Poisoning is under the subject of Bio-assay and Toxicology, useful for the pharmacy and medical or students.

1. 1

2. CONTENTS
 Definition
 Classification
 General Management of Poisoning
 Heavy Metal Poisoning
 Snake Poisoning
 Conclusion
 Referenences
2

3. WHAT IS POISON
■ “Poison is a substance {solid/liquid/or gaseous}, which if
introduced in the living body, or brought into contact with any part
there of, will produce ill health or death, by it constitutional or local
effects or both”
■ “Any substance that can harm the body by altering cell structure or
functions”
3

4. 4
ROUTES OF POSIONING

5. POISON
CORROSIVE IRRITANT SYSTEMIC
1
• Inorganic
irritants
2 • Non metallic
3
• Metallic
irritants
1
• Neurotoxic
2
• Cardiotoxic
3
• Asphyxiants
1
• Strong acids
2
• Organic acids
3 • Alkalies
5

6. GENERAL MANAGEMENT OF POISONING
6

7. STABILIZATION
EVALUATION
DECONTAMINATION
ANTIDOTE
ADMINISTRATION
NURSING &
PSYCHIATRIC CARE
7

8. AIRWAY BREATHING
CIRCULATION DEPRESSION
OF CNS
STABILIZATION
8

9. AIRWAYAND BREATHING
Majorly it is characterised by
Cyanosis
Retraction of intercoastal muscles and substernal
muscles
 Sweating
In severe cases:
Ventillation: artificial breathing
Some drugs causes asthma
NSAIDS
Antibiotics
9

10. MANAGEMENT:
In case of Respiratory Insufficiency:
 Remove clothes
Place laterally, lift chin, open the mouth gently.
Incase of airway obstruction:
■ Ventilation
■ Oxygen mask should be provided.
10

11. CIRCULATORY FAILURE
Some of the drugs may lead to circulatory failure which may cause changes in
blood Pressure, heart rate and causes cardiac arrhythmias
Alpha-blockers
Beta blockers
Cardiac glycosides
11

12. MANAGEMENT:
Incase of circulatory failure
 Correct acidosis
 Raise the foot bed for better circulation of blood to the brain
 Hemodynamic changes are also observed.
Incase of heart failure:
 Correction of hypoxia, acidosis, electrolyte disorder.
 Monitoring of ECG
 Incase of “Monomorphic Ventricular Tachycardia”
Lignocaine
Amiodarone
Sotolol should be given
12

13. DEPRESSION OF CNS
13
 May cause “Hysteric or psychogenic coma”
 It is the condition in which the person pretending as he is in
coma.
MANAGEMENT
 It is the condition where the toxic substance is known or
unknown “coma cocktail” is given.
 “coma cocktail” is a mixture of
Dextrose-100ml of 5%
Vit-b1-100mg
Nalozone-2mg

14. EVALUATION OF TOXICITY
It is done depending upon various factors like
 Whether it is Acute or Chronic
 Amount of dose taken
 Time factor
 If the person is in conscious or able to talk, the systemic
evaluation is done.
14

15. MANAGEMENT:
IN CASE OF HYPOTHERMIA:
 HYPOTHERMIA: Decrease in body temperature.
 It can be caused by over usage of
■ Alcohol
■ Anti depressant
■ Benzodiazepines etc.
TREATMENT:
Body temperature should be checked for every 30mints using
thermometer
 Correction of acidosis, hypokalemia, hypotension etc should be done
 Warm water bath is used.
15

16. IN CASE OF ACID-BASE DISORDERS:
 It is based on pH, electrolyte level etc
 If pH is more than 7.4 it leads to metabolic/respiratory alkaloses
 If anion gap is more than 20mmol/l it leads to metabolic disorder
Conditions such as
■ Pregnancy
■ Encephalopathy
■ Diuretics administration
■ Steroids administration cause Acid base disorder.
16

17. IN CASE OF EYE:
 Irrigate coupiously the exposed area with cold water for
15-20mints
 Do not use acid or alkali irrigating solution
IN CASE OF SKIN:
 Cutaneous absorption is commonly seen of the following
substances when they were exposed occupationally/industrially
→ Phenol
→ Phosphorous
→ Pesticides etc
17

18. EMESIS
GASTRIC
LAVAGE
CATHARSIS
ACTIVATED
CHARCOAL
WHOLE
BOWEL
IRRIGATION
GI TRACT DECONTAMINATION
18

19. EMESIS :
 Syrup of Ipecac/Ipecacauna was used in which it is derived from
Cephalia ipecacauna
 INDICATIONS : Alert, Consiousness, and should be given after
4-6hrs after consumption.
 MODE OF ACTION: Activation of peripheral receptors of GIT.
Activation of CTZ and vomiting center
DOSE : 30ml for adult ,15ml for children
Apomorphin
Warm saline, mustard water
Obsolete emetics
19

20. 20

21. GASTRIC LAVAGE (STOMACH WASH)
 Ewalds tube is used in this process in order to clean out the
contents of the stomach.
 In which it is marked 50cm in adults, and 25cm in child
 It is often done following the ingestion of a dangerous
substance, overdose on a drug such as alcohol or before surgery
21

22.  Gastric lavage is indicated to empty the stomach immediately
within 1-2 hours after an orally ingested overdose or poisoning
 Should be considered where there is evidence or risk of significant.
DOSE: 200-300ml in adults
10- 15ml in children
22

23. CATHARSIS (laxative)
“RYLES TUBE” is used in this process in which it is inserted into intestine”
 Two types of solutions are used.
IONIC/SALINE SOLUTION
MAGNESIUM
CITRATE
4ml/kg
MAGNESIUM
SULPHATE
30gm(adult)
250mg(child)
SODIUM
SULPHATE
30gm(adult)
250mg-child
Saccharides
SORBITOL
CONTRAINDICATIONS:
o Coma
o Bowel obstruction
o Convulsions
23

24. ACTIVATED CHARCOAL
 Fine, odourless, black, tasteless, powder
 Small size with large surface area
 Adsorption on to the surface and prevent adsorption of poison.
DOSE: 50-100gm in adult
10-40gm in child
 It is mixed 4-8 times with water and the slurry/suspension is
administerd
CONTRAINDICATIONS: Constipation
Respiratory failure
Vomiting
24

25. 25

26. WHOLE BOWEL IRRIGATION (WBI)
 INDICATION: Ingestion of large amount of
Poisons that are not well bound to activated charchoal,
Sustained release medications.
 TECHNIQUE: Administration of ‘Polyethylene glycol
Electrolyte solution (PEG-ES) via nasogastric tube.
 DOSE: 20 to 40mL/kg per hour until the rectal effluent is clear,
which takes 4-6hrs.
 CONTRAINDICATIONS: Intestinal obstruction
Perforation
Significant GI bleeding
Persistent vomiting
26

27. ELIMINATION
METHODS FOR ENHANCING ELIMINATION OF TOXINS
FORCED ALKALINE DIURESIS:
 It is used to eliminate Barbiturates, Salicylates, Lithium etc.
 500ml dextrose – 5%
500ml Sodium carbonate – 12-13% 1500ml Iv for first hour
 500ml of dextrose – 5%
 It is most widely used process.
27

28. EXTRACORPORIAL TECHNIQUES:
HAEMODIALYSIS
 It mainly depends on 3 components
Blood delivery system
Dialyser
Method and composition of dialysate of delivery
 Drugs removed through this process:
 Alcohol, Antibiotic, Heavy metals, Boric acid, Quinine, Quinidine,
 Salicylates, Benzodiazepines iodides etc are removed.
 Catheter was introduced into Femoral vein
28

29. HAEMOPERFUSION
 Removing the drugs by passing the blood from
patient through an adsorbent material and back to
the patient.
 Molecules which have greater affinity
for the materials, will be removed.
 Drugs removed through this process are:
 Barbiturates, Organophosphates, Digoxin etc.
29

30. PERITONEAL DIALYSIS
o Removal of fluid and waste products via a dialysis catheter
located in the peritoneal cavity: space between the stomach
liver, spleen, intestines and kidneys by
1) Diffusion
2) Osmosis
3) Ultrafiltration
4) Convection
o 10-25% effective than haemodialysis.
30

31. HAEMOFILTRATION
• Blood is injected through haemofilters and filtration occur and
eliminates high molecular weight substances i.e. is around
4000-40,000.
HAEMODIAFILTRATION:
• Combination of Haemodialysis and Haemofiltration
• It is rarely used
31

32. PLASMAPHERESIS
Removal of cellular components of blood
 Resuspended on to colloids, albumin,
plasma proteins reinfused
 Complete removal of toxins.
 DRAWBACK: Patient plasma proteins are decreased.
PLASMA PERFUSION: Combination of haemoperfusion and
Plasmapheresis.
CARDIOPULMONARYBYPASS: Used rarely for removal of
Cardiac glycosides, Verapamil, Lidocaine etc.
32

33. ANTIDOTES
o Used 5-10% because of less available.
o According to WHO
o“ Antidote is defined as a therapeutic substance used to
counteract the toxic actions of a specific xenobiotic”
o Antidotes are of four types.
33

34. PHYSICAL
ANTIDOTE
CHEMICAL
ANTIDOTE
PHYSIOLOGICAL
ANTIDOTE
UNIVERSAL
ANTIDOTE
34

35. PHYSICALANTIDOTE:
 Agents use to interfere with poison through physical
properties ,not change their nature.
 Prevents the absorption of the poisonous substance in
body
EXAMPLES: Demulscents of fats ,oils, egg albumin.
Banana Glass poisoning
Activated Charcoal Alkaloid poisoning
35

36. CHEMICALANTIDOTE :
 They Counteract the action of poison by forming
harmless or insoluble compounds by Oxidizing poisons.
EXAMPLES:
Common Salt : Decomposes Silver Nitrate by
direct chemical action.
Albumen : Precipitates Mercuric Chloride.
36

37. PHYSIOLOGICALANTIDOTE:
oThese agents have action directly opposite to that of poison
o EXAMPLES:
o Chelating agents Unionized Cyclic complex with cations
CHELATE
EXAMPLES OF CHELATING AGENTS
BAL(British Anti Lewisite) /Dimercaprol
EDTA
PENCILLAMINE
DESFERRIOXAMINE
37

38. BAL (British Anti Lewisite)/DIMERCAPROL
 Especially recommended in Heavy metal poisoning
 They form chelates excretes through ,Liver/Kidney
DOSE: 3-5mg/kg (IM)
EDTA(Ethylene diamine tetra acetate)
 Used in case of Lead poisoning
 Forms chelates and excretes through urine
 DOSE:75mg/kg (IM)
38

39. BAL (British Anti Lewisite)/DIMERCAPROL
 Especially recommended in Heavy metal poisoning
 They form chelates excretes through ,Liver/Kidney
DOSE: 3-5mg/kg (IM)
EDTA(Ethylene diamine tetra acetate)
 Used in case of Lead poisoning
 Forms chelates and excretes through urine
 DOSE:75mg/kg (IM)
39

40. PENCILLAMINE
Used in case of Lead, Copper, Mercury poisoning
 Less toxic than EDTA
 Mainly used incase of Wilsons Disease
DOSE :100mg/kg(orally)
DESFERRIOXAMINE
Used in case of Iron poisoning.
 Binds to iron in stomach and blood
DOSE: 8-12gm in 40-60ml water(orally/IV)
40

41. UNIVERSAL ANTIDOTE
• It is used in case of unknown poisoning in the body
• It consists of
Magnesium oxide : 1part
Activated charcoal: 2parts
Tannic acid: 1part
• From the above composition take 1 tablespoon in 200ml water
and given regularly.
41

42. NURSING PROCESS
 Assessment
 Subjective/Objective/Psychological
 Differential Nursing Diagnosis
 Planning and Interventions
 Evaluation and Organic Monitoring
 Documentation.
42

43. PSYCHIATRIC NURSING OR MENTAL HEALTH
• Specialty of nursing that cares for people of all ages with
Mental illness or Mental distress, such as
Psychosis
Depression
Dementia
• Nurses in this area receive additional training in dealing with
Behavioral issues
Psychiatric Medication
Different therapies
43

44. 44

45. ARSENIC POISONING
 It is the common environmental toxicant and is found in
soil, water, and air
Common source of arsenic poisoning:
■ Soldering
■ Electronic compounds
■ Pottery
■ Wood preservatives
■ Coloring agents of toys , wall papers etc
FATAL DOSE: 200mg
45

46. TOXICOKINETICS AND MODE OF ACTION
 Arsenic can enter through inhalation, cutaneous and oral routes.
 Arsenic ion binds with Sulphydryl group (-SH) of enzymes in the
Liver, Lungs, Intestinal walls, Spleen.
 It replaces phosphorous in bones where it may remain for years
 It also gets deposits in the hairs.
46

47. ACUTE ARSENIC POISONING
 Wide spread and damaged to capillaries, epigastric, and
abdominal pain
 Dysphasia, Severe gastroentritis, Vomiting.
 Severe bloody, watery diarrhea, jaundice, muscle cramps
dilated pupil, rapid pulse, coma, death.
TREATMENT:
 Wash the stomach with warm water.
 Administration of ferric oxide, converts to ferric arsenate which is
harmless
 Dimercaprol is a specific antidote.
 Sodium thio sulphate : 1gm in 10ml water, for every 4-6hrs.
47

48. CHRONIC POSIONING
o Peripheral/oblique neuritis, diarrhea, conjunctivitis, edema
pigmentation of skin, liver sydrosis etc are seen
CARCINOMA:
o Four stages
oStage one: Anorexia, Vomiting, Diarrhea, Fatigue are seen.
o Stage two: Conjunctivitis, Running of nose eyes are seen.
o Stage three: Skin rashes, Hyper keratosis of foot, Hair falling
are seen.
o Stage four: Convulsion and Coma are seen.
48

49. TREATMENT
o Removal of patient from exposure
o Sodium thio sulphate : one gram in 10ml sterile water
: given through Iv.
o Dimercaprol : 3mg/kg, every 3hrs.
49

50. LEAD POSIONING
 All lead compounds are toxic.
 Most dangerous: Lead arsenate ,Lead oxide, etc.
COMMON SOURCE OF LEAD POSIONING
 Candles with lead containing wicks
 Ceramic glazers
 paint, ink
 Lead pipes
 Silver Jewellary workers, Renovation of old homes.
50

51. TOXICOKINETICS AND MODE OF ACTION
 Enters through all portal entry
 Stored in bones as phosphate and carbonate
 Lead lines are absorbed in X rays, there width
depend upon duration of exposure.
MODE OF ACTION
 Lead combines with Sulphydryl compounds, interfering
there action.
 Decreases Haem synthesis, Increases Haemolysis.
 In CNS: Odema, Lowers IQ, behavioral changes etc.
 In CVS: Hypertension, Myocarditis
FATAL DOSE: 500mg.
51

52. ACUTE LEAD POSIONING
• Metallic taste, Vomiting, Colic pain in abdomen, Constipation
Black feces , Urine suppression, Lead encephalopathy,
Headache, Loss of vision, Delirium are seen.
TREATMENT
• Wash stomach with 10% MgSo4 and with plain water.
• Bowel wash at regular intervals
• Calcium versinate or Pencillamine are used as antidote.
52

53. CHRONIC LEAD POISONING ( PLUMBISM)
Symptoms include:
• Lead lines on gums
• Constipation
• Paralysis of wrist muscles
• Menstrual Disorders
• Abortion
• Metallic taste, Anorexia, Headache, Vertigo, Drowsiness are seen
TREATMENT:
•Acidosis
• EDTA and BAL are effective.
• BAL : 4mg/kg , every 4 hrs.
53

54. MERCURY POISONING
o Synonym: Liquid Silver
o It is a heavy silver liquid vaporizes at room temperature gives of
a toxic vapour.
o Inorganic salts of mercury are of two types
Mercuric(Hg++)
Mercurous(Hg+)
o Organic salts are more toxic
o Eg: Phenyl and methoxy methyl mercury and ethyl methyl mercury
o Most toxic compound of mercury is methyl mercury.
54

55. SOURCE: Mercury containing Latex paint
Breakage of Thermometer containing Hg.
Mining/Chlor alkali industry.
DIETARY SOURCE: Fish, Shell fish, Marine animals.
FATAL DOS: 400mg
TOXICOKINETICS AND MODE OF ACTION
• After inhalation, passes through alveolar membrane and
enters into blood stream in which Hg Hg++
mercuric form, causes Renal tubular damage.
• They can be absorbed through skin.
55

56. ACUTE MERCURY POISONING
o Symptoms include:
o Metallic taste, Tongue , Mouth becomes Greyish white.
o Nausea, Vomiting, with white mucosa and blood.
o Cold skin, Pale face, Dilated pupil, Shock, Renal failure etc
CHRONIC MERCURY POSIONING (HYDRAGYRISM)
o Symptoms include:
o Multiple neurological disorder, Shyness, Tumors, Loss of sleep
o Acrodynia, Loosening of teeth with painful gums, Anemia etc.
56

57. TREATMENT:
o 3-4 table spoon of Charcoal powder is mixed with water is taken.
o BAL: 100mg Intra muscular is given.
o Removal of patient from exposure
o Promoting elimination by kidney and bowel
o For excess Salivation : Dry extract of Belladonna of 30mg is given
3times in a day
DIAGNOSIS:
o X-rays
o Analysis of Urine, Blood, and Hair.
57

58. COPPER POISONING
 It is a Golden red/Reddish brown powder
 It is important for iron absorption and Haem synthesis
 It has little/ No toxicity
 Soluble salts of copper such as copper sulphate are strong irritants
to skin and mucus membrane.
SOURCE:
 Electrical or Thermal Composites, Contraceptives, Paints, Fungicide
 Welding, Batteries, Insecticides, Wood preservatives etc
FATAL DOSE: 30gm
58

59. TOXICOKINETICS AND MODE OF ACTION
 Daily intake – 2-3mg per day
 Actual requirement – 0.8mg per day
 It is used for functioning of enzymes like Catalase and Peroxidases
 Absorbed through GI mucosa and skin
 Copper is present in serum in two forms
First form is bound to Albumin(7%)
Second form is bound to Caeruloplasmin(93%)
59

60. COPPER POISONING
 It is a Golden red/Reddish brown powder
 It is important for iron absorption and Haem synthesis
 It has little/ No toxicity
 Soluble salts of copper such as copper sulphate are strong irritants
to skin and mucus membrane.
SOURCE:
 Electrical or Thermal Composites, Contraceptives, Paints, Fungicide
 Welding, Batteries, Insecticides, Wood preservatives etc
FATAL DOSE: 30gm
60

61. ACUTE COPPER POISONING
 Symptoms include:
 Metallic taste with excess Salivation, Thirst, Abdominal pain etc
CHRONIC COPPER POISONING
 Symptoms include:
 Constipation, Nephritis, Menstrual disorder, Abortion etc
Vomit: Green/Blue color
 Stools: Brown without blood
 Urine: Ink containing blood stain.
TREATMENT:
 Wash stomach with Potassium Ferrocynate.
61

62. IRON POISONING
 Silvery, white in color , occurs naturally
 It is an essential element and deficiency leads to Anemia.
SOURCE:
 Daily intake is about 10-20mg
 Pregnancy women should take about 25-30mg.
 Carbon steels, Stainless steel, Magnets, Dyes, Pigments,
 Abrasives
FATAL DOSE:200-250mg
62

63. TOXICOKINETICS AND MODE OF ACTION
 Free circulating iron in blood stream causes toxicity
 Metabolic Acidosis
 Hepatic Disorder, Hypoglycemia
 Inhibits the conversion of Fibrinogen Fibrin
 Shows corrosive effect on GI mucosa
 Decreases in Plasma volume
Stage 1: (0.5-2hrs)
 Vomiting, Haematenisis, Abdominal Pain, Lethargy, Shock etc
STAGES OF IRON POISIONING
63

64. Stage 2 (Immediately after stage 1)
 False sense of Security
Stage 3 (2-12hrs after first stage)
 Shock, Psynosis, Falling plasma and blood volumes
 Acidosis, Fever, Hypotension, CNS depression
Stage 4 (2-4 days)
 Hepato toxicity, Convulsions, Coma.
Stage 5 ( It may be seen form days to weeks)
 GI scaring, pyloric scaring, intestinal necrosis, shock.
64

65. TREATMENT
 Wash stomach with normal saline
 Activated charcoal is ineffective
 Desferrioximine is not used for lavage
 One percent MgoH is given orally to decreases the absorption
of iron
 Correction of Hypo olemia and Acidosis
 Desferioximine is given through Iv route about 15mg/kg/hr
and through Im of about 90mg/kg
65

66. SNAKE POISONING
66

67. SNAKE VENOM
Venom is the toxic saliva produced by the modified parotid
glands of the poisonous snakes.
 In which it is Fresh amber colored fluid
First Aid:
Verbal Assurance: Relief from anxiety.
Immobilization: Patient should be put in rest.
 Move slowly as possible, Increase movement Increase Absorption
 Remove jewellery, rings, etc from bitten area
 Rubber bandage with cotton pads are tied, if pressed tightly leads to
■ Necrosis, Pain
67

68. BEVERAGES:
Coffee, Alcohol should not be taken , in which leads
to increase in absorption.
INCISION AND SUCKING:
 For Bitten site Incision is used, For Sucking Breast pump is used.
 Removes 90% of poison , But denied by some authors(20%)
 Parallel incision should not be done more than 3mm depth
 Complications: Bleeding, Infection, Damage of capillaries
CRYOTHERAPY:
Cooling with ice, to minimize the absorption
 Complication include : Gangrene, Necrosis
68

69. DRUGS USED:
 For Mild to Moderate pain : Paracetmol
 For Severe pain : Narcotic analgesics like
: Pentazocine, Pethidine was used
 If cause Allergy to antivenom : Corticosteroids
: Antihistamines was given.
 In case of Vomiting: Patient must lay down
: Chlorpromazine is given through Iv
 Antidotes are sometimes prescribed.
69

70. HOSPITAL MANAGEMENT
Must check:
 Pulse rate, BP changes, Respiratory rate, WBC count, for every hour
 Blood urea, Creatinine, Urine output, Vomiting, Local swelling
 ECG, Necrosis, Pulmonary function test are also checked.
ANTIVENOM THERAPY:
 Polyvalent antivenom is available
 It is a Lyophilized powder produced by Immunization of Horse,
with Venom of snake.
 Anti venom should be given through Iv route.
70

71. CLINICAL FEATURES
WITHOUT
ENVENOMATION
WITH
ENVENOMATION
DRY BITE PROTECTIVE
GEAR
LEAKAGE
OF
VENOM
SUPERFICIAL
BITE
COLUBRID
BITE
ELAPID
BITE
VIPERID
BITE
HYDROPHID
BITE71

72. WITHOUT ENVENOMATION:
 20-50% of venomous bites shows no toxicity.
DRY BITE:
 Snake doesn’t always inject venom.
PROTECTIVE GEAR:
 May not occur on heavily clothed parts
LEAKAGE OF VENOM:
 Inefficient injection of venom
SUPERFICIAL BITE
 Doesn’t bite deeply. 72

73. WITH ENVENOMATION
COLUBRID BITE:
 Pain, edema, numbness are seen up to 1-2 weeks
 Excess Salivation with metallic taste and headache
ELAPID BITE:
LOCAL EFFECTS: Mild pain, Tenderness, Local swelling, are seen
SYSTEMIC EFFECTS:
 Pre Paralytic stage: Vomiting, Ptosis, Blurred vision, Vertigo etc
 Paralytic stage: Paralysis of Facial muscles, palate, Jaws, Tongue
Vocal cords, Neck muscles etc are seen.
73

74. VIPERID BITE
LOCAL EFFECTS: Pain, Tenderness, Lymphadenopathy
 SYSTEMIC EFFECTS: Haemauria, Gingivitis, Intracranial
haemarrohge
 BLEEDING OF : Gut , GIT, Mouth
 Loss of consciousness
 Change in ECG.
HYDROPHID BITE:
 LOCAL EFFECTS: Minimal local effects.
 SYSTEMIC EFFECTS: Paralysis with Ptosis, Blurred vision,
Respiratory failure, etc are seen.
74

75. 75
Here by I conclude that these are the various General principles
of poisoning which are to be followed to save the lives.

76. 76
REFERENCES:
 Text book of Forensic Medicine and Toxicology by – VV Pillay
Pg no: 470-489,518-537.
 Fundamentals of Forensic Medicine and Toxicology,2nd edition by
- Rabindra Basu , Pg no: 361-387.
 Pharmacological Screening Methods and Toxicology by
- Srinivas Rao, Bhagya Lakshmi Pg no: 281-316.
 Goldfrank’s Toxicological Emergencies, ninth edition

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