Treatment of poisoning

Patients with severe poisoning may require mechanical ventilation and / or treatment of cardiovascular collapse. In the case of mental disorders, continuous monitoring and fixation may be required.

Treatment for poisoning with various substances is presented in the tables. In all cases, except the easiest, a consultation with the poison control center is indicated.

Typical specific antidotes

Toxin	Antidote
Paracetamol	Acetylcysteine
Anticholinergic substances	Physostigmine *
Benzodiazepines	Flumazenil *
Beta-blockers	Glucagon
Blockers of slow calcium channels	Calcium preparations, intravenous administration of large doses of insulin with the infusion of glucose
Carbamates	Atropine, protamine sulfate
Cardiac glycosides (digoxin, digitoxin, common oleander, digitalis)	The digoxin-specific FAT fragment
Ethylene glycol	Ethanol, fomepizol
Heavy metals	Chelation)
Iron	Deferoxamine
Methanol	Ethanol, fomepizol
Methemoglobin-forming agents (aniline dyes, some local anesthetics, nitrates, nitrites, phenacetin, sulfonamides)	Methylene blue
Opioids	Naloxone
Organophosphorus compounds	Atropine, pralidoxime
Tricyclic antidepressants	NaHCO 3
Isoniazid	Pyridoxine (vitamin B6)

The application is controversial. FAT - fractionated antibodies.

First medical aid for poisoning

Treatment of any poisoning begins with the restoration of airway patency, stabilization of breathing and circulation.

In the case of apnea or impaired patency of the upper respiratory tract (foreign body of the oropharynx, decreased pharyngeal reflex) endotracheal intubation is indicated. When respiratory depression or hypoxia is inhibited, oxygen therapy or mechanical ventilation is necessary.

Patients with apnea, ensuring patency of the upper respiratory tract, should try to inject intravenously naloxone (2 mg - adults, 0.1 mg / kg body weight - children). In opioid addicts, the administration of naloxone may accelerate the onset of withdrawal, but this is better than apnea. If, despite the introduced naloxone, respiratory failure persists, intubation of the trachea and ventilation is indicated. If the introduction of naloxone breathing is restored, the patient needs observation, and if depression of respiration recurs, you can try another bolus of naloxone intravenously or IVL. The effectiveness of prolonged infusion of naloxone to maintain breathing has not been proven.

A patient with a changed consciousness should determine the plasma glucose concentration immediately, or inject intravenously glucose (50 ml 50%)

Treatment with chelates

Helulating agent *	Metal	Doses of **
Uniothiol, 10% oil solution	Antimony, arsenic, bismuth, chromates, chromic acid, chromium trioxide, copper salts, gold, mercury, nickel, tungsten, zinc salts	3-4 mg / kg intramuscularly every 4 hours in the 1st day. 2 mg / kg intramuscularly every 4 hours on the 2nd day. 3 mg / kg deep intramuscularly every 4 hours on the 3rd day, then 3 mg / kg intramuscularly every 12 hours for 7-10 days until recovery
<3% calcium edetate solution	Cadmium, lead, zinc, zinc salts	25-35 mg / kg intravenously slowly (for 1 hour), every 12 hours for 5-7 days, the next 7 days without the drug, then repeat
Penicillamine	Arsenic, copper salts, gold, mercury, nickel, zinc salts	20-30 mg / kg per day in 3-4 doses (usually the initial dose is 250 mg 4 times a day), the maximum dose for adults is 2 g / day
Succimer	Arsenic, professional poisoning in adults. Bismuth. Lead if the child has a drug concentration in the blood> 45 μg / dl (> 2.15 μmol / L). Lead, professional poisoning in adults. Mercury, occupational poisoning in adults	10 mg / kg orally every 8 hours for 5 days, then 10 mg / kg orally every 12 hours for 14 days

• * Iron and thallium salts with these preparations are not effectively chelated; for everyone you need your chelating drug.
• ** Doses depend on the severity and type of poisoning. A chelating agent for choosing an adult solution, 2-4 ml / kg of a 25% solution to children).

Adults with suspicion of thiamine deficiency (alcoholics, depleted patients) are recommended intravenous thiamine in a dose of 100 mg at the same time or before the introduction of glucose.

Arterial hypotension is treated with intravenous fluids. If there is no effect, invasive cardiomonitoring may be required to manage the infusion therapy and the introduction of vasopressors. The drug of choice for the treatment of arterial hypotension during poisoning is norepinephrine hydrotartrate (0.5-1 mg / min intravenously), but treatment can not be delayed if another vasopressor is available.

[1], [2], [3], [4], [5], [6]

Local decontamination

Any surface of the body (including the eyes) contaminated with poison is washed with a large amount of water, or with 0.9% sodium chloride solution. Contaminated clothing, as well as socks and shoes, jewelery should be removed.

Activated carbon

Activated charcoal is often used, especially if the swallowed agent is unknown or several. The use of activated carbon is practically harmless, except for patients with an increased risk of vomiting and aspiration, although this does not significantly affect mortality and complications in general. Use activated carbon should be as early as possible. It absorbs many toxins due to its molecular configuration and a significant absorbing surface. Multiple assignments of activated carbon are effective in poisoning with substances that undergo enterohepatic circulation (phenobarbital, theophylline), as well as long-acting substances. In severe poisoning, activated charcoal can be administered every 4 to 6 hours, with the exception of patients with intestinal paresis. It is ineffective in poisoning with poison cauterizing action, alcohol and simple ions (cyanide, iron, other metals, lithium). The recommended dose of activated carbon for poisoning should be 5-10 times the amount of poison. However, given that the exact amount of poison is usually unknown, it is usually prescribed 1-2 g / kg of body weight (children <5 years - 10-25 g, the rest - 50-100 g). The drug is administered as a suspension. Its taste can cause vomiting in 30% of patients, in this case, the introduction of the drug through the gastric tube. Do not use activated carbon together with sorbitol and other laxatives due to the risk of dehydration and electrolyte disorders.

[7], [8], [9]

Gastric lavage

Gastric lavage, although well known and, at first glance, a useful manipulation, is routinely not applied. This procedure does not lead to a reduction in mortality and complications and has its risks. Gastric lavage can be recommended within the first hour after poisoning, which poses a threat to life. However, most of the poisonings are manifested later, and it is also very difficult to determine whether it is life threatening. Thus, indications for gastric lavage are rare, and with poisoning with caustic substances this procedure is contraindicated.

If it is decided to wash the stomach, lavage is the optimal method. The effect of ipecacuana syrup + codeine is unpredictable, often causes prolonged vomiting and may not remove a significant amount of poison from the stomach. When washing the stomach, the following complications are possible: epistaxis, aspiration and, rarely, damage to the oropharynx and esophagus.

Lavage is performed by pouring and pouring tap water through a gastric tube of maximum diameter (usually> 36 Fr in adults or 24 Fr in children), for free passage of the remnants of tableted preparations. Patients with altered consciousness or reduced pharyngeal reflexes before washing should be intubated to prevent possible aspiration. To prevent aspiration when inserting the patient's probe, put on the left side with bent legs, the probe is injected through the mouth. Since washing in some cases promotes the pushing of the substance further into the digestive tract, 25 g of activated carbon is first introduced through the probe. Then tap water (about 3 ml / kg) is poured into the stomach and aspirated by a syringe, or it leaves by gravity. Washing is continued to clean water (without residues of a poison agent), in most cases 500-3000 ml of water is required. After washing, a second dose of coal, 25 g, is introduced through the probe.

Rinsing of the whole intestine

This manipulation clears the gastrointestinal tract and, theoretically, reduces the time of passage of pills and tablets along the digestive tract. The reduction in mortality and the frequency of complications as a result of this procedure is not proved. Bowel flushing is indicated for some severe poisoning with long-acting drugs, substances that do not adsorb activated carbon (heavy metals); when swallowing packets of drugs (transport of heroin or cocaine in packets); when suspected of bezoar. When washing, a factory solution of polyethylene glycol (not absorbed) and electrolytes is injected at a rate of 1-2 liters per hour for adults or 25-40 ml / kg per hour for children before the appearance of clean water; The procedure can take several hours and even a day. Normally, the solution is injected through the gastric tube, although some health professionals persuade patients to drink this solution in large amounts.

Alkaline diuresis

Alkaline diuresis accelerates the excretion of weak acids (salicylates, phenobarbital). A solution containing 1 L of 5% glucose solution or 0.9% sodium chloride solution, 3 ampoules of NaHC0 ₃ (50 mEq) and 20-40 mEq K ⁺, can be administered at a rate of 250 ml per hour to adults and 2-3 ml / kg per hour for children. The urine pH is> 8.0. Hypernatremia, alkalosis and hyperhydration are possible, which, as a rule, are insignificant. However, alkaline diuresis is contraindicated in patients with renal insufficiency.

[10], [11], [12], [13], [14], [15], [16], [17], [18], [19],

Dialysis

Poisoning with ethylene glycol, lithium, methanol, salicylates and theophylline may require the use of dialysis or hemoperfusion. These methods are of less importance in the following cases:

• the poison has a large molecular mass or polarity;
• poison is characterized by a large volume of distribution (accumulates in adipose tissue);
• the poison forms a strong bond with the tissue proteins (digoxin, phenothiazines, tricyclic antidepressants).

The need for dialysis is usually determined by clinical and laboratory data.

Dialysis options:

• hemodialysis;
• peritoneal dialysis;
• lipid dialysis (removal of fat-soluble substances from the blood);
• hemoperfusion (most quickly and efficiently removes certain poisonous substances).

[20], [21], [22], [23], [24], [25], [26], [27],

Specific antidotes

Complexing (chelate) drugs are used for poisoning with heavy metals and other substances.

Supportive treatment for poisoning

To treat most of the symptoms (agitation, inhibition, coma, cerebral edema, arterial hypertension, arrhythmias, renal failure, hypoglycemia), conventional supportive measures are used .. Drug arterial hypotension and arrhythmias may respond poorly to conventional medications. In the case of refractory arterial hypotension, the use of dopamine, epinephrine and other vasopressors or, in severe cases, intra-aortic balloon counterpulsation and extracorporeal artificial circulation is indicated. With refractory arrhythmias, an electrocardiostimulation may be required. Often with polymorphic ventricular tachycardia (torsades de pointes), a solution of magnesium sulfate in a dose of 2-4 g intravenously, the imposition of a heart rhythm with the aim of suppressing ectopic foci of automatism, or an infusion of isoprenaline can be used. Treatment of seizures begins with the introduction of benzodiazepines, you can also use phenobarbital. With a strong excitation, the following is necessary:

• high doses of benzodiazepines;
• other sedatives (propofol);
• In severe cases, it may be necessary to use muscle relaxants and mechanical ventilation.

Treatment of hyperthermia often requires the use of physical methods of cooling, rather than antipyretics. In case of organ failure, liver or kidney transplantation may be required.

Hospitalization

The main indications for hospitalization include mental disorders, persistent violations of vital functions, predictably long-term toxicity of the drug. For example, hospitalization is indicated if the patient has swallowed a prolonged-release drug, especially if it has a potentially dangerous effect, for example, a drug for the treatment of cardiovascular diseases. In the absence of other indications for hospitalization and resolution of symptoms of poisoning within 4-6 hours, most patients can be released; However, if the poisoning was self-inflicted, a psychiatric consultation is necessary.

Prevention of poisoning

In the US, the widespread use of packaging for medicines with safety caps has significantly reduced the number of lethal poisonings among children <5 years. Reducing the number of tablets in the package for analgesics, approved for sale without a doctor's prescription, reduces the severity of poisoning, especially paracetamol, acetylsalicylic acid and ibuprofen. Preventive measures include:

• clear labeling of chemical reagents and drugs;
• storage of medicinal and toxic substances in closed and inaccessible places for children;
• timely destruction of drugs with expired shelf life;
• application of CO detectors.

Important is also the educational work on the storage of chemicals in their original containers (do not store insecticides in bottles from drinking). The use of printed designations on preparations will help to prevent an error, both the patient and the pharmacist, the doctor.