Pharmacology (dra Dando)

Clinical Toxicology

13 February 08

POISONING  Opiates (Morphine, Novaine, Heroin, Codeine)

 Quinine
• Overdose of drugs, medicaments, chemicals o Anti-protozoal
and biological substances
• “acute” poisoning versus “chronic’ poisoning RECOMMENDED IV FLUIDS
 Acute: 24 -48 hrs of exposure  Hypotensive patients
 Chronic: weeks, months, years of  NSS
exposure  Adult for maintenance
• Father of toxicology: Paracelsus  NSS
 D5 Acetated Ringer’s solution
GENERAL PRINCIPLES
 Emergency stabilization  Pediatric for maintenance
o First thing to do  D5 0.3% NaCl (hypo)
 Clinical evaluation
o Include good Hx taking & thorough PE POISON COMMONLY ASSOCIATED WITH
 Elimination of the poison CONVULSIONS
 Excretion of the absorbed substance  Aminophylline
 Administration of antidotes  Amphetamines
o Important for certain specific poisons or  Carbon monoxide
drugs  Cocaine
 Supportive therapy and observation  Cyanide
 Disposition  Ethylene glycol
 Hypoglycemic agents
EMERGENCY STABILIZATION  Isoniazid – triad of coma, metabolic acidosis,
 Maintain adequate Airway intractable seizures
o Remove obstructions  Lead
o Conditions wherein suction cannot be  MAO inhibitors
done:  Mefenamic Acid (usual side effect: GI irritation;
- caustic substances (causes ulceration overdose: seizures)
of GI mucosa)  Opioids
- hydrocarbons (causes aspiration)  Organophosphates
 Ensure adequate Breathing/Ventilation  Phenothiazines
o Nasal cannula, intubation  Salicylates (Aspirin)
 Maintain adequate Circulation (put IV lines,  Strychnine
fluids)  Theophylline
 Treat convulsions (e.g Diazepam)  Tricyclic antidepressants
o Diazepam: 1st line of Tx for active seizures  Withdrawal of narcotics, diazepam or ethanol
and status epilepticus  Signs of ethanol withdrawal
o Irritable
 Correct metabolic abnormalities (Electrolytes,
glucose, acid-base) o Agitated
o Base: used for severe metabolic acidosis o Seizure
(Tx: Na, bicarbonate)
o Glucose: for hypoglycemia (Dextrose 50- CAUSES OF CONVULSION IN POISONED PATIENTS
50 concentration)  Direct convulsant effect of the poisons
 Cerebral hypoxia from respiratory or
 Treat coma (e.g Flumazenil)
cardiovascular depressive effect of drugs
o Flumazenil:
 Hypoglycemia
1) Tx for BZD (diazepam) overdose
2) Tx for coma (but not as first line agent)  Severe muscle spasm due to spinal o peripheral
- coma due to overdose of valium effects on the mechanism controlling muscle
tone
COMMON CAUSE OF HYPOXIA  Withdrawal reactions in patients with physical
 Alcohol dependence on abused drugs
 Cyanide  Decreased seizure threshold in an epileptic
o In silver jewelry cleaners patient
 Organophosphates
TREATMENT OF CONVULSION
o In pesticies
• Diazepam
 Carbon monoxide
joyce 1 of 8
 Pharmacology – Clinical Toxicology by Dra Dando Page 2 of 8

o Adult: 5mg IV INFORMATION TO BE ELICITED DURING HISTORY

o Children:0.3mg/kg • Time exposure
o Only compatible fluid is blood (direct)  Needs to be very specific
• Lorazepam (Ativan)  e.g.: N-acetylcysteine, antidote for
o Adult: 2.5-10mg IV paracetamol overdose; effective only in
o Children: 0.05-1 mg/dose the first 6 hrs after ingestion
o Withdrawn from the marked d/t its  e.g. lavage of poison is only good for
associated side effects the 1st 24hours
o Short acting, long duration • Mode exposure
• Phenytoin  Rectal
o LD: 15-20mg/kg IV  Transplacental
o Adult: 50mg/min  Oral
o Children: 1mg/kg/min  Etc
o Inducer of CYP450 • Intake of other substances
o Maintenance drug • Circumstances prior to poisoning
• Pyridoxine (B6) • Current medications
o Adult: 5g IV
• Past medical history
o Children: 80-120mg/kg
• Any home remedies taken
o For INH poisoning
o Tx of convulsions due to unknown
*Organophosphate/carbamate poisoning: manifests
etiology
with DUMBEL
Hypothermia Hyperthermia POISONS WITH DELAYED MANIFESTAIONS
 Alcohol  Antihistamines Ethylene glycol 6 hours
 Barbiturates  Amphetamines o Present in anti-
 Carbon monoxide  Isoniazid freeze 12 hours
 General  Phenytoin Salicylates 36 hours
anesthetics  Salicylates Paracetamol 48 hours
 Opioids  Xanthines Paraquat 48 hours
 Phenothiazenes  Anticholinergics: Methanol
 Sedative-hypnotics Atropine o Toxic alcohol 4 weeks
 Tricyclic  Cocaine Thyroxine
antidepressants  Phenothiazines
 Quinidine *Vodka
- among alcohols, has the highest alcohol content
 Sulfonamides
- converts ethylene glycol and methanol to less toxic
form
TREATMENT OF COMA OF UNKNOWN ETIOLOGY
- amount to be given needs to be computed
• Thiamine (vit B1) 100mg IV
o Tx of Wernicke Korsakoff Synd in COMPLETE CLINICAL EVALUATION
alcoholic px  Complete physical examination
• Glucose  Evaluate general status
o Adult: 50-100ml D50-50  Examine skin
o Children:2ml/kg d10  Characterize odor of patient’s breath
o Most pts present with hypoglycemia  Auscultate the lungs
esp. in alcoholic intoxication  Listen to patient’s heart
o Wernicke-Korsakoff syndrome  Check the abdomen
 d/t sever B1 deficiency  Do a complete neurologic exam
 administer B1 first before giving  Skin changes in poisoning
glucose  Bullae: barbiturates, CO
• Naloxone  Diaphoresis: OP, salicylate, amphetamine
o Adult: 2mg IV every 3-5mins  Jaundice: paracetamol
o Children: 10mcg/kg  Dry and warm: atropine, anticholinergic
o For opiate overdose (coma)
o Expensive
 Flushed: anticholinergics, alcohol, cyanide,
atrophine odors
o Given to newborns whose mothers
 Brerath odors
underwent CS causing respiratory
difficult in their babies  Bitter: almonds, cyanide
 Fruity: DKA, isopropanol
COMPLETE CLINICAL EVALUATION  Oil of wintergreen: methylsalicylate
• Good history taking (d/t vulnerability of children)  Rotten eggs: sulfur dioxide, hydrogen sulfide
 Pears: chloral hydrate
 Pharmacology – Clinical Toxicology by Dra Dando Page 3 of 8

 Garlic: arsenic, OP  Emesis

 Mothballs: camphor (like the one in vicks)  Lacrimation
 Salivation
Bradycardia Tachycardia
 Propranolol  Iron Sympathomimetics Opiates / Narcotics
 Anticholinesterase  CO, cyanide  Mydriasis  Miosis
 Clonidine, codeine,  Organophocphate  Tachycardia  Bradycardia
Ca-channel blocker  Phenothiazine  Hypertension  Hypotension
 Ethanol  Hyperthermia  Hyperventilation
 Ethanol, ethylene
 Seizures  Coma
 Digitalis glycol
 Free-base cocaine CONDITION OR AGENTS PREDISPOSING TO
 Anticholinergics METABOLIC ACIDOSIS OR ELEVATED ANION GAP
 Antihistamines • Methanol
 Amphetamines • Ethylene gycol
 Sympathomimetics • Theophylline, toluene
 Salicylates, solvents • Alcoholic ketoacidosis
 Theopylline • Lactic acidosis

Mydriasis Miosis • Aminoglycosides

 Antihistamines  Cholinergics, • Cyanide, CO

 Antidepressants clonidine • Isoniazid, Iron
 Sympathomimetics  Opiates, • Diabetic ketoacidosis
Organophosphate • Grand Mal seizures
 Isoniazid
 Phenothiazines,
• Aspirin (salicylate)
 Anticholinergics pilocarpine, pontine
bleed • Paraldehyde, phenformin
 Sedative-hypnotics
ELIMINATION OF THE POISON
*Triad of opiate overdose: • External Decontamination – bathing of pt with
 Coma alkaline soap e.g perla, ivory, dove
 Respiratory depression • Emptying the stomach
 Pinpoint pupils o Emesis – only in adults
*pediatrics have risk for aspiration
Clinical Evaluation: o Gastric lavage – H20, NSS, Na Bicarbonate,
Check for Toxidromes activated charcoal
 Signs and symptoms taken collectively can • Limiting GI absorption
characterize a suspected toxicant o Activated charcoal
 These groups of manifestations are observed to o Demulcents (watusi) / neutralizing agents
occur consistently with particular poisons (raw egg white: to prevent absorption)
o Intractable seizures + Coma +
Metabolic acidosis = INH Poisoning SUBSTANCES NOT ABSORBED BY ACTIVATED
*Intractable seizures despite CHARCOAL
administration of diazepam  Alcohol – rapid absorption
 Cyanide
Anticholinergic / Antidepressant Toxidrome  Iron
 Hyperthermia: “hot as a hare” o Lavage with NaHCO3
 Dry mucosa: “dry as a bone”  Lithium - dialysis
 Flushed skin: “red as a beet”  Petroleum distillates (hydrocarbons)
 Dilated pupils: “blind as a bat”  Caustic agents
 Confusion / delirium: “mad as a hatter”
SUBSTANCES WITH EXTRAHEPATIC
Cholinergic Toxidrome (S&Sx of organophosphate RECIRCULATION
and carbamate poisoning) • Aspirin
 Diarrhea, diaphoresis • Cyclosporine
 Urination • Digoxin
 Miosis, muscle fasciculations • Meprobamate
 Bradycardia, bronchoconstriction • Paracetamol
• Phenothiazine
 Pharmacology – Clinical Toxicology by Dra Dando Page 4 of 8

• Phenytoin  DMSA: suximer?

• Salicylate  NAPA: N-acetyl-penicillamic acid – mercury,
• TCAD arsenic, lead
• Anticoagulants  Accelerated detoxification
• Carbamazepine  Cyanide antidote kit – available in US only
• Dapsone  Sodium nitrite and sodium thiosulfate
• Gluthetimide o Sodium nitrite: Induce
• Methamphetamine methemoglobinemia (a condition in
• Phencyclidine which the iron within hemoglobin is
• Phenobarbital oxidized from the ferrous (Fe2+) state
to the ferric (Fe3+) state, resulting in
• Piroxicam
the inability to transport oxygen and
• Theophylline
carbon dioxide)
• Organochlorines o Sodium Thiosulfate: binds with
cyanide-methemoglobin complex to
*Formalin ingestion: detoxify
 No antidote o Used in PGH, a raw material that is
 Give H2 blockers compounded and prepared
 Surgery (cut the part with ulceration) whenever it is needed
 Reduction in conversion to more toxic compounds
ENHANCEMENT OF ELIMINATION OF ABSORBED  Ethanol
SUBSTANCES o For tx of methanol and ethylene glycol
• Forced diuresis poisoning
o Mannitol 20% - osmotic diuretic  Competitive inhibition at receptor site
o Furosemide – loop diuretic
 Atropine (physiologic antidote) – for
• Alkalinization therapy organophosphate/carbamate poisoning;
o Sodium bicarbonate – for weak acids: INH inhibits the enzyme acetylcholinesterase)
poisoning  Pralidoxime (pharmacologic antidote)
• Acidification therapy (for weak bases:  Bypassing the effects of the poison
Methamphetamine/shabu)  Oxygen for CN poisoning
o Ascorbic acid  Pyridoxine for INH poisoning
o Ammonium chloride  Antibody interacting with poison
• Dialysis and hemoperfusion
 Digoxin antibody fragments (Digibind) – not
• Multiple dose activated charcoal
available locally
*Locally: nadia-nadia
INDICATIONS FOR DIALYSIS
 Snake antivernin (available in RITM)
• Amanita phalloides (mushroom) – very - species of Philippine cobra cause
dangerous and lethal causing renal failure paralysis
• Antifreeze (glycol type) - Tx: activated charcoal
o Tx: ethanol e.g. vodka via NGT; prevents
conversion to more toxic from SUPPORTIVE THERAPY
• Heavy metals in soluble compounds • Essential for poisoning patients, especially for
o Tx with EDTA or chelators critically ill
• Heavy metals after chelation • Problems in the critically ill poisoned patients
• Methanol o Depressed sensorium
o Impaired ventilation
ANTIDOTES FOR PATIENTS WITH COMA OF o Impaired cough reflexes
UNKNOWN ETIOLOGY o Prone to aspiration
• Naloxone o Immobility
• Glucose o Fluid, electrolyte and other ,metabolic
• Thiamine problems
• Intravenous fluids: replacement and
ANTIDOTE FOR PATIENTS WITH SEIZURE OF maintenance
UNKNOWN ETIOLOGY • Frequent blood and urine pH determination:
• Pyridoxine (Vitamin B6) acidification and alkalinization therapy
• Prevention of aspiration
USE OF ANTIDOTES • Prevention of decubitus
Mechanisms: • Ulcer
 Inert Complex Formation • Treatment of electrolytes, metabolic and
 Chelating agents (DMSA, NAPA) temperature problems
o Tx of heavy metal poisoning • Monitoring of vital signs
 Pharmacology – Clinical Toxicology by Dra Dando Page 5 of 8

• Monitoring of input and output  Benzene (ADR: Leukemia)

GOOD SUPPORTIVE AND NURSING CARE IS  Toluene (ADR: Kidney failure due to chronic
IMPORTANT exposure)

DISPOSITION CAUSTIC AGENTS

• Observation at the emergency room: atleast  Alkali (ph > 7) Strong alkali: ph >10
24hrs may be warranted  No antidote (only supportive): H2 blockers, PPI
• Frequent reevaluation  Sodium hypochlorite
• Psychiatric evaluation: suicidal patients and  Sodium hydroxide (e.g liquid sosa)
substance abusing patients  “LIhiya” (pang-green ng suman)
• Childhood poisoning: evaluate for possible child  Main Tx: surgical
abuse or neglect Pathology: liquefaction necrosis (esophagus and
• Family counseling and education intestine)
• Physical or sexual abuse among women
• Domestic violence  Acids (ph < 7) Strong acid: ph <4
 Hydrochloric acid
TOP TEN POISONS (All Ages) IN-PATIENT STATISTICS  Acetic acid
National Poison Control and Information Service UP-PGH  Benzalkonium chloride
YEAR 2006 (N=847) NUMBER PERCENTAGE
Pathology: Coagulation necrosis
1. Ethanol – alcohol 95 11.2
withdrawal pts  Others
2. Kerosene (Gaas) 87 10.3  Phenol (e.g. Lysol)
3. Sodium Hypochlorite 62 7.3  Cyanide salts: Silver jewelry cleaner
(Zonrox) - mixed with Na Hydroxide
4. Mercury (thermometer) 45 5.3
5. Jewelry Cleaner (Cyanide) 35 4.1
6. Hydrochloric acid 27 3.2 PHARMACEUTICAL AGENTS
(Muriatic)
 Paracetamol
7. Methamphetamine (Shabu) 19 2.2
8. Paracetamol 16 1.9  Toxic dose: 150-200mg/kg
9. Mixed Pesticides (Baygon) 15 1.8  Toxic metabolite: NAPQI (N-acetyl-p-
10. Jathropa seeds (cause 15 1.8 benzoquinone imine)
hemorrhagic gastritis)  GI, liver and renal damage (4 stages)
 Antidote: N-Acetylcysteine
*Na Hydroxide: Liquid sosa
 Preparation: IV – usual route (e.g. Hydranap)
TOP TEN POISONS (All Ages) TELEPHONE REFERRALS
Oral – in sachet
National Poison Control and Information Service UP-PGH Inhalation
YEAR 2006 (N=2,682) NUMBER PERCENTAGE  Average 50-kh man who ingests 15-20 tablets
1. Kerosene 192 7.2 (500 mg) causes toxic injury
2. Sodium Hypochlorite 131 4.9
3. Mixed Pesticides (Baygon) 118 4.4  Iron
4. Elemental Mercury 90 3.4
 Toxic Dose: 20mg/kg
5. Paracetamol 64 2.4
6. Silica gel (shoes) – 62 2.3  GI, CVS, CNS manifestations (4 stages)
nontoxic, causes mild GI  EGD
manifestation  Antidote: Deferroxamine
7. Jewelry Cleaner 57 2.1
 Causes severe bleeding and hypotension
8. Ferrous Sulfate 53 2.0
9. Hydrochloric acid 48 1.7  e.g. Flintstones, Gummy bears – contains iron
10. Isoniazid 42 1.6 which can cause toxicity

HYDROCARBONS  Isoniazid (INH)

 Kerosene (Gaas)  Toxic Dose: 80-100mg/kg
 Chemical pneumonitis  Triad of INH toxicity: seizures, coma, metabolic
acidosis
o Presents with cough  cyanosis  seizures
 Aspiration pneumonia  Antidote: Pyridoxine (Vitamin B6)
 Treatment: Pen G or other beta-lactams (for
pneumonia)  Aspirin
 No antidote  Acetylsalicylic acid: 100mg/kg (children),
200mg/kg(adults)
 Easily absorbed
 Methylsalicylate: 50-500mg/kg or 4ml
(1.4mg/ml)
 Solvents
 Aliphatic hydrocarbons  Vomiting, tinnitus (first thing to manifest),
 Aromatic hydrocarbons metabolic acidosis, seizures, coma, renal failure
 Pharmacology – Clinical Toxicology by Dra Dando Page 6 of 8

 Activated charcoal / hemodialysis (causes coma,  Naphthalene – causes hemolytic anemia in

seizure) G6PD deficiency pts
 Camphor – most toxic
PESTICIDES  Para-dichlorobenzene – deodorizer (e.g.
 Organophosphates Albatross)
 Malathione - least toxic, causes
 Chlorpyrifos slight gastric irritation
 SSx: DUMBELS
HEAVY METALS
 Carbamates  Mercury (a.k.a Asoge)
 SSx: DUMBELS  Sources:
 Elemental: “quicksilver” metal, cinnabar
 Pyrethroids ore, dental amalgam, apparatus,
 DEET (diethyltolbutamide) thermometers
- present in insect repellants (e.g. lotions)  Inorganic: antiseptics, vaccines
- causes seizures esp in children >2 y/o (merthiolate)
 Permethrin  Organic: contaminated waters from
- anti-pediculosis and scabies: cause seizure industrial waste products, air, soil
(methylmercury)
 Rodenticides
 Zinc Phosphides Small-scale mining practices
 Coumatetralyl  bleeding (Tx: vitamin K) = residue after panning operation where most of the
water are removed
 Herbicides = no personal protective device is provided
 Chemical pneumonitis = route of entry is skin

MIIXED PESTICIDES (e.g. Baygon) Mercury in Thermometer

“There is approximately 1 gram of mercury in a typical
 Carbamates
fever thermometer. This is enough mercury to
 Propoxur
contaminate a lake with a surface area of about 20
acres, to the degree that fish would be unsafe to eat”
 Pyrethroid
 Cyfluthrin *Mercury is not actually absorbed if GI is intact but can
 Transfluthrin cross BBB after 24-48 hrs
 S/Sx: DUMBELS *Tx: cathartics
 Treatment: Atropine, Activated Charcoal
 Organic Chemicals: Methylmercury

Effects of Pesticides:
- Endocrine disruption (cause problems in
reproduction and immune system)
- Neurodevelopmental effects (e.g autism,
cerebral palsy, mental retardation)
- Immune system (can cause cancer)

NON-PHARMACEUTICALS
 Silica gel – gastric irritant
 Chinese herbal meds (e.g. Ma-Huang – has
pseudoephedrine and ephedrine: precursor of
methamphetamine)
 Button batteries
- in <7 y/o, the diameter of intestine is >1.5 cm
- can obstruct trachea, pyloric sphincter
*Mercury vapor – amalgam fillings are chief sources of
- endoscopy is done to get it manually
exposure to mercury vapor
 Watusi
 Yellow phosphorus – most dangerous Minamata Disease (d/t high levels of methyl mercury
(protoplasmic: cause severe hypotension and in big fishes, e.g. tuna)
hypoxia) In 1932, Nippon Chisso Hiyu started to operate an
 Trinitrotoluene (present in dynamite and bombs) acetaldehyde acetic venyl chloride manufacturing plant
 Potassium nitrate using mercury as a catalyst. The plant had been
 Potassium chlorate directly discharging its industrial waste into Minamata
 Moth balls Bay for 36 years with no adequate facilities.
 Pharmacology – Clinical Toxicology by Dra Dando Page 7 of 8

 A higher proportion of learning disabilities was

In 1958, Chisso redirected the outlet drainage canal found among school-aged children with
from Minamata Bay into the tributary of the Minamata biological parents who ere lead poisoned as
River which resulted in the contamination of a wider children 50 years previously
area of Yatshushiro Sea.  Source: paints, lipstick, gasoline, hair dyes

Increase in number of vaccines  Arsenic Poisoning

recommended for routine use in infants
 Keratotic lesions  cancerous
 Patients from Bangladesh dig a well

PLANT TOXINS
 Jathropa Seeds
 Contents: toxalbumins = ricin (toxic content
causing hemorrhagic gastritis), curcin, tannic
Potential increased exposure of infants to mercury from acid
thimerosal in vaccines  Effects: abdominal pain, nausea, vomiting,
hepatic injury, muscle twitching, weakness,
Ethyl Mercury salvation, sweating, dehydration, hemorrhagic
= in children receiving thimerosal in vaccines, the half- gastritis
life of ethyl mercury in blood was 7-10 days or 1/7 to  Tx: activated charcoal
1/5 as long as that of methyl mercury
= a WHO advisory committee recently concluded that it CYANIDE
is safe to continue using thimerosal in vaccine - inhibits cytochrome oxidase
- CNS Effects: shock, profound lactic acidosis
Mercury (Pink Disease) - Toxic blood level: >0.5 mcg/ml
Acrodynia
- Acrodynia is a rare idiopathic chronic toxic  Cyanogen-containing plants
reaction to elemental or inorganic mercury  Linamarin in cassava cake – associated Sxs:
exposure, which occurs mainly in young DUMBELS
children. It is characterized by pain in the
extremities and oink discoloration with
 Cyanide salts
desquamation of the skin
 Metal polishing (jewelry cleaners)
Uncommon Syndrome “Pink Disease”
 Cyanide Antidote Kit
 Pain in the extremities  Amyl nitrite, sodium nitrite, sodium thiosulfate
 Pinkish discoloration and desquamation
 Hypertension RED TIDE POISONING
 Sweating  Diarrheic shellfish poisoning
 Insomnia, irritability, apathy  Okadaic acid (OA) and its derivatives
 Considered as idiosyncratic reaction
 Amnesic or encephalopathic shellfish
Adverse Effects of Mercury poisoning
 Elemental  Domoic acid
- acute necrotizing bronchitis pneumonitis,
insomnia, forgetfulness, loss of appetite, tremor,  Paralytic shellfish poisoning
erethism, renal toxicity  Saxitoxin and gonyautoxin (GTX)
 Inorganic
- corrosive effects: GI ulceration, perforation,  Neurotoxic shellfish poisoning (NSP)
hemorrhage, acrodynia, renal toxicity
 Brevetoxin
 Organic
- CNS: paresthesia, ataxia, muscle spasticity Department of Health
- Infants: psychomotor retardation, blindness, Criteria for Detecting PSP
deafness, seizure, cerebral palsy
 Ataxia +
- Behavioral and learning delays: deficits in
 Additional 2 Motor Distrubances +
language, attention and memory
- Dysphagia
- Inability to stand
 Lead (a.k.a tingga) - Vomiting
 Pregnant women and their developing fetuses - Dyspnea
are at high-risk because lead readily crosses the - Paralysis
placenta  Additional 2 Sensory Disturbances
 For every 10mcg/dl increase in BLL, children’s IQ - Dizziness
dropped by 4-7 points - Headache
- Lightheadedness
 Pharmacology – Clinical Toxicology by Dra Dando Page 8 of 8

- Paresthesias REMEMBER THE DONT’S:

- Dysthesia  Do not induce vomiting in the following situations:
- Hot flashes - drowsy and comatose patients
- Numbness - poor gag reflex
- ingestion of corrosive and hydrocarbon
Specific Treatment - if the ingestion has occurred for more than one
With known or suspected toxin hour
- late pregnancy (last 3 months of pregnancy)
- presence of heart disease

 Do not give milk or vinegar

(-) Respiratory Distress (+) Respi Distress :milk is not a universal antidote

Observe for 24 hrs

Asymptomatic (-) Respi Failure (+)

Respi Failure

Discharge NaHCO3 q 5 hr NaHCO3 q 5

hrs x 24h

Observe x 24 hrs
Ventilatory support

Respi Distress Test dose of

edrophonium

With Response

Public Health Issues

 Reporting to DOH
 Shellfish / Fish Advisory
 Monitoring of other possible patients
 Monitoring of levels of toxins in the area (BFAR)

SUBSTANCE ABUSE
Sedatives
 Diazepam (Valium)
 Lorazepam (Ativan)
 Flunitrazepam (Rohypnol)
 Sleeping Pills (Stinox, Unisom)

*Ecstasy
- side effect: bruxism
- causes seizure, severe dehydration
- more toxic than shabu

Smoking and Alcohol

FIRST AID MANAGEMENT OF POISONING CASES

GOAL OF TREATMENT:
- to limit absorption of poison
- remove from toxic environment
- decontamination Maneuvers