POISONING A poison is any substance that, when ingested, inhaled, absorbed, applied to the skin, or produced within the

body in relatively small amounts, injures the body by its chemical action. Poisoning from inhalation and ingestion of toxic materials, both intentional and unintentional, constitutes a major health hazard and an emergency situation. Emergency treatment is initiated with the following goals !o remove or inactivate the poison before it is absorbed !o provide supportive care in maintaining vital organ systems !o administer a specific antidote to neutralize a specific poison !o implement treatment that hastens the elimination of the absorbed poison

Types of poisoning: INGESTED POISONS "ngested poisons are those poisons which have been consumed, whether accidentally or intentionally, by the victim. "ngestion is the most common route of exposure to toxic materials in the home. !he local actions of an ingested poison can have irritant, acidic #corrosive$, or basic #caustic$ effects at the site of contact. Corrosive poisons % include alkaline and acid agents that can cause tissue destruction after coming into contact with mucous membranes. Alkaline products include lye, drain cleaners, bleach, nonphosphate detergents, oven cleaners, and button batteries #batteries used to power watches, calculators, or cameras$. Acid products include toilet bowl cleaners, pool cleaners, metal cleaners, rust removers, and battery acid. "f a substance is ingested without intent to harm, it&s assumed that it was an unintentional poisoning. !his includes the consumption of drugs, medications, or other chemicals that are used in excessive amounts and result in an overdose. A poisoning is also considered unintentional when a substance is ingested accidentally and unknowingly, such as with children or older adults. 'hen a substance is ingested with the intent to harm, it&s considered an intentional poisoning, such as in a suicide attempt or assault on another person. 'hen you can&t make the distinction between the two because of circumstances, then the poisoning may be considered undetermined until proven otherwise. (ubstances most likely to be ingested include over)the)counter pain medicines, cleaning products, cosmetics, plants, prescription medications, and cough and cold preparations. *atalities usually result from the ingestion of analgesics, sedative)hypnotics, antipsychotics, antidepressants, illegal drugs, cardiovascular medications, or alcohol. !he phases of poisoning are as follows Preclinical phase)some signs and symptoms may not be evident during this phase+ the priority is decontamination

Toxic phase)signs and symptoms and lab changes are evident during this phase and guide treatment+ the emphasis is on shortening the duration of poisoning and lessening the severity of toxicity Resolution phase)this phase encompasses peak toxicity to recovery+ the goal is to shorten the duration of toxicity.

PREDISPOSING FACTORS/PRECIPITATING FACTORS ,ommon substances that can cause poisoning in children include the following Automobile fluids #e.g., gasoline, antifreeze, windshield fluid$ ,osmetics and other personal care products -ousehold cleaning products #e.g., drain cleaners, dishwasher detergent$ .ver)the)counter or prescription medications #e.g., analgesics such as acetaminophen, cough and cold medicines, vitamins$ *oreign objects #e.g., toys, batteries$ Paints and paint thinners Pesticides #e.g., insecticides, weed killers, rodenticides$ Plants Art supplies and office supplies Alcohol *ood products -erbal medicines /isk *actors of Acute "ntentional Poisoning 0ore common in females than in males in all age groups. 1ow socioeconomic status. (elf)poisoning is likely to be seen in men belonging to the unskilled and low socioeconomic groups than in professionals and more affluent groups. !he incidence of poisoning is rising in the those in the 23s and 43s age group as compared to elderly people. !here is higher risk amongst divorcees than in single, married, or widowed individuals. Previous episodes of self)poisoning. !hese people are also more likely to try self) poisoning again in the future. "ncreased risk of subse5uent suicide. .ther precipitating factors are 6nemployment. *inancial distress. Alcoholism. 7rug abuse. 0arital discord /ecent broken relationship. !hose with criminal records. *amily violence.

1osing a parent at an early age. 8ictims of child abuse.

DIAGNOSTICS !he diagnosis in a case of poisoning can be made from the 9$ -istory 2$ Physical Examination 4$ 1aboratory Evaluation and :$ !oxicological (creening 9. -istory 0ost important indicator of toxic ingestion. ,areful history regarding involved toxins, amount of drug and timing should be recorded. "nformation regarding prescription medication, over the counter drugs and illicit substances of abuse should be obtained. *riends, relatives and other involved healthcare providers should be 5uestioned and medications identified. 0edication found on or near the patient should be examined and pharmacy on the medication label should be called to determine the status of all prescription medication. 2. Physical Examination Evaluation of Airway patency, /espiration, ,irculation. /apid assessment of mental status, temperature, pupil size, muscle tone, reflexes, skin and peristaltic activity. 3. 1abororatory evaluation ,linical laboratory data include assessment of the three gaps of toxicology; 9. !he Anion gap 2. !he osmolal gap 4. !he arterial oxygen saturation gap. 6nexplained widening of the difference between calculated and measured determination of these values raises the suspicion of toxic ingestion. :. !oxicological (creening "t provides direct evidence of ingestions, but it rarely impacts initial management and initial supportive measures should never await results of such analysis. "t is used to 9$ provides ground for treatment with specific antidote or method for enhancing drug elimination and 2$ also identifies drugs that should be 5uantified to guide subse5uent management. Also look for characteristic signs of various kinds of poisoning while immediate treatment measures are being started. SIGNS AND SYMPTOMS 1arge #dilated$ or small #constricted$ pupils. (low or abnormal breathing, chemical odors and unusual breath.

<urns or stains around the mouth. =ausea, vomiting and diarrhea. Excessive salivation, sweating, and tear formation. ,onvulsions or seizures. (wallowing and breathing may be difficult, especially if any corrosive was aspirated into the lungs. (tridor, a high)pitched sound coming from the upper airway, may be heard. !he abdomen may be tender and swollen with gas, and perforation of the esophagus or stomach may occur. Abdominal pain

PATHOPHYSIOLOGY "ngested poisons include foods, alcohol, medication, household and garden items, and certain plants. Acids cause coagulation necrosis+ an eschar forms, limiting further damage. Acids tend to affect the stomach more than the esophagus. Alkalis cause rapid li5uefaction necrosis+ no eschar forms, and damage continues until the alkali is neutralized or diluted. Alkalis tend to affect the esophagus more than the stomach, but ingestion of large 5uantities severely affects both. (olid products tend to leave particles that stick to and burn tissues, discouraging further ingestion and causing localized damage. <ecause li5uid preparations do not stick, larger 5uantities are easily ingested, and damage may be widespread. 1i5uids may also be aspirated, leading to upper airway injury. MEDICAL MANAGEMENT "f the toxin was recently ingested, absorption of the substance may be able to be decreased through gastric decontamination. !his may be achieved using activated charcoal, gastric lavage, whole bowel irrigation, or nasogastric aspiration. /outine use of emetics #syrup of "pecac$, cathartics or laxatives are no longer recommended. Activated charcoal is the treatment of choice to prevent absorption of the poison. "t is usually administered when the patient is in the emergency room or by a trained emergency healthcare provider such as a Paramedic or E0!. -owever, charcoal is ineffective against metals such as sodium, potassium, and lithium, and alcohols and glycols+ it is also not recommended for ingestion of corrosive chemicals such as acids and alkalis. Whole o!el irri"atio# cleanses the bowel+ this is achieved by giving the patient large amounts of a polyethylene glycol solution. !he osmotically balanced polyethylene glycol solution is not absorbed into the body, having the effect of flushing out the entire gastrointestinal tract. "ts major uses are following ingestion of sustained release drugs, toxins that are not absorbed by activated charcoal #i.e. lithium, iron$, and for the removal of ingested packets of drugs #body packing>smuggling$.

Ga$tric lava"e% commonly known as a stomach pump, is the insertion of a tube into the stomach, followed by administration of water or saline down the tube. !he li5uid is then removed along with the contents of the stomach. 1avage has been used for many years as a common treatment for poisoned patients. -owever, a recent review of the procedure in poisonings suggests no benefit.?@A "t is still sometimes used if it can be performed within 9 hour of ingestion and the exposure is potentially life threatening. Na$o"a$tric a$&iratio# involves the placement of a tube via the nose down into the stomach, the stomach contents are then removed via suction. !his procedure is mainly used for li5uid ingestions where activated charcoal is ineffective, e.g. ethylene glycol poisoning. E'e$i$ #i.e. induced by ipecac$ is no longer recommended in poisoning situations, because vomiting is ineffective at removing poisons. Cathartic$ were postulated to decrease absorption by increasing the expulsion of the poison from the gastrointestinal tract. !here are two types of cathartics used in poisoned patients+ saline cathartics #sodium sulfate, magnesium citrate, magnesium sulfate$ and saccharide cathartics #sorbitol$. !hey do not appear to improve patient outcome and are no longer recommended. A#al"e$ic$ are administered if the patient complains of pain. Di(re$i$ for substance excreted by the kidney. He'o&er)($io# 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.

N*RSING MANAGEMENT Ensuring airway patency and assessing for the risk of aspiration, especially after any gastric decontamination process #make sure ade5uate suctioning e5uipment is readily available$ ,hecking vital signs and monitoring for hypotension or hypertension 0onitor E,B and neurologic status closely for changes. An indwelling urinary catheter is inserted to monitor renal function. <lood specimens are obtained to determine the concentration of drug or poison. 7etermine what substance was ingested+ the amount+ the time since ingestion+ signs and symptoms, such pain or burning sensations, any evidence of redness or burn in the mouth or throat, pain on swallowing, vomiting or drooling+ age and wight of the patient and pertinent health history. Ensuring telemetry monitoring is intact and active #check for ventricular tachycardias or bradyarrhythmias with hypotension$ "nitiating seizures precautions if necessary. !he patient who ingested a corrosive poison is given water or milk to drink for dilution. 7ilution is not attempted if the patient has acute airway edema or obstruction or if there is clinical evidence of esophageal, gastric, or intestinal burn or perforation.

7o gastric empying procedures such as syrup of ipecac to induce vomiting #never use with corrosive poisons$+ gastric lavage+ activated charcoal administration+ and cathartic. !he specific chemical or physiologic antagonist is administered as early as possible to reverse or diminish the effect of toxin.

N*RSING DIAGNOSES "mbalance nutrition less than body re5uirement "mpaired oral mucous membrane "mpaired swallowing /isk for poisoning Acute pain /isk for injury