Symptomatic intensive therapy in poisoning

Acute poisoning is treated according to a single principle regardless of the level of medical care. The scope of medical intervention may vary from the maximum in a specialized hospital to first aid or medical care. Many first aid techniques (e.g., gastric lavage, laxatives, etc.) are also included in the scope of medical care in specialized hospitals. The complex of medical measures consists of symptomatic (intensive syndrome-based) therapy aimed at maintaining vital functions in the toxicogenic stage of poisoning, rehabilitation of patients in the somatogenic stage, and detoxification measures necessary to remove the toxicant from the body.

Symptomatic (intensive syndromic) therapy consists of the emergency elimination of dysfunctions of vital organs and systems that have developed due to the action of a toxic substance. Among the various syndromes noted in resuscitation in general and in toxicology in particular, it is necessary to highlight the main ones associated with the selective toxicity of a given substance, which are of decisive importance in intensive care and subsequent rehabilitation of patients with acute poisoning.

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Gastrointestinal tract damage syndrome

Gastrointestinal tract damage syndrome, observed in 40% of patients with acute poisoning and more, manifests itself in the form of functional and organic changes. The most common symptoms are vomiting and diarrhea (toxic gastritis and gastroenteritis), which can be considered in some cases as a protective reaction of the stomach and intestines to a foreign substance that has entered and perceived as a symptomatic sign of a number of poisonings, for example, chlorinated hydrocarbons, organophosphorus compounds, solvents, salts of heavy metals, alcohols, caustic liquids. Vomiting and diarrhea, with some exceptions (arsenic compounds, sodium fluorosilicate), do not lead to serious disturbances of the water-electrolyte balance and stop after gastric lavage. In such cases, there is no need to correct the loss of fluid and electrolytes. Organic lesions of the digestive tract are observed in poisonings with destructive poisons (acids, alkalis, some salts of heavy metals, lysol, etc.). Subjective (complaints of pain in the throat, behind the breastbone, in the abdomen, difficulty, painful swallowing) and objective signs (change in color of the mucous membranes of the oral cavity, pharynx, their swelling, pain on palpation in the abdomen, esophageal-gastric bleeding) serve as the basis for urgent medical measures. Medical measures for a chemical burn can be divided into two parts: pain relief and treatment of the burn of the digestive tract itself. The first is usually carried out with the help of painkillers (narcotic analgesics, antihistamines, anticholinergics, antispasmodics). The use of these drugs should be started from the pre-hospital stage, as a rule, before gastric lavage and repeated depending on the severity of the pain syndrome. In hospital, in case of swallowing disorders, cervical paravertebral novocaine blockade, oral administration of enveloping and analgesic agents, antacids, H2 are effective _.-blockers. In order to treat burn damage, a course of glucocorticoids, antispasmodics, antibiotics, and diet therapy are administered. In the reparation period, in the presence of burn erosions, local laser therapy is effective. Monitoring the course of burn disease is carried out using esophagogastroduodenoscopy and gastric fluoroscopy. In cases where the burn covers the stomach and intestines, one should remember about the possibility of developing exotoxic shock, reactive pancreatitis, and peritonitis. Damage to the nervous system is noted in the form of disorders in the activity of the central, autonomic, and peripheral nervous systems. Most often, CNS depression occurs - a comatose state, which always indicates severe poisoning with the development of toxic-hypoxic encephalopathy, which usually requires intensive detoxification measures, the volume and nature of which will depend on the type of toxicant. In some cases of poisoning (opioids, benzodiazepines, methemoglobin formers, organophosphorus compounds), antidote treatment is considered an essential condition for quickly bringing the patient out of a coma. It should be remembered that coma can cause the development of such dangerous complications as aspiration of gastric contents, ARF and OSHF of central genesis. In addition, in the event of the development of a comatose state, special care is required when washing the stomach (preliminary tracheal intubation, monitoring the function of external respiration). In case of CNS excitation due to the effects of anticholinergic or adrenergic drugs, the therapeutic effect is achieved by administering a 0.1% solution of aminostigmine in the first case and sedatives (diazepam, sodium oxybutyrate, etc.) in the second. In case of toxic-hypoxic encephalopathy, HBO is recommended (8-10 sessions). In case of acidotic coma (blood pH less than 7), binge drinking or poisoning with alcohol substitutes, “alkaline” HD is indicated.

Respiratory distress syndrome

Respiratory failure syndrome manifests itself mainly in several main forms. In terms of frequency of development in the toxicogenic phase of poisoning, respiratory failure due to aspiration of gastric contents, paralysis of the respiratory center, hypertonicity or paralysis of the skeletal respiratory muscles predominate. Less common are disorders due to hemic hypoxia (carboxy- and methemoglobinemia) and tissue hypoxia (cyanides). Treatment of these disorders is well known to anesthesiologists and resuscitators and is a complex of respiratory therapy, and in case of poisoning with hemotoxic poisons and cyanides, antidote therapy and HBO are mandatory. In case of inhalation damage to the respiratory tract with poisons of irritating, cauterizing action (ammonia, chlorine, vapors of strong acids, etc.), toxic tracheobronchitis and toxic bronchitis develop, the treatment of which, as a rule, is little known to general practitioners and consists of preventive and therapeutic measures.

In order to prevent respiratory failure, to relieve reflex effects, the patient is given phycin applied to a cotton ball or an antismoke mixture (chloroform and ethanol - 40 ml each, sulfuric ether - 20 ml, ammonia - 5 drops) to inhale.

Antibiotics, bronchodilators, antihistamines, and expectorants are used to treat toxic tracheobronchitis. In the case of respiratory failure due to increasing swelling of the mucous membrane of the larynx, trachea, or bronchospasm, artificial ventilation is started.

In case of signs of hyperhydration and OL, dehydration therapy is used. A combination of 20% albumin followed by furosemide is advisable. Indications for oxygen therapy and artificial ventilation correspond to generally accepted ones.

The most important measure for the prevention and treatment of toxic OL is considered to be the use of glucocorticoids. Starting from the pre-hospital stage and then in the hospital, the patient is prescribed hydrocortisone (125 mg 1-2 times a day) or prednisolone (30 mg 2-4 times a day) intramuscularly.

Hemodynamic disturbance syndrome

The syndrome of hemodynamic disturbance manifests itself mainly in the form of primary toxicogenic collapse, exotoxic shock. The latter is considered the most severe syndrome, requiring urgent correction. The main principles of shock treatment in acute exogenous poisoning, which has a hypovolemic nature, are restoration of effective hemocirculation and pharmacotherapy. The first is achieved with the help of infusion therapy, which plays a leading role in the complex treatment of this syndrome and is aimed at restoring the BCC, improving cellular metabolism, rheological properties of blood and eliminating pathological intravascular coagulation. The volume, composition and duration of administration of infusion solutions are determined by the severity of the patient's condition, the nature and degree of hemodynamic shifts. Control of the adequacy of infusion therapy in exotoxic shock is carried out according to generally accepted criteria.

Hepatorenal syndrome

Hepatorenal syndrome, or toxic hepato- and nephropathy - terms used to designate toxic damage to the liver and kidneys, which develops mainly in cases of poisoning with toxicants that have a direct damaging effect on these organs. Such substances from the group of household and industrial toxicants include, first of all, metal compounds, various hydrocarbons, hemolytic poisons. In addition, kidney damage can develop as a consequence of positional trauma (myorenal syndrome) in case of poisoning with narcotic substances, carbon monoxide. Depending on the clinical and biochemical indicators, the preservation and, conversely, the impairment of liver and kidney function, three degrees of severity of these syndromes are distinguished from mild, when the functions are completely preserved, to severe, manifested in the form of liver (jaundice, hemorrhagic diathesis, PE) or renal failure.

The most successful prevention of liver and kidney damage is achieved with early implementation of intensive detoxification therapy, especially extracorporeal detoxification (hemosorption, hemo- and PD, HDF, plasma filtration, plasmapheresis, albumin dialysis using the MARS method).