the airway; intubate if necessary to correct or prevent:
- Hypoxemia
- Respiratory acidosis
- Pulmonary aspiration

Breathing: Supplemental O₂; assisted ventilation as needed.

Circulation: IV access × 2; cardiac monitoring; correct hypotension with IV fluids; vasopressors if refractory.

ALS Modifications (toxin-specific):

Atropine is often ineffective for bradycardia due to β-adrenergic receptor antagonists (BARAs), calcium-channel antagonists (CCAs), or cardiac glycosides
Benzodiazepines for cocaine-induced tachycardia/agitation and seizures
Calcium for CCAs, hydrofluoric acid, hypermagnesemia
Glucagon for BARAs and CCAs
Digoxin-specific Fab for cardiac glycoside toxicity
High-dose insulin-glucose for BARAs and CCAs
NaHCO₃ for myocardial sodium-channel blockers (TCAs, flecainide)
Nitroprusside for drug-induced hypertension
Phentolamine to reverse cocaine-induced α-adrenergic effects
Avoid BARAs in cocaine-induced ischemia

Glucose — give IV dextrose for any altered consciousness with hypoglycaemia; precede with thiamine 100 mg IV if alcoholism suspected.

"Coma cocktail" (dextrose, thiamine, naloxone, flumazenil) — empirical use is rarely helpful and may be harmful in polydrug overdose; use only when there is strong suspicion of a specific agent.

3. Decontamination

Decontamination can be performed simultaneously with stabilization.

A. Oral (Gastrointestinal) Decontamination

1. Activated Charcoal (AC) — 1 g/kg body weight (max 100 g)

Indications: Toxin with potential for serious toxicity that adsorbs to charcoal; ideally within 1 hour of ingestion (though benefit may extend to 2 hours for some agents)
Contraindications: Unprotected airway; bowel obstruction or perforation; ingestion of pure aliphatic hydrocarbons or caustics; altered consciousness without secured airway

2. Gastric Emptying (Orogastric Lavage)

Use large-bore orogastric tube; alternatively, nasogastric tube aspiration for liquid toxins
Indications: Toxins non-adsorbent to AC with potential for consequential toxicity; ideally performed ≤1 hour post-ingestion
Contraindications: Unprotected airway; ingestion of sharp objects; bleeding diathesis; same contraindications as AC; caustics

Ipecac-induced emesis is no longer recommended.

3. Whole Bowel Irrigation (WBI)

Polyethylene glycol (PEG) solution at 500 mL/hour orally or via NGT, titrated to 2000 mL/hour, continued until rectal effluent clears
Indications: Iron; sustained-release/enteric-coated medications; agents not adsorbed by AC; body packers (drug smugglers)
Contraindications: Bowel perforation, obstruction, hemorrhage; hemodynamic or respiratory instability

B. Dermal Decontamination

Remove contaminated clothing
Wash thoroughly with soap and water

C. Ocular Decontamination

Irrigate copiously with 0.9% normal saline

4. Antidotes

Few toxicants have specific antidotes. Their use does not replace the need for ongoing supportive care.

Antidote	Indication
Naloxone	Opioid overdose (0.4–2 mg IV; repeat every 2–3 min; infusion at 0.8 mg/kg/hr)
Flumazenil	Benzodiazepine overdose (0.2 mg/min IV; max 1 mg) — caution in TCA co-ingestion/chronic BZD users
N-acetylcysteine (NAC)	Paracetamol (acetaminophen) overdose
Atropine + pralidoxime	Organophosphate/carbamate toxicity
Digoxin-specific Fab	Digoxin/cardiac glycoside toxicity
Physostigmine	Anticholinergic toxidrome (select cases)
Fomepizole	Methanol/ethylene glycol poisoning
Hydroxocobalamin	Cyanide poisoning
Calcium gluconate	Calcium-channel blocker / HF / hypermagnesemia
Glucagon	Beta-blocker / calcium-channel blocker
Edetate calcium disodium (CaNa₂EDTA)	Lead poisoning
Octreotide	Sulfonylurea-induced hypoglycaemia
Sodium bicarbonate	TCA / Na-channel blocker toxicity
Pyridoxine (B₆)	Isoniazid overdose
Methylene blue	Methaemoglobinaemia
Deferoxamine	Iron poisoning

5. Enhanced Elimination

Used when the toxin is absorbed and elimination needs to be accelerated.

A. Multiple-Dose Activated Charcoal (MDAC)

Average dose: 12.5 g every 4–6 hours (after initial 1 g/kg loading dose)
Works via: interruption of enterohepatic/enteroenteric recirculation; "GI dialysis"
Definite benefit: Carbamazepine, dapsone, phenobarbital, quinine, salicylates, theophylline
Potential benefit: Amitriptyline, digitoxin, digoxin, phenytoin, sotalol, nadolol, piroxicam
Contraindications: Same as single-dose AC

B. Urinary Alkalinization

IV sodium bicarbonate to achieve urine pH 7.5–8.5
Indications: Chlorpropamide, 2,4-dichlorophenoxyacetic acid, formic acid, methotrexate, phenobarbital, salicylates
Contraindications: Volume overload, pulmonary oedema, cerebral oedema

C. Extracorporeal Removal

Consider when patient is hemodynamically stable (instability may preclude use)
Modalities: haemodialysis, haemoperfusion, haemofiltration, exchange transfusion, plasmapheresis
Indications: Lithium, salicylates, methanol, ethylene glycol, theophylline, valproate (see specific extracorporeal criteria)

6. Disposition & Psychiatric Review

All cases of intentional self-poisoning require psychiatric assessment before discharge
Recurrent purposeful self-poisoning rate is 12–18%, with most events within 3 months
Risk-stratify for ICU admission vs. monitored ward vs. discharge with follow-up
Notify the Poison Control Centre where available — they provide real-time management guidance and collect data

Source: Goldman-Cecil Medicine, International Edition — Chapter 96: Acute Poisoning (Nelson LS, Calello DP), pp. 1111–1124.

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