GENERAL MANAGEMENT OF POISONING

Definition: 

Poisoning occurs when any substance interferes with normal body functions after it is swallowed, inhaled, injected or absorbed. Drug overdoses occur when pharmacologic preparations are taken in excess and lead to toxicity.

PRE-HOSPITAL MANAGEMENT

Suspect poisoning in the following conditions

  • Unexplained loss of consciousness or altered sensorium
  • Vomiting, difficulty breathing, sleepiness, confusion or other unexpected signs
  • Burns or redness around the mouth and lips, which can result from drinking certain poisons
  • Breath that smells like chemicals, such as kerosene, insecticides or any unusual smell
  • Burns, stains and odors on the person, or clothing or on the furniture, floor or other objects in the surrounding area
  • Empty medication bottles or scattered pills

When to call for help

  • Call the local emergency medical service immediately if the person is:
  • Drowsy or unconscious
  • Having difficulty breathing or has stopped breathing
  •  Having seizures

What to do while waiting for help

  • If the person is conscious and you are sure that he has not taken kerosene or petroleum products, corrosives or heavy metals, give charcoal slurry (homemade charcoal –burnt toast mixed with tea).
  • If the patient has taken corrosives, egg white can be safely administered.                                                          Homemade antidote
  • If the patient is unresponsive, open the airway and look for signs of breathing. If no breathing is present, deliver artificial breathing only in the presence of barrier devices or ambu-bag and check for signs of circulation (carotid pulse if you are a doctor/paramedic and cough/limb movements for non-medical personnel).
  • Start CPR if there are no signs of circulation. If the victim is breathing, put the patient in recovery position (lateral position) and reassess every 2 minutes.
  • If the person starts having convulsions, give convulsion first aid:
    •  Protect the person from injury. Try to prevent a fall. Lay the person on the ground in a safe area. Clear the area of furniture or other sharp objects. .Cushion the person's head. Loosen tight clothing, especially around the person's neck. Turn the person on his or her side. If vomiting occurs, this helps make sure that the vomit is not inhaled into the lungs. Stay with the person until recovery or until you have professional medical help.                                                                 CPR
  • Do Not:
    • DO NOT restrain the person.
    • DO NOT place anything between the person's teeth during a seizure (including your fingers).
    • DO NOT move the person unless he or she is in danger or near something hazardous.
    • DO NOT try to make the person stop convulsing. He or she has no control over the seizure and is not aware of what is happening at the time.
    • DO NOT give the person anything by mouth until the convulsions have stopped and the person is fully awake and alert.
  •  If the suspected poison is a household cleaner or other chemical, read the label and follow instructions for accidental poisoning.
  • If the person vomits, clear the person's airway. Wrap a cloth around your fingers before cleaning out the mouth and throat. If the person has been sick from a plant part, save the vomit. It may help experts identify what medicine can be used to help reverse the poisoning.
  • Follow treatment directions that are given by the local emergency medical service.
  • If the poison is spilled on the person's clothing, skin or eyes, remove the clothing. Flush the skin or eyes with cool or lukewarm water, such as by using a shower for 20 minutes or until help arrives.
  • Take the poison container (or any pill bottles) with you to the hospital.
  •  For inhalation poisoning:
    • Call for emergency help. Never attempt to rescue a person without notifying others first.
    • If it is safe to do so, rescue the person from the danger of the gas, fumes, or smoke. Open windows and doors to remove the fumes.                                      Recovery Position
    • Take several deep breaths of fresh     air, and then hold your breath as you go in. Hold a wet cloth over your nose and mouth.
    • When you want to rescue the person from a smoky area, crawl on your knees and pull the patient to avoid inhalation of the smoke/fumes.
    • If in cardiac arrest, begin rescue breathing and CPR.
    • If necessary, perform first aid for eye injuries or convulsions.
    • Even if the person seems perfectly fine, get medical help.

What NOT to do while waiting for help

  • DO NOT administer ipecac syrup or do anything to induce vomiting.
  • DO NOT give charcoal if the patient is drowsy, unconscious or in poisoning with corrosives/petroleum products.
  • DO NOT attempt mouth to mouth breathing if you suspect dangerous poisoning.
  • DO NOT go in to dangerous places without safety precautions.
  • DO NOT give an unconscious victim anything by mouth.
  • DO NOT try to neutralize the poison with lemon juice or vinegar, or any other substance, unless you are told to do so by the emergency services.
  • DO NOT wait for symptoms to develop if you suspect that someone has been poisoned.

HOSPITAL MANAGEMENT

Check Airway, Breathing, Circulation

  • Airway

Check airway for patency and if in doubt, intubate the patient.

  • Breathing

If inadequate or absent respiratory rate, intubate the patient and provide appropriate ventilatory support.

  • Circulation

If inadequate blood pressure/hear rate, administer IV fluids/vasopressors as appropriate.                       Intubation in suspected poisonings with trauma

Gastric Lavage                                                  

With the patient in the left lateral and head-down position, pass the gastric lavage tube up to the pre-measured marking and lavage the stomach with 200-250 ml of water repeatedly until the lavaged solution is clear.

Contraindications to gastric lavage

Corrosive/petroleum products poisoning.

Caution: 

In drowsy or unconscious patient, INTUBATE before you attempt gastric lavage.

Once the poison has moved past the stomach, other methods are needed:

Activated charcoal 

acts as a "super" absorber of many poisons. Once the poison is stuck to the charcoal in the intestine, the poison cannot get absorbed into the bloodstream. To be effective, activated charcoal needs to be given as soon as possible after the poisoning. It does not work with alcohol, caustics, lithium, or petroleum products.

Peglec

Whole bowel irrigation requires drinking a large quantity of a fluid called Peglec. This flushes the entire gastrointestinal tract before the poison gets absorbed.

Antidotes

Some poisons have specific antidotes. Antidotes either prevent the poison from working or reverse the effects of the poison.

Antidotes to Common Poisons


It may also be possible to reverse the harmful effect of a drug even if no antidote exists

  • If a person with diabetes takes too much insulin, a dangerously low blood sugar (hypoglycemia) will cause weakness, unconsciousness, and eventually death. Sugar given by mouth or IV is an effective treatment until the insulin wears off.
  • When the poison is a heavy metal, such as lead, special medicines (chelators) bind the poison in the bloodstream and cause it to be eliminated in the urine.
  • Another "binder" is sodium polystyrene sulphonate (Kayexalate), which can absorb potassium and other electrolytes from the bloodstream. 

General supportive measures:

When there are no specific treatments, the physician will treat signs and symptoms as needed.

  • Sedatives to calm agitated or hallucinating patients until the drug wears off.
  • Intubation and ventilatory support for patients with inadequate or absent breathing.
  • Antiseizure medicines can be used to treat or prevent seizures.
  • Appropriate fluid monitoring and management.
  • Adequate nutrition and bed-sore prevention.
  • Cardiac and pulmonary status monitoring. 

Role of Psychiatry in Suicide Poisoning:

One must clearly understand that the above management would only treat the complications of a psychiatric illness in suicidal poisonings and would not be complete unless augmented with appropriate psychiatric counseling.

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