Management of Poisoning
Initial management for all poisonings includes ensuring adequate cardiopulmonary function and providing treatment for any symptoms such as seizures, shock, and pain.
In the majority of poisonings the mainstay of management is providing supportive care for the patient, i.e. treating the symptoms rather than the poison.
Poisons that have been injected (e.g. from the sting of poisonous animals) can be treated by binding the affected body part with a pressure bandage and by placing the affected body part in hot water (with a temperature of 50°C). The pressure bandage makes sure the poison is not pumped throughout the body and the hot water breaks down the poison. This treatment however only works with poisons that are composed of protein-molecules.
Treatment of a recently ingested poison may involve gastric decontamination to decrease absorption. Gastric decontamination can involve activated charcoal, gastric lavage, whole bowel irrigation, or nasogastric aspiration. Routine use of emetics (syrup of Ipecac), cathartics or laxatives are no longer recommended.
Activated charcoal is the treatment of choice to prevent poison absorption. It is usually administered when the patient is in the emergency room or by a trained emergency healthcare provider such as a Paramedic or EMT. However, charcoal is ineffective against metals such as sodium, potassium, and lithium, and alcohols and glycols; it is also not recommended for ingestion of corrosive chemicals such as acids and alkalis
Whole bowel irrigation cleanses the bowel, this is achieved by giving the patient large amounts of a polyethylene glycol solution. The osmotically balanced polyethylene glycol solution is not absorbed into the body, having the effect of flushing out the entire gastrointestinal tract. Its major uses are following ingestion of sustained release drugs, toxins that are not absorbed by activated charcoal (i.e. lithium, iron), and for the removal of ingested packets of drugs (body packing/smuggling). Gastric lavage, commonly known as a stomach pump, is the insertion of a tube into the stomach, followed by administration of water or saline down the tube. The liquid is then removed along with the contents of the stomach. Lavage has been used for many years as a common treatment for poisoned patients. However, a recent review of the procedure in poisonings suggests no benefit It is still sometimes used if it can be performed within 1 hour of ingestion and the exposure is potentially life threatening.
Nasogastric aspiration involves the placement of a tube via the nose down into the stomach, the stomach contents are then removed by suction. This procedure is mainly used for liquid ingestions where activated charcoal is ineffective, e.g. ethylene glycol poisoning.
Emesis (i.e. induced by ipecac) is no longer recommended in poisoning situations, because vomiting is ineffective at removing poisons
Cathartics were postulated to decrease absorption by increasing the expulsion of the poison from thegastrointestinal tract. There are two types of cathartics used in poisoned patients; saline cathartics (sodium sulfate,magnesium citrate, magnesium sulfate) and saccharide cathartics (sorbitol). They do not appear to improve patient outcome and are no longer recommended.
|Anticholinergics||Cholinergics (and vice-versa)|
|Antipsychotics such as haldol and/orrisperidone||Ropinirole or Bromocryptine (and vice-versa)|
|Atropine and/or scopolamine||Physostigmine|
|Benzodiazepines and barbiturates||Flumazenil|
|Beta-Blockers (Propranolol, Sotalol, etc.)||Calcium Gluconate and/or Glucagon. Salbutamol is also used (and vice-versa)|
|Caffeine and other xanthines||Adenosine (and vice-versa)|
|Calcium Channel Blockers (Verapamil,Diltiazem)||Calcium gluconate|
|Cyanide||Amyl nitrite/sodium nitrite/sodium thiosulfate or hydroxocobalamin|
|Ethylene glycol||Ethanol or fomepizole, and thiamine|
|Hydrofluoric acid||Calcium Gluconate|
|Iron (and other heavy metals)||Desferrioxamine, deferasirox or deferiprone|
|Methanol||Ethanol or fomepizole, and folinic acid|
|Nicotine||Bupropion and other ganglion blockers|
|Organophosphates||Atropine and Pralidoxime|
|Vitamin K anticoagulants e.g. warfarin||Vitamin K|
In some situations elimination of the poison can be enhanced using diuresis, hemodialysis, hemoperfusion, hyperbaric medicine, peritoneal dialysis, exchange transfusion or chelation. However, this may actually worsen the poisoning in some cases, so it should always be verified based on what substances are involved.