# Poisoning --- **Poisoning** is a condition where a substance, called a **poison** is ingested, inhaled, absorbed, applied to the skin, has a chemical action that causes injury. Poisoning is a [[medical emergency]]. Broadly speaking poisons can be: - medications/drugs - plants - environmental pollutants/chemicals ## General Treatment There are a wide variety of poisons, but the general treatment plan for poisoning is as follows: - identify the substance/poison - removal or inactivation of the poison before its absorbed - supportive care to maintain vital organ function - administering a specific antidote to neutralize a specific poison - treatment that quickens the elimination of the absorbed any absorbed poison ## Inhaled Poisons Inhaled poisons are a particularly dangerous because the lungs are a connection straight to the blood stream so treatment has to act fast. - [[carbon monoxide]] - mustard gas - sarin gas ## Ingested Poisons Ingested poisons can be - corrosives - alkaline or acidic agents - can be given water or milk for dilution - only if airway edema or obstruction not present OR no sign of perforation/burn - syrup of ipecac *should be never used with corrosives* - no generally recommended anyway, but particularly in this case - risk of aspiration as well - alkaline: cleaning products (lye, oven/drain cleaner, button batteries) - acidic: metal cleaners, rust removers, battery acid - destruction to tissues - esp. mucous membranes - [[food poisoning]] Shock may result from the cardiodepressant action of the substance ingested, from venous pooling in the lower extremities, or from reduced circulating blood volume resulting from increased capillary permeability Measures are instituted to remove the toxin or decrease its absorption. If there is a specific chemical or physiologic antagonist (antidote), it is given as early as possible to reverse or diminish the effects of the toxin. If this measure is ineffective, procedures may be initiated to remove or dilute the ingested substance. These procedures include administration of multiple doses of activated charcoal, dialysis, or hemoperfusion. Hemoperfusion involves detoxification of the blood by processing it through an extracorporeal circuit and an adsorbent cartridge containing charcoal or resin, after which the cleansed blood is returned to the patient For ingested poisons, we’ll first give an antidote if there is one, and it’s available.  If no antidote, we can try to dilute the toxin by giving the pt a small amt of milk or water – but not if they have impaired swallowing, airway edema or obstruction, potential for vomiting, or if there’s evidence of esophageal, gastric or intestinal burn or perforation.  We could also attempt to remove the toxin using gastric emptying procedures, as ordered.  These include the use of activated charcoal and gastric lavage and aspiration.  Just a note about cathartics:  these are meds used to promote defecation, and they used to be used in conjunction with activated charcoal.  They are not used much any more because the diarrhea they induce can result in hypovolemia and severe e-lyte imbalances.  Other measures may include diuresis, dialysis or hemoperfusion.  Hemoperfusion is a method to clean the blood outside of the body. It involves running blood through a devicefilled with charcoal or resin that can absorb the toxin.  The blood is then returned to the body.  - similar to dialysis • Ingested poisons • Antidote • Dilute • Remove Activated Charcoal preferred method for ingested poisons if given within 30 minutes, can absorb 90% of poison after an hour that decreases to 37% binds to a substance and it's removed through the stool makes the stool black, educate doesn't bind to everything but it can bind to antidotes too, be careful contraindicated with obstruction or perforation Cathartics? medications that promote deification. but they're not used that much anymore because they can cause some hypovolemia and e-lyte imbalances • Gastric Lavage and aspiration (Stomach pumping) not done very often anymore, only used for life threatening cases This is not done very often because the risks outweigh the benefits.  Risks include aspiration and stomach or esophageal perforation. Gastric lavage involves placing a tube through the mouth (orogastric) or through the nose (nasogastric) into the stomach. Pt is placed in Left-lying position. Toxicants are removed by flushing saline solutions into the stomach, followed by suction of gastric contents. Repeat until contents are clear.  Again, this is not done very often because the risks outweigh the benefits.  Risks include aspiration and stomach or esophageal perforation. Other: dialysis or hemoperfusion takes the blood out of the body, brings it though a machine that absorbs the toxin/poinson with a charcoal or resin and then puts it back in - **Gastric lavage** (i.e. stomach pumping) - useful only 1 hour after ingestion - risk of complications such as aspiration or gastric/esophageal perforation - not usually indicated (benefits don't outweigh the risks), only used in emergencies - **Activated charcoal** - only some substances will be absorbed - most commonly ingested poisons *except* - corrosives - heavy metals, iron, lithium - hydrocarbons - PO or through NG tube - should be given in a slurry Medication overdoses: - [[acetaminophen]] is [[hepatotoxic substances|hepatotoxic]], so overdose can lead to liver failure - antidote is **acetylcysteine** (brand name: **Mucomyst**) - should be given between 8-10 hours - can be given IV or PO, but IV is preferable to the patient as it smells really bad--like sulfur - mix with juice/soda - if the pt vomits within an hour you can give it again in an hour - activated charcoal binds to acetylcysteine so don't give it with PO! - [[anticoagulants|aspirin]] - symptoms - nausea/vomiting, dehydration, **tinnitus**, blurred vision, disorientation, coma, cardiovascular collapse, coagulopathy, metabolic acidosis - no antidote - probably end up in the hospital - gastric lavage - activated charcoal - sodium bicarb - monitor serum salicylates - correctly coagulopathies (probably a ) - [[benzodiazepines]] - antidote is **flumazenil** (brand name: **Romazicon**) - reverses sedation - side effects - seizures - has a short half-life and multiple doses may be required - [[opioids]] - [[opioid antagonists|Narcan]] - [[glycosides|digoxin]], which lowers heartrate, but at toxic levels causes all sorts of dysrhythmias, like AV blocks with escape beats (whatever that means) and even V flutter and Vfib which are super dangerous - antidote is **digoxin immune fab** (brand name: **DigiFab**) - uses antibody fragments to bind to digoxin and prevents its effects - really f'ing expensive, like $2000 to $3000 to fully neutralize the digoxin ### Button Batteries Button batteries are an increasing issue among pediatric pts – lots of kiddos swallow these!  When they come in contact with saliva there’s an alkalizing reaction that starts, and it can erode the alimentary membranes – it can cause lots of damage, like eroding through the esophagus, causing significant harm and even death!  In kiddos, s/s might include: - wheezing - drooling - coughing - vomiting - chest discomfort - refusal to eat - gagging when attempting to eat/drink ## Contact Poisons Skin contamination: chemical burns, • Skin Contaminants • Remove clothing, flush with water (usually) ## Poison Control Centers **Poison control centers** are a resource that anyone can call, including healthcare workers calling from healthcare facilities (the ED calls them a lot, apparently). They provide 24 hour assistance. ## Nursing Considerations - important to get patient's age, weight and health history - may be difficult to get a proper history - want to get what, when and how much? - supportive care, ABCs - going to be monitoring a lot: - vitals - level of consciousness - ECG - urinary output - ins and outs - diarrhea, sweating, vomiting - fluids - acid/base balance ___