ACUTE

POISONING
The First Teaching Hospital of Zhengzhou
University
Chao Lan

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Poisoning is defined as “to injure or kill

with poison, a chemical substance that

usually kills, injures, or impairs an

organism”.

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 Acute Poisoning in the
Emergency Department
• Common - 3-5% of ED attendances
• 2000 Deaths per year
• Some of the highest rates of deliberate
poisoning in Europe
• Often multiple drugs
• DON’T FORGET ALCOHOL !!

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The general approach to the poisoned
patient may be divided into seven
phases 。

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(1) emergency management,
(2) clinical evaluation,
(3) eliminating poison from the gastrointestinal
tract, skin, and eyes or removal from the site
of exposure in inhalation poisoning,

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(4) administering an antidote,

(5) elimination of absorbed substance,

(6) supportive therapy,

(7) observation and disposition.

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1. Emergency Management.

（ 1 ） Resuscitation with airway establishment,

adequate ventilation and perfusion, and
maintaining all vital signs must first be
accomplished.
（ 2 ） Continuous cardiac and pulse monitoring
is essential

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1. Emergency Management.

（ 3 ） Rapid-sequence intubation may be

indicated.
（ 4 ） Inserting an intravenous (IV) line and
drawing appropriate blood samples.
（ 5 ） Naloxone 2 mg (IV), thiamine 100 mg
(IV), and 50% glucose 50cc (IV) (if the
patient is hypoglycemic) are given to all
patients in coma
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 1. Emergency Management.

（ 6 ） Maintaining blood pressure

and tissue perfusion may require adequate
volume replacement, correcting acid-base
disturbance, antidotal therapy, and pressor
agents.
（ 7 ） Cardiac arrhythmias and
seizures should be treated appropriately if
possible.

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2. Clinical evaluation.

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• Use all your senses, search for the clues
• LOOK
– Track Marks
– Pupil Size
• FEEL
– Temperature, Sweating
• SMELL
– Alcohol

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 2. Clinical evaluation
（ 1 ） Any patient presenting with
multisystem involvement should be
suspected of poisoning until proved
otherwise. A thorough history and
physical examination are essential.
（ 2 ） A patient with acute poisoning
often presents with coma, cardiac
arrhythmia, seizures , metabolic acidosis,
and/or gastrointestinal disturbances, either
together as symptom complexes or as
isolated events.
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2. Clinical evaluation
（ 3 ） Hepatic, renal, respiratory, and
hematologic disturbances are generally
delayed manifestation of poisoning.

（ 4 ） Laboratory evaluation generally

supports the assessment.

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3. Elimination of Poison.

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 Inhaled Poisons

Objective: Move to fresh air; optimize

ventilation and protect personnel from
exposure

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 Absorbed Poisons

Objective: Remove poison from skin

Liquid: Wash with copious amounts of
water
Powder: Brush off as much as
possible, then wash with copious
amounts of water
Protect personnel from exposure

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 Dilute / Irrigate / Wash
• Use soap, shampoo for hydrocarbons
• No need for chemical neutralization - heat
produced by reaction could be harmful

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 Eye Irrigation
• Wash for 15 minutes
• Use only water or balanced salt solutions
• Remove contact lenses
• Wash from medial to lateral

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 Ingested Poisons

Objective
Remove from GI tract before
absorption occurs

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3. Elimination of Poison
The majority of poisoning occurs via the
gastrointestinal tract. Gastric decontamination
is indicated to reduce absorption of the
poisonous substance. Principal modalities in
historical order include induced vomiting,
gastric lavage, activated charcoal, and whole-
bowel irrigation.

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3. Elimination of Poison

a. Induced vomiting.
– This is may be recommended if the time
since ingestion of the poison is less than
30 minutes.
– (a) digital stimulation (b) Syrup of
ipecac

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 Ipecac
• RARELY used anymore
• If used, has to have been initiated within 30
minutes after ingestion
• Vomiting in 20-30 minutes
• Only removes about 32% of contaminate
• Many contraindications

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 Ipecac
• Dose
– 15 cc if 12 months to 12 years old
– 30 cc if >12 years old
• Follow with 2-3 glasses of water
• Keep patient ambulatory if possible

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 Ipecac
• If no vomiting after 20 minutes, repeat
• When emesis occurs, keep head down
• Collect, save vomitus for analysis

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 Ipecac
• Contraindications
– Comatose or no gag reflex
– Seizing or has seized
– Caustic (acid or alkali) ingestion
– Late term pregnancy
– Severe hypertension, cardiovascular
insufficiency, possible AMI

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3. Elimination of Poison

b. Gastric lavage
– Gastric lavage is contraindicated in
patients who have ingested corrosives or
petroleum distillate hydrocarbons because
of the risk of aspiration-induced
hydrocarbon pneumonitis and
gastroesophageal perforation.

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 Lavage
• Commonly used in ED’s
• Removes about 31% of substance
• Helps get activated charcoal in patient,
especially if patient is unconscious
• Not helpful for sustained release tablets

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3. Elimination of Poison

c. Activated charcoal
– Activated charcoal ,as a suspension in
water either alone or with a cathartic ,is
given orally via a nippled bottle(for
infants), or via a cup ,straw,or small-bore
nasogastric tube.
– The recommended dose is 1 to 2g/kg body
weight.

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 Activated Charcoal
• Adsorbs compounds, prevents movement
from GI tract

• Very effective at adsorbing substances

• Binds about 62% of toxin

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 Activated Charcoal

• Inactivates Ipecac

• Do not give until vomiting stops

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3. Elimination of Poison

d. Whole-bowel irrigation
－ Whole-bowel irrigation is performed by
administering a bowel-cleansing
solution containing electrolytes and
polyethylene glycol orally or by gastric
tube.

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4. Antidotes.
a. Naloxone for all morphine-like drugs
b. Atropine sulphate and pralidoxime, for
anticholinesterase poisoning.
c. Desferrioxamine for iron poisoning
d. Methionine or N-acetyl cysteine in severe
paracetamol poisoning.
e. Nikethamide for alcohol or barbiturate.
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5.Elimination of Absorbed Substance.

（ 1 ） diuresis 　 and 　 forced 　 diuresis: 　

　　　　 Phenobarbital ; Salicylate
（ 2 ） alkalinization 　 of 　 urine:
　 Salicylate; Barbiturates
（ 3 ） hemoperfusion:
　 Lithium;Methanol;Ethylene glycol ;Salicylate
（ 4 ） hemodialysis:
Theophyline; Barbiturates 34
Criteria for HD/Hp include:
• The presence of complications
• Renal failure
• Severe and probably fatal poisoning with
grade Ⅳ coma
• High ingested dose and blood levels
• Progressive deterioration with apnea
• Circulatory failure
• Hypothermia

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Conscious level
• GradeⅠ Drowsy, confused, responds to
command, reflexes brisk.
• GradeⅡ. Unconscious, does not respond to
command, responds to minimal painful
stimulus.
• GradeⅢ Deeper, responds only to severe
stimulus, respiration depressed
• GradeⅣ Coma, no responses, hypotension
severe respiratory depression or apnea
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6. Supportive Therapy.

（ 1 ） Indiscriminately using drugs, antidotes,

and gastric lavage should be avoided.
（ 2 ） Hospitalization in an intensive care unit
is often indicated for the serious
poisoning.

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Carbon monoxide
Poisoning
The First Teaching Hospital of
Zhengzhou University

Chao Lan

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 Carbon monoxide
• Colourless, odourless tasteless non-irritant
gas from incomplete combustion of organic
materials
• 1-2% COHb in non-smokers, 5-6% in
smokers.
• Approx. 1,000 people die /year from CO
poisoning. Less now natural gas has replaced
coal gas.
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 Toxicity
• Main cause of death in children
• Common sources
– car exhausts (lethal in closed garage in
<10 min)
– Unserviced heating systems
– Fires - all sorts

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 Physiology
• Binds to Hb with an affinity 200-250 times that of
oxygen.

• Forms carboxyhaemoglobin, reducing the total

oxygen-carrying capacity of blood.

• Alters shape of Hb molecule making it less ready to

release O2.

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 Clinical manifestations
• Varied
• Depends on
– CO concentration
– length of exposure
– general health of exposed person
• Infants, elderly, anaemia, lung disease at risk

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 Chronic exposure to low
concentrations
• Headache, fatigue, dizziness, difficulty in
concentration, chest pain, palpitations, visual
disturbances, nausea, diarrhoea, abdominal
pain.
• Can easily be mistaken for other illnesses.
• Should be considered in vague presentations.

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 Acute poisoning
• Clinical findings do NOT correlate well with
CO concentrations
• <10% - asymptomatic
• 10-30% - headache, mild dyspnea, “gastro-
enteritis”.
• Coma, cardiorespiratory arrest if >60%

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 Treatment
• Remove from source
• 100% O2 by close-fitting facemask-intubate and
ventilate EARLY if unconscious as high
incidence of regurgitation.
• Dissociation from Hb occurs readily-elimination
t1/2 <50 min with 100%O2.
• Hyperbaric treatment at 2.5 bar reduces this to
22 minutes and dissolves enough O2 to meet
needs of body without HB.
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 Results of hyperbaric therapy
• First used successfully in Glasgow in 1960s.
• Reduces morbidity from 43% to <5%.
• Can even be used in late-presenting cases
with high CO levels.
• Early treatment associated with better
outcomes
• General support also necessary.

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