Oral poisoning an update

Patients who develop fulminant liver failure may be offered life-saving liver transplantation, but the selection criteria are in need of refinement based on long-term outcome data. Patients with salicylate poisoning may present with tinnitus, deafness, hyperventilation, epigastric pain, vomiting, hyperthermia, sweating, dehydration, respiratory alkalosis, metabolic acidosis, and electrolyte disturbances.

Agitation and confusion may indicate the development of cerebral oedema which can be fatal. Treatment includes rehydration, treatment of acid—base disturbance, and close monitoring of plasma levels.

AC should be administered as soon as possible even in delayed presentations. The use of multidose AC is debatable, but should be considered if the plasma salicylate level continues to increase or if a slow release preparation has been taken. Deaths associated with benzodiazepine overdose are due to mixed overdoses, especially alcohol and other drugs. Clinical manifestations are associated with drowsiness, respiratory depression, dysarthria, and ataxia. Coma is not common but is most often seen in the elderly or patients who have ingested alcohol or other drugs.

Treatment is supportive. The use of flumazenil is controversial as it has many side-effects and is rarely indicated. Adverse effects include ventricular tachycardia, raising intracranial pressure, withdrawal in chronic abusers, and seizures if used in the presence of tricyclic antidepressants. It can be used to reverse benzodiazepine coma so as to avoid intubation, but this should be limited to situations of benzodiazepine overdose where no other drugs have been taken Table 2.

Increasing doses of opioids progressively produce euphoria, pinpoint pupils, sedation, respiratory depression, and apnoea. Complications include hypotension, convulsions, non-cardiogenic pulmonary oedema, and compartment syndrome from prolonged immobility. Where this is suspected, serum CK and urinary myoglobin should be measured to look for evidence of rhabdomyolysis.

This antidote can precipitate an acute agitated withdrawal state and when giving it staff should be mindful of their own safety. Naloxone can be administered i.

It has a short half-life 20 min if given i. It can rarely cause ventricular dysrhythmias and hypertension and drowsiness at very high doses. Tricyclic antidepressants cause fatalities each year in the UK. The predominant cause of death is cardiac depression by sodium channel blockade with resultant decrease in cardiac output. Overdose presents with a sinus tachycardia, mydriasis, coma, hyperreflexia, convulsions, ECG changes, and hypotension. Treatment includes prevention of absorption using AC.

Sodium bicarbonate is given as a loading dose 8. Sodium bicarbonate should be administered even in the absence of a significant metabolic acidosis as it helps to stabilize the Na channels in the myocardium and prevent cardio-toxicity.

Convulsions can be treated with benzodiazepines initially, but anaesthesia with propofol may be required. Phenytoin is the anti-arrhythmic of choice and glucagon can be helpful if there is evidence of myocardial depression.

These drugs include citalopram, fluoxetine, flovoxamine, paroxetine, and sertraline. Nausea, vomiting, agitation, tremor, nystagmus, drowsiness, dysrhythmias, and mild hypertension are the most common features of overdose. Convulsions have been reported up to 10 h post-ingestion. If administered with other drugs like cocaine, tricyclics MAOIs, or MDMA which release serotonin or affect its reuptake, this may result in serotonin syndrome.

Serotonin syndrome consists of a triad of altered mental status, neuromuscular hyperactivity, and autonomic instability, similar in presentation to neuroleptic malignant syndrome—hyperpyrexia, acidosis, arrythmias, and rhabdomyolysis are seen. Treatment is supportive but should include AC up to 1 h post-ingestion. Convulsions should be treated with benzodiazepines and phenytoin.

Cryoheptadine and chlorpromazine are 5HT-2A antagonists and have successfully been used to treat serotonin syndrome, but there are no controlled trials to support the use of either agent. If rhabdomyolysis is suspected, urinary alkalinization and volume replacement may be helpful to reduce renal failure.

Fluid resuscitation including mmol of 8. If renal failure occurs, haemodialysis or haemofiltration is required. Methanol and ethylene glycol poisoning results in a severe high anion gap metabolic acidosis. Both are metabolized via the enzyme alcohol dehydrogenase resulting in formation of acids formic, glycolic, and oxalic, respectively which accumulate in the body and are responsible for neurological damage and death.

Overdose with these agents can be treated with oral or nasogastric ethanol because of its greater affinity for alcohol dehydrogenase.

However, maintaining plasma alcohol levels in the correct range is difficult and time-consuming, particularly if the patient is undergoing dialysis. Fomepizole blocks the metabolism of methanol and ethanol and can be injected 12 hourly. It is expensive and not widely available. Acute poisoning is relatively common and is the cause of significant morbidity and mortality. NPIS and Toxbase provide a 24 h information service for all aspects of poisoning.

Treatment of poisoning remains largely supportive. Few drugs have antidotes and therefore treatment is aimed at reducing further absorption of the drug, increasing its elimination, and treating the side-effects. Gastric decontamination with AC is time-dependent, but can significantly reduce drug absorption. Forced emesis and gastric lavage are no longer recommended. Google Scholar. Google Preview. Oxford University Press is a department of the University of Oxford.

It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide. Sign In or Create an Account. Sign In. Advanced Search. Search Menu. Article Navigation. Close mobile search navigation Article Navigation. Volume This article was originally published in. Article Contents Oral poisoning: an update. Initial approach to the poisoned patient. Supportive care and monitoring. Gastric decontamination.

Induced emesis. Gastric lavage. Activated charcoal. Whole bowel irrigation. Increased elimination. Treatment for specific poisons. Oral poisoning: an update. Specialist Registrar. E-mail: caf. Oxford Academic. Consultant in Intensive Care Medicine and Anaesthesia.

Select Format Select format. Key points. Table 1 Specific signs in poisoning and overdose. Common Findings. Other signs and symptoms. Potential Treatments. Open in new tab. Open in new tab Download slide.

Table 2 Common antidotes. Indicated in poisoning with. Google Scholar Crossref. Search ADS. Folate deficiency in primates is predictive of The predominant cause of death is cardiac depression by sodium poor outcome in methanol toxicity and it is suggested that folate channel blockade with resultant decrease in cardiac output.

A QRS interval of. Treatment includes Acute poisoning is relatively common and is the cause of signifi- prevention of absorption using AC. Sodium bicarbonate is given as cant morbidity and mortality.

NPIS and Toxbase provide a 24 h a loading dose 8. Treatment of poi- intermittent bolus. Sodium bicarbonate should be administered soning remains largely supportive. Few drugs have antidotes and even in the absence of a significant metabolic acidosis as it helps therefore treatment is aimed at reducing further absorption of the to stabilize the Na channels in the myocardium and prevent cardio- drug, increasing its elimination, and treating the side-effects.

Convulsions can be treated with benzodiazepines initially, Gastric decontamination with AC is time-dependent, but can sig- but anaesthesia with propofol may be required. Phenytoin is the nificantly reduce drug absorption. Forced emesis and gastric lavage anti-arrhythmic of choice and glucagon can be helpful if there is are no longer recommended. References Selective serotonin reuptake inhibitors 1. Postgrad Med J ; — 16 tine, and sertraline. Nausea, vomiting, agitation, tremor, nystag- 2.

Convulsions have been 3. If administered with other 4. Heard K. Clin Lab Med ; 1 —12 otonin or affect its reuptake, this may result in serotonin syndrome. Position Paper: Ipecac Syrup Serotonin syndrome consists of a triad of altered mental status, American Academy of Clinical Toxicology, European Association of neuromuscular hyperactivity, and autonomic instability, similar in Poisons Centres and Clinical Toxicologists.

Clin Toxicol ; — 43 presentation to neuroleptic malignant syndrome—hyperpyrexia, 6. Vale JA. Position statement: gastric lavage. American Academy of Clinical acidosis, arrythmias, and rhabdomyolysis are seen. Chyka PA, Seger D. Position statement: single dose activated charcoal. Convulsions should be treated with benzodiazepines and pheny- American Academy of Clinical Toxicology; European Association of toin.

J Toxicol Clin ; and have successfully been used to treat serotonin syndrome, but — How long after drug inges- Interventions for Paracetamol tion is activated charcoal still effective? Activated charcoal alone Fomepizole in the and followed by whole bowel irrigation in preventing the absorption of treatment of methanol poisoning. N Engl J Med ; 24—2 sustained release drugs. Clin Pharmacol Ther ; — 60 Jones LO.

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