This document provides an overview of poisoning, including definitions, types, clinical manifestations, and general management principles. It discusses specific agents like carbon monoxide, organophosphates, corrosives, and barbiturates. For each agent, it describes mechanisms of toxicity, clinical features, diagnosis, and treatment approaches. General treatment principles outlined are supportive care, administration of antidotes, gastric decontamination, and enhancing elimination. Nursing interventions for poisoning include respiratory support, fluid management, administration of antidotes like naloxone, and monitoring of vital signs and lab values.

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Wallaga University
Institute of Health Science
School of Nursing and Mid-wifery
AHN Speciality
By: 1.Takele M. ( Bsc )
2. Ashenafi T. (Bsc)
Poisoning

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Session objectives
At the end of this session the learner will be able to:
Define Poisoning
List Type and Clinical manifestation of Poisoning
Explain General principles of poisoning Management
Discuss Supportive measures of poisoning
Discuss Poisoning with specific agents [Barbiturates,
Carbon Monoxide, Pesticides]

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Introduction to Poisoning
 refers to the development of harmful effects following
exposure to chemicals.
 Any substance can be poisonous depending on the dose
and/or duration of exposure.
 Exposures can occur via oral, pulmonary, dermal, or ocular
routes.
 After exposure, factors such as dose, absorption,
distribution, and elimination are important determinants of
toxicity.

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…
 The setting of exposure may be
o Occupational, environmental,
o recreational, medicinal or suicidal.
 Poisoning may result from varied portals of entry
including:
– inhalation
– ingestion
– Cutaneous exposure
– Injection

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A. Carbon monoxide poisoning
 CO is an odorless, tasteless, colorless, non irritating gas
formed by HC combustion.
 Atmospheric concentration is generally below 0.001%,
 higher in urban areas & closed environment.
 Smoke inhalation is responsible for most inadvertent cases
of CO poisonings.

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…
 CO binds to Hb with much higher affinity than oxygen (240
X) forms carboxyhemoglobin & tissue oxygenation is
impaired.
 Patients may manifest symptoms ranging from mild
confusion to coma.

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Clinical features
• History of prolonged exposure to smoke from charcoal in
closed environment.
• Acute poisoning result in headache, nausea and
vomiting, muscle aches, sleepiness, weakness, chest
pain, shortness of breath.
• Severe toxicity causes confusion, agitation, impaired
thinking,
• May progress to coma, convulsions, and death.

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Diagnosis
 is based on a compatible Hx and physical exam
 elevated carboxyhemoglobin level measured by co-
oximetry of a blood gas sample

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Management:
 The most important interventions to general supportive
measures are:
 removal from the CO source: remove the patient to open air
 administering oxygen by face mask.
 Comatose patients should be intubated & mechanically
ventilated using 100% oxygen.

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B. Organophosphate poisoning
 Organophosphates & carbamates are potent
cholinesterase inhibitors.
 cholinesterase hydrolyses acetylcholine.
 Ach- neurotransmitter that released at the ends of nerve
fibers in somatic and PSNS.
 They are capable of causing severe cholinergic toxicity.
 Routes - cutaneous exposure, inhalation or ingestion.
 Examples include Malathion & Parathion.

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Mechanism of Organophosphate poisoning
• They inhibit/hydrolyse cholinesterase:
• Leads to accumulation of ach in the CNS, ANS & NMJ.
• Cholinergic effects overwhelm.
• Toxic dose: depends on substance.

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Clinical features
 “SLUDGE”: Salivation, Lacrimation, Urination, Defecation,
Gastric Emesis
 DUMBELS: Defecation, Urination, Miosis Bronchorhea,
Emesis, Lacrimation, Salivation
 Killer Bees: Bradycardia, Bronchorhea, Bronchospasm.
 CNS features: seizures, loss of consciousness
 NMJ features: paralysis, muscle fasciculations
 Patients will also have characteristics garlic like odor of
breath.

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Treatment
 Airway control, respiratory support, decontamination.
 NB Protective clothing must be worn to prevent secondary
contamination of health care workers.
 Prevention of absorption -
 Activated charcoal for pts presenting within 1hr.
 Administration of antidotes.

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Antidotes
• Atropine: used for reversal of muscarinic effects including
pulmonary symptoms.
• Atropine suphate, 2 mg i.m. or i.v. given every10- 20
minutes until signs of full atropinization are observed .
• Signs of Atropinizations
 flushed and dry skin
 dilated pupil
 dry mucus membrane

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C. Poisoning by Corrosives (Ingested/Swallowed)
 Corrosives are primarily chemical like acids and alkali that
cause tissue injury/burn to body.
 Acids cause coagulation necrosis with scar formation
that limits penetration and depth of injury.
 Alkali cause liquefaction necrosis and penetrate more
deeply.
 Common acid household products are
 toilet bowel cleaners, battery fluids,
 laundry detergents and cleaning agents with sodium phosphate,
sodium carbonate, and ammonia.

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Common presentations
 Gastrointestinal symptoms:
-burns of oral cavity, esophagus or gastric mucosa
-associated nausea, vomiting, epigastric pain, dysphagia or
odynophogia.
 Significant injury: airway compromise or GI perforation
complicated by peritonitis, mediastinitis, sepsis and shock.

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Food Poisoning
 Food poisoning is a sudden illness that occurs after
ingestion of contaminated food or drink.
 Botulism is a serious form of food poisoning that requires
continual surveillance.
 Food, gastric contents, vomitus, serum, and feces are
collected for examination.
 The patient’s respirations, blood pressure, level of
consciousness (LOC), CVP (if indicated), and muscular
activity are monitored closely

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Treatment
 An antiemetic medication is given parenterally as
prescribed if the patient cannot tolerate fluids or
medications by mouth (Tintinalli et al., 2016).
 For mild nausea, the patient is encouraged to take sips of
weak tea, carbonated drinks, or tap water.
 After nausea and vomiting subside, clear liquids are usually
prescribed for 12 to 24 hours, and the diet is gradually
progressed to a low residue, balanced diet.

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General approach
 We should have a consistent & systematic approach for
evaluation & management of poisoned patients .
 Diagnosis and resuscitation proceed simultaneously.
 The first step is always to fix the ABCs.

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General Signs and Symptoms
 Symptoms of poisoning vary greatly.
 Aids in determining whether or not a victim has swallowed
poison include:
• Information from the victim /observer.
• Presence of container known to contain poison.
• Burns around the lips or mouth & breathe odor
 Conditions of the victim (sudden onset s/s).
 Size of pupils : dilated vs constricted(pinpoint)

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General treatment principles
Emergency treatment is initiated with the following goals:
 Removal or inactivation of the poison before it is absorbed
 Provision of supportive care in maintaining vital organ
function
 Administration of a specific antidote to neutralize a specific
poison
 Implementation of treatment that hastens the elimination of
the absorbed poison

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General treatment prin…
“SAGE”
• S - Supportive care: ABCs and the “coma cocktail”.
• A - Antidotes: specific therapy for certain exposures.
• G - Gastric decontamination: removal from stomach, skin,
eyes.
• E - Enhancing elimination: includes dialysis, urinary
excretion, hemofiltration.

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S= Supportive Measures
 Avoid further exposure to the poison.
 Fix ABC problems
 Correct hypotension and hypoglycemia with iv infusions.
 Maintain body temperature.
 Transport the patient head upwards and sideways to
prevent vomiting and aspiration.

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A= Universal antidotes
 Thiamine- alcohol with drawl
 Oxygen- carbon monoxide poisoning
 Naloxone- opioid toxicity
 Glucose- hypoglycemia

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G=GI decontamination
 Process of removing potential contaminants.
 Remove all contaminated cloths from the patient and
dispose it.
 Wash skin and hair with soap and water while wearing
glove.
 Eye exposure: irrigate with copious amounts of water or
saline for 10 – 15 minutes

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…
 Four basic techniques are used
1. Inducing emesis/vomiting using syrup of ipecac
2. Gastric lavages
3. Activated charcoal
4. Whole bowel irrigation/WBI.

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1.Inducing emesis - Syrup of Ipecac
• Facilitating vomiting
• Indications
– Very recent ingestion (<1hr)
– Toxin known not to cause decreased LOC.
– Toxin known not to fit through OG tube.
• Contraindications
– Ingestion > 1 hr ago
– Toxin known to cause decreased LOC/seizure
– Caustics, hydrocarbons

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2. Gastric lavage
 Washing out the stomach
 Indicated for ingestion of large amounts of tablets
and capsules
 Generally used for poisonous with a high inherent
toxicity within 2 hrs.

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Orogastric Lavage …
• Intubate patient, if they cant protect their airway
• Place in left lateral decubitus position
• Head tilted 20 degrees downward
• Insert 40F orogastric tube (24F peds)
• Instil 200 ml- 300ml N/S repeatedly until fluid clears

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Contraindications
 Patients with decreased LOC
 Unprotected airway
 Ingestions of corrosive agents, hydrocarbons
 Patients at risk of gastrointestinal hemorrhage.

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3. Activated Charcoal
 Minimizes systemic absorption from the GIT.
 Consider use if within 1 hr of ingestion of the poisonous
substance.
 Given orally or via NG tube, 1-1.5g/kg as suspension in
water.
 Has no value in strong acids, alkali, corrosives, heavy
metals, lithium, paraffin, methanol & ethylene glycol
ingestion.

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…
• Contraindications:
– Known or suspected GI perforation
– GCS <8 or declining rapidly (risk of aspiration)
– Known ingestion of substance that charcoal does NOT
absorb

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4. Whole bowel irrigation
 Provides an effective means of GI decontamination
 Indicated of drug packets, sustained-release or enteric-
coated preparations are ingested, or agents not well
absorbed by activated charcoal.
 Instillation of large volumes of polyethylene glycol in
osmotically balanced electrolyte solutions.
 This promotes rapid mechanical elimination of ingested
toxins.

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Enhancing elimination
Urinary Alkalinization
• Infusion of sodium bicarbonate to raise urinary pH .
• Enhance clearance of toxins excreted by kidneys (e.g.
barbiturates, ASA).
• Works by “trapping” agents that are weak acids in the renal
tubules and increasing their excretion in the urine.
• Indicated for symptomatic ingestions of salicylates ,chlorpromazine &
phenobarbital
• 1-2 mEq/kg NaHCO3 IV push Target urinary pH 7.5-8.5
• Monitor electrolytes.

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Poisoning With Specific Agents
Barbiturates poisoning
• ‘sedative – hypnotics’ that lower excitement &
induce sleep.
• Clinical features of acute intoxication includes
– slurred speech, in coordination
– impaired attention or memory.
– Severe overdose leads to coma
– vital sign abnormalities are:
• Hypothermia
• Respiratory depression
• Hypotension

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Barbiturate
• Barbiturate overdose fatality is usually secondary to
respiratory depression.
• Major complications associated with barbiturate poisoning
include pneumonia, shock , hypoxia, and coma.
• Other associated life-threatening complications include
acute renal failure and pulmonary edema.
• Rx: Forced diuresis with fluid loading and diuretic
therapy is most effective for phenobarbitone.

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Lab Investigation for poisoning
 Random blood sugar
 CBC
 BUN and creatinine,
 Electrolytes
 Liver function tests
 Chest X-ray for possible aspiration pneumonia
 Toxicological analysis of identified substance (e.g.gastric
aspirate) or from serum

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Nursing Interventions for poisoning
◯ Provide measures for respiratory support (oxygen, airway
management, mechanical ventilation).
◯ Monitor compromised circulation (resulting from excess
perspiration, vomiting, diarrhea).
◯ Restore fluids with IV fluid therapy.
◯ Monitor blood pressure, cardiac monitoring, ECG.
◯ Assess for tissue edema every 15 to 30 min if bitten by a
snake or spider.

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◯ Administer opioid medications for pain due to snake or
spider bite
◯ Monitor ABGs, blood glucose levels, coagulation profile.
◯ Administer IV diazepam (Valium) if seizures occur.
◯ Reverse heroin and other opiate toxicity with naloxone
(Narcan).
◯ Implement dialysis and an exchange blood transfusion as a
non pharmacologic technique to remove toxic agents.

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Reference
1. Brunner_&_Suddarth’s_textbook. (2018). medical
surgical nursing.
2. RN Adult Medical Surgical Nursing 9.0 th Edition.
3. Medical-Surgical-Nursing-Demystified
4. Standard Guide Line Treatment for Hospitals,
March 2021

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Thank
you!